I II, II I 'Illi @ i 11 * "I@Qll@iii l@iiii, ICAL PROGRAMS C/LMC DIVISION OF REGIONAL MED AD HOC REVIEW COMMITTEE PANEL "A" 6 7 8 Conference ROOM-G/Hr Parklawn Building, 10 5600 rishers Lane, Rockville, Maryland, 20852, 11 Wednesday,, May 22, 1974. -121 131 - - - 14 PRESIDING: 15 CLEVELAND R. CHAMBLTSS, Acting Deputv Director. 16 PRESENT: 17 MRS. FLORENCE TIYCKOFF DR. PHILIP WHITE 111; DR. WILLIAM VAUN MR. ROBERT TOOMEY 19 MR. JOHN THOMPSON - DR. ROBERT SLATER 20 MRS. JESSE SALAZAR DR. WINSTON MILLER 21 DR. ALEXANDER McPHEDRAN DR. ROBERT CARPENTER 22 2:1 24 ER RLPUKTING CO. INC. lasuchusetis Aveniie, H-E. ICAL PROGRAMS C/Lmc DIVISION OF REGIONAL @IED 2 AD HOC REVIEW COMMITTEE 3 4 5 PANEL "A" 6 7 8 9 conference Room G/H, Parklawn Building,, 5600 Fishers Lane, 10 I Rockville, Maryland, 2OBi52, Wednesdayl May 22, 1974.@ 12 13 14 PRESIDING: 15 CLEVELAND R. CHAM13LTSS, Acting Deputv Director.. 16 PRESENT: 17 MRS. FLORENCE WYCKOFF DR. PHILIP 1,MITE- 18 DR. WILLIAM VAUN MR. ROBERT TOOMEY --i4R. JOHN THOMPSON DR. ROBERT SLATER 20 MRS. JESSE SALAZAR DR. WINSTON MILLER DR. ALEXANDER McPHEDRAN 21 DR. ROBERT CARPENTER 22 2:3 24 2;-j ER RLYURIING CO, INC. lassachusetts Avenue, N.E. . A @Ann) ColiTr.,IITS, qional 17 3Alabama Re. 27 4 Motion for ne-coni@ndalion 5I\r)-,an-3as TteL-r:Lonal ilIncltcal Program 32 43 t!otion for Reco-.@an(lat-ton 7 '51 Bi-v,ta,Le Regional i@(lical Prorjr,@- 8 tlotion for reco"noildatioll .9 Colorado-l-lyominG Be@bion.ll..dical Program 60 10 klotion for Recommendation 77 11 Georgia Regional I-ledical PioGram co 12; Motion for recommendation 87 331 rlorida,ll-ion-cil 1,10 dicai ri,oGrILini 14 notion for recoiniiienCntion in, 15 Dledtc-il lyi,(;i,rtlim In(Jiana II(-,-gional r) Motion for recori",if. 1',Ition 17 I.Icdical- Prorram 'llisconsin Regional .Motion for recomiiien(-lcition. l@ns-,is Regional IliedicLil PrLry,,-iin 21) -ition Motion for fccomin@,n(l, Inter-tlountain Ilegiotial Progr-,Im 22 notion for recorll-.l,:!tifl"41tiorl 2:t Michigan Ilegion,,il rroCI"lm 24 @lotion for rcco,!il,;@,ri, 25 (cont,-Inii,,,(' oti nc,@xL- pace) CO, INC C 0 N T 13 N T S 2 PAGE 3 klisolosippi Regioiial I-ledic',Il Pro 4 klotion for recommendation 192 5 Illinois Region,,ii I."o-dical Pro(;rim I ")3 -A I-lotion for recominencll",tion 215 7 Louiciiana Ilegional I,,Ic(lic,,il P-rogram 21.7 8 n@l a t-. io n motion or recomme 22-( 10 12 13 14 15 17 20 2 1 22 23 P R 0 C E E D I N G S 2,1 all MR. CHAMBLISS: Let me take this opportunity to c 3 Panel "A"to order and welcome you here to this particular 4- work group. 5 -think u should kn that a we get int our yo ow s 0 6 procedures for the next day or so that I will have at my right 7 and at my left two operations Branch chiefs, Mr. Lee Van: 8 Winkle,, who is the operations-chief for the South-Central 9 Operations Branch of@the Division of operations and Develop- 10 men t, and Mr. Mike Posta,-"who is the operations Branch Chief for the Mid-Continent Ooerations Branch. 12 I think the panel should know that we had expecte 13 as Dr."Pahl mentioned,, Mrs. Silsbee to have chaired this panel 14 and it's-.-due-to her illness that I've been asked, just in the' 15 last-few hours, to chair @e panel, Dr. Pahl and 1, as he mentioned, have been looking 17 at other things over the last eighteen months and especially 18 these matters having to do with OMB questions,,With answering questions from the Department dealing with the congressional relations, all the Questions coming from the Congress having 20 21 to do with the phase-out and the status of the program, the inter-agency aspects of operating the program, and both of us 2- have left all but entirely the operational aspect of operating 2;1 the division to Judy, who has, I"might say,, served with great 24 distinction. [ER RLPUKIING CO, INC. chusetts Avenue, N.E. 5 When the annals of RMP are written, she will truly 2 be one of the strong people of Rmp, a great person, a great i 3 lady, a prodigious worker, and a good friend to all of us. .4 Hopefully she will be here while these proceedings 5 are underway, but Mike and Lee will provide me with lateral 6 support, and at the same time we will have support from 7 members of the operations Staff and also a representative from 8 the Grants Management Staff in the person of Mr. Larry Pullen. 9 1 think the committee is well-aware of the fact lo that we are operating under a court order and I will only say 11 one additional thing: Dr. Endicott said that things are a 12 mess; I agree. I will only add my word of wisdom, if you can 13 -call it that, and that is, we have lived in a chaotic c-omu- 14 nity over the past few months and this,, in a way,. culminates some of the trials that we have undergone by reviewing the 15 1(; applications from the regions that came in on May lst,, their application for funding beginning July 1, 174. 17 I think, as we get underway,, you should know we will 18 be operating under the Mission Statement that we all know so well. We are operating under no restrictions as relates to 20 the program activities of the RMPS. 21 And maybe I at this time should call upon Lee 22 Van Hinkle to just set forth in highlight fashion some of the 2.3 review guide procedures that we'll be utilizing. 24 Lee, won't you 2.:-) HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. n t' )nnn,) MR. VAN WINKIX: I just primarily want to call your 2 attention to the review guides that you have, and I know that 3 Dr. Pahl said it earlier, but I think it should be repeated that I think this group has to focus on the over-all program 5 of the Region and the proposal as submitted rather than on a 6 technical review of the individual projects, and we do have 7 the criteria listed. 8 I think the only other thing that I want to mention 9 at.all is the review sheet that Vou find attached in there,. 10 We will expect the two reviewers to fill that out and we'll 11 collect those as we go along. 121 DR. MILLER: When do you want them? 13 MR. VAN WINKLE: Sir? 14 DR. MILLER-. When do you want them? 15 MR. VAN WINKLE:. We'll give you time to complete them 17 MR. CHAMBLISS: At the end of each review as we sit j8 here. 19 DR. MILLER: At we sit here? MR. VAN WINKLE: Yes. Before we go to the next 20 21 application, we would like you to fill it out in talking 22 with @liss Leventhal -- and pick it up at that time. 2:1 DR. SLATER: I want to haIve some timd-to rewrite my commentary on those, so I'll get it back to you during this 24 25 session, but it won't be immediately after my oration. HOOVER KLPUKTING CO, INC. 320 Massachusetts Avenue, N.E. 7 MR. CHAMBLISS: Thank you, Lee. 2 I.should mention that, as you have probabl3, noted 3 in some of the background materials, that the focus f the review will, by and large, touch on about eight elements. 5 The first is program leadership; second, program 6 -staff; third, regional advisory group; four, past performance 7 and accomplishments of the region; five, the region's objec- 8 tives and priorities; six, the proposal; seven, feasibility; 9 and eight, and finally, CHP relationship. 10 I think one additional item of procedure may be in 11 order here, and it's a further elaboration on the fo@s for 12. review. Dr. Pahl mentioned that the policy issues would .13 simply be flagged and we would not necessarily attempt to 14 resolve them here; that the target amount should be the principal benchmark for a backdrop for the review. 15 16 Lee has mentioned that the two reviewers will review 17 and the second reviewer will simply add additional comments or 38 observations. We hope to follow the exception principle if we are 20 really going to get through in our appointed time. We also will have Staff c(xluttents as necessary and- 21 required and for each of the regions under review the Staff q2 person handling that particular region will be at the head 2:3 table here. 24 After that, a brief discussion, and we will attempt 2;-p HOOVER RLPORTING CO, INC. 320 Massachusefts Avenue, N.E. 1 at need to b' clarified, to clarify any items or matters th e 2 looking forward to the presenter giving us a recommendation 3 and the rationale for his recommendation, ending up with a 4 motion on that particular recommendation, and frcm there wLw 5 will ask each reviewer to complete the rating sheet as we've 6 touched on. 7 There are ap .plications at the back tablet complete 8 applications on the back table, for each of the reviewers who 9 will need them, and we would simply ask you-as a final matter 10 of procedure, kindlv speak into the microphone so that our 11 recorder can got all of the details. 12, Are there any questions at this moment before we 13 begin to proceed? 14 Dr. Vaun? 15 DR. VAUN: I've heard Lee refer a couple of times to 16 the fact that we're not going to.db a technical review, if I 17 understand what he's saying. However, I'd like to know how 18 we're going to reach a judgment about funding levels unless we address some of the technicalaspects of the programs. 20 on the basis of the guidelines submitted, namely, leadership, past performance, it's going to be very difficult 21 22 to arrive at a funding level. Lee, how do you want us to work this magic if weire 2:1 not going to look at the projects? 24 MR. VAN WINKLE: Well, I think that you do have to 25 HOOVER REFURYIN(I CO,' NC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 9 look at the projects because that's a part of the total pro- 2 posal that came in, and if what you see in here is not 3 related to the goals and objectives of that region, then I -4 think you have real cause for concern, and certainly if there 5 are items included in here that are strictly against policy 6 of the Regional medical Program, that also has to come out. 7 But I think you have to look at what they've sub- 8 mitted, the individual pieces; but as to getting into the 9 individual technical aspects of a particular activity that's 10 what we're trying to avoid. 11 DR. VAUN: Okay. 12. MR. VAN WINKLE: The actual makeup of that activity that you're looking at. 13 14 MR. CHAMBLISS: Let me just add one additional piece 15 of information so that we have something of a framework. The panel will have a total of 28 applications to review with a requested amount of $65.5 million. There's one continuation 17 request; there are 23 continuati on and new activity requests; 18 1,) there are 24 additional applications expected from this set of 20 regions in July. 21 Twelve of the regions that you will be reviewing have had -- twelve of the twenty-eight have had new coordi- 9.) nators since the phase-out was announced. There have been 2:3 limited site visits. However, there have been Staff visits to 24 nineteen of the regions in question. Two have had review 2;-w HOOVER REFORTiriG CO, INC. 320 Massachusetts Avenue, N.E. 10 I certifications; six have had management surveys; and twelve 2 others have had technical assistance.visits. 3 So there is a body of intelligence residing in the 4 Staff as to how the regions are functioning and operating., I 5 thought you would like to have that just as a backdrop. 6 MR.- VAN WINKLE: Can I add just one thing? 7 MR. CHAMBLISS: Yes 8 MR. VAN WINKLE: Dr. Vaun, I think what we're seek- 9 ing here is the development of a level of funding and not a 10 funding level level of approval, if you will, not funding 11 level, and the funding level actually will be determined some- 12 where within that level of approval. If you come in, let's say, with a leval of approval 13 14 on one program at $2 million, the actual funding level will be' made up to that figure, it won't exceed it, and it may be less 15 .than that. 16 DR. SLATER: Could I 17 18 MR.. CHAMBLISS: Dr. Slater. DR. SLATER: May I make a point? 1, like you, have been trying to get a grasp on this in comparison to the old 20 21 days and, furthermore, in the light of what Mr. Rubel is talk- 9.) ihg about, and I have the same concern that you have, that while not really examining these projects which are presented 2:1 in variable detail from one region to another, I'm attempting 24 to make some kind of an assessment, really, to give you, in a 2.:-) HOOVER RLPOftTING CO, INC. 320 Massachusetts-Avenue, N.E. sense,, professional backup as to what kind of funding these 2 regions should have. 3 Coming through to my mind all the time is the fact .4 that since we're apparently going through such major changes 5 in the next few years in which RMP will be recast in some way 6 or the other that what we're here to-do, really, is to just 7 I look for the most obvious problems or errors which you as 8 Staff have'to correct in order to justify the expenditure of 9 these funds and that we're not going to varv, really very 10 much from the figures you have here, because the mos 11 important role w e have to Play now in this interim p,riod is 12; to stabilize those staffs out there in order that one has a .13 group of People that are well-trained and indoctrinated to 14 move ahead in some fashion in the years ahead. 15 So I must say I don't have too much difficulty I(; making assessments. I'm having to rely so much on what 17 they've already decided to do there, that I think we're 18 really here just to provide professional extramural moral I!) support more than anything else -- obviously, there Are going 20 to be some holes in that, but, generally speaking, that's how I read it. 21 MR. CHILMBLISS: I assure you we need that, too, but 22 we do need your professional judgment. 2;@ DR. SLATER: I agree. 24 MR. CHAMBLISS: And we need your views and we would 2;-p HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. 12 like you to work on the exception principle. If there are 2 matters that are exceptions of policy issues, then we would 3 like to have your judgment on them. 4 DR. SLATER: I'm not trying to be soft, but whatI 5 am concerned about is that with the stability of thelstaff and 6 the projects and all they mean out there is perha s the most p 7 1 important element in the survival of the whole pattern of activity that was started eight or ten years ago. 9 MR. CHAMBLISS: Mr. Thompson. 10 MR. THOMPSON: On the interface with kidney, EM 11 emergency medical services, and PSRO, did the Staff through 12! and edit any of these in any way, identify those pr ects that .13 are obviously in conflict with kidney, emergency, and PSRO? 14 MR. CHAMBLISS: We have in fact gone through all the 1.5 requested project activities and have seen -- attempted to 16 determine if there was a conflict with the policies of another 17 program. We have also had discussions with the key staffs of 18 the kidney program, the emergency medical services program, I!) and they will give us-some assistance in these reviews where 20 we find conflicts. 21 A number of these activities, the regions have been into actually before some of the legislation was passed -- 9.) quality assurance, which borders very closely to PSRO, and.so 2;1 on and those activities are )5eing continued. 24 However, in the case of EMS, you should know that it HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. W2thinotnn DC-20002 13 is a program decision and a matter of statute that the RMPS 2 or no other program will enter into EMS activities so as to 3 build a system of emergency medical care. -4 Our regions have had facets of a system and, theie- 5 fore, with the understanding that we have between EMS and RMP, 6 those activities are permissible for funding under this set of 7 applications, so their basis they are not'designed to 8 produce total systems. 9 MR. THOMPSON: But maybe the problem is that if vou 10 put money into those nobody will ever be able to design a 11 total svstem because those pieces will be out, you can't pick 12. them-up- 13 MR. CHV4BLISS: Well,, at the local level the CHP 14 aaencies have been coordinating to see how the RMP proposal 15 fits into the total need"a@.the local level, so there has been i(i a degree of coordination and cooperation there to make sure 17 that the pieces that we support have sane relevance to what 18 else is going on. MR. THOMPSON: But I detect something in the appli- '20 cations I read$, which, although it is not in direct conflict 21 with the PSRO organization, it is obviously addressed to the 2,-' tactic that hospitals, if they have any brains, have suddenly 23 got to realize that they've got to get their own quality assurance program, optioning (phonetic) subbing it out to a 24 PSRO or do it themselves, and some of these projects are 2;-) HOOVER RLFORIING CO, INC. ,VO Massachusetts Avenue, N.E. 14 asking for money to let hospitals build up their own quality 2 assurance programs so they can eventually do this for PSRO. 3 I object to it for two reasons. one is they should .4 have been paying attention to quality a long time ago --'ail 5 of a sudden they shouldn't have discovered the wheel. But 6 this isn't related to PSRO 7 MR. CHAMBLISS: Indeed it is. As a matter of policy 8 Council policy, we have stated many times that the RMPs could not become involved in PSRO development per se; they could not 10 use their funds for the operational aspects of a PSRO. 11 DR. McPHEDRAN: They could be involved in develop- 12; ment? .13 MR. CHAMBLISS: They could not be involved in the 14 actual development, but that if there were studies, data 15 collection or peripheral.-activities related to quality i(i assurance, that they could be involved in that using RMP funds. 17 MR. VAN WINKLE: I'd like to add-one comment. As j8 far as th e Staff comments you find in here, they have flagged I!) items for your attention, items that they felt were of concern 20 that they wanted to be sure that you looked at. 21 Now they haven't made any recommendation on those 22 to the cri,iiittee. Thevlve left that up to the committee. 2:1 And in looking at the criteria that you're going 24 through as far as leadership, RAG, and all of these items, I want to assure you that the Staff have looked at all of those 2;-) HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. items, too.. and if you see no ccmmentr it, doesn't mean that (sic) 2 they haven't looked at them and are satisfied with what they 3 see, but if you have any question, we'll be glad to have the 4 Staff respond to it. 5 MR. CRAMBLISS: Mr. Posta. 6 MR. POSTA: I would like to make a ccmnent concern- 7 ing, for instance, EMS activities. Many of our states are 8 making applications to HSA for various EMS activities. Dead- 9 lines in certain areas have been April 15t@h. 10 We have other opportunities in,area research for EMS 11 that are going to be funded by another bureau and we have, 12: from a Staff standpoint, made it clear that whatever we -- meaning RMP, DRMP -- will be funding will be double checked 1 14 with the other agencies to avoid duplication in these type of 15 efforts. 16 MRS. WYCKOFF: Is that what you mean when you list -- 17 well,,- four EMS projects under concerns, that you're going to 18 check them with these other to see if.they should have applied I!) somewhere else? 20 MR. POSTA: Right. And to see also if they're 21 flagged whether or not the amounts of money requested in this 22 application is, in essence, double that of what has been approved for the first six .months of the year. So we do it 2:3 24 both ways. I-le keynote an expansion of an activity moneywise as HOOVElt RLPORIIMG CO, INC. 320 faasuchusetts Avenue, N.E. 16 well as 2 MRS. WYCKOFF: I see. 3 MR. VAN WINKLE: Continuations here aren't of 4 concern in terms of the new legislation. Continuations are 5 not of concern insofar as the new legislation. Only new start- 6 UPS. 7 MR. CHAMBLISS: All right. 'Are there other 8 questions? If not, I think we should begin our review and our 9 listing shows that the first-regional medical program to be- 10 reviewed is Alabama. 11 and Mrs. Salazar, and the The review is by Dr. Vaun 12 Staff person, who is already here at the head table, is Mr. .13 Joe Jewell. 14 will the first reviewer make his or her presentation? 15 17 18 20 21 22 2;3 24 HOOVER REFORIING CO, INC. 320 Massachusetts Avenue, N.E. 17 ALABAMA REGIONAL MEDICAL PROGRAM 2 MRS. SALAZAR: Alabama has always led this parade 3 MR.@-CHAMBLISS: Use the microphone. 4 MRS. SALAZAR: of the reviews, and I'm afraid I 5 fell-into that trap and I may get carried away, but I hope not. 6 The present fundina of the Alabama RMP is $687,000 in the third year of a triennial status, with-the year ending April 30th, for a total of four operational years. 9 The activities that were reported in the application 10 are related to phase-out pursuits,.rescinding of phase-out, 11 reactivation, retooling, in response to the off-again/on-a4ain 12' syndrome that has bedeviled the regions all across the country .13 this past year. 14 In view of this, the Alabama application,. to me, is 15 somewhat astounding froma number of standpoints. 16 First, after the phase-out orders in February of 17 1973 only two projects were approved for partial support and onlv four which were funded through contracts were continued beyond June 30, 1973. 20 Two: the Regional Advisory Council elected to remain 21 intact the RAG is called RAC there -@ it retained its work- 22 ling committees, and, indeed, throughout such troublesome times 2:1 iof adversity it grew in strength and.wisdom, guiding and sup- porting the RMP efforts throughout the region. The RAC has met 24 1 ,four times, reviewed proposals, set priorities, implemented new 2.7i HOOVER RLPUI(LIPG r-0. INC. 320 Massachusetts Avenue, N.E. W2thinuinn 1) C 2OW2 18 by-laws, counseling and opening avenues of communication in 2 their respective geographic areas.of the region. 3 Vacancies that have occurred on the staff have been 4 filled very promptly and attendance at all meetings has 5 averaged better than 66 Y)ercent. 6 There is a nine-member executive board of the RAC. 7 It has met six times, average,attendance at 75 percent. The 8 chairman is a member of the State Health the State Board of 9 Health Department. 10 The third astounding feature of this application, to 11 me, has to do with the ability of the region to seek and 12 obtain local support for twelve out of sixteen of their con- 13 tinuation programs, twenty-one out of the thirty new proposals, 14 Spoken or stated another way, in addition to the $2,648,000 15 they are requesting,, $1,922,000 almost $2 million will i(i be supplied by state, local, and other federal monies. 17 or still another way, 73 percent of this application, 18 will generate other grant-related support, resulting in A total of $4,500,000 for the Alabama RMP is that correct, Joe? 20 MR. JEWELL: That's correct. 21 9.) MRS. SALAZAR: The Review Committee and the EMS Com- mittee have remained active, with the latter forming the 2:3 nucleus of the State Advisory Committee to the Governor and 24 the State Board of Health. 2;-) HOOVER RLPORTING CO, INC. 320 Massachusetts Avenue, N.E. Ml' qnnn,) I 19 The.membership of the RAC is adequately represented 2 by providers and consumers from each of the 10 CHP B agencies 3 and it includes the Director of the State CHP A Agency and a 4 representative complement of health educators and providers, 5 officials, and the like -- there's a mayor, too, as I recall. 6 The University of Alabama in the Birmingham Medical 7 Center serves as the grantee and the present Executive 8 Director of the Alabama RMP is on leave of absence from the 9 university at 100 percent of time. Maximum'resource support 10 from the university is accorded the Regional medical Program. 11 The present Director has had extensive experience 12: with the Alabama -PJ4'-P, having served on its first Regional 13 Advisory Committee in 1967. She has been a member of various 14 committees for about three years, has served as a part-time 15 Associate Director professional She has also been a member of the faculty of the School of Medicine for over 25 years, 17 and for the past twelve years as Assistant and Associate Dean is for Continuing Medical Education'. She is active in medical affairs throughout the state., The Deputy Director has been with the program since 20 October 1970 and the Assistant Director for operations has 21 22 been employed by the Alabama PLIP for seven years. The position of Associate Director for Health Care 2:1 Serviceso which will provide liaison with health providers 24 throughout the region, is open. Recruitment is un erway. HOOVER RLPORTING CO, INC. 320 lAassachusetts Avenue, N.E. Washington, D.C. 2DO02 20 This unit is pursuing PSRO efforts and will provide 2 an appropriate channel for.emerging national health insurance 3 information. 4 An Assistant Director for Multimedia ActivLties And i 5 an evaluator round out the professional staff and bring the 6 total to its approximate prephase-out status. 7 There's a sense of optimism and enthusiasmlthat 8 comes through in this application. It communicates a feeling 9 of confidence in the competency and the wisdom and the motiva- 10 tion of the staff. 11 The region appears to me to be on target in meeting 12 its goals and objectives as revised in 1971 to meet @e chang- 13 ing national and local priorities. 14 It is quite apparent that enormous staff energy went 15 into'creating four of the initial six B Agencies in the state and it is still wielding a great'influence on theemergence.6f 17 the other four. The Director of the CH P A Agency is a-member of RAC 18 and several members of the Area Health Councils are also RAC members. B Agency members frequently attend RAC meetings. 20 There is excellent communication among all groups. 21 22 The endorsement of the Alabama Advisory Council for CHP A Agency is quite guarded, and there are some stated 2;3 24 reservations concerning the duplication in sponsoring agencies, but for the most part these are fairly superficial. 25 HOOVER REFURYING CO, INC. 320 Massachusetts Avenue, N.E. W-thinafnn n r. gnnog 21 As far back as 1967 the Alabama Regional Medical 2 Program proposed in its first planning grant the development 3 of six cormunity-based health education centers to serve 4 regional needs for health manpower education, service, and' continuing education for all health professionals in the 6 region. Eleven programs are now ongoing, coveting all geo- 7 graphic areas of the state, and one it emerging in.the 8 resource-poor southeast section. 9 There is an,exciting program that is entitled I 10 "Project HELP' which emerged from.a tripartite agreement among 11 University of Alabama, Birmingham-Auburn.' and the State Health 12@ Department for health education of the public. It utilizes the services of the Agriculture Extension Service at Auburn 14 University and county agents and councils in every county of 1.5 the state. This program,will receive future funding through i(i state education funds. 17 The present Application, as I said, generates a 18 feeling of optimism in the reader. Cooperative arrangements have been achieved. Staff of -both CHP A and Bs are actively 20 involved in RMP affairs. Projects, both_proposed and ongoing, are timely, relevant, and appear to be viable. They are par- 21 9.) ticularly applicable to the region's@health nee ds, but also in line with national emphases, such as PSRO and quality and cost 2:1 24 controls of the health delivery system4 These are all spoken HOOVER REFOXIING CO, INC. 32OMassachusettsAvenue,N.E. 22 Flor'the July submission the region is preparing 2 additional projects in neonatology and one to develop a rural 3 community health task force. it is significant, I think, to note that the 5 Regional Advisory Council incorporates in its committee 6 structure the CHP B planning agencies. These areawide 7 advisory bodies formulate policy and approve plans pertinent 8 to health issues, not only project proposals from Alabama RMP 9 but others requesting federal and state funds that affect 10 their geographical areas. 11 From the very limited information to be gleaned from 12, the resort on the HRA-T4, I believe it's called,,which is the 13 Equal Employment Opportunity breakout and my previous 14 knowledge of Alabama, it does.appear to me that the Alabama 15 Region has made progressl,in its Equal Employment Opportunity 1(; for minorities, but, I believe, still has a long way to go in 17 achieving adequate representation of these minorities on their 18 committees, particularly in the professional and clerical staff, as well as membership of planning groups and committees at the community level. 20 I'll cite you one example: the Regional Advisory 21 9.) Council membership is fifty-eight, only four of whom are blacks; the total professional staff is sixty-three, with 2:3 24 eight blacks. I will withhold my recommendations, Mr. Chairman, 2;-) HOOVER RLPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wa,.thinoton- D-C, 20002 23 until the other review. 2 MR. CHAMBLISS: Thank you. 3 I will now call upon the second reviewers Dr. Vaun. 4 DR. VAUN: I'm not going to address attention exten- 5 sively to the background because I think Mrs. Salazar has 6 covered that well, and in a discussion that the two of us had 7 initially, we agreed that she-would address the background and 8 I would talk somewhat about the projects. 9 I will start exactly opposite. I will address-first 10 and foremost my recommended level of funding, and then tell 11 you how I arrived at that in analyzing the project. 12! I have recommended that their request of $2,648,439 13 be reduced to $2,028,389 -- this may be backwards? but this is 14 my approach to this one with the background you've gotten on 15 Alabama. I think they've done a good job. I think the 17 projects that they've submitted are congruent with their 38 stated objectives, and I saw one thing that came glaringly 1!) through in the Alabama application, and that is that they gave 20 me a feel for priorities, both from the CHP point of view and 2.1 from the RMP point of view, and I hope this doesn't act to 22 their detriment because it was really a splendid job and it's 2;3 part of the way I arrived at the reduction. Also I arrive4 at the reduction,on the basis of 24 2;-j some experience with like projects and observations about the HOOVER RLPURTING CO, INC. 320 Massachusetts Avenue, N.E. 24 successes of like projects. 2 For the core operation of the Multimedia learning 3 skills, the only reduction in core was $10,000 from that 4 specific aspect of their project and not from project staff 5 itself. 6 From the continuation projects -- and I re lly won't 7 go into the details unless you want me to -- I have arrived 8 at a level of funding reduction.of $107,753. From their 9 $565,005,@ I have come down to $447,,252, and there is@only-one 10 project that I really didn't feel warranted funding it all and 11 that was the No. 82, which is entitled 'Audio-'OisuallAssist- 12 ance in Educating Hypertensives.' 13 I don't know,, I feel that there's so much of this 14 around now that spending $7,000 on it in another,area just 15 doesn"t seem like it was worth the effort4 16 The other $100,000 came from reduction of funding of 17 several of the projects. As I say, I'd be delighted to submit j8 my recommendations to Staff or go over them here, whichever you wish. MR. VAN WINKLE: I think it will probably depend on 20 commendation is. 21 what the final r DR. VAUN: Why don't I go through the rest of them? 22 MR. VAN IIINKLE: All right. 2:3 24 DR. VAUN: From their'new ProJects, they submitted $1,422,440; 1 would recommend a reduction of $492,297 to bring 25 HOOVER RLPUKTING CO, INC. 320 Massachusetts Avenue, N.E. Washinoton. D.C. 20002 25 their new application award to $930,143. 2 I was a little concerned again, although the pro- 3 jects are congruent with their stated objectives -- I think A $11,000 for trophoblastic disease left me a little cool at' 5 this stage of our development; immunofluorescence for renal 6 biopsies in the State of Alabama also left me a little 7 concerned at this point; a rather sizeable sum of money for 8 cervical cancer screenings I reduced substantially. 9 And then the PSRO which was $151,000i and a few odd 10 dollars, thought should be substantially reduced by 11 $100 000. I just didn't feel this was appropriate. 12 So you have my recommendation in the light of Mrs. 13 Salazar's background, and I wonder if that couldn't set the 14 pattern. Don't you think it would be wasteful for both 15 reviewers to spend a great deal of time presenting the back- ground? Couldn't we arrive at some agreement and one person 17 take-one task and the other person take another task and, 18 hopefully, come together on it? MR. CHAMBLISS: Certainly I would await the judgment 20 of this committee on that point. I think it will tend to expedite things. 21 9.) MR. THOMPSON: So moved. 2.@ DR. WHITE: I take exception to it and object, in the sense that many of us have done work already admittedly 24 scanty but it might be somewhat difficult for us to recast HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. n r- )Ann,) 25 ourselv es in roles which we hadn't been expecting. 2 DR. VAUN: In the light of consultation amongst the 3 two reviewers 4 DR. WHITE: If time permits. 5 DR. VAUN: maybe one would have spent more time 6 on one thing than' the other, they could agree on a presenta- 7 tion@ 8 DR. WHITE: If the two 9 DR. SLATER: Mr. Chairman, I think it's quite easy 10 to draw up background. Anybody can do that. But I think if 11 there has been a fair amount of time spent in looking at the 12 projects and considering them in the terms of the criteria you 13 want, I think the individual reviewers have,to go into this. 14 There won't be that much duplication except as to background 15' history. That seems redundant. MR. CHAMBLISS: I se@'to get a sense from the com- 17 mittee that you would prefer to hold to the original approach. 18 DR. WHITE: I think everybody has to play his own role, and.if you don't like the way I do it, you can holler at 20 me, 21 MRS. WYCKOFF: I tried to follow this thing, wh ci is quite different 9.) MR. CHAMBLISS: You are seemingly suggesting that 2:i we have the clock before us and"we can always call tirqe,.., 24 All right. Can we get a motion, then? 2;-) HOOVER RLPURIING CO, !NC. 320 Massachusetts Avenue, N.E. W.@hi..fnn n r. ?nnn2 27 DR. VAUN: Mrs. Salazar hasn't made her recommenda- 2 tion yet. She was going to withhold her recommendation. 3 MRS. SALAZAR: I defer to you as the principal 4 reviewer. 5 DR. VAUN: Again',, Bob,, I'm new to this. Do I make 6 the motion, or does somebody else? 7 MR. CHAMBLISS: You can make the motion if you 8 choose, Doctor. You've already given us a level of funding 9 that you have recommended and the.rationale for that level.. 10 If you will put that in the form of a motion, the chair will 11 entertain it. 12. DR. VAUN: I will move that the request of the 13 'Alabama Regional Medical Program be reduced from their 14 requested-amount of $2,648,439 to $2,028r389' 15 MR. CHAMBLISS: There's a motion on the floor that the recommended level of funding-for the Alabama Regional 17 Medical Program be placed at $2,O2Op389 DR. VAUN: $2,028,389. MR. CHAMBLISS: $2,028,389. 20 Is there a second? MR. TOOMEY: I second it. 21 MR* CHAMBLISS: It has properly been made and 22 seconded. 2:3 Ts there any discussion on the motion, please? 24 Dr. Miller. HOOVER RLPUKIING CO, INC. 320 Massachusetts Avenue, N.E. W.q-zhino,tnn DC-20002 1 DR. MILLER: To what extent do we need to pay atten- 2 tion to these motions for dollar levels in terms of the 3 relative relationships of the various RMPs on this list? This 4 motion places Alabama at a level that -- does it or does it 5 not -- it exceeds the targeted available funds item, and with- 6 out any consideration to the probability of what their state- 7 ment was, an estimate of $1.1 million application to be sub- 8 mitted in July-. Are you goina to count them out, almost surely 10 from much of anything on July lst by this level at this time? .11 MR. VAN WINKLE: Dr. Miller,, again, this is just an 12, approval level. That's what's being recommended, an approval 13 level. It does not necessarily mean that when it's actually 14 funded that's what it's going to come out to be. DR. MILLER: Could I ask, then another question? 15 What happens if this co@tee ends up with an approval.level 17 of $114 million this time; then you decide who gets what, right? 18 MR VAN WINKLE: I suspect Council will MR. CHAMBLISS: Council will then make its recom- 20 mendations based on the findings of this committee. 21 22 DR. WHITE: I think that's quite appropriate. T e 2;3 fact that someone here has seen fit to suggest that Alabama deserves more would be taken into consideration even though 24 11 @ they may not get that amount they migh get more in 2;) HOOVER BEFURTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 l')A')% rAC rtZrIZ 29 proportion than some other region. 2 MR. CHAMBLISS: That's quite true. 3 DR. WHITE: It's simply aguideline. 4 DR. SLATER: I'm just wondering how to deal with' 5 this, too. I wondered how, as Dr. Vaun has, to deal with 6 dollar amounts, and I guess what I'm searching for are guide- 7 lines. I've wondered whether or not we can't find the same 8 problems that you have and indi cate that our guidance is that 9 within the framework of whatever cutbacks you have to mak6. 10 they shall not that they will have to redefine their distri.- 11 bution of funds to exclude the coverage rather than try and 12 set a dollar level at this stage of the game. 13 In other words, I'd rather find fault with the 14 thing, with the specific project, if we get into that degree 15 of detailing, and then leave them with whatever funding level 1(; is ultimately going to be made'possible, but within theIgu3de- 17 lines that they're not to spend money on those particular 18 aspects. MR. CHAMBLISS., That is correct, Doctor. 20 DR. SLATER: That gets us away from dealing with odd 21 dollars, and I don't know whether that satisfies your thinking DR. VAUN: I'm not sure I understand it. 9.) DR. SLATER: Rather than assigning dollar cutbacks 2:1 as you have, identify the concerns that you have and give 24 guidance to the Staff and the recommendation to the Council 2;-) HOOVER REFURTING CO, INC. 320 Massachusetts Avenue, N.E. Washinzton, D.C. 20002 30 that within the framework of whatever dollar cutbacks -- 2 they're asking for a hundred and thirty-six -- there probably 3 is going to be some cutback, but in whatever framework, the .4 money they receive shall not be spent on those particular 5 projects. They have to define how they 6 MR. CHAMBLI SS: Well, I think he's simply been 7 generous in giving us the dollar amounts and where, and we 8 will the Staff will certainly take that into account as 9 this goes through the review process. 10 MR. VAN WINKLE: And we would like Dr. Vaunts 11 written figures details. 12. if you have them, we'd certainly appreciate them. 13 DR. VAUN: Maybe I'd better get clarification of 14 that. Does that mean that if I submit the details that this 15 is a mandatory translation to them where they cannot spend the funds? 17 That's what you were saying. MR. CHAMBLISS: It does not. You have simply, based 18 on your professional judgment, indicated those areas of concern, and they will be passed on through the review process 20 and finally acted upon. 21 9.) DR. VAUN: But it will be up to.the region to decide 2:3 finally'.> MR. CHAMBLISS: Yes. 24 DR. VAUN: Fine. 2;-) HOOVER RLFORTING CO, INC. 320 Massachusetts Avenue, N.E. I., nil qnnn,)I 31 DR. SLATER: Your indication of dollar amount is 2 simply a reflection of your extent of concern. 3 DR. VAUN: Gut feeling. .4 MR. CHAMBLISS: Is there further discussioxi? 5 I'll call the question. Those in favor of the motion, may I have the usual 7 signal of voting? (-Ayes respond.) 9 MR. CHAMBLISS: And those opposed? 10 (No response.) 11 MR. CHAMBLISS: The motion, then, is carri6d, and 12. we have finished our first review. 13 14 15 17 19 20 21 22 2:3 24 2-7) HOOVER REFUNTING CO, INC. 32OMassachu ttsAvenue,N.E. Washin2ton. D. . 20002 32 ARKANSAS REGIONAL MEDICAL PROGRAM 2 MR. CHAMBLISS: In our next region we have,only one 3 reviewer here at the moment. That region is Arkansas. And A we will ask Dr. Carpenter if he will carry the entire load'for 5 that region. 6 Dr. Carpenter. DR. CA"ENTER: Thank you. 8 I'don't have anything like the kind of background on 9 this region that Mrs. Salazar did. My view is that the region 10 has maintained the mechanism of the regional program adequate- -.11 ly. The advisory committee remains intact; the review system 12! remains intact; and that what we have is an application pre- 13 pared by a reduced staff in an appropriately reasonable 14 fashion, but in a depressive time which has forced them to, in 15 the first place, be responsive to a large number of federal 16 initiatives, some of which I donit believe were at their 17 emotional heart. 38 Secondly, they had to respond, obviously, very 10 rapidly and they, in the process, were forced to give up much 20 of the matter of pressing for very detailed program objectives and there's essentially nothing in the application about 21 22 evaluation either of the past program or of the and no suggested specific evaluation of most of the projects. 2:1 24 And,,.so, one has -- as Iread the application, I 25 have the feeling of a regional program which is a bit at sea; HOOVER REFUNTING CO, INC. 320 Massachusetts Avenue, N.E. n i, )nnn,) 33 has no real continuing thrust that can organize Arkansas in 2 any'significant way, though it does have enough thrust to 3 contribute here and there in a kind of stopgap way, which I .4 think most regions are going to have to be content with. 5 1 believe that if I were in Arkansas I would spend 6 the next year trying t-a document -- trying to develop a highly 7 professional staff and document what its effect can be in 8 terms of a detailed project plan. 9 1 have in view the July submission. You can see 10 from your computer printout here that the present funding 11 level is $144 million; that -- as that somewhere,, if we go 12! through with their,projected application, in July we'll be at 13 a level -- which I'm having trouble reading of only 15 per- 14 cent @igher than what might be expected. on the other hand, @15 it would be twice what theylrd now spending. And I just don't believe that they've had an oppor- 17 tunity to organize a coherent program that's twice as large as the one they're presently involved in. 18 So my inclination would be to fund them at about the 20 same level now and if the July application shows progress in 21 terms of more detailed planning, then I think there's an opportunity to provide them with what will, I suspect, be a 22 large enough amount of money for them for the next year. 2:1 So I'd recommend a fuAding level of $1,450,000. 24 MR. CHAMBLISS: At the current annualized level HOOVER REFURYING CO, INC. 320 Massachusetts Avenue, N.E. W..hinatnn n (,. gnnn? I 34 al- MR.- POSTA: Excuse me,, Doctor. That current annu 2 ized level projected over a year for Arkansas is $1,848,000, 3 the first column. 4 DR. CARPENTER: My first column shows a million four, 5 MRS. WYCKOFF: So does mine. 6 DR. WHITE: Do does mine. 7 MR. POSTA: I guess it's the 17th edition. 8 MR. CHAMBLISS: We're working from the May 21st 9 edition. 10 MR. POSTA: I'm sorry about that. 11 MR. CHAMBLISS: Thanks for that presentation. 12 1 would like to ask if Mr. Posta will provide, in 131 the absence of the second reviewer, the committee with any 14 additional information that he chooses on Arkansas. Mike? 15 MR. POSTA: I hdve been associated as operations 17 officer to Arkansas since 1970. The Mid-Continent Operations 18 Branch considered Arkansas to be one of the better programs in the Mid-Continent Operatioos Branch, primarily because of 20 the coordinator who has.just resigned in February. I think that Dr. Carpenter's comments were quite 21 relevant because Dr. Silverblatt has left the State of Arkansas. There is a question of leadership. 2:t However, Mr. Roger Warner has been the evaluator 24 the monitor and evaluation chief of.that particular section 2;-) HOOVER RLPORTING CO, INC. 320 Massachusetts Avenue, N.E. W.@hin-tnn n (' 2flffl7 i 35 and has clone ' good job in this regard and is serving in an a 2 acting capacity now. 3 The Search Committee is in process of selecting 4 another coordinator. Mr. Warner is one candidate. 5 Seven of their top professional people have been on 6 board for about seven years* 7 Now, last year when they came in --.meaning the last 8 Council meeting in November of 173 -- the region responded to 9 the five initiatives which DRMP had sent out to all of the 10 RMPS; that is, "We want to do more in planning; we want to do 11 more in quality care; we'd like to get something going in 12 kidney, EMS, and hypertension." Most of their ap their thrust during .13 _placation -- or 14 that period of time was in these five areas, and in this par- 15 ticular application they,.have what they call an "umbrella concept" within the core staff of ten particular areas where 17 they have maintained.those five original ones that we've men- 18 tioned and brought in position extenders more of a program force, unified health planning and new legislative concepts more in the area of hypertension and a couple of others that I 20 can't recall. 21 Seventeen of the activities are hew; seven are con- 22 tinuing. 2:1 I might refer you to your yellow sheet in the book. 24 I think you all probably have that.' It more or less reflects HOOVER RLPUHTING CO, INC. 320 Massachusetts Avenue, N.E. 36 1 what Dr. Carpenter just mentioned with reference to staff. 2 They have currently on board 16.6 full-time people. They do 3 propose 29.6 in order to do the job that they've set out. 4 I think there's been no problems whatsoever with'the 5 CHP A and B agencies. Arkansas was one of the first regions 6 to have a complete blanketed state with eight CHP funded 7 agencies. 8 The ARMP and the CHPS, along with what we call an 9 "Estes" (phonetic) program, the Experimental Health Delivery 10 System package, have been in operation in Arkansas for about 11 four'years. They have been funded with about $3.4 million of EMS activities from HSA. 12. In this particular application they do have an 13 14 umbralla.concept since the core staff did develop the EMS 15 proposal that was approved by the then-HRA agency. I could go on, 9'ut I--thi'nk I'd better stop. 17 MRS. WYCKOFF: What do you mean by "an umbrella concept"? I see this in a number of these, and I wonder what 18 does that consist of? 20 MR. POSTA: Well, within the total program staff 21 budget, they have said, "we would like to administratively break up our entire program staff into ten areas," and they 22 break out their budget Accordingly, and those ten that I men- 2:1 tioned in hypertension -- they have one on arthritis that I 24 didn't mention each of these people on staff would be 25 HOOVER KLFUKIING CO, INC. 320 Massachusetts Avenue, N.E. W.ehinufnn n r. 7nnfig 37 1 working in these particular activities. 2 Within the application, which does request,$890,000 3 in this total program staff budget, you have about 13 percen 4 of the over-all request in what we used to call a develop-- 5 mental component or, as they call it, contingency funds -- or 6 as some of us would call water. 7 But I might say in all fairness to Arkansas that 8 that is a mechanism of funding, and I dare say that @ll of the! 9 applications you see -have-. certain developmental component 10 funds,listed. MR. CHAMBLISS: All right. I wonder, at the end of this presentationoiif 12 -13 there's a motion for Arkansas, or are there further matters to 14 be discussed? Are.there further questions? DR. WHITE: Their request is for a million eight, 15 16 and that's only $400,000 more than they are getting at the present time. 17 18 DR. CARP@ER: Yes, and they're going to dome in for some more in July. 19 1 think it's very hard to set the funding level. 20 21 For me,, it was very difficult. I If you try to go by you look at the projects and try to see which.one would amount to 22 something. I just don't have any confidence in anything from 2:1 what they've described, and I, obviously, don't think we ought 24 to make it impossible for them to start any projects. I think 2;-) HOOVER REPORTING CO, INC. 'A')D M;izqachusetis Avenue, N.E. 38 1 their core needs to be protected, which I -- and, so, I sort 2 of added a few projects to core. 3 DR. SLATER: The question I'm asking is whether you 4 feel that they need to re-present what they have apparently 5 done ineffectively for the July deadline so that they in fact 6 are going to be coming back for the total amount that they 7 were shooting for? 8 I'm not quite sure what the guidelines are that are 9 associated with your suggestion for a continuation of funding 10 at the Present rate. 11 DR. CARPENTER: I was wondering about that, too. 12@ DR. SLATER: Are they just to be given the money and then permitted to cut back where they see fit? How does this 13 14 help improve their function? I feel the same way you do; I'm at a loss as to how 15 to react to them. 16 MR. VAN WINKLE: It would be too late, though, I 17 think, to amend their July 1 proposal because their RAGs are 0 meeting at the present time on that proposal I think most of them are, aren't they, -Mike? 20 21 MR. POSTA: Yes. They expect about $800,000 new 22 activities to be submitted in that July 1. DR. CARPENTER: Let me comment on that. I think 2:3 0 they do have RAG approval on these -projects, and I -- it's 24 obviously suggesting an enormous am bunt of work in an already 2;; HOOVERREFURIINGCO, INC. 39 1 overburdened staff,, but if I was to be convinced that they 2 could spend more money effectivelyy I would need additional 3 information about their -- the goals and the evaluation .4 systems for the projects that they intend, and I would think 5 it might be interesting to think whether we want to suggest 6 that some region provide that kind of information in view of 7 the difficulty of the rush (phonetic) of the projects. 8 MR. VAN WINKLE: All I was looking at is that 9 Council will be meeting and we cannot relay any information io back to them until after Council meets and their July 1 appli- 11 cation would probably almost be in the mail to us by that time 12 DR. CARPENTER: But presumably -- and this is what 'the key issue is in July if you are not going to do a 13 14 project review and you are going to have only an application that describes projects 15 MR. VAN WINKLE: it'll-be a full-blown map -- 17 DR. CARPENTER: Well,, you see, that gives you -- MR. VAN WINKLE: It'll have to stand on its own. 38 DR. CA RPENTER: Then thatt standing oh its own, 20 could say#, "Hey,, look at all the progress we've made since last time in our project plan." 21 9.) DR. 14HITE: May I ask a questio n. Mr. Chambliss? MR. CHAMBLISS: Dr. white. 2:3 DR. WHITE: This was a highly regarded region at 24 one time; is that correct? 2.:t HOOVER RLPURTING CO, INC. 320 Massachusetts Avenue, N.E. Withinatnrt fir, ?nOO2 39 1 overburdened staff, but if I was to be convinced that they 2 could spend more money effectively? I would need additional 3 information about their -- the goals and the evaluation -4 systems for the projects that they intend, and I would think 5 it might be interesting to think whether we wan t to suggest 6 that some region provide that kind of information in view of 7 the difficulty of the rush (phonetic) of the projects. 8 MR. VAN WINKLE: All I was looking at is that 9 Council will be meeting and we cannot relay any information lo back to them until after Council meets and their July 1 appli- cation would probably almost be in the mail to us by that time 12 DR. CARPENTER: But presumably -- and this is what 13 the key issue is in July if you are not going to do a 1 14 project review and you are going to have only an application. that describes projects 15 MR. VAN WINKLE: It'll-be a full-blown map 17 DR. CARPENTER: Well, you see, that gives you -- 18 MR. VAN WINKLE: It'll have to stand on its own. DR. CARPENTER: Then that, standing oh its own, 20 could say, "Hey, look at all the progress we've made since last time in our project plan." 21 9-3 DR."ATHITE: May I ask a question,, Mr. Chambliss? MR. CHAMBLISS: Dr. White. 2:1 DR. WHITE: This was a highly regarded region at 24 one time; is that correct? 25 HOOVER RLPURTING CO, INC. 320 Massachusetts Avenue, N.E. nr, )nnn,) 40 1 een a hi MR. CHAMBLISS: It has b ghly regarded region@ 2 DR. IIHITE: The question now, Bob, is that@there has 3 been a change of leadership and sane disassembling othings? 4 DR. CARPENTER: You know, it's hard to tel whether 5 there's been a change in leadership or just, no matt r how 6 good your leadership is, this is an impossible SitUaf,.LWLL, and 7 it might be possible to say well, look at this --@I don't 8 know if you'can -- but as I look at the staff, theye@e being 9 asked to do some very difficult things in terms of, irou know, io the details of the sickle cell project, for instance,, and 11 they're not able to do it, and I don't know whether that -- 12 maybe in the past they would have gotten the expert i'se they need from their voluntary groupsi For some reason or another, 13 14 they don't seem to have it now. 15 1 can't tell whether it's the leadership or the time element. 16 DR. SLATER: Your real concern here is not, 1 17 is gather, on a project basis whereby you feel that one wants to cut back there, but some sense that the program isn't as 19 20 strong, that the staff leadership isn't as,strong, and it 21 doesn't satisfy these criteria as well as you would like and, 22 therefore, it should be generaIlly kept at the present level? DR. CARPENTER: Yes; I doubt that the staff can 2:3 enforce high-quality projects of the type suggested. 24 DR. WHITE: That's a reasonable concern. 2;) HOOVER RLFUI(IING CO, INC. 32OMassachusettsAvenue,N.E. 41 1 MR. POSTA: I feel very awkward in defending the 2 region. I really do. I don't think that's my role as Branch 3 Chief, on top of that. 4 DR. SLATE,R: May I speak to that? I think it's very 5 important -- if the Staff have direct contact with the people 6 there and they have a sense of history that we certainly can't 7 pick up from one reading 8 MR. POSTA: I assure you this is not the bpst 9 application that Arkansas has ever submitted, and that's true 10 because 15 days after they got instructions, the coordinator 11 had long departed. 12 However, they do have what I consider a good, small 13 staff. Arkansas has never had a.big staff. We're talking 14 about a state that's forty-ninth in the country as far as 15 average income is concerned, They have limited providers. 16 1 think that just-as an example in this patticu- lar ap 17 plication, for the amount of other sources of support which is included in your conglomerate budget, they have state funds, local funds, and other federal support of $415,000; mainly through the RMP, the EDIS anpl ication was approved and 20 21 plans put into the CHP A agencies were likewise approve They, along with the VA, were instrumental in draft- 22 ing the proposal whereby Arkansas has a state Estes program. 2:@ These folks have been working closely together. The Univer- 24 sity personnel is involved and definitely involved with these 2;-) HOOVER RLPORTING CO, INC. 320 Massachusetts Ayenue, N.E. Wnthinafnn n c 2onn2 42 particular projects that are in the application, including the 2 particular function, such as quality care. They have the 3 nucleus of the program in the form of a contract now going.on 4 which has set the stage for the other eleven bigger or larger 5 hospitals in the state to follow that pattern. 6 The hypertension program which was athrust from 7 us, as of last year they have carried-the ball with that and (sic) 8 have hypertensive programs going on in each of the sta es. 9 They have drastically improved as far as the 10 minority concerns-their Council and review committees have 11 had in the past. I 12, Their turnover of the Regional Advisory Group is .13 almost nil, and I feel that the ARMP,, the Arkansas RMP, is 14 much of a stronger agency when you look around at the CHP and 15 its leadership there and,,the Estes program -- in particular, .16 in the EMS portion that is being funded under Estes. They're looking to ARMP for that leadership and guidance to carry that 17 38 program in the State of Arkansas. Now, that's not to gay how much money they've come 20 in and gotten for cancer -- or have received from the cancer program or the heart program or others. 21 2-1 Now, I'm responding only because of what was said 2:; earlier with the previous region, and you're coming to a decision here. I agree that the token figure of 140 percent 24 it something to shoot for after the may 1 application is HOOVER REFORIING CO, INC. ,VO laassachusetts Avenue, N.E. 43 received, and'i really don't think your recommendation is that 2 far off, but I felt that I needed to defend this region just 3 a little bit more, because we feel, at least at this level,,. 4 that they haven't done that bad a Job. 5 MR..THOMPSON: You see, this comment is now pushing 6 us down to looking at specific projects. This is what worr ies 7 me. 8 MRS. WYCKOFF: And we can't do it. There's not 9 enough information for us to.do it that way. 10 MR. CHAMBLISS: We do not propose to look at speci- 11 fic projects, but simply the program and'the objectives of the 12 program at this particular state. '13 1 would say, based on the presentation from the 14 presenter and Mr. Posta -- I would ask -- I perceive the 15 recommendation that Dr. Carpenter has made with regard to the level of funding. I have heard a number of items of rationale 17 as to why he arrives.at that point, and I'm wondering if I could get,a motion on the floor for your recommendation, Dr. 18 1!) Carpenter. DR. CARPENTER: Well, in view of some of the dis- 20 21 cussion, let me move that we approve $1.5 rhil-lion@.for.Ar%ansas. MR. CHAMBLISS: It has been moved and seconded 22 2:@ MR. VAN WINKLE: No second yet. MR. CHM4BLISS: It has been moved that the level of 24 a million five be recommended for Arkansas. 2;-) HOOVER RLFURIING CO, INC. 320 Massachusetts Avenue, N.E. 44 Is there a second to the motion? 2 DR. VAUN: Second it. 3 MR. CHAMBLISS*- It has been seconded by Dr. Vaun. 4 Is there discussion on the motion? 5 DR. WHITE: I can sympathize with Bob in trying to 6 come up with a figure that's more than he wanted but less than 7 they asked for, but I don't know how we come to that ration- 8 ally. Is there some other alternative to this? Is there some 9 way of saying they deserve to be considered for an increase in 10 monies beyond that which they're currently getting? We would 11 not like to see, them get more than the -- what do they call 12, it? targeted funds, and preferably less. 13 MR. THOMPSON: They didn't ask for the target 14 they only asked for 80 percent of the target. 15 DR. CARPENTER:,.But they'll be up to 115 percent by .the time it's all over. 17 MRS. WYCKOFF: They want $782,000 new. That's a lot 18 of new. DR. SLATER: May I ask a question on this? on the next round that weire going to be sitting on, are the criteria 20 going to be different than this roundi or are we really going 21 to be looking at projects in the old way?. 22 2:3 MR. CHAMBLISS: The criteria will be the same. DR. McPHEDRAN: We will not be looking at projects? 24 2;-) MR. CHA14BLISS: We will just engage in the project HOOVER RLFUKTING CO, INC, 320 Massachusetts Avenue, N.E. 45 I review 2 DR. SLATER: Since this is on the floor, and having 3 known Arkansas in the past, I have to give the benefit of the @4 these situations. I doubt to the staff in Arkansas under 5 think they've been through the mill and if there is a proposal 6 that comes in that looks as if they're a little bit at sea, I 7 don't know what else to do except say, "That's the way our 8 c.ountry operates right now," and I'm inclined to move the 9 money out of here so they can stay alive in their present io state of health or at least their desired state of health, and 11 I'd like to speak in favor of giving them what they ask for. 12 MR. CHAMBLISS: Any further discussion here? DR. CARPENRLTR: I have-obviously thought of that, 13 14 too,, as an approach we can take. I @ve-in the-back of my mind, 15 I guessi something which,.is going to surface repeatedly, and .it might as well surface now. 16 I think that local planning efforts have been slip- 17 shod and we're now moving toward a time when we're going to 18 try to redo the mechanism for local planning, and I believe that one of the messages that has to get back, one of the 20 21 matters which deserves our consideration, is that-you just g-) can't reward low quality planning, and I don't see that -- you know, for instance, as this region begins to choose who its 2:3 leaders will be in the health planning businessi I think they 24 need to choose very talented people-, and I'm not anxious to 25 HOOVER RLFUKIING CO, INC. 320 Massachusetts Avenue, N.E. 46 1 lead them astray. 2 MR. LISS: Is there any further discussion on 3 the motion? ort f m et halfway 4 MRS. SALAZAR: In an attempt to s 0 e Ihe 5 between these two points of View, I would hope that t 6 message that goes back to this region is not punitive in any I 7 way. Certainly the staff must be having a pretty hard time 8 with their strong leadership having disintegratedf and I think 9 they need to be encouraged at this time rather than unished. 10 MRS. WYCKOFF: What about the kidney and the EMS and 11 that sort of thing there? Did you discount those aslthings that should be supplied from other sources? 12 DR. CARPENTER: Well, frankly, I didn't. I don't -- 13 it seems to me that the health planning leaders-hip in an area 14 might well invest some monies in assisting that area to meet i very specific goals of categorical federal programs, so with 17 that philosophy, then, I didn't get -- and from what I heard about our guidelines, I gathered that we could permit some of this. I didn't really -- I can't say I discounted those. MRS. WYCKOFF: What about this arthritis money? 20i MR. THOMPSON: That's separate. 'There.'s a @cial 21 group of people out there (indicating). DR. CARPENTER: Is that a core I think that's 2:1 part of their core activity to assist the region to develop an 24 application for arthritis funds, and develop the regional 25 HOOVER ELPURIING CO, INC. 320 Massachusetts Avenue, N.E. 47 1 system in support of that application. 2 DR. SLATER: I wonder if there's some other alterna- 3 tives available here. We've in the past been able to send .4 messages back. For instance, staff guidance. We've been able 5 to lay out visits if we're concerned -- site visits if we're 6 concerned about providing allocates (phonetic) of money. We 7 have been able to Pass things on -- for instance, hold it over 8 until the next round subject to review by an elite group. 9 Are we under sufficient pressure here to respond to. this one-time allocation? It's a survival matter, and we just 10 11 use our best judgment here? 12 MR. CHAMBLISS: Certainly we're called upon to use our best judgment, but the region will get advice as this 13 whole round of review terminates, and the concerns being 14 expressed here now will be incorporated into the advice letter 15 .going to the region. 17 DR. CARPENTER; I have a question here. When their 18 July application comes in, will it be a request for a certain dollar amount of supplemental funds or will it be a request for 20 a new funding level? MR. CHAMBLISS: It will be for both, You na e 21 in your column "July 1 Estimate" that the region anticipates 22 that it will request a sum approximating $800,000. 2:i MR. THOMPSON: Additionally. 24 MR. CHAMBLISS: That's simply a request. That does 25 HOOVER RLPOHIING co, INC. 320 Massachusetts Avenue, N,E. 4 8 because you know the I not mean that that sum will be awarded, 2 over-all limitations that we have on total funding. All of 3 this will be fitted into the amount of the available dollars ..4 that we have once the final decisions are made by-the court. 5 DR. MILLER: That $800,000 is going to be for a 6 series of projects, new projects, right? 7 MR. CHP14BLISS: Right. 8 DR, MILLER: on what basis are we going to make a 9 decision about awarding Arkansas $800,000 for a bundle of new io projects? 11 MR4 CHAMBLISS: That is only an anticipated figure. 12: That is what DR. MILLER: I don't care whether it's $100 or 14 DR. WHITE: It's going to be on the sam6 amount of 15 concrete evidence-that w have today@. MRS. WYCKOFF: Exactly, DR. SLATER: It seems to me that we're going through 17 18 a problemIwhereby a traditional review committee is having a hard time learning how to opeiFate like a council, and this is 20 in fact what we're being asked to do. We're being given a 21 list of projects we are not able to technically analyze, but we're asked to look at their conherence within the framework o 22 the history of the program and the objectives of RMP. And it 2:1 seems to me that's what the Council used to do, and it may 24 well be that in the future, whatever comes out of tie HOOVER RLPOHIING CO, INC. I?n Mn@qathii.,Ptt,; Avenue. N.E. 49 1 legislation, some other kind of system will have to be put 2 together, but I would guess that we're not going to be able to 3 operate comfortably like a traditional review committee and 4 we are having to look much more at policy and staff security 5 and so on. 6 MR. CHAMBLISS: We share your discomfiture 7 DR. SLATER: I don't know how else to make these 8 decisions. 9 MR. CHAMBLISS: Dr. Vaun? 10 DR. VAUN: As the seconder of the motion, I'd like 11 to reaffirm my second of the motion on the basis of the dis- I1 12, cussion I've just heard. I don't see that this is in any way a hindrance to the group. 13 I think it would be dangerous to give them.more 14 money than the leadership can use At this point, and they have 15 an opportunity to come back again, and if there's going to be a total and complete presentation, if they get a few messages 17 on this round, there's no reason why the discussion can't be different on the next. I don't think this is a punishment or a harm to them.; 20 I think it's a rational decision on the basis of their leader-I 21 ship at this point. 22 MRS. WYCKOFF: Call for the question. 2:1 MR. CHAMBLISS: I would simply ask that those in 2A favor of the motion let it be known by the usual sign. 2;-t HOOVER REPOR I ING CO, INC@ co 1 (Ayes respond.) 2 @IRO CHAMBLISS: Those opposed? 3 (Opposed respond.) .4 MR. LISS: There are two opposed, Dr. Slater 5 and Mr. Thompson. 6 The motion is carried. 7 Did you have further 8 MR. POSTA: I wanted to know what is the official 9 motion? 10 MR. CHAMBLISS: The official motion is that it is ii recommended that the level of funding for the Arkansas 12, Regional medical Program be placed at $1,500,000, with the .13 concerns expressed by the members of the Review Committee 14 going to the region. 1.5 DR. CARPENTER:,. Particularly that they suoport that core. i(i 17 MR. CHAMBLISS: Shall we move then to our next region, Bi-State? qp 20 22 2:1 4 2 HOOVER REFURTING CO, INC. 320 M-,24sac@,,jsettsAvenue, N.E. 1 BI-STATE REGIONAL MEDICAL PROGRAM 2 ey and MR. CHAMBLISS: The reviewers are Mr. Toom 3 Dr. McPhedrant and Mr. Frank Zizlavsky will be the Staff 4 person here to give the necessary support. 5 Mr. Toomey. 6 MR. TOOMEY: I utilized the review 7 THE REPORTER: Ilm sorry, sir, I can't hear you. 8 MR. TOOMEY: for the basis of this discussion. 9 In reading the application I think the first thing that struck me was the microphone was the fact that the 10 Regional Advisory Group disbanded and turned over the respon- 11 sibility for the program to a 15-man executive committee. 12! That 15-man executive committee has functioned. However, as 13 time went on, very recently the,program coordinator himself, 14 15 Dr. Stoneman, resigned, 4nd in the material that was sent I .had, in reading it, a tremendous feeling of frustration on the 17 part of the material that was written. All of the program staff, howeveri seemed in terms 18 of their experience to be an experienced staff. I could look the figures up, but it seems to me at the present time they 20 have somewhere in the neighborhood of eleven program staff; 21 whereas their organizational program would call for about 22 nineteen. In looking at the pas@ performance and the accom- 24 plishment of the Bi-State RMP, it seemed initially in tune 25 HOOV-ER REPUHTING CO, INC. 52 1 with the heart disease, cancer, and stroke programs, although 2 it was affiliated with both WAshington University and St. 31 Louis University and these two universities were the granting .4 agencies. 5 Later in the program the major thrust was in emer- 6 gency medical services. 7 in looking at the even more recent programs, thev 8 have not substantially addresse d the problems of accessibility 9 and availability of care with the exception of the emergency jo medical services, nor have thev addressed themselves to the 11 needs of the minority groups, nor to health delivery systems. 12. In fact, they are in a very, very particularly difficult kind of situation because they're attempting to provide-a program 13 14 for t@e rural Southern Illinois and the urban St. Louis area, and I'm sure that the conflicts in terms of the needs of both 15 these areas are expressed in terms,of the variety of programs. 17 At the present time they are requesting EMS con- tinuation grants, assistance to local planning, including some 18 I!) health manpower planning, quality assurance, manpower recruit- 20 ment for the disadvantaged,, and projects related to dancer and kidney disease. 21 Now, with the exception of the EMS, the projects 22 that they propose do not in fact fall within a document which 2:@ was in this proposal which was calledf "The Health Needs of 24 Bi-State RMP Region as Identified by Joint RMP and CHP 25 HOOVER REFUN1 ING CO, INC. 32OMassachusettsAvenue,N.E. 3 1 Planning Conference." 2 In February RMP and CHP met together and they 3 selected three or four areas that they felt were necessary,for -4 the development of programs within the Bi-State area, a need 5 for improvement o4: emergency medical services -- and that one, 6 of course, they have worked on. 7 Secondly, need to improve accessibility to quality 8 health care. 9 And the third was nee d to improve the availability 10 of trained health manpower for the entire region. 11 And the fourth was need to coordinate health care 12 delivery planning. ..13 Skipping the feasibility for a moment., as far as the 14 funding is concerned my ccmment.here would be that the projectc probablv could be accomplished, but they do not seem to be compatible with the needs expressed in the joint WIP-CHP memo. 17 In terms of their relationship with comprehensive 18 health planning, despite the memo that is in the proposal from RMP, my feeling in reading the comments from CHP -- well, I noted them as being polite but restrained, and very restrain- 20 21 ed. I think I read into it, certainly, that there was not a tremendously happy relationship with that relationship. 2- As for the funding -- you can read this with me 2:1 I did not have it and I am interested in seeing it -- but at 24 the present time the present level of spending annualized is 251' HOOVER RLPURTING CO, INC- N.E. 54 1 $870,000 -- almost $871,000. The targeted available funds, 2 $1,256,000. The May 1 request which I am presently discussing 3 is $1,129,000, but there is a July 1 estimate of $410,000 .4 which places them at a figure in excess of the targeted avdil- 5 able. 6 on the basis of my own review of thisp reading this. 7 material, frankly -- and the feeling that I got from reading 8 the projects and reading the comments and relationships with 9 CHPF it would seem to me to be the unsuitability of the 10 projects in terms of the direction in which I felt RMP was 11 attempting to move itself, 12@ I recommended only $800,000 in funding for this .13 current recommendation. 14 MR. CHAMBLISS: Thank you. We will now call upon our second reviewer, Dr. 15 McPhedran. DR. McPHEDRAN: Mr. Toomey and I both were on what 17 I guess was the latest site visit, formal site visitt to Bi- State, and the program -- this regional medical program we 20 thought at that time had had a lot of difficulties with organization and there was some delay, as I recall, in their 21 2--) getting triennial approval, and I think that was true of 2:3 several other regional medical prog rams, but we were always concerned about leadership in this proc .jram. 24 They had had a great many problems,with-their 2;-) HOOVER RLPUXTING CO, INC. 32OMassachusettsAvenue,N.E. 55 relationships with the medical schools and it was perhaps a 2 blessing in disguise when the medical schools 4ithdrew, but 3 don't really think that the program leadership appears to have 4 entirely gotten -- once they got rid of what was really an' 5 incubus, that is, their relationships with the medical 6 schools, I don't really think.that they got any sort@of 7 coherent direction of their own. 8 And I'm surprised to see that the Regional Advisory 9 Group seems to have relinquished its responsibility --- I'agree I0with Mr. Toomey's assessment of that. I thought that the ii Regional Advisory Group itself was capable of providing 12. stronger leadership than that. 13 In reviewing the projects, I looked at the two new 14 ones sort of as a touchstone for what direction they wanted to 15 take -rather than, I thought, technically reviewing them. I think that the RAG or what was left of the RAG 17 when they met in February with CHP, I think that they felt that the rug was pulled out from under them when no new EMS 38 I!) projects could be begun and what they have actui&lly-,requested 20 in -the way of new projects are perhaps a dim reflection of what they would like to have. 21 Of those two projects, though, one of them does address minority recruitment and it has been such an important 2;3 24 lack in this program before that I think note should be made of the fact that they seem to have come up with a project that, 25 HOOVER BLYUKIING CO, INC, 32OMassachusettsAvenue,N.E. 1 in the bare bones that are given here, looks reasonable. 2 The other new project, which is a study of what's 3 happened to manpower trained in a consortium that they partly -4 sponsored, is something which I find myself not much in 1 5 sympathy. It seems to me that the study -- I don't see why it 6 requires this separate funding. 7 So that, rather than use this as a part of technical 8 project review, I think that I would like to present it as a 9 kind of example of what I think are the difficulties that 10 they're having in getting a program direction. 11 Similar things could be said about some of the con- 12@ tinuation projects, but I was interested to note that the 13 I-requests for quality assurance -- two of the requests for I quality assurance relate to programs in out-patient practices 14 1.15 and I don't know whether,.that comes under the same kind of scrutiny as PSRO in hospitals Mr. Thompson shakes his head 17 and says not -- because this is 18 MR. THOMPSON: Right now legislation restricts it. DR. McPHEDRAN: The restriction relates only to hospital-based activity, hospital and nursing home activit es. '20 21 Well, that's what I thought, but I wanted to be sure about that. 22 MR. THOMPSON: With the option, and ou know damn 2:3 y well they ain't going in that direction. 24 DR. McPHEDRAN: But the purpose of these projects 25 HOOVER KLPUKIING CO, INC. ,),)n .. @-it, Aventip N FI 57 for continuing support seems to me laudable, although I must 2 say I didn't like what I saw as a technical matter in one of 3 them. Nevertheless, I felt that their purposes were laudable. -4 I don't disagree with Mr. Toomey's funding level, 5 because I find such difficulty in coming up with one of my 6 own. It's very hard to know. I think that, for example,, the 7 request for core staff, which is about $550,000, as I recall, 8 for direct and indirect costs I assume that that's based on 9 an expectation that they would have their eight plus five 10 staff,, a total of thirteen staff. Since that is at least half 11 ofwhat we five-eighths of what we would be talking about, 12, Idon't really know whether they can get along and do anything 13 worthwhile without increasing the core staff, but I'm reluc- 14 tant to accede to the request to increase it by that amount 15 because I'm not really sure that'they can use the staffing. And Mr. Zizlavsky has been there recently, I think, 17 on technical matters, and maybe he could address himself to 18 that question. MR. CHAMBLISS: Mr. Zee, will you fill in there? MR. ZIZLAVSKY: There's about three or four areas 20 I'd like to comment on, and I might as well comment on the 21 program staff area right now. That $$50,000 figure for program staff is really 2:@ gobbled up by indirect costs from these two universities. 24 That's Point 1. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. 58 These five additional staff -- four of these staff 2 are secretaries. They may be a little heavy in the secre- 3 tarial area -- in the secretarial-clerical area by having .4 seven secretaries for eight or nine professionals, so that may 5 be a little too much. 6 The basic other program staff request is for a 7 deputy coordinator and what they would call a programs opera- 8 tion regional outreach person. I think these two are 9 legitimate requests. 10 A comment about the RAG responsibility and the ii decrease from 75 members down to 15 members. Going back into 12. our history, not to drag this out$ but May 1973 was a efgo/no 13 9011 type of month. Everybody was down. The results from 14 RMPS came out in terms of recommendation for funding on the 15 phase-out plans. Bi-State's program -- final redommendat ons for Phase-out on this program were pretty skimpy. By June 30th they probably had five or six total 17 staff on board. I'm not asking for any sympathy from the reviewers, but it was at this time in may that the Regional Advisory Group thought RMP was really going under, and this 20 21 was the main area where they delegated their responsibility to the executive committee. 22 Subsequently they have come back and they are start-;, 2:1 ing to build right now in terms of increasing the RAG. They 24 had not made that decision yet because of the future problem i 2-7) HOOVEft REFUR lifig CO, INC, I?fl M;4q@rhil.@ptt@ Avenue. N.E. 59 1 in terms of health resource planning. Why put types of 2 people on Regional Advisory Groups which might not be the 3 future type of people? '4 Mr. Toomey is correct that in several areas they, 5 have not addressed accessibility and availability. They have 6 improved in the area of minority representation. During the 7 phase-in period they have been able to hire one minority 8 person on program staff and they're leaning heavily on this 9 person to really get into the St. Louis area, which really in 10 the past they have not done an effective job. 11 I would have to go Along with the recommendation for 12 .$800,000 considering the factor that the July request is a 13 $410,000 request. They are under review for 31 projects 14 presently, which there isn't any information in this applica- tion. 15 My best estimates in talking to the program involve 17 that they decrease the 31 projects down to 24 projects, and 18 this is the $410,000 estimate coming up. MR. TOOMEY: May I ask Zee a question? was my feeling right about the relationship between 20 21 the CHP agencies and the RMP agencies? I got a feeling of some conflict. 22 MR. ZIZLAVSKY: The only area of conflict is dealing;, 2:3 in the area of EMS4 There was a subtle arrangement that when 24 the EMS activities started up and the eight contracts were 2;-) IIOOVER REPUKTlfc Co, INC. 60 awarded from HSMA (phonetic) at,the time, the St. Louis area 2 came in with a rather large contract. Simultaneously'it was 3 submitted to RMP and we recommended a $200,000 recommendation .4 and they finally received $100,000, and they were one leg up 5 on EMS planning for the St. Louis surrounding area. 6 This present project director, Dr. Wheeler, also 7 has almost a million dollar project request in to the Kansas 8 City Regional Office,. which is their respective regional 9 office, for new EMS legislation. We had a phone call yesterday 10 from the regional office, and so we're on top of this situ- 11 ation. 12@ In getting very specific, the A C which is the 13 Alliance for Regional Comprehensive Planning, in the St* Louis 14 area is an eight-county CHP B agency, they wanted to get into 15 the area of EMS planning,, but the was funded in this area i(i for planning. The National Advisory Council limited their 17 activities to planning and training and there was an agreement 18 between the.RMP and the CHP that the RMP do the work. The conflict now comes out in this application because no signals were given from the Kansas City Regional 21 Office. RMP can no longer get into this activity-. These are new monies. 22 I think you're going to see that this is just a 2:3 symptom of what's happening nationally. Hopefully, we'll 24 keep our we're on top of it, though. HOOVER REFURI ING CO, INC. 320 Massachusetts Avenue, N.E. 1 MR,; CHAMBLISS: Dr. Vaun. 2 DR. VAUN: Could you elaborate just a bit on this 3 large amount of money that's being gobbled up indirectly by 4 the two universities -- just a little bit? 5 MR. ZIZLAVSKY: Well, maybe "gobbled up" was too 6 strong. 7 MR. THOMPSON: Ripped off? 8 MR. ZIZLAVSKY: Pardon? 9 DR. VAUN: "Ripped off," he said. 10 MR. ZIZLAVSKY: As you casually look at the indirect 11 costs rates established for St. Louis and Washington Univer- 12! sity, you have something like 80 percent rate for Washington University and 68 percent for St. Louis University. .13 I attended their March -- no,, their April 1974 14 Regional Advisory Group meeting when they were discussing 15 their money problems, and everybody was concerned how to get 17 more money, and I suggested to them that one of the areas they might consider was to reduce their indirect costs rates as some of the Regional Medical P-rograms have done, and MRS. WYCKOFF: They haven't done it nationally,, then, 20 by putting a ceiling; it's all negotiated? 21 MR. ZIZLAVSKY: It's all negotiated, yeah. Larry 22 Pullen may want to comment on the technicalities of how these-@ 2.'i '--don't know--- 24 MR. CHAMBLISS: Well, suffice it to say that it is a 2 HOOVERRLFORTINGCO,INC. ',@'OlilassachusettsAvenue,N.E. 52 negotiated rate and there would be very little that'we could 2 do at this point. I simply bring that to the attention of the 3 committee. 4 MR. THOMPSON: Most universities have off-campus, 5 rates 6 MR. CHAMBL ISS: Mr. Thompson makes the point that 7 most universities have off-campus rates. That's nowhere near 8 this. Some do, yes most do, but in the case of this rate, 9 it has been negotiated and we would be at.a loss to make'a jo change there. The chair would entertain a motion on Bi-State. 12 MR. TOOMEY: I'll so move. .13 DR. McPHEDRAN: 1 second Mr. Toomey's motion I 14 assume it was the 15 MR. CHAMBLISS:,, It has been moved and seconded that 16 the recommended level for Bi-State be $800,000. 17 Is there discussion? DR. IIHITE-. Could I ask -- this is the ceiling now, $800,000. Suppose the staff comes to looking at this whole. 20 thing and they devise some kind of formula whereby everybody 21 gets X percent of what they ask for or what we said they should get? These people may end up with substantially less 22 money than they have this year. Is. this what you want? 2:1 MRS. WYCKOFF: What d'oes this do to the continuation 24 projects that are listed at $500,000 there? Are some of HOOVER RLPORTING Co, INC. ,zO .'Massachusetts Avenue, N.E. 63 1 those capable'of being terminated or phased out.> 2 MR. ZIZLAVSKY: There's a total of 17 projects. 3 Fifteen are continuations. There are only two new projects.. .4 MRS. WYCKOFF: What about the fifteen? Are most,of 5 those 6 MR. ZIZLAVSKY: I'm trying to get -- in terms of 7 being continually supported by outside sources of funding? 8 MRS. IIYCKOFF.- I wondered if they could be shifted 9 over to something else quickly, you know, if thev're dependent jo on continuations 11 MR. VAN WINKLE: Your staff and continuations come 12 UP to Over a million. ..13 DR. McPHEDRAN: I'd like to say something that, in a 14 way, is in response to what Dr. White said. We had an in- formal conversation earlier in which we were talking about what happens when this $115 million is to be distributed on 17 relatively short notice and after so much phas@-out has 18 occurred, and of th e two possibilities -- one, that it might not all be used and, two, thaf it might all be used but used 20 in a way that would not necessarily reflect favorably on DRMP 21 or the Regional Medical Programs -- I guess that'l would 9.) re ally rather see the former. I think I'd rather have us be in that position, so 2:@ that's why, I guess, I favor these low funding levels, becausez 24 1 don't really feel that this program, this Bi-State Regional 25 HOOVER RLPUR I ING CO, INC. .12n Ma@sachusett& Avenue. N.E. i'4 Medical Program, can usefully employ a whole lot of money, and 2 I think I'd rather see some of it just not distributed. I 3 can hardly imagine that that will happen, but if I had to .4 choose, I think that's the way I'd choose to do it, so that's 5 why I think I support Mr. Toomey. 6 MR. TOOMEY: I'm like Dr. Slater. It's a little bit 7 difficult to be precise and to be totally objective about 8 these things. 9 As Dr. McPhedran said, we visited there I guess 10 it was two years ago -- and in the course of two years therelsi 11 much that slips your mind, but I'm certainly reminded of the 12. fact that Southern Illinois, in the rural sections, has some 13 very, verv great needs and also great opportunities for some 14 good planning because Southern Illinois University is tremen 15 dously interested in what goes on in those rural communities. This is covered by Bi-State RMP, and there was 17 rather an impassioned -- I guess in a sense an impassioned discussion by one of the Southern Illinois representatives at the meeting that we attended, and I don't see anything really that relates to the rural needs of Southern Illinois. 20 21 And then there is little or no doubt that in both East St. Louis and St.-Louis that there are major problems of 1 22 I- planning and health delivery, concerns related to accessibil-- 2:3 ity, availability, sponsorship of progr@s, and I had the feel- 24 ing both at that time and now in this presentation that the 25 HOOVER HEPUKili4G CO, INC. 320 Massachusetts Avenue, N.E. 65 1 staff was just not focused in to see what could be done, even 2 to study and to analyze and review and work toward those 3 areast and it may be, having been there and having undergone 4 the kind of disillusionment, in a sense, that you would feel 5 and it's within this very subjective kind of feeling that I 6 made the motion. 7 A VOICE: Call for the question. 8 MR. CHILMBLISS: I heard that the question has been 9 called. 10 Is there further discussion? 11 MRS. WYCKOFF: This means it's less than they're 12 getting now; is that correct? 13 MR. CHIU4BLISS: The recommendation is that Bi-State 14 be funded at the level of $800,000. DR. ISLATER: May I ask a question? would you recom- 15 mend that they be phased out? I!m wondering why we're setting 16 $800,000. lqhat we're saying is 17 is MR. T0014EY: I don't think they ought to be phased out. I think that Bi-State a% an organization should be divided into at least two parts. It would mean the construc- 20 21 tion of another unit, but I think that, as far as-I'm concern- ed, this would make sense. 22 DR. SLATER: Then I think some kind of rationale fori 2:3 this that's constructive in the,sense -- in the sense that youl @)4 just put it if you go back with a budget cut superimpo ed 2.-) HOOVER RLFURTING CO, INC.I rzO?,!?ssac@,jseits Aienue, N.E. 66 on top of a phased-out program that's already existing -- 2 MR. CHA14BLISS: Staff will take note of the rational 3 and the concerns that you've expressed here, I'll call the Question, then. Those in favor, ldt 5 it be known by the usual sign. 6 (Ayes respond.) 7 MR. CHAMBLISS: And those oldposed?- 8 (No response.) 9 MR. CHAMBLISS: Then the motion is carried. 10 I would simply ask -- we're reaching the dinner 11 hour the lunch hour, rather -- I will'ask before we break 12: for lunch that those reviewers take just a moment to complete their review sheets, and we'd appreciate it. 14 And then I'd like to get a consensus from the com- 15 mittde as to when we should return. It is now ten of 1:00. I would say -- I would suggest if we could be back by 1:30, 17 it would give this committee a chance to move forward. 18 I would simply let you know that we have accomplish- ed one fourth of today's workload, and I would@certainly.su @,9 20 gest that you return so that we may complete the twelve, 21 regions that we've set aside for this day's work., 22 1 would now say that lunch is now being served. 2:t (Whereupon, at 12:50 p. m., the committee recessed,, to,resume at 1:30 p.,m. of the same day.) 24 25 HOOVER RLPOKIING co, INC. 19A ;i@,nrhii'lettsAvenue.N.E. 67 iD-PM-5/22 I AFTERNOON SESSION 1:35 P.M. 2 MR. CHAMBLISS: If we'could reconvene the Panel, 3 I would like to put you on notice about some adjustments that 4 we would like to make. 5 The first adjustment that we would call to your 6 attention is that we have a new Recorder; Miss McClure is 7 no longer with us and Mr. Dillingham is now our official 8 Recorder. 9 Secondly, I would have you note that Doctor white has to be away from the Review Committee for an hour or so, 10 and he has asked if We would move Georgia.up just below Colorado-Wyoming, and that would give him an opportunity to 12, go away and return later on in the afternoon. His co-reviewe: 13 has been notified. 14 I would like you to note also that we would like 15 to move Wisconsin up in '-Lhe Place.of Iowa, and hopefully we 1(; would be able to get Wisconsin today. 17 MR. THOMPSON: We don't have to stop, do we,in case 18 we go beyond that target? 19 MR* CHAMBLISS: Oh, no; we can go as long as the 20 Committee wishes, and I would encourage the Committee to have 21 a late dinner if it so wishes. 22 DOCTOR SLATER: Do you think there is any possibili- 23 ty of finishing by later tomorrow afternoon? 24 MR. CHAMBLISS: We would endeavor to do so, and 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D@C. 20002 t,)n,)i rjr.rr@ 68 WHD-2 witli your help, we can. 2 I have a sense of where the Committee would like 311 to go in terms of the timeframe and the workload. ire 'there 4 other suggestions here? 5 MR. TOOMEY: Let's finish by tomorrow afternoon. 6 DOCTOR SLATER: That means getting the whgle group 7 together again by what -- 3:3017 8 MR. CHAMBLISS: I would like you to note that on 9 Friday the two panels must reassemble. 10 DOCTOR SLATER: We are suggesting that for 3:30 tomorrow afternoon. 11 12, MR. CHABMLISS: We will have to see how other panel is moving. 13 MR. THOMPSON: I can't be here Friday myself. 14 15 MR. CHAMBLISS: There has to be some coalescence of the various recommendatbns from the two panels, some coordination. 17 18 I would then call next-for review the application of Colorado-Wyoming, and please note that Doctor White and 19 Mrs. Wyckoff are the reviewers, and Miss Mary Murphy is the 20 staff person. 21 Doctor White? 22 2.3 24 25 40OVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Mashington, D.C. 20002 l@Aql rAP tftt 69 #HD-3 I RE GIONAL MEDICAL PROGRAM REVIEW 2 COLORADO-WYOMING 3 DOCTOR WHITE: As a preamble, I might mention that 4 I am a lumper rather than a sorter, so I have looked at this 5 in a rather global manner, rather than looking at projects. 6 I have the,fortunate perspective of having made 7 two site visits to Colorado-Wyoming in the past, and know some- 8 thing about it from personal experience. 9 I know Doctor Nicholas, who is the present coordin- 10 ator of the Region. Tom was Chairman of the RAG for a couple of years, and then decided to take on the job of coordinating the program, and has done a commendable and worthy job. 12 13 Tom is a fellow who has been known around the Region for many years; in addition to his talents as a physician, he 14 runs a ski-resort, a small private plane enterprises because 15 he practiced in Buffalo,"W m ,yo ing, and this required commuting by airplane in order to go anywhere. 17 So he is well-regarded., well-known, and ambitious, 18 an energetic, relatively young man. He is active in the area, 19 he is knowledgeable in the area and he is accepted in the 20 area. 21 The staff, according to the proposal presente to us 22 at the present time, has been retained, in large part. This 23 Region remained optimistic,.e.ven through the period of trial 24 & and tribulation. Most of them remained on the staff; some of 25 HO(YVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 70 WD-4 1 the names I recognize as having been there two or more-years 2 ago, and they are planning to add even one or.two more to the 3 staff to deal with this Health Resources Planning and Develop- 4 ment, which seems to be the direction that they're told to 5 go in conjunction with the Hill-Burton, CHP and othe S. 6 There is an adequate description in the application 7 as presented, in which they describe the staff and tLe indi- 8 vidual qualifications, and so far as I can tell, all seem to 9 have the appropriate backgrounds, experiences and degree Aiid I believe there has been Washington staff :Visits out there 10 to assure that they have good management practices, nd follow 11 the guidelines that have been laid down. 12, The Regional Advisory Group has continued to be very 13 14 active. it has completed, in this period of time, a review of all past funded projects, since 1968. Now, I've forgotten 15 exactly how many of theselprojects there were altogethek; I 1 6 think more than 20 -- obviously more than 20. 17 18 of these are now self-sufficient, either being 18 run by someone else or generating their own support, and six 19 they feel will become self-sufficient when RMP expires. 20 The Regional Advisory Group has been expanded in 21 numbers to deal with the geographic dispersion that is 22 required in Colorad-Wyoming, in the sense that they can't get 23 together easily, and also expanded to deal with certain new 24 objectives. They have brought on talents which have to do wit.,i 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 71 HD-5 1 developing health resources and things of that sort. 2 They have continued to meet quaterly, as scheduled, 3 and almost every individual member of the Regional Advisory 4 Group is said to have participated in other committee func- 5 tions, and to have made site visits, particularly in refere..-- 6 to this review of past projects. 7 It has reconsidered its goals, and has determined 8 th at the Regional Medical Pro gram of Colorado-Wyoming is a 9 viable one and will continue, in some form or another, even 10 after funding subsides. 11 Its past performance, I think,,,is excellent, as 12, witnessed by the fact that a significant number of its pro- 13 jests undertaken in the past are now self-sufficient and con- 14 tinuing. It has become an accepted and utilized resource; 15 for example, it was designated by the Governor of the State to be that agency which w&uld undertake planning for the 17 Emergency Medical Services for the State of Colorado, an I 18 think in Wyoming as well. And it will continue to function 19 in,this regard. It has -- in our past visits, and both Mrs. Wyckoff 20 and myself have been there -- I think we have recognized that 21, 22 their goals and objectives are consonant with those laid down by the Office here in Washington. 23 So far as I can tell,,wit hout looking at the projects 24 in great detail, and basing my judgment on the fact that I 25 HOOVER REPORTING CO, INC. 320 Mamchusetts Avenue, N.[. Washington, D.C. 20002 r.At C.CCC 72 IHD-6 1 trust these people, I believe that what they are proposing to 2 do this year will indeed be feasible within a year's time, in 3 large part, and will have some hope of continuing under some- 4 one else s aegis at the termination of the support from 5 Washington. 6 The activities proposed consist of seven activities 7 addressed to the problems of availability, accessability of 8 care; one addresses the need for more primary care types of 9 individuals, and it is worthy of.note that the Regional 10 Medical Program in both Wyoming and Colorado was instrumental in getting legislation passed to oermit'utilization of these 11 other professionals in rendering health care. 12, It-has two new and one old objective, which served 13 the rpgionalizationalization concept; this is important.to 14 this area because this is such a widespread geographic area, 15 with dispersed populationcpnters and very sparse population 3.6 centers as well. 17 The only -- there were,some proposals which I was 18 not sure were appropriate under the material that we received 19 from Washington. They are proposing a Bone Pathology Center, 20 which I assume has to do with cancer in large part, and it 21. seems to me I read something -- and Mike, you can correct me 2-? on this -- that some of these things were to be taken over by 23 the National Cancer Institute, were'they not, in some way or 24 another? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (202)546-6666 73 WHD-7 1 It also wants to continue a Cancer Registry, which 2 I think is more appropriately under the support of the Cancer 1 3 Institute, and radiation time-sharing studies. 4 Even in the past I had some concern that they were 5 emphasizing pediatric dialysis cen,ters-inordinately at the 6 expense of certain other activities, and they are proposing 7 even now to establish a pediatric nephrology center, to the 8 tuhe of $83,510. 9 I don't believe their EMS activities conflict with 10 the policy, in the sense that they are continuations, more or less, of what was going on in the past, and they will not be 11 operational programs, but mainly development and planning. 12, So far as I can tell from the letters of endorsement, 13 their,relationships with Comprehensive Health Planning are 14 15 amicable, and,indeed, they dovetail very closely in some of the more remote areas; Gka pd Junct.ion is one which comes to 16 17 mind, for example. The letters were generally supportive, neither 18 vindictive nor overly filled with praise, but I think they 19 .0 indicate that there is a good relationship between Comprehen- 20 sive Health Planning and the Regional Medical Program and that 21 in all probability, there will be joint development of programi 22 for these health resources facilities. 23 The other comment I would'have is that the whole 24 tenor of the application is one of reasonable optimism hot 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (7fl2l546-6666 74 THD-8 1 that Regional Medical Programs-in its present form will be 2 continued, ad infinitum, but that they have at least estab- 3 lished that they have a viable role in the State of Colorado 4 and that the State Health Department, the schools whatever 5 other funding agencies come along, wbl.utilize this talent 6 that is already there and not let it disband and disperse and 7 be lost. 8 I did not come to any firm figure in terms of 9 recommending support., I have a certain undasy feeling of dis- 'ietude in the sense that I find it difficult to really under- 10 qu stand how any Regional, no matter how good it is,-can ask for a hi hly substantial increase in its sums, and in such short 12, 9 period of time adequately reviewed their pertinence to their 13 needs. 14 Now, I can't say that for sure, because I did not look at each of their pro@qts in great detail, but just on that general principle, I would think that, and it would be 17 my recommendation, that Colorad6!-Wyoming be considered for the targeted amount, and I say that in terms of what I just discussed and in terms of knowing that they are going to be 20 coming in in July asking for another quarter-million dollars 21 and that in all probability they are not going to get what 22 they asked for in any event. 23 That would be my Fe,commenaation, that they.be 24 allowed up to $1,587,644, which is the targeted available fund@ 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington. D.C. 20002 (2021546-6666 75 'ID-9 seen, with the option that they can apply for more@,in July, 2 which they expressed an intent to do. 3, MR. CHAMBLISS: Thanks for your recommendation, 4 Doctor White. 5 We will now call upon Mrs. Wyckoff. 6 MRS. WYCKOFF: I made a very long report, and 7 Doctor White has said most of it, so I don't want to take up 8 more of your time with this. 9 I feel that the characteristics of this Region, -10 which is a very far-flung one, which it is the same dis- 11 tance from St. Louis to Washington as it is across this Region -- that is quite a large Region, and their interest in 12. regionaliza-Eion and in reaching out, and in their use of 13 things such as the Emergency Medical Services, and their 14 attempts to strengthen the services to this extremely rural 15 area, are very worthwhile-land very-well-design64. DOCTOR WHITE: Doctor Nicholas is a real mountain- 17 man, who understands the mountain psychology. 18 MR. CHAMBLISS: He is from Buffalo. 19 MRS. WHYCKOFF: He knows how to work with this Board. 20 and he has kept their enthuasiasm-up. I think they are very 21 fortunate in getting a man who not only was a rural person 22 who understood the difficulties in the rural districts, but 23 he also came into Washington onbusiness, he was sent on site 24 visits by the RMP and learned a great deal about the whole 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washiitgton, D.C. 20002 /')A')% rAtZ C.CRC gHD10 I complex works, so that he is a sophisticated man, and yet 2 he is a man who has knowledge of the small rural community's 3 mind. 4 I think he has done a very successful job.in that 5 Region, through a traumatic experience, and I believe they 6 have done the best we could possibly expect from them. 7 1 agree with Doctor White's recommendation for the 8 fundin@, and I would urge that we give them what they ask for 9 at this time, even though I think perhaps the question he 10 raised about the cancer projects may have some validity and that those possibly can be transferred. I would like to turn in this long-winded written 12, affair so that it does not take up your time, but it has com- 13 ments,on a number of the projects. Is that acceptable? 14 15 MR. CHAMBLISS: I am sure the staff would be most appreciative of your note@,. and they will take into account your concerns, Mrs. Wyckoff. 17 18 MRS. WYCKOFF: I have.some grave qntstions in here 19 about the relationsh .ip of CHP and RMP in terms of their fundingt and the agency that is going to pass judgment oh 20 the agency that funds it noxq and how you work out these 21, relationships in a satisfactory way, but I assume that with 22 the new legislation, all this may,become'academic. 23 So I would like to second'Doctor White's motion that 24 it be funded at the requested amount. I that they are capable 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (2021546-6666 77 WHD-11 1 of spending the money 2 DOCTOR WHITE: I suggested the targeted amount. 3 MRS. WYCKOFF: The targeted amount. 4 MR. CHAMBLISS: The matter before the Committee now 5 is simply a suggestion, and I would certainly entertain a 6 motion. 7 MRS. WYCKOFF: All right. I'll make a motion to that effect. 8 9 DOCTOR WHITE: I'll second that. 10 MR.* CHAMBLISS: It has been so moved.- 11 "That the level of funding for Colorado-Wyoming RMP be set at $1,587,644, which is the equivalent of 12 the targeted amount for that Region." 13 The Committee has expressed its concerns with regard 14 15 to the cancer activities and DOCTOR WHITE: YA11ney. 17 MR. CHABMLISS: And the kidney activities as embraced in the motion. 18 That has been properly moved and seconded. Is 19 op there discussion? 20 In the absence of discussion, I'll call the question. 21 All those in favor? 22 (Chorus of "Aye.") 23 Those opposed? 24 VOICE: No. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (202) 546-6666 78 WHD-12 1 MR. C@IBLISS: The motion is carried, with one 2 negative vote in the person of Doctor Miller. 3ii It is so ordered. 4 5 6 7 8 9 10 12. 13 14 15 17 18 iq 20 21 22 24 25 HOOVER REPORTING CO, II(C. 32OMassachusettsAvenue.N.E. Wash@on, D C@2JW2 79 :WHD-13 1 MR. CHAMBLISS: I would simply like alert the 2 Committee to stand guard for so me momentary changes in the 3 order here. 4 'I have pointed out one, that Doctor White will have 5 to leave, and we will take Georgia next so as to permit his 6 temporary departure from the Committee, and then I would call 7 to your attention the fact that our staff support for Illinoi@,- 8 Mrs. Kyttle, has to be out of the room, and I might say that 9 she is one of the persons who has transferred from RMP. She 10 has to be out of the room momentarily also, and she will return around 4:00. 12. We would then substitute Indiana in place of Illinois. We would make a change in Inter-Mountain and Iowa, 13 and pick up at Kansas, Louisiana, and move down from that 14 15 point, so there are a few changes that I would ask the Committee to take cognizarece of. 1(; We will now call upon Doctor White again, and 17 18 Doctor.:Catpenter for a review of the application of the Georgia Regi onal Medical Program, and they will.be supported 19 20 by Mr. Jewell, from staff. 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (2021546-6666 8o WHD-14 1 REGIONAL MEDICAL PROGRAM REVIEW 2 GEORGIA 3 DOCTOR WHITE: I'll follow the same general format, 4 but in reality, comments are very akin to those made previous- 5 ly and only the names need changing, in a sense. 6 Georgia is in a triennial status. It's been awarded 7 that in the past in recognition of its quality; again I have 8 the advantage of having made two previous site visits to that 9 Region, and have come to know J. Gordon Barrow,professionally 10 reasonably well during those two visits. 11 I link one can say, without too many reservations, 12. that Doctor Barrow is one of the better Regional Coordinators. 13 He is the original and only one in this particular area; even prior,to his activities in the Regional Medical Program, he 14 was very active in similar so rts of activities in the State 15 of Georgia. He has the appropriate accent, and is well-accept--e-d- 17 18 by one and all in that area, and.he has done a commendable job in establishing a very close relationship with the Georgia 19 Medical Association -- or Society; I've forgotten which it's 20 called -- so that they are the sponsoring fiscal agency. 21 There has never been this conflict of interest which 22 seems to have arisen in certain regions between established 23 medical organizations and the medicAl programs. 24 He has indeed cemented relationship, both in Atlanta, 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.[. Washington, D.c.20002 (202)546-6666 81 WHD-15 I and clearly out in the regions of Georgia. 2 At least on my previous site visits, it was my 3 1 feeling that the people in that area who attended the visits, 4 have come to recognize that the Regional Medical Program of 5 Georgia was indeed a resource upon which a wide variety of 6 people could call for help, ranging from patients to health 7 professionals. 8 The ttaff, again, consis ts of thirteen xey and 9 stable people who hIave been there an average of five years 10 and three months, and again,,are well-qualified in terms of their backgrounds and degrees for positions that 'they hold. They are organized well into administrative and 12. operational groups with defined responsibilities and areas of 13, operation. 14 15 The Regional Advisory Group has continued to be 16 active; it meets regularl!(.. In their words, it did not wither, 17 it developed alternate plans, not just for the phase-out, but 18 for its continuation beyond the-time when support would wither. It even conducted a "retreat" which was apparently 19 well-attended by most of the members of the Regional Advisory 20 21 Group, in which they examined the alternative pl-ans for survival with or without Washington's support. 22 Again, it is clear that'the individual members of 23 the Regional Advisory Group pot,onl y participate in the 24 deliberations of the meethgs, but participate in terms of 25 HOOVER REPORTIK CO, INC. 320 hiassachusetts Avenue, N.[. WasMnglon, D.C. 20002 (7n9i curl.fifiFA 02 WHD-16 I serving on committees, making site visits and interchanging 21 with Comprehensive Health Programs throughout the state- 31 Its past performance has sometimes been misunder- 4, stood. It also has this regionalization, or "umbrella" so@t of concept, and in the past we have kind of thought at times 5 6 that they were continuing an old activity under a new name, 7 but in reality they were continuing a new activitylunder an 8 old name, is what it amounted to. 9 And they have gone out and they have used community 10 hospitals as a source or a center from which to spread out, creating a net of educational care facilities, investigation and the like, and the only question I saw in the whole appli- 12. cation was whether or not they should broaden out and no longez 13 use just -hospitals as a center, a focal point, but perhaps 14 15 that there are other kinds of health agencies that could also serve this function as W6p., but that was a comment. They have indeed establi shed well-defined catchment 17 area s and regions which subserve. their projects and programs 18 and activities, and by virtue of this they also have a close 19 10 relationship with the area Comprehensive Health Planning- 20 agencies. 21 It has an Emergency.Medical Services project which 22 is largely that concerned with planning And coordination. I s 23! i continuation by others at the present time is not clearly 24 specified. There is no hard money, or firm commitment by any 25 HOOVERREPORTINGCO,INC. 31OMasgchusettsAvenue,N.E. Ivashivo..I, D.C. 20002 83 , WHD-17 1 other agency or organization which indicates tlia t it will con-. 2 tinue@ but..presumably something might arise on the scene. 3 Its objectives and priorities have been well speci- 4 fied in the past, and are unchanged at the present time; they 5 still have to do with availability and accessibility and .0, development of new types of manpower and utilization and net- 7 works of specialized services. 8 It also is undertaking a fairly extensive program 9 for planning and developing health resources, and I guess this raises a question in.my mind, particularly after hearing 10 Doctor Paulls comments this morning, that although these 11 Regions have been encouraged to do this, what is going to 12 happen if they expend a lot of money, a lot,of time and Alot 13 of effort meeting, getting toget her, saying 'This is what the 14 health resources facility should be for the State of Georgia," 15 and in the meantime Congress is passing a law which is dia- metrically opposed to this sort of thing? 17 Is this something that we should attend to? Should 18 we say: #No, let's not be doing that until we see, when the 19 dust settles, where we're going to go." or should we hope 20 that by virtue of their doing something now they'll have some 21 future influence on Congrdss? I don't know. 22 Their relationship with Comprehensive Health 2tl Planning, I believe to be good. They exchange memberships on 24 11 the respective committees and Regional Advisory Groups and 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. W@irtgtaii, D.C. 20002 (202) 546-6666 84 WHD18 boards; they have funded one another for certain types of 2 activities, there are certain adequate letters. of support 3 from the Comprehensive Health Planning agencies, without 4 serious adverse comment. 5 I think it is important to notice also that they 6 have not @- even though they were told they might expect 7 140 percent, they have not chosen to ask for it, and they 8 have also indicated that they felt they would not be,asking 9 for any money in July. 10 They have given considered thought to what it is 11 they would like to do and-'they want to get underway @t the present time, and it is going to take less money tha they 12. 13 thought they may possibly be awarded. It seems to me this does reflect some thinking, some 14 15 merit. This is a Region of merit, a Region of past perfokm- ance, and I would feel they.are entitled to what they 16 requested, or any fair proportion thereof that is finally 17 evolved. 18 MR. CHAMBLISS: All right; our next reviewer for 19 Georgia is Doctor Carpenter.- 20 DOCTOR CARPENTER: Well-, it 3s'always a p easure 21 to follow Phil, because he makes it so easy. 22 I would just -- this application was an enormous 23 relief to me. I thought in.s.ome areas that maybe I was wrong 24 about Regional-Medical Programs, and I found that if I was, at 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (202) 546-6666 85 WHD19 1 least Gordon Barrow in Georgia agreed with me. 2 So I can hardly say enough good things about the 3 Region. 4 You know, for instance, they don't charge.indirect -5 cost rates, except on a few -- I don't know:76-46 less 6 than $100,000 in the total program of nearly three-plus 7 million dollars -- less than.$100,000 of indirect costs, 8 They have their own goals; they are leading the 9 development of the health-care,system in Georgia, I believe, 10 as much as any organization I have ever seen lead in such a complex environment as the state, among its health care pro- viders and interested consumers. 12 They have their own goals and they are pursuing 13 them actively, but they take full advantage of Federal prior- 14 15 ities, and move in new areas with amazing speed. They have responded to.the minority problem very 17 well; there are -- there are a large percentage of minority people, particularl in the projects. They 18 y I am tempted to read two paragraphs out of the pro- 19 jects, because they contrast so much with the Arkansas descrip- 20 tions and some of the other ones I have seen not really 21 trying to single out Arkansas, but to make the point that 22 these people do have specific goals, they do indicate in their 23 project descriptions their understanding of the pitfalls in e 24 developing. You know, no matter what you try to do, there are 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 i,)n?@ ur-rrrr 86 WHD20 I always problems, and they indicate, I believe, that they are 2 aware of the importance of the problems. 3 And I could go on and on, but I would agree with 4 Phills funding recommendation, and Iwould make a motion then 5 that we approve support of the level requested. 6 DOCTOR WHITE: I'll second that. 7 MR. CRAMBLISS: There is amotion that: 8 "That the funding level for the Geor 9 Regional medical Program be set at $3,629,.757, which 10 is the total amount requested by the Region." MR. VAN WINKLE: And you might note that they donl.t propose to come in July 1. 12 13 MR. CHAMBLISS:, Now that you have heard'th@ motion, is there discussion? Mr. Thompson? 14 15 MR. THOMPSON: Some people may not know that they have had probably the most-successful EMCRO programs which was 16 17 an Experimental Medical Care Review Organization, and they 18 have been designated I think so-far, as the only statewide 19 PSRO, which also indicates the kinds of togetherness that somehow this state manages to put together. 20 MR. CHAMBLISS: All'right; further discussion on 21 Georgia? 22 Then I'll call the question. All those in favor of 23 the motion, please say "Aye.. 24 (Chotus of "Aye. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 i,)n,)N 9;Ag-grrg 87 IHD21 1 And those opposed? 21 (No response) 31 There is no opposition, and I would simply say to 4 the staff, as they convey to the Council, the obser ations 5 -- the recommendation made about the Region in addi ion to 6 the level of funding support recommended. 7 I would ask Doctor White, in that he will be leav- 8 ing,shortly, if he would be kind enough to prepare the-revi.ew 9 sheets, and we would very much appreciate that,. and you like- 10 wise, Doctor Carpenter. Thank you. DOCTOR WHITE: The question arose: do you @ant these signed? Should they be signed? 12, MR. CHAMBLISS: We have no aversion to the being 1.3 signed; it is hot required, but if you like. We can be much 14 more specific in our observations. 15 DOCTOR WHITE: You know- it comes from one of two 16 17 people anyway. 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[ Washing-ton,-D.C. 20002 88 WHD-22 I MR. CHAMBLISS: I would indulge the Committee and 2 Doctor White for one further observation here,. and that is 3 that Doctor White is also scheduled to review today the-appl'l-l 4 cation for Louisiana. .5 Would you be disposed at the moment to continue, 6 Doctor? -or would your time not permit? 7 I only call upon you on that momentarily. It is 8 not required, however. 9 DOCTOR WHITE: Well, my hesitancy reflects the 10 fact that I don't see-Doctor Perry here* MR. VAN WINKLE: .Doctor Perry will hot be on the 11 Panel. 12. DOCTOR WHITE: Therefore, I am the only person who 13 is going to have any say-so about Louisiana, I guess, 14 MR. CHAMBLISS: You will have support from staff, 15 however, in the person of )4r. Zivlavsky. DOCTOR WHITE: It would make me more comfortable to 17 do it at a later time. 18 MR. CHAMBLISS: Indeed so; no problem at all. 19 I would then call the attention of the Committee to 20 the application from the Indiana-Regional Medical Program. 21 The reviewers there are Doctor Slater and Doctor Thompson. 22 I have skipped Florida. I waid if the Committee 23 will indulge my mistake, I will change that and revert back to 24 Florida, and then come to Louisiana. I would thereupon call 25 HOOVER REPORTING CO, INC. 320 Mamchusetts Avenue, N.C. Washington, D.C. 20002 (202)546-6666 WHD23 1 upon Doctor Miller, who will be supported by Mr. Van Winkle, 2 from staff. 3 4 5 6 8 9 10 12 13 14 15 17 18 19 20 21@ 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 go fHD-24 1 REGIONAL MEDICAL PROGRA14 REVIEW 2 FLORIDA 31 DOCTOR MILLER: I probably have a little bit d3ffer- 4 ent point about many of these things than many other members 5 of this Committee, having directed a Regional Medical Program for seven years, and.I tend to be a little critical. which I 7 hope you'll bear with me, and I won't feel offended f you 8 vote down my views-more liberally than I make judgme'l 9 Florida, our Regional Medical Program.has :)een.an outstanding RMP; for a long time it has the second h ghest 10 current level of annualized funding, according to ou list, 11 under California. 12 It is an ambitious RMP; it has always has n ambi- 13 tious,program. It is well organized, with good leadership, 14 15 good program staff-, excellent Regional Advisory Group, excell- ent past performance and accomplishments -- I could go on and, 16 17 give details of these things, but there is not much point. 18 They are all veryIgood. 19 Their objectives and priorities are not quite so succinctly specified or controlled, but nevertheless do addres; 20 the program activities, address all the key issues that we 21 focus on. 22 I can't find anything really wrong with any componen- 23 of their application, which.i.s large, for three million dollari;; 24 11 the staff's only question for Reviewers' attention was the 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (202)546-6666 gi t didn' WHD-25 1 MAST program, which is an EMS component, but staff 2 feel that there was any problem here. 31 So the proposal, the operational activities and aii't 4 are indeed congruent with the Region's explicit priorities 5 and suggested areas of emphasis, and they get along well with 6 CHP, and the CHP relationships are good. 7 So then you get down to the problem which I 8 addressed in all of these five that I reviewed in d tail, 9 under a couple of basic principles. Is 10 The first one was that virtually all the p 11 should be given complete support for their core staff and for continuation of program activit ies that they have g tten 12 started and that have been going all right. 13 But then provided the budgets are not doubled 14 or tripled, that is. But-then the pr@blem of new projects and the feasi- bility of getting them completed in a successful way, with a 17 18 meaningful impact, with recognition as an RMP activity, in 19 one year, seems to me to be quite a big question. 20 The staff did not summarize, in the Florida program here the answer to the question:. 21 "Are continuation projects budgets raised too 22 much for the next year, out of proportion to what they 23 have been this present year?" 24 And I would like to ask staff if that is true, ecause a 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 92 WHD-26 I number of these projects have rather large budgets, nuch the 2 same, however, as you have just reviewed in the Georgia .3, program, with rather tremendous individual budgets for some of the program activities. And in Florida, in the Florida RMP, the numbers of' lost my page here, but there are something like -- 35 7 projects, of which 25 are new, I believe. 22 are new, and no. 8 previously funded, and if one goes into those projects, there are a number of them that are certainly very questionable as 10 to whether they can be successfully and very conscientiously completed in one year, activities-that would be worth the 12 rather large budget requested. The bilingual communications system of translation 13 from tnglish to Spanish, of $1210,000, without any real indica-- 14 tion that it is going to be continued by anybody else. 15 A number of thede. Visitor 'assessment of visitot's needs for health care of visitors to Florida, with a budget 17 18 of $189,000, a Florida perinatal program, which is an obviously 19 needed thing, but with a budget of $212,000 and no real indica- tion exactly as to whether they would be continued, except to 20 say that efforts would be initiated to try to find out if they 21. can be continued. one would hope so, for $212,000. 22 Improving health care assessment quality assurance,, 23 which is an excellent plan,. in community hospitals. Anybody 24 who has worked in- one of those things, in those endeavors, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington,-D.-C. 20002 93 WHD-27 I which we did, knows that there is a very limited amount you 2 can accomplish in one twelve-,month period and a budget of 3 $212,000. 4 A program to start a midwifery project, which is 5 obviously very much needed in many places in this country 6 but it is one mid-wife with a budget of $87,000. 7 An Indian health care program for acute critical 8 illness in Indians; we started'developing one of those in Minnesota, figuring it would take at least three years to.get 10 it going. So, I 11 find myself being critical of dealing out rather tremend ous amounts of money, even to what I regard as 12 one of the best RMP's in the country, to activities like this 13 14 that have relatively high budgets and, I think, somewhat 15 questionable potential for comparable achievement. 11 Now, if the RMP@was likely to be funded for another three-year period, every one of these things would be good, 17 18 and they would be ahead. We'll-come to Missouri later, and I think the situation is similar there. They would be ahead 19 20 of -1 the game, because they would have started things, moved very rapidly in their.very large endeavors, and then moved 21 right ahead then with some critical key issues and have a 22 year's head start on a lot of other programs that then will 23 start three-year projects of such things. 2,4 So in terms of that, obviously 6ne should okay 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 l'in')k R.AIZ r,(Zrr 94 WHD-28 their funding. 2 They also plan to come.in for another application 3 in July, for another one and a half million dollars. 4 So they're not modest. They are good, but not 5 modest. Applying for a total of four and a half million. 6 I fail to be able to differentiate the charge to 7 us of reviewing these things without considering the@e cost- 8 benefit aspects of particularly new-project activities, and 9 consequently -- well, my first recommendation after studying 10 all this was that they be cut by a million and a hal@:* 11 I guess, in view of what has gone on this @orning, 12. I would say that was an unusual recommendation, and erefore 13 I would well, I would.like to.hear Staff's reactions, 14 since the other Review committee member is not'here. 15 MR. VAN WINKLE: In terms of the continuing support, Doctor Miller, I can only go on their past record, which has 17 been-excellent. That has been one of their main objectives 18 in their cost-sharing of funds, 'and I just noticed the one 19 statement in here that since July of 171,$3.7 million have been invested by the Florida RMP, and that was augmented then 20 by $5.2 million of other funds that they were able to drum 21 up, and then after completion of the FRMP supports they con- 22 tinued a number of those projectswith other funding in the 23 amount of another one and a half million. 24 So they have had a very good record of continuation 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[ Washington,-D.-C. 20002 95 WHD-29 1 after their phase-out. 2 Now, I noticed, too, some of the large increases 3 in budgets, and did check this out,' Doctor Miller, and parti- 4 cularly on,their continuations; their budgets were jumping 5 very high. 6 DOCTOR MILLER: Oh, yes; maybe twofold. 7 MR. VAN WINKLE: And what I found out is that we 8 were comparing against four@mohth budget; the previous budget 9 that you were looking at was only for a four-month period. 10 DOCTOR MILLER: I did not have the previous 11 they are not in here, the previous budgets. MR. VAN WINKLE: No, but I went back to check, and 12. it looked like a horrible jump, but then when I annualized 13 that 'against this, and as an example, I just pulled one out 14 here. They had started-out only in two counties, and it was a pilot study; they now are moving out into all 67 count- 17 ies of the state. 18 19 The one on the next page, for example, was a pre- test pilot program in three hospitals. They are now moving 20 21 that computerized system that they developed into.a state- wide program now. 22 And as I went through each of these, I found that -- 23 you know, that type of justification. The one on the commun- 24 ity organ-donor program, that started only in Dade County; it 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. W@ington, D.C. 20002 II)A,)% uiz_iz4zrr 96 IHD-30 I is now moving out into four surrounding counties around Dade, 2 and it will increase the capability. 31 And I think one other thing I would like @o mention 4 about Florida, along with the other good things you say, is 5 that they also do not have an indirect cost rating. 6 DOCTOR MILLER: No. They are a separate corpora- 7 tion which has its costs all direct. 8 MR. VAN WINKLE: I am not sure what other -- I 9 really can't say anything as to the continuations, other than 10 the fact that their past record has been excellent. DOCTOR SLATER: May I ask a question which bears 12, on the indirect versus direct charges? 13 Are the direct,usually less than the indirect 14 charges being made by universities or other institutions? 15 MR. CHATABLISS: Yes, they are. DOCTOR SLATER: @Considerably less? 16 We seem to be very concerned about the indirect 17 18 costs that are charged to the program. I am just trying to 19 get a fix on the difference in amounts, or a percentage, let's say. 20 MR. VAN WINKLE Well,,let's assume that you had a 21 two-million dollar grant to a program. You might have anothe@ 22 80 percent of that added on to that, that we have to put out 23 in terms of indirect costs. 24 DOCTOR SLATER: Right, but if you build the direct 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 ll)fl9l rig.grigg 97 ID-31 1 costs into the two million dollars, what would that total 2 package come to? 11 31 DOCTOR MILLER: I can answer that partly. 4 It depends a lot on how the big institution handles 5 its accounting for indirect costs. If the big institution, 6 now, like a big university -- we ran through this in 7 Minnesota, because a part of ours was a university component 8 and may have indirect costs now, if the university figures 9 its indirect costs across the board, with all departments, 10 which includes all laboratories and research units and so 11 forth, and they got all the costs of all those research units 12 built into the total indirect cost rate, then a desk operation like RMP is charged an exorbitant amount'of indirect costs. 13 If however they have two levels -- and they fre- 14 quently do -- and fty cost-acco unt indirect costs on the basis 15 16 of the kind of work we ar@ doing, then it is -- it may not, depending on how efficient the big organization is -- their 17 indirect costs may riot come out.any bigger than if you do a 18 direct cost. MR. VAN WINKLE: Doctor Miller, you were talking 20 about this Region looking ahead, and that is precisely what 21 22 they are doing during phase-out. They did not stop. They said: "No way are we phasing out;" they never 23 at any time believed they were going to phase-out and they 241 continued their program, and when the June 15th turnaround 251 HOOVER REPORTING GO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20302 ,/202)546-6666 98 WIID-32 I came, they were way down the road. That is precisely the way 2 they are going to look at it ri ht now.' 9 3 DOCTOR MILLER: I expect that is precisely what they 4 are working,on right now. 5 MR. VAN WINKLE: They intend to be whatever organize- 6 tion that is that responds to the new legislation. That is 7 their intent, whether it has.anything to do with this appli- 8 cation or not -- but I do know that is their intent. 9 MR. CRA14BLISS: I might simply suggest to Doctor 10 Siater, if I may, that as we move from the world of founda- tions to the world of institutions, this issue will become a very keen one, about indirect costs. 12. 13 DOCTOR SLATER: I'm sure it is. MR. CHAMBLISS: It is one that has been rather per- 14 plexing for many of us. DOCTOR SLATER: -Foundation spending is very simple, 16 by simply saying: 17 18 O'We never pay anybody more than 15 percent, if that; we can't do it." 19 MR. CHAMBLISS: I wonder if the Reviewer, Doctor 20 Miller, is now -- are there further questions? I would enter- 21 tain -- I would like to have a recommendation, and I see 22 Doctor Vaun's hand. 23 Doctor Vaun, did ygu have a question? 24 DOCTOR VAUN: Yes. Winnie,you raised the question 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[, Washington, D.C, 20002 (202)546-6666 98 .-A KHD-33 I about the possibility of these projects after a year, or the 2 possibility of accomplishing the objectives and goals within 3 1 a year. 4 I wonder, if in the stage of transition now, that 5 is a legitimate question? Not considering Florida' past 6 performance, but I wonder if that is a real questio on our 7 part in this panel? I would just like some reaction to that. 8 To me, it sounds like you are questioning the 9 whole management ability of that program when you ask that 10 question. In other words,.if they didn't thixyk that there 11 was either a reasonable chance of follow through wi@h funding from other sou reasonable chance that the would 12. rces, or a accomplish their objectives, than how can you say ir one 13 breath that it is a reasonably well-managed program, and. yet 14 you have sizable questions about the money? 15 DOCTOR MILLER-." When RMP's first started, the RMP 16 17 was a source of "soft gold" from the Federal Government. I went through this, in the process of getting people to change, 18 19 because these are the kinds of budgets we had in all our applications. They were huge. 20 Now, it is quite obvious if you haven't heard.it, 21 22 but it has been expressed very widely -- RMP is now another source of soft gold for one year, only. 'All the frozen money 23 has been released, and RMP now has'more money in one year thar 24 they had before. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (202) 546-6666 99 'D-34 1 Now, I don't -- maybe you don't -.- I'm not sure 2 that it is politically desirable to try to react against 311 that at this circumstance. 4 MR. VAN WINKLE: Doctor Miller, I am familiar with 5 the review process. I have been at some of their meetings, 6 and it is probably one of the toughest groups I have ever 7 encountered. 8 As I mentioned to you this morning, at the last RAG 9 meeting I attended, they became so personal I almost wondered 10 if there was going to be a little bloodshed. f that pro- Staff.are involved with the development o gram from Day-one, and long before many of those proposals 12, ever come to the first committee in the review process, Staff 13 has already been at work on their budgets. 14 They have two different review groups that have a 15 go at those, and again, Yoy.can get reductions in any one or 17 all three of those three review groups. I sat through one on a Saturday, and then on the Sunday I thought all the slashes 18 had been made, and then went to the Council meeting on a 19 20 Sunday and found out that it was not resolved at all. DOCTOR MILLER: Yes. The letter says that it had 21, over 100 projects applications that they reviewed. 22 DOCTOR CARPENTER: How many did-they accept? 23 DOCTOR MILLER: 35. 24 MR. THOMPSON: May we arrive at-some kind of money 25 HOOVER REPORTING CO, INC. 320 Massuhusetts Avenue, N.[. Washington, D.C. 20002 (202) 54"666 @L-- iuu WHD-35 1 here? 2 MR. CHAMBLISS: The Chair would entertain a motion 3 based on the presentation. 4 MR. THOMPSON: I'm not going to let him off the 5 off the hook; he hasn't made a recommendation. 6 DOCTOR MILLER: All right. 7 They are planning on coming in with a million and 8 a half-more application. Their target total is $3.2 million, t 9. they are applying for three million now. Their current fund- 10 ing level is $2.3 million. I would recommend a funding level'of $1.7 million. 12 MR. CHMIBLISS: The recommendation is alfunding 13 level of $2.7 million for Florida. Is that in the form of a 14 motion, Doctor? DOCTOR MILLER: If you wish. 15 MR. CRAMBLISS: /And is, there a second? 17 MR. THOMPSON: I will second it. MR. CHAMBLISS: It has been moved and seconded: 18 "That the funding level for Florida be estab- 19 lished at $2.7 million." 20 Is there any discussion? 21 (No response.) 22 If there is no discussion, are you ready fcr the 23 question? Those in favor? 24 (Chorus of "Aye.") 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 (202) 546-6666 101 WHD-36 1 Opppsed? 2 (No response) 3 The motion is carried, and it is so recommended,'at $2.7 million. 5 I would say that the Committee is moving along 6 rather well, and that we will go to the next Regional Review,' 7 and that is Indiana. 8 9 10 12, 13 14 15 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 102 WHD-37 1 REGIONAL MEDICAL PROGRAM REVIEW 2 INDIANA 3 1 MR. CHAMBLISS: Indiana will be presented by .-4 Doctor Slater and Mr. Thpmpson, supported by Mr. Jewell. 5 DOCTOR-SLATER: All right, sir, I'll begin with 6 Indiana. 7 The budget request, as you have seen on'Line 43 8 of the print-out there, they are annualized now at $1,057,000, 9 and they Are requesting $1,221,000 against a targeted fund 10 of $1,430,000, so they are considering about 84 to 85 percent 11 of what they are targeted for, but coming back in July for another $400,000, which would bring them up to about 112 per- 12 cent of their current. 13 I looked at the proposal and tried to sort it out 14 15 in the sense of the guidelines that you gave us,,- and lot me introduce this by saying that I found it very difficult to come to grips with what they are doing. 17 When I looked at the specific projects that they 18 have been involved in in the poast, and what they have been 19 able to accomplish, I am impressed that something is going on 20 out there, and I do believe they can't write a proposal very 21, well, or write a report. I found repetition and lack of 22 clarity, and so I think that I am going to reflect that. 23 I would say that this is a traditional type of RMP 24 program in contrast to the one Illl'report on later in IllinoiE.' 25' HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 103 hip is'satisfactory. WHD-38 1 Program leaders Program staff -- every one of the current 2 staff 3have been in RMP for over four years and they have experience 4 The non-medical professional people, with the excep 5tion of the Dean, who has been associated with the school and 6the.program support for some time, are now instituting them- 7selves to the level of 33, with good representation in 8 Indianapolis and the regional areas. 9 At the 37 level, they had 30 people from Indianapoli @io and seven from the regions. They are now going to try, in their new level of 33, develop a better balance for minority 12. and geographic representation. 13 They have the usual types of committee Executive., satisfac- Review, Evaluation and so on, which I thought was', 14 tory. 15 They outlined that they have two major thrusts; they 16 attempt to develop guidelines on.standards and criteria on two 17 main types of activity. 18 19 One, the identification of hospitals to provide better capability there, with particular,reference to state 20 21@ emergency medical services, and secondly, they are interested in enhancing a whole series of specific programs which have to 22 do with quality of medical care, access and the like. 23 . .1 These are identified as renal dialysis, kidney- 24 transplant, radiation therapy, angiography and the like. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. lo4 rn WHD-39 1 Now, as far as past performance is conce ed, 2 they describe themselves as really.spearheading regionaliza- -3 tion and improved cost-effectiveness by acting as coordind- 4 tors, planners and developers, and I wrote a quote here: 5 "They are interested in more quality of health 6 care available to more people at less cost." 7 That, I thought, was a nice, general ".motherhood" statement. 8 Within that framework they really have been working 9 closely with CHP, and have been attempting to extend sub- regional RMP development that is tied in with the existing B 10 agency development in Indiana. 11 Examples of what they have done in the past, very 12 briefly, are that they have developed a data base to reveal 13 health deficits I am not quite sure what that means, becausE 14 there wasn't enough inf6r ,mation. 15 16 They have organized sub-regional CHP provider- consumer-groups in six areas, five or more on the Board. 17 They have promoted programs to meet these above 18 needs. For instance, physician-extender and continuing educa- 19 tion programs, they have been involved in legislation on 20 statewide emergency medical services, a couple of neighborhoo 21 health centers in the urban areas, state'stroke-therapy 22 services, consultation in organized coronary-care units I 23 could go on. 24 All of the above, with the exception of a little bit- 25 IIOOVER REPORTING CO, INC. N r 105 initiated gHD-40 I of continuing R-MP staff and money input, have been 2 and are on-going and phased over to.other support. They are 3 not totally independent; where the line is drawn, I am not sure, but they have made a major effort to act as a catalyst 5 and move programs they started out onto other funding lines. 6 At the moment, they also have some limited demon- 7 strations; hypertension screening and care programs in dis- 8 advant@ged urban areas. They are looking at what they call 9 the "assurance of quality of care." I wish they had just said they were setting up a perinatal upgrading program, 10 11 instead of all the generalizations. 12 They have a kidney disease program which includes immunologic studies. This is a hope to define ways by which 13 you can prevent organ rejection. I was concerned-,about this 14 because I think it should be funded by -- it is a basic 15 science study and should be funded by some other method. Now,, the objectives and priorities -- after all 17 18 these years of effort they had a mail poll recently among 19 25 RAG members and 65 non-RAG members, and they carefully 20 itemized what they came up with, aInd honestly, it is what you put together as a first-run ten years ago. 21 Continuing medical education, needs of under-served 22 areas, emergency medical services, hypertension, innovative 23 health-care strategy -- it's all over the map. But it's 24 traditional, in the sense of what many RMP's consider to be 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. lo6 WHD-41 1 the umbrella'approach of improving the quality of medical carE. 2 At the moment they are moving ahead with the hope 31 of having two major thrusts. They described this as expansion 4 of the program staff -- and I need some help from Staff on 5 that if John hasn't got a better understanding of it. -- And 6 regionalization. 7 Within that framework they-then present,a proposal 8 which moves along lines that include emergency medical ser- 9 vices, for which they already were able to achieve 1974 1.egis- 10 lation, which only provided them $75,000 for the state, so they are asking for another $95,000 to enhance that program 11 until they can get better funding from the,state. 12 They are also wanting -to have help for health- '13 14 resources planning in cooperation with the six CHP exksting B agencies. 15 On page 25, they outline, in three or four lines each, 13 new activities for which they have planned a July 17 18 application, which amounts to $400,0.00. In the present proposal they are asking for $616,000 I believe it is -- for new program staff, and what I don't 20 understand from their proposal, and maybe the Staff person 21 here knows, is whether or not the $616,000 of new money for 22 program staff is to program that $400,000 of 13 new projects. 2.3 I don't know whether they are i"nterrelated or not. 24 The specific projects range across the board. They 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n r 9nn6g 107 NHD-42 1 want a kidney-transplant exchange information system -- only 2 $8,776, and what this means really is to computerize in their 3 Southeastern Regional Organ Procurement Program the 8,000 4 tissue types scattered among the population of people who 5 they can count on to contribute organs. 6 I would gather that that would pay for a computer 7 clerk, or something. It is a tremendous pro'ram to buy for 9 8 $8,776. 9 The second point was care for hypertension patients 10 in Marion County, which -- for $141,000@ That is,,a specific 11 center model they want -- they want to fund the equipment and 12, overhead on a center in which screening, clinical care screening, clinic, diagnosis and treatment, including nurse- 13 14 practitioner follow-up of these patients, can be gotten off the ground. They want to be able to acquire data, study, 15 study the compliance rate of these people in this deprived 17 area. They are looking for the development of a statewide 18 "tele-medical" system, which is really a telephone-answering service, for $41,000. 20 They are looking for the development of as I 21 mentioned earlier -- quality assurance, which is really impro 22 ing perinatal infant death, in Marion County, where they have 23 I? again inner-city high-mortality rate. They are attempting to 24 put together six hospitas to do mor tality reviews, with the 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. lo8 WliD-43 1 idea of upgrading the performance of the doctors as well as 2 patient compliance; that to be done for $23,766. 3 Those are worthwhile project s -- most of them ar6 4 very worthwhile. 5 Looking at the feasibility of all of this, I found 6 it a little difficult to assess. I assumed -- I gave it a 7 "satisfactory." I can't tell on the basis of the way the 8 program.is written, even in the terms of past performance. 9 The relationship with the Comprehensive Health 10 Planning, I would say, is very close, insofar as the evidence 11 shows. 12, Overall assessment of this, I gave average,:or-,C- minus,, largely based on their inability to present it very .13 well. Again, I come back to the fact that they are overly 14 general and euphemistic,"l@cking specificity in the writeup, but on the basis of what they have already done, it looks as if they are capable of performing reasonably well. 17 18 John Thompson and I looked at what might be pulled on this, and I think we feel the Emergency Medical Services is open to question with regard to that $95,000. I question 20 whether or not we should be funding the kidney dis ease innuno- 21 logical rejection studies; you mentioned the dialysis -- kidne@ 22 dialysis program as well. 23 I need specific information on what the $616,000 24 for program staff is aimed at. I somehow just could not decipher 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue. N.[. log WIiD-44 1 that. So I will leave my final comment up in the air, except 2 that I do believe that despite the fact that they are only 31 asking for 84 perc ent of the targeted funds, they still may 4 be asking for too much at this time, with this type of appli- 5 cation. 6 MR. CHAMBLISS: All right. Our next presenter, Mr., 7 Thompson. 8 MR. THOMPSON: I am very much in agreement with 9 Bob's ev aluation. It is very difficult to understand what' 10 the goals and objectives of this particular program are, 11 because they Are stated in such general terms, you know, 12 like regionalization -- that's a goal. The nearest thing we can get -- and the only reason 13 14 I can pick this up is because it was underlined is the 15 development of innovative programs in health-care delivery to with special emphasis on under served geographic popula- 16 tiohs and medical areas, and on public and professional edu- 17 cation about health-care matters that will assure quality and 18 cost-effectiveness of service. 19 If those are their goals and objectives, none of 20 the particular programs that we are asked to review have any- 21 thing to do with those goals and objectives. 22 The second -- I'm not quite as obviously optimistic 23 about the relationship with CHP, because every reference to 24 CHP and I would like to have Staff input is very care- 25 HOOVER REPORTING CO, INC. 320 Massactiusetts Avenue, N.E. 110 #HD-45 fully phrased. 2 For example: "Communications have never been so goo([ as they now are with CHP." 4 Well, I have been in areas where, if you said "hello" and somebody said "hello" back, between the two people 6 communications had never been so good! Because before they 7 wouldn't even talk to each other. 8 I can't operationalize that kind of a phrase. 9 The staff is over 72 percent of the total request 10 over 72 percent of the total request is fot.core-staff, and 11 the reason I am concerned about the EMS component,is that it 12, specifically states -- in one of the few specifics in the 13 whole,thing -- that, and I quote: 14 "The general objective of this project is to develop an areawidd'yMS system adequate for the needs 15 of those counties constituting Region 7." So that is obvious that they are building an EMS system, and 17 18 whether this system is in conflict with that or EMS or not, I think we ought to define. 20 I am certainly not turned on by that "Dial-a-Diseasc:" 21 project which they have, where you dial in someplace, and they slam on an Ely Lilly cassette, I think, that te s you 22 all about the problems of the man over 40, and about 23 (Discussion off the record) 24 MR. THOMPSON: But, to continue, I would rate it as 25 HOOVER REPORTING CO, INC. Nr ;IHD-46 1 poorly as Bob did, and certainly not give them the amount of 2 moiaey.they asked for. 3ii But on the other hand, if we want to maintain the 4 capacity for this outfit to do something, and 72 percent of 5 the whole project is staff, you can't cut it too muQIh, so I 6 recommend a cut of $100,000, from what they request,, to bring 7 it down to 8 DOCTOR SLATER: To come back on to that staff, the e other support services that:are involved 9 staff request, th 10 with staff, come to not $616,000, but $882,000, and @that is 11 really to improve the Emergency Medical Services system 1 12. development, Family Practice program development, integration of Comprehensive Health Planning and IRMP activities, hospital 13 14 access studies. A lot of thi@'lps to do with data collection and planning. They see themselves as the planners for Indiana, 17 as far as I can make out, including the C@IP. The CHP group -- excuse me, and I guess I need clarification as t o whether 18 or not this is real. .MR. CHAIIBLISS: I would ask ---we are cognizant of 20 your recommendation in terms of the funding level, but I 21 would ask, are there any inputs-as it relates to CHP for that 22 state for that Region? 23 MR. JEIQELL: Which tion should I answer first? ques 24 MR. CIUV4BLISS: Answer the Committee's question 25 HOOVER REPORTING CO, INC. 111-A IIID-47 1 f irst. 2 MR. JEWELL: On CIIP, Mr. Chambliss, this is a con- 3 tinuation application, and about two months ago I was out 4 there to their wedding of M4P and CHP, so we were wondering 5 what the children were going to look like. But they had the 6 A agencies, and all their B angencies are funded, and I was surprised at the quality of men that I met up they and 8 -they Kere all men. 9 This was a two-day meeting, where they got in a 10 room, in a motel, and laid it out -- what they had not told 11 each other, what they wanted to tell each other so I can 12. only attest to the viability of the statements in their cover 13 letter, that what I witnessed there on one visit was a very useful, viable discussion, and I am not really that much inter- 14 ested in meetings. 15 16 Doctor Slater,"oji.your request for program staff, 17 sir, there is $616,000 that they are pulling out, and it will be funded under the program-staff component, sir. 19 It will not buy new people, and this is for RFP'S, 20 if you will, sir, to address these priorities that they iave 21 listed on the last page of the application. EMS, Health- Resource Planning Criteria and Standards, Arthritis Study, 22 Cancer Control 231 DOCTOR SLATER: The 13 new projects? 124 IIR. JEWELL: Well, they are contracts; yes, sir, but, 2 HOOVER REPORTING CO, INC. 320 !@,ass3c@!dsetts Aver@ue, N.C. .q@ir,gton, D.C. 2= -202) 546-fE66 t 112-113 ,'iD-48 I that would just be funded out of the program staff component. 21 There are -- their actual progra'm staff request, money-wi.se, 3 is about $265,000. DOCTOR SLATER: They are only going from 9 to 18, 5 so I see. What this meanst then, is that that money is to 6 provide for contracts for people for work to be done in those 7 13 areas. I see. 8 MR. JEWELL: Yes. 9 'MR. THOMPSON: Are they going to have their contracts 10 finished in time for July submission? 11 MR. JEWELL: No, sir; no, sir. 12 DOCTOR SLATER: They have another $400,000. 13 MR. JEINTELL: This is for the next year, Mr. 14 Thompson. These are two separate groups. Their other hopes 15 and submissions for the July submission are, I think, on page 25. 17 DOCTOR SLATER: I was wrong about the program staff, 18 John. The program staff is to improve the contract for more Emergency Me dical Services, to help develop their system for 19 the Family Practice Program Development Integration of 20 Comprehensive Health Planning with the RMP. 21 That is what the $616,000 in contracts is going to 22 be for; is that correct? 23 MR. JEWELL: Yes,. @3.r. 24 DOCTOR SLATER: Maybe it was here, but I didn't get 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D@C. 20002 114 VIIID-49 1 that originally. g to recommend? 2 MR. THOMPSON: What are we goin I e will recommend $100,000 311 DOCTOR SLATER: Well, w .1 4 less, and with recommendations that this be applied to what 5 the immunologic? 6 MR. Cl@,4BLISS: We gct asense of your recommenda- 7 tion; we will ask that that be placed in the form of a motion 8 momentarily, but I would simply have the Committee note that 9 there is a representative here from the HEW Region Office 10, 10 which in Indiana is a part of that regional configuration. 11 I would simply call upon Mr. Wally, if.he wishes, tc 12, make a statement regarding that program or regarding the CHP- RMP relationships, and he may do so at this time. 13 MR.WALLY: I am not that totally familiar with it, 14 but I know that in Region 5 we are encouraging a merger. We 15 are encouraging a merger, or as it was put before, a marriage between-RMP's and CHP's in their approach to the whole compre- 17 hensive health program. 18 So you may find that that sort of seems like ambi- valence on their part, but we are encouraging them. 20 I guess this is optimism on our part, that new legi 21 lation will encompass that kind of a framework. 22 DOCTOR SLATER: It may be too late, but I would 23 quietly recommend that they get somebody else to do the writ- 24 ing of these proposals, sharpen the focus and reorganize them 25 HOOVER REPORTING CO, INC. 320 Niassachusetts Avenue, N.[. Washington, D.C. 20002 (702)50-6666 115 WEHD-50 1 better. 2 MR. TH014PSON-: To you there were three questions. 311 There was the CHP-RMP; there was the progr@m of .4 specifi.c'ally-stated EMS programs, and the'very scientifically 5 based renal programs, specifically in the project itself. 6 Now, I think the Staff person can answer fairly 7 well; they ar.e doing RFP's or something, rather thanlincreas- 8 ing staff, .to explore further programs, but we still,are STUCR 9 with the problem that there seems to be very little ::elation- 10 ship between the goals and objectives as stated on p ge 19 11 of their report,,and the Programs we have been askedito 12. review, which, in fairness to them, all have been co tinuation 13 programs. MR. CHA@IBLISS: The Chair is open for a motion here. 14 15 Will.you so move the recommendation that you just made, 16 Doctor Slater? 17 And that motion, as I gather it to be, is: 18 "That the-Regional level of funding be recom- mended at $1,121,159, and that due notice be given to 20 the CHP relationships, the renal aspects of the applica- tion and the EMS." 21 MR. VAN WINKLE: What about ',--he CHP relationships? 22 MR. CRMIBLISS: It has been moved and seconded, and 23 is there discussion? 24 MR. VAN WINKLE: I want to be sure of this, because 25 HOOVER REPORTING CO, INC. 320hiamchusetts Avenue, N.[. Washinvoo, D.C. 20002 116-- gHD-51 1 we are going to have to take the message about it to them. 2 DOCTOR VAUN: Carrying through the theme of the 3 illicit relationships, the reason I say that is that one of lqw 4 the ways to avoid CHP comment is to put $600,".'!""@O in a slush 5 fund. 6 MR. THOMPSON: Most of which is devoted to tasks 7 that CliP ought to be looking at. 8 MR. CHABMLISS: Is there further discussion? 9 Question? All those in favor? 10 (Chorus of "Ayelf), 11 Those opposed? 12. DOCTOR VAUN: No. 13 MR. CHM4BLISS: Doctor Vaun is in opposition, and the "Ayels" have it; the motion is carried and Staff will take 14 15 due note of your observations, Doctor Slater, regarding the over-generous non-specifi writeup of the application. 17 DOCTOR SLATER: Which I rated as C-minus, by any elementary school standards. I.am very unhappy with this; I am very unhappy with the amount we have given them, I don't 20 know what to cut it back to, because it is almost impoIssible to make a judgment. 21 MR. THOMPSON: I think a critical question is 22 whether the $600,000 was a dowry or a bribe. MR. CHAMBLISS: Those are two legal phenomena, and 24 the Staff will take note of them. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 (202)546-6666 WHD-52 I DOCTOR WHITE: I won't cast a negative vote; I will 2 just abstain. 3.1 MR. CHIUABLISS: I think those of you on the 4 Committee who are interested in measurements would like to. 5 know that we are 66 percent through our workload for today, 6 we are now 35 percent through our workload for this panel., 7 it is getting close to 3:00 o'clock, and those of 8 you who would like,coffee may have a chance;.those, of you 9 who would not like to have coffee and would rathei..have it 10 later on today? I am with you and we can proceed; it is left to you. (Discussion off the record) .12. MR. CHK%LBLISS: Would you like a break? 13 14 DOCTOR SLATER: Why don't we take a break and bring it back to the table? 15 16 (Whereupon a short recess was taken.) 17 18 19 op 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Mawchusetts Avenue, N.[. @,i@rigton, D.C. 20002 (202) E46-6666 iig IHD-53 1 MR. CHAIIBLISS: All right; I would like to reassemble 2 the Committee and lay out a suggestion for you, in terms of 3 what we might be able to do today. 4 If we could consider the regions in this order, I 5 think it might lay out for us a work-plan for the balance of 6 the day: 7 Wisconsin, coming up first. 8 Kansas. 9 Michigan. 10 Mississippi. .11 Missouri, and perhaps Illinois, and 12, Louisiana. 13 If we could make that accomplishment today, we would 14 be well into tomorrows work and that would mean we would have 15 completed half of our re"g;'p@s. I hear the words "let's go," and I am ready, and I 17 hope you are. 18 I would then call upon Doctor Carpenter and Doctor 1!) Scherlis; I will call upon Doctor Carpenter, and Mrs. Parks 20 as his Staff support, to now begin the presentation of the 21@ application from Wisconsin. 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massaf husetts Avenue, N.C. Washington, D.C.20002 t9n2i 546-fifi66 120 IHD-54 1 REGIONAL MEDIAL PROGRAM REVIEW 2 WISCONSIN- 31 DOCTOR CARPENTER: Thank you, Mr. Chambliss. 4 This one is to some extent a rerun of what we have 5 heard..before. The Region has, as you have heard this morning, 6 lost its distinguished coordinator, and so we have a.Region 7 with a very illustrious past history that now, I believe, 8 judging from the rather poorly.written application, is ina 9 crisis of leadership, and so it is hard, first of all, to know 10 whether again, whether it is just that the words did not get on paper, or whether the leadership really is going to 11 12. be a problem.. 13 I think I have no way to judge that it won't be a problem, and so you can see something about where.,I start. 14 The program staff and professional staff well, 15 it is worth noting that,th e asking for a 276 percent @y ar increase in their funding, and the- program staff has fallen 17 to eight professionals. 18 The Advisory Group is not -- it has m et three times or so, but not accomplished anything that is too clear in 20 21 terms of responding to the vicissitudes of the recent past. I think past performance has been quite good. They 22 have terminated 18 projects, and all but-three of those are 23 still operating in the state, in independent funding. 24 The objectives and priorities are very vaguely 25 HOOVER REPORTING CO, INC.. 320 Massachusetts Avenue, N.[ Washington, D.C. 20002 (202) 546-6666 121 I-IHD55 1 stated; they seem to be little more than a description of 2 Federal priorities. 3!! Except for this evidence of past performance, there, 41 is no evaluation to speak of of what is going on now and the 5 projects themselves have vague goals; frequently there are 6 multiple projects in a single area, and no evidence of coor- 7 dination. 8 For example, I think there are six or seven projectE 9 in the area of continuing education and the-Continuing 10 Education Committee of the Region has not met for,the last 11 year. 12. I think their CHP relationships, as far as I --could make out, were reasonably good, although in one instance 13 Comprehensive Health Planning responded with negative comments 14 of a technical nature about one of their projects, and as 15 read the project description, I must say that I believe CHP 17 was right. 18 And the Region did not take any note that I can see of the ideas coming from the Comprehensive Health Planning agency. 20 So I did not think there was any way this region 21 could be considered above average, and I was -- in other t3me@f 22 you know, this Region would not have been an average region, 231 and therefore, the 276 percent @ncrease in funding did not 4 seem very logical. 25 HOOVER REPORT[ITG CO, INC. 320 i'liassachusetis Avenue, N.C. Wa&@iiigto, D.C@ 2M 122 WHD-56 1 There were several things, many of which were broug1t. 2 to the attention of the Staff, on these yellow sheets here. 3 You notice there are now eight full-time professionals on the! 4 staff, and it is proposed they hire an additional i people 5 in the next year to a program which will presumabl phase out 6 at the end of that time, and although in the past ere has 7 been a close relationship to the Governor's Office n this 8 state,-nothing,is made of that.in the present application, 9 and there is no reason for me to assume that those 15 people .10 would have any kind of continuing employment, and urless the labor market is better in-Wisconsin than it is in Letroit, !peopl 12, they are in trouble, in trying to recruit that many e. I 13 Nor am I certain that in the course of a yeart even if they could find them, they could get them organized into 14 a constructive program. 15 The Region ag'@pent $1,,400,000 on Emergency 17 Medical Services, and -- or at least they were awarded $1,400,000 -- and I would assume they spent most of it, in 18 19 the last -- they have $118,000 to run them to June of '74, 20 and they are requesting essentially another million more. The program is very well described. This particula 21 project is very well described; they think, you know, the goa s 22 have been set up for some time and they'are good goals, to 23 show that there has been qi4ite a bit of thinking. 24 But.I guess we have the problem now, with independent 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington. D.C. 20002 12 gHD-57 1 funding available elsewhere, whether it is appropriate for us 2 to spend that much money in very direct -- you know, by buying 3 telemetry equipment, in the direct development of the EMS 4 system. 5 On the other hand wellt I am not sure; it may-,be 6 that there is adequate staff in that area, so this one thing 7 they might do'particularly well. I can say no more about 8 that. 9 There are $430,000 in continuing education projects, 10 plus $100,000 for a discharqed-summary review for the hos- 11 pitals in the state, so it is $530,000 in essence@lfor that, and that in a place where the continuing education committee 12, does not meet, and where there is no particular indication 13 that,,you know, it would be fine if they could say: 14 IlWe are going to look at the discharge summar- ies and try to ide@@@fy somethings that continuing education is needed for." .17 But there is no suggestion of any melding of -the idea of 18 19 quality review in continuing education that I can think of, or that I can find. 20 21 There are a couple of research,projects that snuck in: development of sero-diagnostic procedures for gonorrhea 22 and quantitative cytotoxic assays,, and they are exciting 23 projects. The cytotoxic assay, though, they didn't even 24 bother to describe it as a part of the Regional program, so 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (?n2) 124 HD-58 1 there is another $100,000 that troubles me. 2 There is $156,000 in mental health programs, and I 31! -- they are not such bad programs, actually -- are we allowed 4 in that business? MR. CHP14BLISS: That is an expressed concern of 6 Staff, and we would certainly note your concern, because it 7 does raise a substantive policy issue of funding., 8 Your question is very germane. 9 MR. VAN WINKLE: Those programs have traditionally been funded elsewhere. 10 11 DOCTOR CARPENTER: Well, you know, I suppose you can make a regionalization out of mental health as well as 12. out of physical health, but we will leave that for the policy-- 13 makers. 14 1 15 I wonder if Staff would like to comment before I guess at a -- or before,one of you all guess at a funding 16 level? 17 MR. CHAMBLISS: Mr. Van Winkle, will you and Mrs. 18 Parks? 19 20 MR. VAN WINKLE: I want to say one thing about-EMS. This was a proposal that had been submitted to us, 21 to a select EMS Special Review Committee; it wad approved 22 for three years, and received two-year funding direct from 23 here, in addition to their.normal operatig -funds. 24 The reason we flagged it was not that it was any- 25 HOOVER REPORTING CO, INC. 320 Massachusetts Aveiue, N.[. Washiiigton, D.C- 20002 (202) 54@ 6 125 4HD-59 1 thing new; it is a continuation but we flagged it because 2 what did they get on their first award? 3 MRS. PARKS: I think it was about $1.6 million or 4 something, for a two-year period. 5 MR. VAN WINKLE: They are asking almost as much 6 for the third year as they had for the full two years, and 7 that seemed like a tremendous Iincrease in funds to us. It 8 looks like a doubling up in the last year. 9 MRS. PARKS: Well, this is why it was flag d, 10 simply because it was a tremendous increase over wha they 11 have gotten. 12, DOCTOR CARPENTER: What do you know about e manage-. ment system for the use of those funds? Is it these eight 13 14 staff,people, or do they have now a group of people who are established 16 MR. VAN WINKLE:,/They are well-established, and 17 Mike, from the Mid-Continent Branch, has visited that program, 18 cnan EMS basis, and I think the concurrence is that this is 19 probably one of the better EMS programs that they have run into in the country. 20 MR. POSTA: Of all the supplemental funds that RMH 21 22 put.out -- we did visit 23 projects this past year, and they wae without a doubt the top program. 23 MR. V;Li WINKLE: But our question was -- the reason 24 we brought it to you is that that seemed like a tremendous 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C.20002 @., 'Itp 126 WHD-60 I jump in funds, because that is about what they had for a two- 2 year period, and now they are asking for almost that for 3 the third year. 4 MR. CHAMBLISS: I would like the Committee to know 5 that we are asking for your judgment here as to -- and your 6 recommendations about the funding. 7 DOCTOR SLATER: Well, just a minor one, because it 8 is such a small amount of money. Mrs. Salazar and I were 9 consulting, wondering whether that Self-Administered Sex 10 Therapy Program is violates the Federal guidelines for 11 RDIP s. 12. MR. CHAMBLISS: That is certainly one of the policy 13 matters we will'be handling. 14 MR. VAN WINKLE: Ile could not particularly tie that 15 back in to their goals and objectives. 1(; MR. THOMPSON: @o got the book? 17 MR. CHAMBLISS: That has been noted with great 18 interest; that will be taken into consideration. 19 MR. THOMPSON: Who is the Principal Investigator? 20 MR. VAN WINKLE: Doctor Carpenter, I would like to add one thing. 21. 22 We have Staff concerns here about the leadership of the program. I think you should know they quite recently 23 came in for some rebudgeting,of,some dollars they had, and up 24 to this point in time I don't believe we have approved that. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D@c. 20002 127 'HD-61 1 14RS. PARKS: We have not gotten the additional 2 information. 3 1 MR. VAN WINKLE: We have told them to go b4ck-home 4 and further justify the information that would even allow 5 them-to-rebudget. 6 So we are concerned? and we think we have tried to 7 express this. 8 MRS. PARKS: During the phase-but, Doctor (,arpenter, 9 they did lose just about all of their key professionals on 10 their staff, and of course, as you mentioned., Doctor Hersbeck 11 finally left, too. 12. At one point they were down to just about o one T except the present Coordinator, and the management aspects of 13 14 the program -- there was actually no one there-at one point to handle the program. They have hired accountants now, and though while it 17 is.kind of early to really evaluate his effectiveness, he 18 seems to be getting in there and-trying to get some of the 19 problems straightened out. 20 MR. VAN WINKLE: He is one of the positive things we see. 21 22 MRS. PARKS: Right. And the request for additional staff frankly, I can not justify it because I am hot clear 23 on what all of these people.willultimately do and it just 24 seems awfully itious to me. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 (9fl9l rAg.@fi6fi 128 WHD-62 1 DOCTOR'SLATER: It sounds to me as if the judgment 2 is going to have to be made substantively, rather than in 3 any specific objective grounds that you have. 4 What I hear is that we don't now know how the staff 5 will be used, and we are uncertain what -- whether or not 6 they can really float that much by way of programming if they 7 have the money. 8 I am talking about making a recommendation of 9 $2 million. They are at $1.73 now; that leave about another 10 @500,000 to come back in for in July to get up to the 100 percent. The 276 percent is just out of the question. 12 DOCTOR CARPENTER: Is that a motion,.' 13 14 DOCTOR SLATER: I am just asking if that is a sort 15 of ballpark -- if we are both together. DOCTOR CARPENtE@@: I,,couldn.'t@decide between $1.70 and $2.0. 17 MR. CHAMBLISS: The Chair will entertain a motion 18 19 here as to the level of funding recommendation. DOCTOR MILLER: Could I ask a question first? 20 MR. C@IBLISS: Yes, Doctor Miller. 21 DOCTOR MILLER: Is it.true, and to what ektent is it 22 true, that the current level of annualized funding, as you 23 have,listed here,, in most cases probably is the level that was 24 the highest that Region ever had in the history of the Region? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (202)546-6666 129 WIID-63 1 MR. CRAMBLISS: Is.that the case? 2 MR. PULLEN: Yes, sir. 3 DOCTOR.MILLER: I think most of these are just 4 about the top that the Regional Medical Program has ever 5 had. 6 MR. PULLEN: I think- it was more the 779. 7 MR. CRAMBLISS: Nonetheless, in this Region, if you 8 add to it the Emergency Medical activity, you would find it 9 a-substantively higher level of funding of Regional program ,the level. 10 activities; I think this is about DOCTOR CARPENTER: Do you have an expenditure report 11 12, for the July meeting? llhat Am I asking for? That would be too early, I 13 guess? Yes; sorry. 14 DOCTOR SIATER:,, Recommendation for two million 15 dollars? DOCTOR CARPENTER: Yes. 17 18 MR. CHIUIBLISS: I am advised by Mr. Pullen, of our Grants Management Staff, that the expenditurereports were due 20 May lst, and they are in the process. They are being pro- cessed now, so the answer is yes, we will have an expenditure 21 report by July. 22 DOCTOR CARPENTER: If they are expending at the rate 23 they say they are, in July, or as they say they might be, and 24 we want to push the Emergency Medical Program at that time, we 25 HOOVER REPORTING CO, INC. #.t r 130 :WHD-64 1 would have another opportunity, or if we wanted to take the 2 lid off, then I would second what I understand to be a motion 3 for two million dollars. 4 DOCTOR SLATER: Two million dollars. MRS; PARKS: Two million? 6 MR. CHAI-,IBLISS: The motion has been properly moved 7 and seconded that: 8 "The level of funding to be recommended for 9 the Wisconsin Regional Medical Programbe set at two 10 million dollars.' .11 Is there, further discussion.>- 12, Are you ready for the question? 13 DOCTOR CARPENTER: Yes, can I add a little, or at 14 least,think about adding something to the record? In view of the problem of whether they can effectr 15 ively use that money for the Emergency Medical Service, would 17 it be practical to ask them for an interim funding report? 18 This one here will only carry them into '73. I guess that would be July of 173, so if -we could have a few months more 19 p information, I think it might help them. 20 MR. CHIU4BLISS: Yes, we can request that, and Staff 21 will do that. 22 Is there further discussions 23 Call the question;.all t@ose in favor? 24 (Chorus of "Aye") 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 131 qHD-65 1 Opposed? 2 (No response) 3 The motion is carried. 4 - - - .5 MR. CHAMBLISS: I would like now to turn your 6 attention to the Kansas Regional Medical Program. 7 The presenters for Kansas will be Mrs. Wyckoff and 8 Doctor.Vaun, and Staff support'will be in the person of miss 9 Mary Murphy. 10 11 12, 13 14 15 17 18 19 20 21 22 2t3 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 132 'IHD-66 1 REGIONAL MEDICAL PROGRAM REVIEW 2 KANSAS 3 MRS. IQYCKOFF: This is a modest request IKansasl 4 I am going to follow your design that you have in e Review 5 Sheet, and try to construct my report along those nes. 6 Program Leadership: the Coordinator, Doct r Brown, 7 has been with the Kansas RMP for several years and nows how 8 to.work with the Kansas state and local organizations. 9 He understands the nature of Kansas and has its support. He has bent over backwards to get provide support 10 in the early days,. and has never fully recovered fr m that effort. 12. 13 He has a good working RAG, which has met egularly 14 every,month. His Executive Committee functions regularly, as 15 does his project-review committee. They have good-EMC 16 representation. The program staff. During the cut-back the staff 17 18 was reduced, and if you w.ill look at the little yellow sheet here you will see that he has, really, a very small staff of nine professionals, two clerical. 20 MR. CHAIMLISS: If-you would kindly talk just a 21 bit louder, please? 22 MRS. WYCKOFF: The remaining staff are skilled, 23 having a minimum of 16 months RMP service. They have had to 24 do dobule duty in project development and monitor@. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 (202) 546-6666 133 %711D-67 1 The Health Service education directors have helped 2 to fill the vacuum created by the loss of coordinators. 31 There is a close and cooperative effort work with the CHP. 41 There are no minority members on the staff as fat 5 as I can tell. 6 The RAG. The RAG has about three or four consumers 7 among 22 persons, and appears to have only one minority mem- 8 ber, though there are a very few on s ome of the subcommittees. 9 The RAG is hard-working and dedicated, and has an 10 @ecuti've Committee that keeps things moving in between 11 Council meetings. -Its Project Review Committee screens and evaluates and recommends all projects to the Council, and 12. the Evaluation Committee monitors the projects. 13 The RAG shows itself capable of acting well under 14 the stress of the present application. It has a liaison su:)- 15 16 committee relating to CGPI. However, this report is probably the most confused 17 report that I have ever read, and if I seem confused, it is 18 because I have been mired in it, trying to find what it is 19 20 he's trying to say. So you will have to excuse the jerks 21 when we jump back and forth between subjects. 22 I will stick, however, to the design we have ere. The past performance has addressed substantive prob- 23 lems, in accessibility and availability, both in rural and 24 1 .1 I urban ghetto areas. For example, under "Accessr" they have 25 HOOVER REPORTING CO, INC. 3','O Masmchosetts Avenue, N.C. Washik-tor., D.C. 20002 fl)M% CAR@rIg 134 the Model Cities Program, which of course was closed down 2 by other factors than RMP. The Ottawa County health clinics, the Dart City 4 Indian Health Care Clinic, DeSoto Rural Health Clinic, Kansas 5 City Rural Clinic; under their efforts toward efficiency and 6 quality in professional performance, they have improved the 7 Kansas Library Information system. 8 They have a rural circuit course for nurses that 9 has been effective. 10 These are examples of what they have had; the cadre training for pharmacists, and under "New.Skills" @y have, 12, had several courses for clinical nursing and dental systems. Under teir "Past Efforts at Regionalization," 13 14 they have their Great Bend project. I had great pleasure in 15 making a site visit to that oncn, and it is quite an experience, 1(; I assure you, puddle-jumping..,across those:fields in a tiny 17 little four-seater plane with Doctor Nicholas. I realize how thoroughly rural a lot of Kansas is. They had an extended coronary care unit, like most of the RMP's of that day, and nephrology training. They have 20 been working to set up the the'core staff has-been working 21 'to set up four big health education service centers, and they 22 are now coming in for a substantial amount of money for these. 23 They have helped uithother Federal programs; fty 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 135 IHD-69 have been called upon to help with the Emergency Medical 2 Service, and they have successfully launched the bi kidney 31 program which is quite well known throughout the center of 4 the country. 5 The measure of their work, I think, is seen by the 6 fact that the major the 13 major programs that have been 7 terminated have been continued with local support or with 8 other support. 9 Their Circui-t-Nursing Course, their Physi ian lo Placement program, their Kansas Library project, th Nurse- 11 Clinician project, the basic education for medical lerks, 12 and the formal regionalizati6n of the kidney program, and -13 method of treatment. 14 Under Point No. 5, "Objectives.and Prioriti sr' they'say their objectives have shifted from the emphasis on 15 the information gap to direct concerns for the expansion of new services, Region-wide projects, or categorical disease and quality assurance. 18 19 Much work has gone into sub-regional area develop- ment of these manpower services, area education progra ms 20 including public education. 21 They have had varying degrees of success in carryin( 22 out their short-term objectives in the following fields: 23 Health-care delivery,"primary care-. 24 1. More effective health manpower; 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[ 136 GiD-70 2. Quality medical care assurance. 2 3. Disease control. 3 And it is not until you get under "Disease Control" that they "4 mention anything to do with planning. 5 The new proposal falls into place as congr en wi 6 the-major thrusts listed above. 7 The 13 projects for which they asked continuation 8 funds are in line with their program objectives., and they .9 have been carefully and favorably reviewed by CHP. 10 Four new projects:are as follows: 11 Quality assurance of diabetic care: $ 8,500. 12 They proposed to develop a model management sys m, protocols for the health-care team, education, assessments 13 14 of patients,,projects in training and utilization of the diabetic nurse-practitioner, the CHP 15 The CHP comments: 'The issue of funding beyond the first year 18 is not addressed, and efforts to obtain patient input 19 and acceptance are not described. However, the major 20 outcome expected appears@to be in standards for use in peer review and in professional education systems at 21 KUMC. 22 This will supplement the 'uvenile diabetes project 23 now under way in Wichita, and sponsored by the Kansas Diabetes 2,4 Association. These fit under their objective 3 above: qualitN 25 HOOVER REPORTING CO, INC. 137 WHD-71 I improvement.. 2 The second one, the second new project that they 3 are asking for is primary health care in DeSoto, a small 4 rural community -- $26,288. 5 The rural community has raised $4,000 in this rural 6 connty of a population of about $7,000 for a primary care 7 clinic sponsored by the Cedar Valley Medical Association. It 8 is now operating with a nurse-practitioner and a part-time 9 physician. 10 CHP okays the project but raises the question about 11 the development of criteria for disposing of grant-related .12 income. This is one of their rural access objecti ves. The third one is the Berkley Health Education pro- 13 14 ject,'which as I guess you know, is a 6th and 7th grade publi,l education program -- a campaign against smoking. 15 The fourth one -the per'lrEtal mortality project regionalization, is for $305,000 and it is a very elaborate 18 project, and they admit that this will take at least five years before this can become operational. 19 20 The RAG says that this has special merit, and I question very seriously how we are to interpret the term 21 "feasibility" when they say that with five years that five 22 years is the limit that they need. 23 Now, with CHP relationships, I would say they are 2,4 very good, although they have not been funding CHP activities 25 IOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Nashington, D.C. 20002 138 HHD-72 1 as much as some of the other RMP'S. 2 I notice on the Staff summary that the concerns 3 here -- No. 1, Project 70-A, Emergency M edical Training, 4 Extension of Project 70 -- was initiated from program stff 5 funds and is a continuation of the activity. 6 This seems a legitimate enough program, if we are 7 permitted to fund this sort of-thing. 8 The second, Project No. 51, where the funds went 9 from $24,000 -- or $48,000 in one year to $117,1000 in one 10 year, is a pretty big jump, and Project No. 52, which has 11 gone from $40,'OOO to $112,000, is also a pretty bi@jamp. 12 But from the little I am able to find in material, it seems as though they have been preparing to expand, and 13 that they possibly can do this effectively with the increased 14 15 funds, since they have bwilt a network at the junior colleges, and they have laid the groundwork for the health services education work. The one I raise the question about, however, is the 18 $305,000 perinatal project, and I would like to hear from 19 Doctor Vaun about it. 20 MR. CHAMBLISS: Will you continue, Doctor Vaun? 21 DOCTOR VAUN: I think the Director comes through as 22 a very strong and good leader for @he project. I am impressed 23 with him, I am impressed with the continuity of RAG at a 24 very difficult time; I am impressed with the shift of object- 25 HOOVER REPORTING CO. INC. 139 ,D-73 ives, and more so with the addressing of projects to the 2 rather mundane, everyday needs of people, like dental atten- 3 tion, and diabetes, rather than tribioplastic tissue's@. 4 I am tremendously impressed with the scope of 5 their projects relating to real health care needs. 6 I am further impressed with the continuation of 7 fundings on projects that have been terminated. They have 8 a good track record with that. I would hate to dock them 9 anything, but as 14rs. Wyckoff has identified, I think they@ lo are overly ambitious in their perinatal projects, and I .11 don't see coming through any special contribution !on the part 12 of the hospitals. 13 I think their faculty is terribly fat, with two 14 part-time neonatologists; I didn't know there were that 15 many in any one state, lea alone-that they' were going to be 16 faculty, and -- you know, again addressing thernselves to the development of their own intramural audio-visual aids this just leaves me a little cold.. 18 So I would recon-nend,..subject to Mrs. Wy6koff's 19 modification, a $100,000 reduction from their request. The 20 request'was $1,733,'380; I would recommend $1,633,380. 21 I.Oo it with tongue in cheek, because it would 22 23 appear that these people came in with a very reasonable request. They didn't ask for the Moon, like some of the pro- 24 grams have, and I hate to dock them anything, in view of the 25 if%nucoorbnblriupr.n owe i4o HD-74 1 fact that they are not even up to what target might be, but 2 said, is overly ambitious, QQe5 LLOt I think the project, as I address certain items that I think are terribly impor an 4 So I think I am going to recommend that th e 5 docked $100,000. 6 MR. VAN WINKLE:, And do you want a message to get 7 on that particular project? 8 DOCTOR VAUN: I think something should be 5 id. 9 about it in light of'what Mrs. Wyckoff commented abo t. 10 MRS. WYCKOFF: They are only asking for 771percent 11 of their target, and when they get -- if they get t whole 12 $300,000 that they ate asking for in July, they.wil only f their target. 13 get 91 percent o 14 so theirs is a very modest request, actually. I am sorry that they have put jeo many eggs in one basket. 15 DOCTOR SLATER: Question. If there are funds left over after these two rounds, is-it possible for these Regions -,17 18 to come in again for further supplementary funding? 19 IAR. CHAMBLISS: No, there will not be, Doctor Slater. 20 DOCTOR SLATER: This is the end of the l-Lne, even 21 if there is money left over? 22 MR. CHAMBLISS: They will not have a new opportunity 23 11 to apply. The July 1 application date is the final date as 24 things stand at the moment. 25 i4nnvFR RfPnRTING CO- INC. 141 NHD-75 I MRS. WYCKOFF: I woul d like to ask about this 2 indirect cost information that is in this project. It ranges 3 from 55 percent down to 8 percent, and I wondered if -- if 4 it is perinatal, what would affect this? 5 MR. CHAIABLISS: I wonder if our Grants Management 6 man would speak to that?"I do recall Kansas having perhaps 7 one of the very low indirect cost rates, sometime ago. MR. VAN WINKLE: This is different institutions, 9 is it not? 10 MRS. WYCKOFF: Yes, it is their whole list. MR. CHAT4 11 BLISS@ Staff is checking that now. 12 MR. VAN WINKLE: It is just the varying rates, I would'guess, between whatever institutions receiving the 13 funds-- 14 MRS. WYCKOFF: Z.hop-etwe are talking about the 15 right one. MR. CHAMBLISS: I would simply ask one question of 18 the reviewers. Are there any comments to be made with regard 19 to-CHP-RMP relationships,in this Region? MR. VAUN: I think Mrs. Wyckoff mentioned that. 20 From the report they appeared good. 21 MRS. WYCKOFF: Yes, their relationships are good. 22 I do.think they need a little ppodding on the affirmative 23 action program. 24 They have a very small staff, but I think they 25 iinrturD DcorinTime en imp 142 iD-76 should pay attention to it on their Board on their RAG. 2 So, with that as a suggestion, I would like to move 31 approval of the 4 DOCTOR VAU14: $100,000 reduction in their-request. 5 MR. CHAMBLISS: Is that in the form of a motion? 6 MRS. WYCKOFF: $100,000. 7 DOCTOR VAUN: $1,633,330.00. 8 MR. CHAMBLISS: All right; that is a motion, I take 9 it? Has it been seconded? 10 DOCTOR VAUN: I will second it for Mrs. Wyckoff. 1,2. CHAMBLISS: It has been moved'andseconded; is .12 there discussion? 13 MISS MURPHY: I would like to make an addition. 14 -MR. CHAMBLISS: We would like to have further input from the Staff. Miss Murphy? 15 MISS MURPHY: I@would like to add that they did hav(, a minority professional on the staff, and with the phase-out 18 she left them. I think that improbably what has actually Iq happened.in a lot of areas. DOCTOR MILLER: In response to a question by Doctor 20 Slater, it is fair to say to tell the Committee that the 21 PJ4P-DIOIP staff does intend to award all the funds that are 22 23 available, if the IReview Committees approve that much and the National Council approves it. 24 MR. CHAMBLISS: Yes,. they do indeed. 25 HOOVERREPORTINGCD,INC. 32OMasuchusettsAvenue,N.E. Vi@izgton, D-C. 20OU 143 WliD-77 DOCTOR MILLER: The intent is to award all the 2 money requested now -- between now and the next period. 3 MR. CH@IBLISS: If it is properly reviewed and 4 recommended, yes, we will. 5 DOCTOR SLATER: Well, the question came up- this 6 morning, on whether we might like to recommend withholding, 7 rather than give it away to the programs. DOCTOR MILLER: We might,' but if we do it will just 9 be on expended funds; it will not be awarded any other way. 10 MR. CHAMBLISS: All those in favor of the motion? 11 (Chorus of "Aye"). 12 Those opposed? The "Ayels" have it, the motion is carried, with 13 a recommended level at $1,633,380. 14 15 18 19 20 21 22 23 24 25 .tnntirn nrDnnTIMf- f-n lkff' 144 qHD-78 1 MR. CHAIIBLISS: Shall we now draw our attention 2 to reviewing the application from the Michigan Regional 3 Medical Program? 4 M. TOO@IEY: Did you rule on this Inter-Mountain? 5 MR. CHAMBLISS: The Inter-Mountain Region will be 6 reviewed in lieu of Wisconsin in our final session. That is' 7 how we got Wisconsin early oh, and Iowa was also on@ that 8 we were holding over, and I thought I would review t em n 9 -that order, until Doctor White returns. 10 MR. TOOMEY: Unless there are other reasons, I am 11 here, Mrs. Salazar is here and Miss Murphy is here; y don't 12 you get rid of Inter-Mountain? MR. CHAMBLISS: All right. All the parties are .13 14 here, and Inter-@iountain will be presented by Mr. Toomey and Mrs.-Salazar, with Miss Murphy as the Staff person. 15 18 .19 20 21 22 23 2,4 25 40OVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 14 ID-79 1 REGIONAL MEDICAL PROGRAM REVIEW 2 INTER-MOUNTAIN REGION 31 MR. TOO@IEY: Once again, back several year.s ago 4 I had the opportunity to visit the Inter-Mountain Medical 5 Program prior to awards, prior to Doctor Stuart's becoming 6 Coordinator. I think it was Mr. Hagman who was the Coordina- 7 tor' back then when I visited. 8 The implication, in my-opinion 9 DOCTOR SLATER: Would you speak up, sir? 10 MR. TOOKIEY: Program leadership is satisfactory, 11 from all appearances. I have not met Doctor Stuart@-but I. 12 understand that he is rather a contrast to the form r program coordinator. 13 The former program coordinator had some Oifficult- 14 ies with the administration of the University of Utah, and 15 apparently from the matex4al in.the application, Doctor Stuar-- has been able to overcome those problems, and their relation- ships were on a very sat isfadtory basis. 18 @19 The program staff seems adequate in size; their capability seems to be sufficient. When I was there a year 20 and a half -- two years ago, they had some trouble with the 21 22 evaluation prbg.r@ and apparently that program still exists, because one of the positions are still vacant, and the 23 Deputy Director of the program,is in charge of the evaluation 24 at the moment. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Viashinaton, D.C. 20002 146 fHD-80 I Their Regional Advisory Group, as far as I see, 2 both in the application and from my pers onal contact, is 3 sather outstanding. They are interested, they meet regularly 4 as a matter of fact, they had five meetings that were-listed 5 over the past year. Their Executive Committee meets -- has 6 met at least three times. 7 The past performance and accomplishments of the 8 tnter-Mountain IU4P seem to be adequate. Their relationship 9 with the Comprehensive Health Planning agency in the area. 10 they cover, which incidentally covers Utah, Montana or 11 parts of Montana, Colorado, Wyoming and Nevada, and they .12 have programs that have been extended into each of' these ia areas. They have established as their objectives and 14 priorities programs related to rural health care needs, to 15 strengthen -- the strengtzehing of.the local health planning-#, to -quality Assurance -- projects related to quality assur- 18 ance in primary health care, an(I the Emergency Medical Services. GP Their proposals seem to conform at the present to 20 these major thrusts that I just mentioned. 21 I think however, that it is important to note that 22 there are 11 programs for which they are requesting continua- 23 tion funding, and that there are 38 new programs for which 24 that they are proposing in this present application. 25 HOOVER REPORTING CO, INC. 320 Masuchmfts Avenue, N.[. Wasbin@n. D.C. 20002 7 14, Because of the 11 and 38 -- that's 49 projects 2 it seems as though they have in fact bitten off rather much 3 to do, and because of this they have requested considerable 4 sums of money, and if you will look at line 15, the-Inter- 5 Mountain section, their current level of spending, annualized, 6 is $1,878,000. Their targeted available funds are $3,597,000. 7 for hich is 106 Their May 1 request is .$3,849,000, w 8 percent of the targeted available funds, and the total of 9 the July 1 estimate is another half-million'dollars, which 10 would bring them up to $4,349,000, or 120 percent of the targeted available funds. 12 In terms of the yellow sheet that you have in your booklet, there is -- the very last line, I believe, the In ter- 13 Mountain Regional Medical Program is considered a.good pro- 14 gram, but it is felt that the Region is over-funded. I might say I heard this from several source from people who have been acquainted with the program, but I have to say, in defense of what has been done, that-it has 18 been a very aggressive, a ve@y viable, a very concerned pro- gram, and it would seem to me that on the record of their 20 past accomplishments, they would probably rate as certainly 21 a good to excellent program. 22 I would agree, on this premise, that they should 23 peftps have a greater consideration given to the amount of 24 money that they are requesting, more on the basis of the fact 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 148 gHD=82 I that they are requesti ng three and almost four times as 2 many programs -- to be put into operation as what they 311 currently have in operation, and from that basis it would 4 seem'to me questionable as to whether the total amount of 5 dollars should be provided. 6 They have done one other thing, apparently within 7 the past year, the implications of which I am really unable 8 to evaluate at the moment, but because of the interest in 9 RAG and apparently because of the extreme what I would, 10 consider to be their concern that they continue with an on- 11 going operation, to pick up the main threads of an @NLP pro- .12 gram and develop a new organization called the "Health 13 Development Services Corporation," and this was,not in exist- ence when I was in Salt Lake City, previously. 14 I did not have the opportunity to talk with the 15 staff about this, but it deiamed,.f'rom very quickly reading this paper, which is an attachment in your booklet, that it seems they have created an or ahization structure which would 18 9 19 allow for the work of the Regional Medical Program to be carried on, to secure funding from numbers of sources, and 20 to provide for -- really through the sale of their services, 21 2-2 to provide for the'continued development of many of the n6ede@ programs in those areas.- 23 This sort of Health Development and Services 24 Corporation, which is a separate organization, has come back, 25 HOOVER REPORTING CO, INC. 320 @Aassachusetts Avenue, K.E. W@@@n D-C.20002 140 %7HD-83 now, to IIUIP and requested funds for some of the projects 2 that IRMP has approved in the amount of almost $405,000. 3I' So IRMP will be funding an organization which was created by IRMP to pick up the threads of the work of 5 Regional Medical Programs in carrying it on, and it is a 6 voluntary non-profit organization, and I don't mean then at 7 all to imply that there is a thing wrong with it. I just 8 think it is a very in novative and aggressive kind of move 9 on the part of the people in that area to provide.for them- 10 selves a mechanism to continue their work. 11 The other thing to which I would call your atten- 12 tion is the extent to which IRMP is -- and you will find this, again, in your yellow sheets -- they are providing 13 14 assistance to the Idaho Comprehensive Health Planning agencyi the Utah agency, the Montana agency, the Western Colorado A 15 agency, comprehensive heai-Eh planning, and in Nevada the Comprehensive Health Planning A agency, so that these plannini 18 agencies in the state, which make up a part of the Inter- Mountain section, are being specifically funded out of the 19 20 RMP funds, and I haven't added it up but it makes rather a substantial sum of money. 21 In addition to which they have a number of projects 22 related to the development of ifluence in the hospitals to 23 act, I presume, in a more efficient and effective manner. 24 Management consulting services, management engineering, and 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 150 WHD-s84 multi-hospital in-service training, and several others. 2 I would just comment in general on the fact that 3ii that it is the responsibility of personally I am not sure 4. the Regional Medical Programs to specifically focus on the 5 development of the hospitals to enhance their capabilities 6 from a management standpoint. This is the question that I 7 do have, 8 I don't have any question about their support that 9 the A agenciest particularfy in fact -- in light of the fact 10 that it is one of the areas in which the IRMP says they are 11 interest, to strengthen local health planning. 12. I don't know whether strengthening the A agency can be construed as local health planning, but I attempting 13 14 to give consideration to planning needs in that area-. In net, when I look at the record they have, when 15 I have the remembrance of my visdt with the group in Salt Lake City -- their leadership, particularly, from the Regional Advisory Group, and t he fact that their objectives and their 18 priorities are in line with those that they have selected -- 19 or, let me put it this way: their project is,pretty much in 20 21 line with their objectives and priorities that th.ey have selected, and it seems to me that we have a good to excellent 22 Regional Medical Program which shows good strength, innovative 2.3 ability, a desire to continue fhe work,,to enhance the 24 j, ;I planning, to provide for better services in the area, and it 25 HOOVER REPORTING CO, INC. 320 Masm,.husetts Avenue, N-E. 151 THD-85 is only that-I have some doubts as to some of the projects. 2 That is one facet, and I have some doubts as to the ;i 31!i capabilities to initiate, desirably, 3,8 new pro]ects, so that 4 I would change the recommendation change the funding that 5 they have requested, and I don't now, Mrs. Salazar, you 6 want me to say what i think it should be, the neighborhood 7 in which I think that funding should be? 8 MRS. SALAZAR: Yes. MR. TOOMEY:' I think it should be reduced somewhere 9 10 in the neighborhood of two and a half million dollars, as opposed to the request they have, which is $3.8 million. 12. MR. CHA14BLISS: All right. Will -- Mrs.'Salazar, 13 will you make your presentation?. I-IRS. SALAZAR: I have.nothing to add. Some-of the concerns that I have had about the application have been 15 explained by Yx. Toomey, who-has-been in the Region since I have. His last visit pre-dates my numerous visits. -17 I do have one question that perhaps Staff could 18 19 address themselves to, which @-als with the Region's past history and mechanization, dealing with hardware. 20 That was one of the old problems that-we used to 21 discuss. 2,2 Secondly, in reading the last site visit report, 23 which took place in January, I believe, of this year, there 24 were some very serious issues raised as to minority groups 25 HOOVER REPORTING CO, INC. 320 Ni&wchusetts Avetue. N.[. 152 WHD-86 participating in RAG's or Executive Committees and staff. 2 And this, too, is an old program that has been with us for a 3 long time. 4 MR. TOOMEY: I did not have time to read Mary's 5 report on the last site visit. 6 MRS. SALAZAR: The third thing that I might ask is 7 what will be the interface to assure that there will not e duplication of funds going into the new corporation and irto 9 the Inter-Mountain Region Medical Program? How do.they co- 10 ordinate the efforts? Are they two free-standing, and how 11 do they relate? 12 MR. CRAMBLISS: If you raise a question about the corporation, I think the Committee might be interested in 13 something of a report that our Grants Management branch has 14 :15 developed on the corporation, and-I would ask Mr. Pullen if he would express those concerns to the Committee, please? MR. PULLEN: These.are some of the concerns expressed by the Grants Management Branch about the Health 18 Services Health Development and Services proposed by the 19 Inter-Mountain RMP. 20 It does not appear to h.ave the final approval of 21. the grantee to organize a staff. Such a corporation, with 22 RMP employees. We are not aware of the use of RMP employees 23 solely to staff an affiliated organization, as proposed, and 24 we seriously question the proposal-of the corporation as bein 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. IIID-87 I necessary to fulfill IRMP requirements. The proposal appears 2 to be broader in program and geographic scope than the RMP. 3"1 Since it exceeds that of the IRMP-BMS Alaska Projec'l- 4 nt@al costs I do not think it is appropriate for the developme 5 through employee support to be charged totally to t@e grant. 6 As previously advised, the RMP does not charge any 7 organizational costs for this corporation to the g- nt funds. .8 It is understood that this organization is designed to assume 9 all of the normal functions of the RMP program.'staff after 10 termination of grant support. 11 If the corporation is determined to be a f@ee-stand-- 12 ing organization, then.the incorporating costs shoul be 13 spread among the various supporting agencies, not solely to 14 the I@. 15 A statement from the grantee will be required to -16 indicate that the development of-such an organization with itE gra n-t funds is in keeping with the grantee policy, particular- 18 ly considering the broad scope proposed. 19 This proposal would seem to be a mechanism to by- 20 pas-s the changing of an RMP from a university to a free-stand- ing organization which the coordinators have been.discouraged 21 from finalizing prior to passage of legislation. 22 It could well be that if we are able to approve 23 24 this technique, other RMP's mayeelect to go the same route with grant funds in Anticipation of.passage,of new legislation. 25 IOOVER REPORTING CO, INC. @20 Massachusetts Avenue, N.[. l@ngion. D.C. 20002 154 MR. CHAMBLISS: I think that may answer some of D-88 2 your questions. It does express some concern emanating from 3,, the Staff regarding the corporation. We admit that it does have innovative fea ures, 5 but whether there is a bit of prematurity here at the momen 6 will be left for your judgment. 7 i4r. Posta would add further comments. 8 MR. TOOMEY: I don't know enough about it, becuase 9 you know, I didn't get a chance to read this. until ust this 10 morning. 11 MR. POSTA: This, I might say, @Lr. Toomey@ is i -i2 relatively new as far as the other administrative problem 13 issue that we have had to do business with for the last two 14 week s. 15 First of all, we have heard from the Region, too, 16 which which assures us that this is a separate entity, as of July 1, the same as the Health Department or AID or 18 any other institution. I think our concern as far as IRMP is concerned is how much R@IP or grant funds have gone into 19 20 this particular corporation since its birth in January of this year, through a charter with the Secretary of State of 21 Utah. 22 The grantee has worked with the Attorney General; 23 24 they do not think there is any hanky-panky going on. The 25 grantee has written a letter to the RMP giving their views 155 WHD-89 on this particular corporation, and they defiitely will 2 -dichotomize those costs going to the RMP and to this particu- 3 lar corporafion, which to date have amounted to about $18,OPO. 4 That is the latest on the corporation as of this morning. 5 We just got this $18,000 figure this morning. 6 MRS. WYCKOFF: How do they;.from the Health-Set 7 corporations that have been formed all over the country that 8 are non-profit and separate and funded by RMP? 9 14R. POSTA: I wish I could tell you; I can't. 10 I do know that our original I.should say from 11 the Mid-Continent operations concern all,along has been: who 12 are on the Board of Directors? Are these folks a part of the IRMP? And if they 13 are, this might be a conflict of interest, and@@hey would 14 15 have to make this decision. This is what we are still working oh, but I think it is a legal corporation the same as any other corporation 18 asking for a charter in most of your sta es. 19 MR. TOOMEY: As I Oanderstand it, there is an overlapping of the Board membership between RAG and the 20 Board of the Health Services Development Corporation, and 21@ there are employees of IRMP who are on the Board of this new 29 23 corporation, employees. MR. POSTA: Well, the Coordinator, possibly or 24 probably. 25 HOOVER REPORTING CO, INC. 32O Massachusetts Avenue, N.[. 156 @fD-90 1 MR-. TOOMEY: Well, in there it said there would 2 be minority representation from the employees. 3i'i But the other thing it seems it is going to do is 4 to essentially really act as a broker. It will go out and 5 develop programs and then it will come back and attempt to 6 convince IRMP to fund those programs; am I not right? 7 Between the money that is,going througa that organ- 8 ization and the fact that there are 38 new applications, 9 and there are questions about a number of them,. I felt that 10 two and a half million which is, I believe they are 11 annualized now, out of that $1,800, 000, so this represents 12@ an increase over their annualization, but it is a million- 13 three under what they are requesting. MR. CHAMBLISS: Yes. 14 The first presenter, Mr. Toomey, came up with a 15 recommendation, but as I recall,,that has not been placed in .16 the.form of a motion. 18 MRS. SALAZAR: I would be glad to second, but I prefer to withhold & second uctil I-hear some other comments 19 on the other points that I raised. 20 MR. TOOMEY: You see, the point I think the thinc 21 that worries both of us right now is the fact that so many 2-2 people -- well, a number -- two or three people -- have made 23 the comment: 24 "This is an organization which already had HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 157 ,IIHD-91 1 already had a million-eight and seems to be overfunded," 2 and so now they come back in and their request just about 3 doubles that, and you reduce it by a million-three and I 4 think the ques@n still is: is it overfunded, and I don't 5 know how to answer that. 6 MRS. WYCKOFF: Are any of these project numbers 7 money that goes into this organization? We can't tell from 8 this which ones they are. 9 MRS. SALAZAR: Some project staff will be function- 10 ing in this new organization, as I understand it on page 14, 11 but -they would gradually phase out as this thing becomes a 12 free-standing agency. But this is the part that bothers me, as to who is 13 14 looking at that during that interim period when IRMP isi over.- 15 lapping this organization. MR. POSTA: As @-underst'ood that document, the Executive Committee of the Regional Advisory Group is the --17 18 watchdog organization of this new corporation. So far as Mr. Toomey has m@ioned, $1,3,000 19 20 MR. TOOMEY: And the projects that toy talk about, the ones that are meaningful -- medical consultation for 21 rural communities, that's a 99; rural medical technology 22 systems, medical casultations, $40,000. Rural medical tech- 23 nology systems, which is Number,104, is for $115,000. 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Viashindon. D.C. 20002 1 Rural quality assurance, No. 105, is for $126,000. WHD-92 2 And rural medical practice and management.. $114,000. 3 That is No. 106. .-4 The other one is modeling the Utah Health Care@ system, which is only $7,100. 6 That is a level of,about two and a half million; 7 why don't I cut that back to two? 8 I move that we allocate two million dollars to the 9 @Inter-Mountain Region Medical Program. 10 MR. CHAI@IBLISS: There is a motion.on the Iloor that 11 the Inter-@iountain Regional Medical Program be set ta level 12 of two million dollars. 13 Is there a second? 14 MRS. SALAZAR: This is across'the board, lir. Toomey 15 that,you are talking about? MRS. WYCKOFF: Now they are at one million-eight, so this -- it raises them $200,000. DOCTOR MILLER: They are at $1.88 million. DOCTOR SLATER: $200,000 instead of two million. 20 DOCTOR MILLER.@ It raises them $120,000, so you essentially are holding them to the same level ofl.current 21 22 funding. MR. CHAMBLISS: Is there a second on the motion? 23 DOCTOR VAUN: I have a'question, but I don't have 24 a second. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 159 iD-93 MR.. CHMIBLISS: All r'ght; maybe the motion will 2 die for want of a second. MR. THOIIPSON: I will second the motion, just@to g it o' n. MR. C@%IBLISS: The motion has been made and secon- 6 ded that the: 7 "That the level of funding for Inter-Mountain 8 Region be set at two million dollars." 9 Is there discussion? Doctor Vaun? 10 DOCTOR VAUi4: I still have not heard an answer to 11 Mrs. Salazar's question. All I have is hearsay that they .12 are over-funded. I mean, does anybody have any evidence that 13 they have a Swiss bank account or that their projects are lousy? One or the other? 14 otherwise, this is hearsay and I don't think we 15 should use that to reall@cut the program fairly substantial amounts of money. Their performance has been good, I think,, 18 that is what we have to go on,@and not the hearsay that they 19 are overfunded. MR. POSTA: Doctor Vaun, could I respond to that, 20 21 please? DOCTOR VAUN: Somebody had better, I think. 22 MR. POSTA: I think that the Council took a fall 23 site visit to Inter-Mountain this last go-round, and was 241 concerned primarily because of the.turf problems that existed 25 HOOVER REPORTING CO, INC. 320 Masmct@usetts Avenue, N.C. 'Natlington DC-20002 16o gHD-94 1 in Mountain States Regional Medical Programs, the Inter- 2 @4ountain Regional Medical Programs, and Colorado-Wyoming, 3 and I wanted to be careful not to say that this problem is @4 has been solely Inter-14ountain's. 5 But Inter-Mountain has had more turf problems that 6 than all Regions in the country put together. They are 7 even in Alaska now, doing an,EMS project. 8 But,that is to their you can pat them on the 9 back with one hand, but other people, particularly Mountain 10 States Colorado-Viyoming and the like, don't particularly 11 card for-it. 12 So I think that what I am saying is as straight- 13 forward as possible, that there are some people that feel 14 thatIthis Region has got too much money and they are getting.- 15 in everybody's way in the surrounding territories. Now I, what we di@'demand'in this particular abplica- 16 tion is to have the inter-Regional Coordinators group, which is composed of the three Coordinators of those three RMP'S, 18 together with the coordinators, get together and take a look 19 at everything that has been accomplished, And everything that 20 is requested, and everything contemplated on being rebudgeted 21, they actually met on May 9th and have submitted a letter 22 signed off by six people, that all but ten activities have 2.3 24 been'approved by all three Coordinators and RAG Chairmen. They will meet again, and have mentioned two ates 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n f, I)nnn9 161 ID-; 95 1 that they will be meeting together final dollars will be 2 distributed among the three Regional Medical Programs. 3 But I think, to zero in, Jesse, on your question 4 concerning why do we think this is overfunding, it is com3.ng 5 from several different discussions with your group. 6 MR. THOMPSON: @lell, if you have hard evidence 7 you know, when they say Inter-MountAin -- that's between 8 any.two mountains you can find. 9 MR. TOOMEY: You take a look at the suppor.t of 10 the Nevada A agency, and I think they have only touc,@ed a 11 little bit of Nevada, and here they are funding A agents 12 for the whole darned state. 13 MRS. IQYCKOFF: I just don't understand the policy 14 of funding A agencies and then turning around and asking for their approval. There is something corrupt about that. They 15 wouldn't dare not approves. MR. CHAMBLISS: Is there any further discussion? Miss Murphy, I think Jesse had a question about the minori- 18 ties, and we have always brought that up, and it seems every 20 time we get a few on the staff MISS MURPHY: Then the phase-out-came, and we lost 21 several Orientals, but the day after our site visit, the 22 2tl Great White Father brought some Indian into the Inter-@iountaiii. 24 Regional Program from the Arizopa area, and th--y hired him on the spot. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 162,' @lliD-96 I So they hired him on the spot, and he is responsible 2 for all the Indian components that are in the projects. But 3 they still ins@ that they have their quota of minority com- 4 pared to the number of minorities in the Inter-Mountain 5 Region. 6 About hardware, I went through rapidly; I counted 7 about,$173,000 for all the projects. I don't have anything 8 else.to compare to. 9 MRS. WYCKOFF: Are there RMP projects where we are 10 assisting tlie state legislatures with information on an 11 organized basis? 12 MR. CHAMBLISS: That is a policy issue; we have discouraged this before, Mrs. Wyckoff. lie have discouraged 13 14 this before, in this Region, I might add. 15 @IRS. WYCKOFF: There is a great increase in the 16 amount of money for@thatl -Loo.- MISS MURPHY: We discussed that at the site visit 18 and CHP had asked for that program, and their concern in the 19 comments was that they had not elicited the people that would 20 attend, so they had turned the program, the seminar, completely over to CHP, and I think it was 110 or one of those Regions, 21 and they are going to run it. 22 23 They are going to select the people right up there themselves. 24 MR. CHAMBLISS: It simply still has some connotations 25 HOOVER REPORTING CO, INC@ 320 Massachusetts Avenue, N.[. ni,,)nnn,) 163 IIID-97 though, that we might question, especially in dealing with 2 the legislature. 31' MR. THOMPSON: Your primary purpose is to set'up 4 HMO'S; to find out if the state legislature prevents commun- 5 ity sponsored practices, then you have to go to the state to 6 carry out your main objective. 7 MR. CHAMBLISS: We would agree there, but the ques- 8 ti6n is, who should do it? 9 MR. THOMPSON.4 RMP. 10 MISS MURPHY: RMP is the only one with th money; 11 the CHP doesn't have the money. 12 DOCTOR MILLER: Maybe I missed something erd, but 13 perhaps somebody could go over it again. 14 What is the purpose of this new organization? Was 15 this.new corporation formed to replace RI.4P when it finally dies out, or to be the fu@ure coordinator of CHP-RMP, Hill- 16 Burton and so forth, if that evolves? Or is it a foundation- -,17 PSRO approach, or I didn't quite get what the purpose of it is. 19 20 MR. CHAMBLISS: Would you enlighten the Committee on that? 21 22 MISS MURPHY: I think possibly it is your certain your second comment. I thik, they will be ahead as far as 23 the unified health plan is concerned. 24 DOCTOR MILLER: Do they have some articles of 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. @liashington, D.C.20002 164 4HD-98 incorporation or by-laws that would really tell what they 2 are supposed to do? 3 MISS MURPHY: We don't have the by-laws, hut they 4 are incorporated, and there is the whole document. 5 DOCTOR ILILLER: One of the things you are telling 6 us from the Staff standpoint is that one of the thi gs you 7 ought to figure out is how they are going to react to the 8 future legislation, which has not yet been written, which is 9 a favorite story of yours, and in the past, too, I think. 10 But anyway, how do you put all these prog:rams 11 together at the local level? If that is what this is, we 12, ought to give them a bonus instead of cutting down heir funds. Because that is one of the goals. 13 MISS MURPHY: When they formed this,corporation, 14 they,did it with the understanding they could go to places like Robert Wood Johnson Znd try-to get funding that they could not get through the University, because it is a state 18 university, because that is part of the psychology. 19 MRS. SALAZAR: I guess one of the problems that I 20 have with this is the fact that they did not move away from the university immediately. 21 MISS MURPHY: T@ is my complaint. They want the 22 best oflnth worlds. 23 DOCTOR SLATER: The new organization is tied to the 24 university, tc>o? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washinpton. D.C. 20002 165 D-99 1 14R. CHAI@IBLISS: Does this discussion, Mrs. Salazarf 2 begin to clear up some of your questions regarding the cor- 3 poration? 4 Shall I call for the question? 5 DOCTOR MC PHEDRAN: Before you do, I would like to 6 ask Mrs. Salazar, now do you agree with 14r. Toomey's funding 7 recommendations 8 MR. CHAMBLISS: All right; and Mr. Toomeylrp-recom- 9 mendation is that the Region be funded at a level of two. million dollars. 10 MR. VAN WINKLE:"That has been seconded. MR.'CHAMBLISS: That has been seconded. T ose in 12 13 favor, may I have the usual sign? (Chorus of "Aye") 14 Those opposed? (No response.) The "Aye's" have it. -17 Now, may I call-, please, just a short break for the 18 convenience of our Recorder? Just a couple of minutes, 19 please. 20 (Whereupon a short recess was taken.) 21 22 2.3 24 25 DOVER REPORTING CO, INC. @O Massachusetts Avenue, N.E. 'ashington, D.C. 20002 166 WHD-100 1 REGIONAL MEDICAL PROGRAM REFIEW 2 MICHIGAN RL,GION 31 MR. CH2UIBLISS: We would like to resume, after a. 4 momentary break; we will begin with Michigan, and as we begin, 5 with Michigan, we would like the record to show that Doctor 6 Carpenter has in fact absented himself while this Region is 7 under review. 81 The presenters here, Mr. Toomey and Doctor White, 9 supported by Mrs. Parks. 10 Will you proceed? 11 MR. TOOMEY: I am of the opinion that the Michigan 12 program was -- I .am not of the opinion; I know it was difficult to read, difficult to understand,.and I have feel- 13 ings of inadequacy in talking very much about it, ,.because 14 I think that the proposal has a number of inadequacies. 15 Program leadership was difficult to determine for the kind and quality of program leadership; as a matter of @17 18 fact, I am not even sure at the present time who is the program coordinator. 19 In a listing of staff, it listed Doctor Tupper, and 20 in all of the signatures it had Doctor Graham-Welk as the 21 individua 1, and --so I have some concern -- not concern, t 22 23 I just don't know. The program staff; they have 12 people, four cleri- 24 cal, five professional and three in management. 25 HOOVER REPORTING CO, INC. 370 Massachusetts Avenue. N.E. 167 WHD-101 1 The question you had on tIhe review shseet is the 2 adequacy of the program staff to manage and monitor the 3 operation of projects, undertake such activities as will con- 4 tribute to local CHP plan development and related efforts, 5 and my one note here is that I found it difficult to find 6 an answer to that question. 7 The Regional Advisory Group seems to meet only as 8 needed, and it was difficult to determine their participation 9 except on a project review Committee basis. 10 The question related to past performance and adcom- 11 plishments; these items do not appear to.be or have been @12 consonant with the recent program thrusts, except for Emergency Medical Services, and more recently, today -- and 13 14 this f did not know -- hypertension was encouraged because and a good thing it was, because the program is seems to have more than its share'of hypertension projects in it. Objectives and priorities at the present time relat(t 18 to cancer, kidney, Emergency Services, hypertension, nursing homes, health manpower and development, and the proposal is, 19 as written, it seems to me, to be questionable in terms of 20 its appropriateness. 21 The funds they are requesting $3,77'7,000, of 22 which $1,675,000, is a continuation project, and $1,755,000 23 24 for new projects; they have an estimated July request of $800,000, and Michigan's target figure is $2,000,000 -- their 25 )OVER REPORTING CO, INC. OMassachusettsAvenue,N.E. isbington, D.C. 20002 168 D-102 targeted available funds, is $2,'969,,OOO approximately 2 -three million dollars, and their request at the momat would 3 total, -as I said, $3,077,000 and when you add the $800,000 4 that they anticipate, it goes to better than four and a half 5 million dollars, which is 154 percent of the targeted avail- 6 able funds. 7 I think there are problems related to the Emergency 8 Medical Services; they are permanently requesting $750,000 9 increase in the funds for Emergency Medical Services, to pro- 10 vide a continuation of linkages and relationships between 11 the Michigan RI-,IP and the non-@IP programs. 12 I think overall, probably I would say that I was 13 disappointed. I was disappointed in what seemed to be a 14 lack of program leadership; I was disappointed in the infor-' 15 mation I could get out of it from the Regional Advisory Group. I had disappointments as I attempted to review the past per- -1.0 formmce and accomplishments and I felt --they were -not consoli- --17 18 ant with the objectives and the priorities, and I felt that 19 their request for funds was very much out of line. 20 14R. CH2U4BLISS: All right. Shall we turn to the second reviewer, Doctor White? 21. DOCTOR WHITE: I share Mr. Toomey's views, to some 22 extent. 23 24 It was difficult to fe'rret out f.rom this proposal 25 who, if anyone, was leading the organization at the present )OVER REPORTitiG CO, INC. 10 Massachusetts Avenue, N.[. ashini!ton. D.C. 20002 tlHD-103 1 time. 169 2 As he mentioned, Doctor Tupper was indicated on -- 3I' in the narrative; in one of the budget pages it stated this 4 was a TBA slot; either Doctor Tupper was being magnanimous 5 and loaning his services, or there was indeed a lack of an 6 executive director. 7 They have a bit of-a confusing relationship, in 8 that they have what they call an Executive Director who is' whose responsibilities are the overall direction of the, 9 10 program, and then they have a Program Coordinator, which I feel fills the more traditional role of the RMP Director. 11 12 I am not quite sure that both are necessary, but on the other hand, I seem to recall that Michigan got good grade; 13 in th6 past. It was a fairly well-regarded Region at one 14 time, at least, and I don't know what has happened in this transition, but obviously'/there is'some question as to whether @16 or not leadership is.'adequate, at the present time. And also, I share Mr. Toomey's concern as ta 18 whether or not the Regional Advisory Group, although it has 19 c@inued to meet quarterly at full strength, has participated 20 at the same degree of enthusiasm and the same critical atti- 21 tude as it has in the past. 22 It does state, however, that the Regional Advisory 23 Group is meeting; the members of-!it meet with the Comprehensi%e 24 Health Planning and Hill-Burton personnel to develop health 25 DOVER REPORTING CO, INC. @O Massachusetts Avenue, N.[. lashineton, D.C. 20002 170 ID-104 services resource, and I raise the question again, as Doctor 2 Miller did a rioiaent or so ago: is --his an appropriate thing? Are these people something which will come to naught by 4 virtue of the fact that they can't get the Congress to do it 5 anyway? 6 They do seem to have appropriate Regional Advisory 7 Group representatives on Review and other Committees, and on 8 paper., at least, it would indicate that they have a good, 9 thorough review process. I question that for someting that 10 I will bring up later. 11 Their past performance I did not evaluate well; I 12 could not tell exactly from their narrative how many of these have been picked up by others and how many were continuin 13 14 Some of them seemed relevant, and I based that 15 assumption.on the fact that they were previously given eval- uations of good management and good hypothesis; therefore, one would assume that their continuing projects, having been -17 approved under the old set-up we.re reasonable ones. 18 Their new ones, howover, raised the question in my 19 mind as to whether people haven't been too critical. They 20 have something like 40 projects, in 6ne guise or-a.nother, 21. and I don't really get the idea from reading this that they 22 have spent a great deal of time in developing these or in 23 giving them adequate review, even t hough they -nay have gone 24 through the holes that are appropriate. I wonder if some of 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Waqhino,tnn- D.C. 2nBO2 it 171 gHD-105 1 them weren't just kind of hanging there in the wings aiCd 2 have never even been given a great deal of attention in the 3 past, and now they say: 4 "Boy, we'd better get these done while we've 5 got the chance. 6 Many of th eir projects presumably could be accom- 7 plished in short-term, but one at least has a short-term 8 two-year time schedule, which obviously precludes its being 9 accomplished in a single year. This' is another examplei I. 10 think, that they have not looked at critically. 11 They do have a relationship with Comprehensive 12 Ilealth Planning, and are participating in this blanket sort 13 of of agency that is to take over. They indicate that they have a'meeting scheduled 15 in July, at which tey willl come to some further concrete conclusions about this. Some of the titles of the projects also raised the question in my mind as to relevance to Regional Medical 18 Programs. Some of them seemed naive -- or I am, and that is possible; some of them seemed clinically oriented, like 20 their clinical research projects, in a sense, rather than 21 educational demonstration projects. 22 I question, for example, what is their "buddy?" 23 They have something here called"a "budd@ system," for the 24 role of supporting a buddy in hypertension control. I don't 25 HOOVER REPORTING CO, INC. 320 MassachusettsAvenue, N.C. nn n@nnn 172 qHD-106 I know if this simply is something'like Alcoholics Anonymous 2 you call and say: "I'ri having an attack; I need your help." 311 They have a great deal of emphasis on hypelrtension,i 4 they have one which I can't think really can be accomplished 6 in a yearts time. I'm not sure really one can evaluate 6 hypertension in a variable population and come to aly valid 7 conclusions in a year's time; you can't oven collec the ata 8 in a year's time. 9 A comprehensive relaxing therapy. Well, '@his smacks 10 of accupuncture. 11 Well, these are the questions I have in mind. 12 Number 1, their leadership is unclear. 13 Number 2, how cAtical were they in evaluating what is going on? 14 15 No. 3, 40 projects seem an impossibility. Some of them are obviously an Impossibility by their own statements, and I think that their request for funding is ludicrous in 18 terms of the amount of activity@they could really undertake 19 in a year's time and get something out of it. 20 As '4r. Toomey mentioned, they are asking for $3,700,000, they are targeted for $2,900,000; they are 21 22 currently $1,400,000, and they want to come in for $800,000 in July. 23 24 If you gave them two,million now, you would be doing them a favor, and anything they get in July presumably 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 17-@ qHD-107 1 could be critically appraised. 2 MR. TOO,1,4EY: The 40 projects they have listed as 311 "Review and Co projects entitled mments" by CHP agencies, the 4 "Action taken" -- they are all asterisked as statewide pro- 5 jects that referred to the Councils of the B agencies, but 6 there were four of the 40 projects that were endorsed by 7 these CHP agencies. The other 36 are either."no action 8 taken," "pending" or no action or pending. They had four 9 endorsements. lo DOCTOR IIIIITE: I think Mr. Toomey pointed out, and 11 Mrs. Parks certainly did a creditab le job in bringing this 12 to our attention, this expansion of funding for some of the operating projects, the doubling of the budgets for some 13 things that seemed hardly valid. 14 I guess the one exception I might take is, if 15 -indeed they have a commitment, 'which they say they ave, - from state agency in Michigan, to continue the EMS service -17 at the end of one more year. 18 MRS. PARKS: Right@ This is what I understand. 19 20 DOCTOR l@ITE: Then perhaps it,is a.valid investiga- tion. 21 MR. V@'4,WINKLE: Doctor White, on the matter of 22 the Coordinator, this was a very strong program under Doctor 23 Hustice, and then there was an einterim period before Doctor 24 Tupper came aboard, and the program slipped very badly. 25 HGDVC,R REPORTING CO, INC. 320 M@asgchusetts Avenue, N.[. 174 WHD-108 I Doctor Tupper turned that program all the way around and 2 brought it right back up to the top. 3 Tupper left; he's living in Grand Rapids right now, 4 and if ou know the geography, that is some distance-from y 5 where this is located. He is on a full-time job, and I think 6 he is lending his name to this, and I think it is a private 7 commitment on his part to give it some guidance. 8 MRS. PARKS: He is available? 9 MR. VAN WINKLE: He is available by Phone and by 10 request, but Doctor Graham-@lelke was a former staff member 11 whom they brought in who in fact is running the program from 12 day to day, and Doctor Tupper has very little input at the present time, very little.input, and I think your criticisms 13 14 were well justified. 15 DOCTOR MILLER: Could I ask a question, both with regard to this EMS busine@t because there is some confusion nd certainly, about the limitations on EMS. -17 in my mi 18 Now, here is one; we said -- our directions said that a program in M@ID can continue a previously started EMS 19 but can not mount a statewide EMS system. 20 21, Well, here is one that has gone from $36.,OOO a year 22 to $750,000 and it is obviously developing a statewide system, 23 or trying to in one year. Is this directly opposed to the principle, or is it 24 1 not? Because we have some others that are coming up where the,,r 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 i?n7N rdgSrrr, 175 @IHD-109 obviously got a statewide EMS system. 2 MR. CIIAI@U3LISS: Will you comment, Mr. Van Winkle? 3 MR. VAN WINKLE: This is A continuation project. 4 DOCTOR MILLER: Yeah, but a continuation from 5 $35,000 to $750,000? That is quite a continuation project. 6 MR. VAN WINKLE: We are aware of this, but t ey are 7 saying that as far as it being affected by this new law that 8 we can have no new starts, but-we can continue to fund what 9 has been funded. 10 But we strongly questioned this use. DOCTOR MILLER: We question whether this can be 12 ripened into a full-fledged $700,000 system in one year with 13 a with Regional Medical Program funds. 14 MR. VAN WINKLE: There is one other DOCTOR MILLER: I will tell you, practically it is ridiculous. I have had oiYe of.those things. 16 MR. VAN WINKLE: I would like to hear from some of those physicians about this automated peritoneal dialysis 18 also. 19 The kidney program is going almost totally with 20 home dialysis, using artificial kidney, and now all of a 21 22 sudden, we are going off, apparently, in this year with Auto- 23 mated peritoneal, and I can't very well see people walling around the street carrying a bottle in their hand, and I 24 don't know if it is a part of the Michigan State Renal Plan. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washingtoii, DC. 20002 (202)546-6666 1 715 'HD-110 There is no mention of it, and Michigan does have a very 2 highly sophisticated renal program you know, a state pro- 31 gram that is supposed to cover all of this. DOCTOR SLATER: Presumably this has all been 5 cleared by their professionals before it ever gets ere. 6 DOCTOR MILLER: Peritoneal dialysis? I didn't 7 think they did it any more. 8 MR. VAN WINKLE: I didn't think so either. 9 MR. CHAIABLISS: I think the Committee should know io thag both the EMS and the kidney activity will be commented 11 on by the other agencies that are supporting those ctivities 12 and we will have input from them. 13 DOCTOR SLATER: 'Can we-put a contingency on this 14 subject to clearance of the technical use of@'this', despite 15 the fact that they have already approved it at their own -- ? MR. VAN WINKLE: I think it raises two questions. If this came through their review process, and they are send- 17 18 ing it in saying that it has been technically looked at and 19 cleared, then I question the process. DOCTOR WHITE: That is right. That is why I said 20 on paper it looks good but obviously they have gone through 21 the motions without having any enthusiasm about this. 22 23 MRS. WYCKOFF: Don't they .still have to get an ad hoc panel of experts on kidndy programs? 24 MR. CHPJ4BLISS: Are the reviewers prepared to make 25 DOVER REPORTING CO, INC. ?O Massachusetts Avenue, N.[. Washington, D.C. 20002 177 [iD-lll I a recommendation on funding, in the light of the discussion 2 that has taken place? 3!1 DOCTOR MC PHEDRAN: Ijust wanted to ask the 4 other people that are:likely to comment on F2.IS goin', from 5 $34,000 to $750,000; they are not likely to take exception 6 to-that. They might have to bear the burden of expense 7 otherwise. 8 I mean, I don't think that because we think that 9 that is tantamount to a new projet -- we ought to be able,to it 10 say that that is tantamount to a new project, and we can imagine anything.going from that low a figure to that high a figure without it being a newIproject, so Ithink e 12 13 ought to be able to settle it here and not leave it for some- body else to take care of. 14 MR. CliAl4BLISS: Then we would like your specific 15 16 recommendations here as itz/relates to EMS. MRS. WYCKOFF: Why don't we ask Doctor Dushan 18 to comment on -dis thing?' He is on the panel, and he is a pathologist. 20 MR. C@IBLISS: Would the Committee seek that? DOCTOR MILLER: There is a Jurisdictional question, 21 however, that I wish you would answer for us. 23 We are not empowered to make technical review MR. THONIPSON: I don't,think we can; I think all 24 we can do is cut the,hell out of them. 25 IOOVER REPORTiriG CO, INC. @20 Massachusetts Avenue, N.C. vishjngton, D.C. 20002 202) 5,16 6666 178 IFID 112 DOCTOT-Z MILLER: Therefore, if we are facing a 2 technical question, that is beyond our jurisdiction. MR. THOMPSON: No way. 4 DOCTOR WHITE: I take exception. We are not 5 looking at the quality -- well, at the peritoneal dialysis, 6 perhaps, but not at the Et,!S together. 7 DOCTOR MILLER: No. But about this kidney tling, 8 this is atechnical question. 9 DOCTOR SLATER: Let's ask another point. 10 Are they requesting funds for services, or simply 11 planning, evaluation? We can't provide money for.dialysisr 12. can we7 13 MRS. PARKS: For.the EMS? MR. CH2UIBLISS: For the kidney. 14 15 MR. VAII WINKLE: They are trying to determine the feasibility of it. MR. THOMPSON: You ought to get some kidney people 18 to look at that. MR.' VAN WINKLE: I related it back to process here. 20 MR.-CHAI---IBLISS: We would simply like to have on record an expression of your reservations' if there are anyll 21, 22 and then Staff will proceed further on that. MRS. WYCKOFF: Couldn't we have the old process 2t3 we used to have, of a special Committee on Kidney, to look 24 at this for us and give us a report later,'or give the report 25 OVER REPORTING CO, INC. ) Massachusetts Avenue, N.[. sitington, D.C. 20002 2)546-6666 @ID-113 ter? 2 MR. CIW-4BLISS: Yes, we will. That.expertise now 3;: n him to resides with Doctor Goodman, and we will call upo 4 give us input as -- and an assessment of this parti ular 5 activity. 6 DOCTOR SLATER: Well, let's leave it that unless 7 we approve it, we don't think it should be includediin the 8 figare. 9 MR. CHAMBLISS: That is. very clear. 10 MR. THO@IPSON: The issue, I think, ib whether we 11 think it is a whole new project. 12, DOCTOR MILLER: Mister Chairman, could we get some 13 understanding here with regard to future actions we@are 14 going to have to take tomorrow, that a continuation of an 15 E-'@-IS project for M4P would be one that is proceeding at not 16 a total statewide plan, ugless it previously was approved, @17 and would be of a magnitude of funding similar to what it has 18 done previously, and that anything beyond that, moving in 1!) or beyond the jurisdiction of PI..IP's in EMS, would that be 20 fair? MR. CHAMBLISS: Not entirely; we have discussed 21 22 this with El,-IS and they feel that unless there is a total 2tl system involved with all the components of the Emergency 24 Medical Systems, that these activities would be proper for 2,5 funding under,MIP. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, 14.1. Viashington, D.C. 20002 (202) 54H666 iou @ill'D-114 1 But we raised another question of magnitude in 2. terms of funding, and I think that in and of itself would 3i: require interaction between these two programs, and a 4 closer examination of the project, so as to take care of 5 the concerns that you express. 6 We will do that; we will call in Mr. Stryker, and 7 I believe -- Mr. Reardon, and Stryker, and get their assess- 8 ment of this project. 9 The level of funding requested here is very high; lo they have gone, as you have indicated, from $30,000 to $700,000, and we in fact will bring them' in.and get their 12 views here, and it will be taken into account as this,recom- mendation goes forward. 13 MR. V@,i WINKLE: All we have to look at is@a Form 14 15 here; we don't have, you know, the original applicat ion, 15 but it certainly looks l'i@e,a full statewide comprehensive EMS system. MR. TOOiNlEY: Mister Chairman, my recommendation 18 that I have here, on the presumption of the tliree-quarters of J!) -0 20 a million for E.4S, and the amount of money that was involved in the hypertension, I was going to recommend two and a half 21 22 million dollars until I heard this morning that hypertension projects are within the province -- and I Ihadn't counted 23 i them but I think there were 13 or 14 hypertension projects. 24 With this in mind, I would recommend funding at the 2t5 HOOVER REPORTING CO, tNC. 32,11!@lassict,us@,tts Aieiue, N.[. D,C. -C,6,,6 181 WliD-115 level of three million dollars. 2 YR. CHAIIBLISS: You have heard the recommendation. 3 I Is there a motion to that effect? 4 MR. TOOMEY: I so move. 5 DOCTOR SLATER: Seconded. CT 6 MR. It has been moved and seconded 7 that the level of funding for Michigan be set at three millioi 8 dollars. 9 Is there discussion? 10 DOCTOR VAUN: Yes. I find that at serious conflict 11 with the two million dollars that was recommended by your 12 reviewer. 13 DOCTOR MILLER: 'I found a serious objection in this 14 DOCTOR VAUN: He recommended two; you recommended 15 three. 1(; DOCTOR IIHITE: I said we'd be generous if we gave them two million dollars. 18 MR. CHAMBLISS: All right; we have something of a dilemma here. 20 DOCTOR IFHITE: That's all right; the motion is on the floor. 21 22 MR. VAN IIINKLE: llas there a secoi-id? 23, MR* CHAMBLISS: Yes, there was a second. All thos: in favor? 24 25 DOCTOR SLATER: Aye. HOOVER REPORTING CO, INC. 320 %iassachusetts Avefiue, N.[. D.C. 201,@02 181 WHD-115 1 level of three million dollars. 2 MR. ClLM4BLISS: You have heard the recommendation. 3 tion to that effect? Is there a mo 4 MR. TOOMEY: I so move. 5 DOCTOR SLATER: Seconded. 6 MR. CHAMBLISS: It has been moved and seconded 7 that the level of funding for Michigan be set at three millioi 8 dollars. Is there discussion? 10 DOCTOR VAUN: Yes. I find that at serious conflict 11 with the two million dollars that was recommended by your 12 reviewer. 13 DOCTOR MILLER: 'I found a serious objection in this 14 DOCTOR VAUN: He recommended two; you recommended 15 three. DOCTOR WHITE: I said we'd be generous if we 'gave them two million dollars. 18 MR. CHAIIBLISS: All right; we have something of a dilemma here. 19 20 DOCTOR WHITE: That's all right; the motion is on the floor. 21, 22 MR. VAN IIINKLE: Was there a second? 23 MR. CH@IBLISS: Yes, there was a second. All thos(@- in favor? 24 DOCTOR SLATER: Aye. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, DC.20002 182 1 MR. CHAI-IBLISS: Opposed? MD-116 2 (Chorus of "No") @3 MR. CHAMBLISS: The motion did not carry n the 4 matter of three million dollars. 5 That motion is lost. 6 DOCTOR SLATER: That is the only motion that's been 7 lost all day. 8 DOCTOR MILLER: It shows we are disturbed., 9 MR. CHA11BLISS: The Chair is open, then, for another io motion. 11 MR. TOO@1EY: I will go back to my origina recom- 12. mendation for $2,500,000. floor for -13 MR. CHA14BLISS: There is a motion on the 14 a level of funding for $2,500,000. Is there a second? MR. THOMPSON: Second. 15 @Ut. CHAMBLISS: It has beeh moved and seconded. -11 Are you ready for the question? 18 DOCTOR WHITE: I would like ome discussion. I would point out again the various number of pro- 19 20 jects; whether they are meritorious or not is immaterial, one would think. I do not believe that they could have been 21 given the critical appraisal they deserved within the time- 22 span that is allowable, particularly if the leadership has 23 faltered in the meantime; without infringin(,- upon a territory 24 which we are not allowed to get into, I would point out that 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N,E. W:i@hinatnn Dr 20002 183 iD-117 1 point out that the specific objectives of the EMS program -- 2 the specific outlets they are seeking, setting of of standards 3@, for courses, the training of 1800- E14TA's -- I confess to be 4 unfamiliar with what is involved with that, but it seems to 5 me it is a big number within a single year. Perhaps not. 6 Perhaps the evaluation of this program as to its 7 benefit to I-Lichigan, I don't think you can evaluate it in a 8 year's time; you can't even get it done, so I don't think you 9 can evaluate it, in a coordinated statewide EMS component 10 to be assumed by the Michigan Department of Public Health. 11 Now, I will retract a statement Imade earlier, than. 12 if the State Department is going to take over, perhaps this 13 is worthwhile, because as I read this now, it appears to me 14 that perhaps the Michigan Department of Public Health is 15 going to take over responsibility for training rather than for the establishment of existing programs. Therefore, I doubt that $750,000 is a wise invest- 18 ment. DOCTOR WHITE: I don't think we should settle this 19 question without beggingthe question, I guess. 20 MR. TOO@IEY: The funds requested are for program 21 22 staff of approximately $350th6us&nd and for the continuation projects of approximately $1,675,000, which gives you, at 23 two million dollars just to con@inue their project staff, 24 25 their core staff and their program staff in the continuation HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 184. 1 projects. That two million dollars allows for no additional 2 projects. 31 I mention that merely as a sidelight. If the 4 concern is a further reduction from the two and a half to 5 approximately two, as I sai d, this allows for continuation. 6 Now, I will once again admit that their $600-700,003 7 -- and I did the arithmetic very quickly -- in hypertension 8 projects in some of them, for instance, hypertension pro- 9 jects in'the Detroit Department of Public Works, as an 10 example,.and then you mentioned, Doctor White, the buddy 11 system of hypertension, whatever that is. 12 And then on top of that, you know, I am extremely skeptical of the -- in the application anyway, but I hate to 13 14 cut them down to exactly where they are where we are now. DOCTOR MILLER:,. Question, please. MR. CHAMBLISS: Is there further discussion of the motion,on the floor? It has been moved and seconded. Shall 18 I call the question?. All those in favor of setting a level at $2,500,000 19 20 for Michigan, say "Aye." 21 (Chorus d "Aye") Those opposed? 22 23 (Chorus of "No") MR. VAN WINKLE: Almost all ought to have a show 24 of hands. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. f% i, )nnn,) 185 (ifID-119 1 MR. Clflil,,MLISS: I would ask for a show of hands, 2 please. Those voting "Aye.," may we see your hands? 3 (Show of hands) MR. CHAI@IBLISS: Five in favor? 5 Those opposed? 6 (Show of hands) 7 MR. CHAMBLISS: The "Ayes" have it and the motion 8 is carried. 9 10 12 13 14 15 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. WRqhinciAn I) r 9(inn? 186 IID-120 REGIONAL MEDIAL PROGRAM REVIEW 2 MIS.ciISSIPPI REGION MR. CIIA@IBLISS: May we turn our attention then to 4 Mississippi? The reviewers there are Doctor Vaun and Mr. 5 Toomey, supported by Mr. Van Winkle, and I should make men- 6 tion of the fact that the Committee has set as its goal the 7 review of three additional Regions this afternoon, and 8 there will be two left when MIssissippi is completed. 9 DOCTOR SLATER: What are the others, sir? 10 MR. CHAMBLISS: Illinois and Louisiana. 11 DOCTOR VAUN: First, I should be should '@ssue 12 a disclaimer. My daughter happened to be looking through at the p ictures and Ididn't, and she said: @13 this; she looked 14 "Daddy, you needed a haircut for the picture." 15 Remembering the nature of the visit, however, I am sure there was no effort on Doctor Lampert's part to seduce me into giving him more money-, and I will describe the nature, of the visit, which has, I think, some bearing on the issue. 18 MR. CHAMBLISS: We *gill not consider that as a 19 conflict. 20 DOCTOR VAUN: I think it was September -1972 when 21 Doctor Joe Hess and his storm-troopers went down to straighter 22 up the Mississippi Regional Medical Program. T ey were 23 having a great deal of difficulty and they went down there 24 to take them to task. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n i, I)nnn) 187 ID-121 I must admit retrospectively, as I look back on 2 what we did when we were there, we might have been a litth 31 too critical for Mississippi not having evaluation of their 4 projcts, because in the subsequent years I haven't seen much 5 evaluation of anything from anybody, let alone Mississippi. 6 But nonetheless, fty were in trouble-with leadership 7 problems, and the question that kept coming across the table 8 during the day was: it is very hard to tell where 01' Miss 9 ends and RMP begins, and that was a serious problem and there 10 seemed to be a great deal of incest between the progra mand 11 the 01' Miss. I am indeed pleasantly surprised to see-this 12 summary of-projects come out these years later, because 13 whether it was us or whether something has happened down 14 there, certainly this is a pretty good iece of work that p 15 has come.out since then,,,and I am rather pleased with it. I think it would sugge st that there are some strengths there that we did not identify at that time,, but 18 Doctor Lampprt has obviously done a pretty good job of his ty rough time. 19 burden of sustaining staff through a pret 20 It would appear that the CHP relationships are satisfactory. I think that here the projects address them- 21 selves more now to the health care needs of Mississippi 22 rather than to continuing this so-called soft money for the 23 University Of Mississippi when NIH was phasing out and other 24 aspects of that nature. 25 HOOVER REPORTING CO, INC. 320 Massachusel@t@nue, N.[. 18 8 qHD-122 1 Maybe it said the General was no longer there, but 2 there was a retired General,.down there who was running at that 3i! tim the University of Mississippi and also seemed to be, to. a large part, with a certain lady, running the RMP. 4 5 Things have changed, and I think that though their request at this time is unrealistic, I think that the RMP of 6 7 Mississippi deserves a few pats on the back. 8 I am recommending a reduction of funding which I 9 will hold until Mr. Toomey has his licks,.and then together we will4recommend something to you. 10 11 MR. TOOMEY: Well, once again I am following the format; I felt the program leadership was strong and viable. 12. I felt the program staff to be competent. 13 14 RAG meets, the Executive Committed meets, the Planning Committee meets, the Manpower and Education Committee 15 met several times, Health Systems' and Public Education. 16 Their past performance has been impressive; for 17 instance, I don't want to go into these, but the first stroke 18 and intensive care unit, careoand training, the first chronic 19 pulmonary disease unit, treatment and training program, the 20 first on-going effort toward coordinating continuing health 21 education, the first system for coronary care and training 22 and there really are A dozen of these "firsts," that indicate 2 tl the impact of the Mississippi Re@gion on the Regional @ledica 24 Program on the state of Mississippi-, and frankly I felt it was 2-5 HOOVER REPO TING CO, 320 Ma@chusetts Avenue, N.[. R INC. 189 I-ID-123 1 quite impressive. 2 Additionally, they were extremely felt -- 3 -perceptive in establishing goals and they were quite precise 4 in the establishment of objectivesin order to support the 5 accomplishment of those goals. 6 The proposals that they have are congruent and they 7 certainly mesh well, generally speaking, with the proposals 8 that were made. 9 I looked at the CHP comment, the state comprehensive 10 plan came with an endorsemat of 39 out of 59 projects that had been proposed. There were four responses from comprehen- 11 sive health planning agencies, and the tone of these respon- 12 ses were all extremely cooperative, extremely friendly, and 13 seemingly with a good relationship between the two. 14 15 One of the items -- perhaps Doctor Vaun mentioned this -- but we again run fnto the 'situation where the funds for the continuation of the projects already proposed or 17 already on the boards is $1,200,-OOO and their proposals -- 18 the;funds for their new proposals are $1,155,000, which means that requests for new funds are just about as great for 20 -- as for the continuation enterprises. 21 In brief,, I think that this was an extremely well- 22 done proposal; it indicated a considerably higher degree o 23 strength than several of those that I have reviewed earlier, 24 and I ended up with an evaluation of this project as being in 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. W;k,hingian I)C-20002 fHD-124 1 a good to excellent stage. 2 DOCTOR WHITE: Mrs. Wyckoff has been doing a techni 31 cal review here and has a question to ask. 4 MRS. WYCKOFF: What is "Pierre the Pelican".? 5 MR. CIIAMBLISS: That was a policy question we raised 6 too; we wanted to know. 7 DOCTOR VAUN: I thought I went through that very 8 carefully, and I don't remember any pelican. 9 MRS. WYCKOFF: Pierre the Pelican'is No. C-179.. 10 There is also 137, "Solid Waste," and "Solid Waste Management Training.'' 12 MR. VAN WINKLE: It is education of illiterate mothers. It is a pamphlet that goes out; it is quite well 13 14 done. 15 MR. CHAMBLISS: Would the reviewers have any recom- mendations here? DOCTOR VAUN: Our independently arrived-at judgments 17 18 are reasonably close it would appear, so I would make a recom- mendation that the Mississippi RMP be funded for $2,200,000. 19 MR. CHAMBLISS: Is that a motion? 20 DOCTOR VAUN: I so move. 21 MR. CHMBLISS: Second? 22 DOCTOR WHITE: Seconded.. 23 -MR.,CHAM BLISS: It isemoved and seconded that 24 Mississippi be funded at a level of.$2,200,000. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. W2ehinaftin n r. 7nnn2 WIID-125 1 Are there questions or discussion? 2 DOCTOR MILLER: Yes, I would like to ask the 3 i reviewers-. did you look at the magnitude of the collective 4 -- of the renal programs? 5 I see two programs which total $230,000; are they 6 running a statewide renal program, and is that contrary to 7 RMP principles? 8 MR. CHAMBLISS: No, it is not contrary. 9 DOCTOR VAUN: But that, plus a few others, when I 10 said I arriv ed at my personal evaluation MR. VAN WINKLE: I raised the question because of 11 the substantial increase in the costs. 12 They are opening up a now unit and I think we will 13 have to flag this for Doctor Goodman, in kidney, because it 14 is an expansion for dialysis facilities. We want to be very 15 sure whether they have proper clearances on this sort of 16 @ thing. DOCTOR MILLER: How about EMS here? It goes from 18 17 to 92; that is only four and a half times, it isn't 20 19 times. 20 MR. CHAMBLISS: We don-It see the magnitude there 21 that you referred to earlier on, Doctor Miller. 22 DOCTOR MILLER: No, not quite. 23 MR. THOMPSON: What happened to the turf problems 24 they were having with Memphis for a-while? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. @n q@Aft@ WHD-126 1 MR. CHAMBLISS: There has been an agreement between 2 the two Regions on the. overlap areas in Northern Mississippi, 3 I believe, has there not? 4 MR. VAN WINKLE: Yes, including the CHP A agencies. 5 As a matter of fact there is combined funding. 6 MRS. WYCKOFF: There is a beautiful interface and it is working very well;. very nice interface -- joinI 7 t fundingi, 8 joint meetings, both RMP and CIIP. 9 There is one CHP in Northern Mississippi and both 10 Mississippi PMP and Memphis RMP have funded.it and started 11 it 12 MR. VAII WINKLE: And are evaluating it. MISS MURPHY: Right, and it is a very nice inter- 13 face., 14 15 MR. CHAMBLISS: Shall I call the question then? All those in favor of thd@otion?- (Chorus of "Aye") Those opposed?' (No response) 19 The motion is carried and the level is set at 20 $2,200,000 for Mississippi. 21 22 2tl 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 REGIONAL MEDI HD-127 1 CAL PROGRAM REVIEW 2 ILLINOIS REGION 3ii MR. CHAMBLISS: Shall we now turn our attention to 4 a review of the Illinois Regional Medical Program? 5 Doctor Sl ater is here, Doctor Scherlis is not here, 6 and 7 We have Staff support for you, Doctor Slater, in 8 the person.of Mrs. Kyttle, who is very knowledgeable about that region. 9 10 DOCTOR SLATER: I was just going to say, M s. Kyttle 11 and I have power of veto over this group, because welboth 12 agree that Illinois is first-class, recommend it havb full funding; I have nothing adverse to say and I am handing in .13 my recommendation as good-excellent, with a final superior 14 at the end. Do you want to @earabout'this program? I would like to tell you, because I think it is really good. 17 You may take my light-hearted vein as a little bit 18 of hypoglycemia. 1 9 All right. I think the main reason to procee 20 with this is really to bring into focus the orientation that 21. this particular pr)gram has, which I find exciting after having 22 listened to points of view expressed from the various regions 23 today. 24 The staff role -- the program leadership, as I can 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. WHD-128 make it out,-has been very strong. Doctor Cxeditor has been 2,i able to carry a very strong program forward while phasing 3"1, down. He went from a professional staff level of four 4 this has now been built up to approximately 12, an(!'he counts 5 on a few more people but he does not plan on grossly expanding 6 the central staff, despite a considerable a 100 percent 7 expansion of funding requests. 8 During the course of the phasing down they felt that 9 there was a great deal to be learned out of the.experienc.e 10 they-,had been through, and joining forces with the CHP, they 11 actually sat down and looked at the planning techniques and 12. the outcomes and-developed a planning model which was built on the comprehensive social approach to health care planning. .13 14 it was for.this reasm that they really wanted to spend a couple of million. 15 They finally published-a book which has just come 16 out, on health care development which I think is worthwhile 17 18 spendng a moment on, but as back-up on this I can say that the RAG had been intimately involved in this along with CHP, 19 and in general, the program, against this kind of backing, 20 has been organized into two types of approach. 21 A health process approach, if you liket which is 22 looking at problem-oriented medical records, patient educa- 23 tion techniques, on the one hand, and disease-oriented pro- 24 grams, improvement and specific care, models such as kidney, 25 HOOVER REPORTING CO INC. 320 Massachusetts Avenue, N.E. n I' 194 'HD-129 1 cancer and hypertension, on the other. 2 They have elected, within that framework, to put 311- a great deal of emphasis on a few specific types of prominent, 4 concerns. Problem-oriented records, for one, and prob ems 5 of hypertension for another, and thus have in-depth experience 6 with a high investment historyin those two areas, and at the 7 same time they have had very good out-reach to the disadvan- 8 @aged urban areas as well as the areas in the Region of Chicago, in terms of the types of RMP support for primary care 10 and the like, which I will mention briefly. Let me just give you an inkling in their approach 11 12. to planning. They decided that rather than take the rather 13 global, generally-stated type, of expression of goodwill that 14 has been .really traditional to @IP's, they would take an 15 objective approach to planning, so they sat down with the CHP group and the RMP group aied-said: "Well, what are the human goals? What are we attempting to achieve here? And within that framework, 18 what are our objectives?" 19 Objectives being slightly more sharply defined, and then, out 20 of this one comes health-care goals -- more specifically, 21 health-cdre objectives, and then down finally down to 22 programmatic goals. 23 So that, one: when this was developed with the 24 people they had available, they were listening to consumers 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 1.95 130 1 as representatives of CHP, and finally coming out with IUIP 2 professional providers providing an answer to the expressed 3, desires of the people in that Region.. 4 A couple of examples. At the Human Goals approach, 5 the most broadly oriented description, the people wanted 6 optimum functioning of the health system, optimum longevity 7 of life, optimal tranquility. 8 Well, this is pretty general when you start moving 9 along to the kinds of interpretations of objectives. The 10 -lay people said they really wanted to be able to prevent dis- ease, they wanted to be able to cure curable conditions and 11 treat treatable conditions. 12. It is interesting that.Creditor..goes on and says-. .13 "The interpretation of those sets of objectives 14 .by any group in an area realLy is dependent Upon the make- 15 up of the group, and depending on the environmental- .educatinal-health orientation, socioeconomic relation- 18 ships, you may come out with a variety of different 19 projects which lead to these ultimate goals." So that on the basis of that CIIP type ofactivity, 20 the provider looks at this, then comes down to the presentation 21 @of health-care goals, which is emphasis on accessibility, 22 ,quality of care, effective management, optimum cost relation- 23 ships, and so on. 24 Moving to another stage down the line, they take a 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. n r )rwiin,) 196 'HD131 1 more sharply defined look at objectives, such as improving 2 the-understanding of health care; specifically, availability 31 of the entry points of the system, optimal relationships of 4 the system. I won't go on, except to say that when they get to 6 programmatic levels,"they have specific series of approaches' 7 that can-be taken within these health care objectives, and 8 then they have taken a variety of programs or projects which have been fed @o them from the Illinois area, and categorize 9 10 them specifically as,meeting these objectives within the frame- work as a whole. 11 Now, that to my mind, is a pretty neat way of putting 12, in specific terms of reference some workable pattern, instead 13 of fi@e lines of such gen(ral statements that one wonders 14 what -- whether or not the thinker is very clear when he is 15 attempting to do it. 16 It does provide a procedure to examine what projects 17 18 one is cover.ing now, where there are gaps in the system, and it really puts into a highly analytical form some of the more philosophical objectives that we are groping to satisfy all 20 the time. 21 So I was impressed with that, and that is the pro3'ec: 29 of the phasing back. They have taken time to analyze where 23 they have been and where they are going. 24 So now, everything that is presented in the present 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. n r, I)nnnl)f 1 97 WHD132 1 proposal is cast within those general frameworks, and all 2 batted out by the RAG and Comprehensive Health Planning. 311 Well, I guess, against that background, then, how 4 have they performed? 5 They have had a series of projects, I think, that 6 there are about ten here, whi ch have been started up over the, 7 past few years and in one way or another have been s un off p 8 and picked up fully operational by other groups. Health care at home has been picked up as a free- 9 10 standing enterprise by a group in the area. .11 Health information and referral is terminating because they had inflated ideas about what they cou l@ perform 12, and they just decided to phase it out. 13 14 Multiphasic screening in industry has been.picked 15 up by the Heart Association and shared with a variety of industrial managements. I;.won't go into all of'them, except to say that 17 they have had a series of specific projects started, proven 18 19 and moved on out while they used their funds catalytically to start something else. 20 I was interested then in a series of 21 _proposals 22 that they put forward. I have not mentioned that part of 23 the specific activity -- well, which I just mentioned in e passing -- part of the specific activity is to go into depth 24 on how the problem-oriented medical record might be more 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 19 8 WlID133 1 effectively utilized, and then put a great deal of funding 2 into that in the past, a great deal having been spent in 31 teaching other groups and institutions how best to use the 4 problem record, and they have about four pa -es of -oriented 9 5 institutions and groups, that they have set up training and 6 demonstration programs for, and they plan to continue that 7 in this next year. The other major venture, of course, has been in 8 hypertension, and they have been attempting to develop a 9 10 computer technique which will provide a simplified diagnostic 11 and therapeutic protocol for that. In fact, relatively simple screening and input of information can provide back a protocol 12, which is applicable to large,numbers of people in the disad- 13 14 v.antaged areas. I am fascinated by the fact that they figure they 15 can have that computer program so that it is about ten cents 1(; per.computer ruh after you go through the matter of ata :17 collection, and input. 18 So the proposals then boil down into two parts: 1!) those that are going to be continued, and those that are 20 going to be new. 21 Problem-oriented record -- tey want to proceed 22 withimplementation, as they have already been doing, for 23 $105,00O.i They sent in an evaluation report, the evalua- 24 tbn indicated that this was a very -influential program up to 25 HOOVER REPORTING CO, INC. 320 Massacliusetts Avenue, N.[. 199 WHD134 1 now. 2 The computerized hypertension treatment, they 31 needed to continue to work on that, and that is $205,000. 41 A group of physicians in residence out of Champagne County 5 are looking to problem-oriented record systems integrated 6 into what is called the "Plato 4 Dance Computer," about which, 7 I know nothing. Apparently it has been funded before and 8 they want to continue that into the future. 9 They have had a Chicago alliance tor vo awareness 10 under way, and that is to be continued. 11 Peoria frozen blood program, which is simply a matter of providing frozen blood for people in need, undergo- 12 -13 ing kidney dialysis and other types of extreme problems. 14 Now, the new programs,have moved beyond the existing problem-oriented record to take this out into ambulatory 15 16 care programs that they have in the out-patient program depart- 17 ment and elsewhere, Ifor the next year, and they provided 18 evaluation as well as to the effectiveness applied to ambula- tory care. $128,000. 19 And then a nice little touch here. The Christian 20 Action Ministry are concerned about access to care services 21 of a broad type; inner-city health and social needs. This is 22 such matters as day-care centers that have a heath component, 23 and they all interact. Not-.mub@ $44,000, but well-spent 24 money, in that type of thing. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 200 WlID135 1 They want to hold a series of dialysis consumer 2 workshops for $30,000. Again., I think a valuable type of 3 patient education. 4 And Access Chicago, a rehabilitation institute 5 program, to take a look across the city and,find.out how 6 barriers to handicapped people can be decreased and develop 7 this as a public monitoring system; just $12,000. And then, finally, this is interesting because I 8 would like to know about this project; an institutional cardic- 9 10 vascular center. They are asking for $100,000to help organ- 11 ize this. This is against a background grant of $38 million to pull together eleven institutions to develop a.'multi -- 12 or at least a consortium of activity in cardiovascular dis- 13 ease. 14 15 I think that is real original planning. Who has that proposal? Does anybedy have that? 1(; 17 MRS. KYTTLE: National Heart and Lung. DOCTOR SLATER: I would like to look at it sometime; 18 I think this is what cities need to do mote of. Finally, they are asking for $643,000 for statewide 20 hypertension control program. That is going to be built on 21 their model, which is going ahead from the present fnnding 2-? because of the'action -- the present action that they are 23 also funding for 350,000 inner-city people who are going 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 i 201 rfID-136 1 to be programmed into that computer and hopefully monitored. 2 They have developed a very fine record of starting 31 little projects and seeing that they work,either spinning 4 them off or expanding them up to a broader application at the state level, and clearly they are moving in the Direction c 6 of hypertension. 7 Now, looking at all of this in terms of the feasi- 8 bility,.I would say that the feasibility of what they are 9 asking for this year in new-projedts have a good cha ce of 10 flying, and if they run out of funds by the end of t e year 11 they will spin these off or re-fund them or -find ways to 12. carry them out. That has been their record and-it has been very successful. 13 No question about their relationship with CHP and 14 15 overall, I give this a rating of superior, and I feel that I would recommend that they @a-ve all of the funds they are asking for, which is only 78 percent of the funding tat is 17 18 allocable to them, and if there have to be any cuts at all made, we provide them the chance to cut back where they deem fit. 20 I doubt if that is going to be ne cessary. 21@ MR. THOMPSON: I guess I have one problem. I wish 22 somebody, would do what the RMP did in the early days when 23 finally we got sick and tired 'of,giving money to computers 24 and money to this and that, and finally somebody came in with 25 @@OOVER REPORTING CO, INC. 20 Massachusetts Avenue, N,I. lashingtoii, D.C. 20002 WHD-137 1 a big print-out out of a computer, and told us all the money 2 was being put into computers. 3 And I want to know how much money is being put into 4 the problem-oriented record. Not only here, which is a 5 $3 million grant going up there out of Research and Developme t, 6 out of Gerry Rosenthal's shop. I mean, boy! I don't know -i where all that money is going. 8 I am not against the problem-oriented record; don't 9 get me wrong. This is kind of getting over7killed with money. 10 DOCTOR SLATER: DIo you think it would be worth- while for RMP as one of its final acts to lay on a sophistica- 12 ted -- a professional visit, not just to this program, but to take a look at the financing of problem-oriented I records 13 14 or computer-type programs just so as we go out of business.- here and face probably a lot more money available through 15 other agencies in the fi ,6;d., where we are at with this? MR. THOMPSON: Now we are talking about something 18 else. What does it -- what is the take out of all the RMP activities? 19 DOCTOR SLATER: Well, you would like to get a 20 national fix on this; it would be interesting to have a play- 21 back from the other Regions. 22 MR. THOMPSON: Computerizing the problem-oriented 23 record? That is a new catchword, along with quality assur- 24 ance.'l 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 f9n7l 203 THD-138 MR. CIIMIBLISS: I do think that is a rather sub- 2 stantive question you raised. The Council did look at multiphasic screening in 3 the same way that you are looking at the computerization of 4 5 records. I don't know how we can go about getting a fix on 6 that; we will raise your concerns, though, and,appreci&te your observations here. 7 MR. THOMPSON: Well, you know, we went through 8 9 that cervical screening mess for- a while. You know, that was all there, and if you read 10 DOCTOR'SIAATER: That's a horse of a different 11 color. I think that here you are really providing a real 12, aid to differential diagnosis and the position tracking of 13 the patient; the cervical diagnosis was prefaced on incorrect 14 information. 15 MR. THOMPSON: I am not arguing about the validity of it; I just wonder how much bucks? DOCTOR SLATER: I would like to pick up Mr.. 18 Thompson's concern and say that Ifeel this proIgram is work- 19 ing, is producing so well that we should not hold back on the 20 funding for this, but that the larger concern that is.raised 21 by this type ofactivity probably will be the basis for a 22 recommendation for a task review of not what just RMP has 23 been doing, but an overall.pictqre of the Federal Government 24 in supporting this type of activity., and what is its.meaning, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 2 04 WHD-139 ]I what is the situation today? 2 MR. CHAMBLISS: Doctor Carpenter? 3ii DOCTOR CARPENTER: I have some questions about the 4 problem-oriented record, too. You need a piece of paper at 5 a staff meeting and you have to have something on the paper 6 in order to make it go, and I don't understand what the money 7 is for. 8 MR. THOMPSON: They are all computerized. DOCTOR CARPENTER: What I actually want.to raise, 9 10 is the issue of $643,000 for screening program for hyperten- 11 sion. MRS. WYCKOFF: It's a million if you count the 12 other-.-two projects. with it. 13 14 DOCTOR CARPENTER: Okay, a million. Thank you. How many previously unrecognized hypertensives will be brought 15 to treatment as a-result of'this-program, and who will do the 1(; treating? DOCTOR SLATER: Now yo u are getting into project 18 detail for which there is not information here.' 19 DOCTOR CARPENTER: I am raising a management ques- 20 @n; I think if those questions have not been dealt with in 21, the application, there is something wrong with the Region's 22 management. 23 DOCTOR SLATER: I am assuning that the quality of 24 the review process, if it is affected by the quality of the 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n (' )nnn,) 205 WHD140 1 way this is written, can answer that question. I can't 2 answer it. 3 MR. CHAMBLISS: Do you have comments, Mrs. Kyttle? 4 MRS. KYTTLE: I don't know the preciseness of the 5 treatment, but I know the protocol and the thrust of the 6 proposal, and it is an empirical thing. 7 It mobilizes the state into local organizations 8 that will specifically survey for hypertensives, assure that they are recognized, identify, treat it in a fashion so that 9 10 the rest of the state can get the information, so that t e basic data shows in Illinois that-hypertension is epidemic. But no one is organized to attack the problem, and 12 this is not so much a treatment of the specific patient as 13 it is'organizing the system of care that treats the pAtient.. 14 15 DOCTOR CARPENTER: What part of that budget..'..is invested in personnel? 17 MRS. KYTTLE: I can tell you that in just a minute. 18 $48,800 -- no, no; wait a minute. I'have the wrong one4 $291,000. 19 MR. THOMPSON: How much? 20 MRS. KYTTLE: Out of $743,000 no; e-xcuse me. 21 $100,000 of it is coming from other sources, and 22 the $743,000 is the total cost, but RMP is being asked for 2 il $634,000. $291,000 is a line item for saJxies and wages; 24 $170,000 for equipment, $28,000 for supplies, $15,000 for 25 HOOVER REPORTINO CO, INC. 32O Massachusetts Avenue, N.[. Washington, D,C, 20002 205 WfiDl4l 1 travel, $23,000 for rent. 2 It creates local consortia of some,-- type, and 3 there are charges listed here, and $25,000 in the other 4 categories. 5 MRS. WYCKOFF: How is it related to Projectil8 6 and 32? 7 MRS. KYTTLE: This --is statewide; 18 is@Mid,-Stdte a 8 nd Souths4de. Southside is a cooperative B that Illinois 9 has used as a springboard for a lot of its activity that it l'O tries out in Mid and Southside, anq then comes off a @ater timeframe as a national DOCTOR SLATER: This is not a final programi, but they are estimating a million hypertensives out there; 360i,. 13 14 in this'experimental program. MR. THOMPSON: My concern now well, two question 15 one is that you sdid the-c'ontrol program is based ).7 on a computer print-out, computer diagnosis. MRS..KYTTLE: That is in a controlled population. 18 MR. THOMPSON: Yes, I understand that, but somebody said that they were fooling around with some kind of a computer 20 program in hypertension, and would apply this' computer pro- 21 gram -- which again, unless I misunderstood you, is not com- 22 pleted yet -- to a statewide control program. .3 DOCTOR SLATER:- I think I left that impression. 24 MRS. KYTTLE: The precepts of that program will be 25 .R REPORTING CO, INC. )ssuhusetts Avenue, N.C. igton, D.C. 20002 Izu WHD142 I fed to the local boards that will be established, but to 2 speak to the whole future of the thing, three things have 3;1 happened in Illinois all at once, that-the.Illinois Regional @4 Medical Program has been waiting for for a long time.. 5 They got a new A man; they could not move statewide 6 well with their former CHP A man, who was replaced by a 7 former Board member of the Illinois Regional Medical Program Board of Trustees. 8 9 The concept of@the key factor analysis for planning 10 has been a philosophy- of the program before phase-out but could not be moved statewide because it met A opposition. It no longer meets A opposition, and they are now 12, able to move it. 13 They have a new State Health Officer who is a former 14 15 RAG member, and she is now wokk@ with the program in state- wide areas that they have 4iot had an opportunity to work well 17 in before, And most importantly of all for this project, we 18 are thinking about now the state-wide hypertension, and we have a new Governor that stood off from that from matters 19 medical. 20 No one, not the A man, not the new Public Health 21 Director, and not the existing RMP could open his door, 22 because he had other assessments tb'make. Ile only now has 23 established someone in his officp to work with the Illinois 2,4 Regional Medical Program to develop a regional legislative 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N@l. @Nashington, D.c.20002 Innn, cxr rcrt 208 iii)143 1 package. 2 They got to him with the epidemic hypertension 3 figures, and he is working wit h them for a legislative pack- 4 age that they hope will continue much of this. 5 DOCTOR SLATER: Let me give you the wording on this, 6 John. I think we may have it here: 7 "The immediate objective is to develop a 8 state network of hypertension registries which is to 9 evaluate quantity and quality. CHP B agencies would.be 10 asked to assist in components of the program, which in ;turn will mobilize regional resources to determine 11 registry input, reporting of requirements and action to 12. be taken in terms of screening, referral, management, 13 and consumer and professional education. 14 Discussion has begun with state dficials, 15 and heart associatiorZ legisla tion." MR. THOMPSON: Is it against the law for CHP B 17 agencies to run prog rams? They are not the implementers, if 18 that is the questi on that I hear you stating. DOCTOR SLATER: CHP B agencies will be asked to 20 assist in regional components of the program, which in turn 21 will mobilize resources and essentially determine registry 22 input, and so forth. 23 MR. CHAMBLISS: The re.is a 'Substantive issue here, 24 I think, and that is one of balance on the part of the @IP, 25 IIOOVER REPORTING CO, INC. 32ONlassaGhusettsAvenue,N.E. iV@siiiiiF.ton, D.C. 201',02 WIID-144 1 and is there and we would like your judgment here is 2 there an over-emphasis in the area of hypertension, especially 3,; since there are 350,000 people to be screened on the computer. i 4 set up? 5 I simply throw that out for your assessment. Of 6 course we would like to have your views here on feasibility. 7 DOCTOR SLATER: My impression of this as I read 8 it through, and I would like to heat what Mrs .. Kyttle's under- 9 standing is, having visited there, is that they made a speci- 10 fic decision programatically, sometime ago to go to two 11 routes. one is to satisfy some of the start-up needs of 12 13 what you might call dommunity-action programs, health care access and the like, which have been reflected in these pro- 14 15 grams that have been passed on, and are not fr6e"standing. And the second"d ,pcision,.some of these mass-popula- 17 tion approaches which are clearly associated 'with the mechan- 18 ical improvement of screening and information gathering, so they can be applied to masses of individuals who are disad- 20 vantaged, and in order to get to that level of technology, they need a reasonable level of hardware,, as John was putting 21 forth. 22 Now, I think the questidn'is whether or not this 2@3 is incorrect, that at the natbnal level we have decided like- 24 wise to go this route of kind of the task approach to cancer 2,5 IIDOVER REPORTING CO, INC. 320 Massachusetts Aveiiuc, t4.[. ,tori, D.C. 20002 Vj,IID145 1 originally it was heart disease, cancer, stroke, and now event 2, more so we have oriented our efforts on a programmatic basis to such things as cancer. So I have trouble maki 4 ng a decision at this level 5 based on the -- that they have done the wrong thing.' I think; they have taken an experimental approach as part of the 6 pluralistic way of going about it, and they are not doing it 7 to the exclusion of all other activities. 8 9 They could have a lot more Christian Action Ministry., 10 and I think they might -- I think that would be very effect-. ive and I am sympathetic to that, but I say there, they decid7 12! ed to put a lot of money into this one orientation. DOCTOR VAUN: I move that Illinois get their full 13 request. 14 MR. CHAIIBLISS: All right. There is a motion on 15 the floor, and will you cite the dollar level t at you are referring to, please? 17 DOCTOR SLATER:, I suggested that they get what 18 they requested -- 78 percent of what you indicated. MR. VAN WINKLE: $2,816,935. 20 DOCTOR IIHITE: I'll second. 21 MR. C@1BLISS: It has been moved and seconded 22 0 that Illinois be recommended for the level they have requested, 23 $2,816,935. Is there further discussion here? 24 DOCTOR MC PHEDAAN: I guess I'll go along with that,l 2,5 tiOOVER REPORTING CO, INC. 320 l,'ia@chusetts Avenue, N.[. "i3, D.C. 2000?. WlID146 1 but I think we ought to mention we think it is going to be 2 difficult for them to spend that amount of money on hyper- i 1 3 tension, on the hypertensionidentification in that length 4 of time. I really think it is going to be hard. 5 There are places where similar efforts have been tried in the past. Doctor Joe Wilburfore, in Atlanta, and 7 there are a lot of problems with it, and the implications 8 that Doctor Carpenter makes are a very important one. 9 That is, in places where there are a large number 10 of hypertensives, particularly in deprived people,, it is extremely difficult to get them into effective treatment and it always seems a pity to identify the programs a lot of 12, 13 and not be able to follow up at all, and I think it takes 14 away from the luster of the Regional Medical Program that is engaged in an activity like that' that is effectively followed 15 up. 17 So I think I guess that maybe is one of the 18 things that Doctor Carpenter is concerned about. -DOCTOR SLATER: We are more concerned about the 1!) 40 20 fact that they are attempting to do too much in too short a period of time rather than that. 21 MR. TIIOMPSON: Plus the fact we have gone through 22 cancer detection, we have gone through multiphasic screening,, 2 t3 we have gone through all these kinds of things where everybody 24 runs around, finds a lot of pathology that nobody sees until 25 HOOVER REPORTING CO, INC. 320 tiassactitisetts Avenue, N.[. D,C. 20,512 (20',)) 212 W@ID147 I the damned stuff is treated, because it is outside the system. 2 MRS. KYTTLE: Mr. Thompson, not in Illinois. When 31' Ifollowed up there, Illinois had an interesting spin-off 4 from the foll ow-up. 5 It was referring all of these people with identifie 6 hypertension to doctors, and the doctors all said: 7 "You know, I've got sicker people in my office." 8 And so the RAG in Illinois decided that one of the spin-o s 9 from their next controlled hypertension would be to educate 10 physicians to treat mild hypertensives. They were willing toltake on the referred c2itical hy perten sives, but they 11 couldn't get the mild, even though they followed them up, .12. 13 they hauled them right into the doctor's office and that is 14 where it fell down. MRS. KYTTLE: But you know, some screening dropped 15 the man and didn't follo@ up, but they did not. They followed up; they re-screened. 18 DOCTOR SLATER: It is very important; even if it is negative, it is certainly something that helps the system. DOCTOR MILLER: Mister Chairman, could I ask a 20 question? 21 I have known a good deal about the Illinds program, 22 and to a great extent the strength 6f the Illinois program is 23 directly related to Doctor and Mrs. Creditor. 24 Doctor and Mrs. Creditor are both moving to Urbana, 25 IOOVER REPORTING CO, INC. '@20 Massjchuselts Avenue, N.E. Viisiiingtop,, D,C. 20002 t'Af: rti:r, WHD148 and though he is going to spend 25 percent of his time on 211 continuing this program, the magnitude of the effort has got :3@'i to be led by somebody better than just a Creditor on 25 per- 4 cent of his time from Urbana. 5 What assurance do we have that a similar competent 6 person is going to take over or that he will be able to help recruit, or maybe can we help them recruit one? 8 DOCTOR SLATER: I apologize for forgetting to men- 9 tion that. I 10 MR. CH2UlBLISS: That.is very critical, yes. 11 DOCTOR MILLER: The two of them ran that program. .12. MR. CIL7UIBLISS: Would Staff have any comments on 13 the efforts in recruitment there? 14 MRS. KYTTLE: What I mean -- well, as I mentioned 15 in my staff paper, the Board talked with Dean Bloomfield, and I have talked with Dean Bloomfield. 16 17 The Board'has decided that 25 percent of Doctor 18 Creditor, which they think will also bring them 25 percent of ',,Irs. Creditor for free, is good enough, and they would rather go with that than to recruit hastily. They are recruit.. 20 ing; they have a Search Committee. 21 Bloomfield is a member of the RAG; he is deeply 22 involved in the problem-oriented record. That is how a lot 2.3 1 ii of it got going down in Smithfield or Champagne and Urbana 24 in the first place. Dean Bloomfield assures the Board, and me 25 HOOVER REPORTING CO, INC. ,IIID149 that that is not going to be a skimpy 25 percent, and that 2 it would be his assessment that it would be the better of nts, at least through December, and recruit- the two arrangeme 4 ment efforts are going on. 5 They have found no one; the Board wants an!M.D.. 6 and tney are simply not coming up with a successor to Doctor 7 Creditor, and there is no assurance. 8 MR. CHAIVIBLISS: I would simply ask the Committee, 9 is there a judgment that it wishes to express on the@issue 10 of recruitment? 11 DOCTOR WHITE: I would like to agree thatithe Boar is using some sense, because I can't imagine,knowing@what is 12. going to happen in July of 1975, that they could get anybody 13 14 who is really effective as a replacement. DOCTOR CARPENTER: There can't be anyone who could 15 1(; solve the problem of bringing 66 percent of the hypertensives 17 in a population to effective treatment that wouldn't make a 18 national contribution that would be enormous. That will take someone five years of his life to prove that he's a relative 20 f@ure in this area, as a lot of people have done that in other screening areas. 21 Is there a Project Director here that we have not 22 heard about who is committed in the)o'ng run to the control of 23 hypertension in a population? 24 DOCTOR SLATER: Doctor Kyttle Doctor Koe. -Can 25 HOOVER REPORTING CO, INC. 320!,',,a@sact@usetts Avenue, N@E. it!Etoii, D.C, 20002 'VIIID150 11 you talk to that? 2 MRS. KYTTLE: Well, they thought Fred Coe might 3@l have met this, but he can't at this time. 'Can not be dis- 4 tracted from what he is doing. 5 Doctor Creditor is temporarily listed as t e Project 6 Director in hypertension. That is temporary, and it is almost 7 a cloak; because this project creates a State Board, they 8 have proposed a candidate, and I do not know who it is, that 9 the Public Health people, the CHP people, the Medica@ Committee and the IRMP would proposed to the Governo@'s 10 office, and now that the Governoris office has gotten 11 involved, and this they look at.as the possibility of the pro-I 12. 13 ject for the hypertension. effort being the continuing Regional Medical Program Director. 14 15 So they are approaching it cautiously, because the man has to be ratified by so many different interests. 17 MR. CHP2.IBLISS: We have a call for the quest3on? The motion has-been to recommend a level of funding 18 for Illihois at $2,816,935. All those in favor? 20 (Chorus of "Aye") 21 Those opposed? 22 (No response) 23 one in opposition,,and the "Ayels" have it. 24 I would say that with regard to Illinois, the 25 HOOVER REPORTING CO, INC. 320 filassachusetts Avenue, N.[. D.C. 200@"' )151 discussion will be noted and taken into account, as presen- 2 ted here by the members of the Committee. I would call your attention to one thing, that our 0 4 workload for today is still one short, interms of the number 5 of Regions to be reviewed. 6 The last Regi(n for today is Louisiana; I would have 7 a hope that we might finish by ten after 6:00. Is it your 8 pleasure to continue? Let's g.o. 9 10 12. 13 14 15 17 20 21 22 23 24 25 IIOOVER REPORTING CO, INC. 320 klassactitisptts Avenue, N.[. 20002 'HD152 1 REGIONAL MEDICAL PROGRAM REVIEW 2 LOUISIANA REGION 31 MR. CHAIABLISS: All.right, the reviewers for 4 Louisiana are Doctor White, who will be supported by.mr. 5 Zivlavski. 6 Doctor White, will you proceed, please? 7 DOCTOR WHITE: I am sorry that this comes at the 8 end of the day, because I have yet to make up my mind what 9 should be done about Louisiana; as I was saying earlier to 10 Doctor Vaun, I had a feeling I was in an intensive care unit, 11 and I really had a patient who had died but was oft a respir- .12, ator and I didn't quite know how to pull the plug. 13 Yet, on second thought perhaps there is a feeble 14 beat going on there that I didn't detect at first glance, and maybe something can be salvaged. 15 Well, with tha@,as a preamble, you can see my confusion. 17 Louisiana has had a checkered career in the past. 18 It had a Regional Medical Program, but it has never been awarded a triennial status. 20 It was a difficult chore to even get the concept 21 accepted in the state of Louisiana for many years. Doctor 22 Zabatlyea took on the job, I forgot'.when sometime ago; he 23 had been President of the State Medical Society, he was an 24 acceptable individual, and on the basis that my knew him and 25 klOOVER REPORTING CO, INC. fi@sactiusetts Aveiiiie, N.C. iHD153 1 on the basis t hat the thrust would be on planning initial ly, 2 it got off the ground, and in reality the Regional Medical .13 Program has functioned there for a number of years much like i 4 the CHP agencies were supposed to function. 5 And on a site visit a year or two ago, this was 6 noted, and I was asked then that a Regional Advisory Group 7 begin to become more action-oriented. At the same t@me we 8 became aware that Doctor Zabatlyea was really runnin this 9 9 thing; the Regional Advisory Group was sort of thereiin name 10 only. Mr. Smith then took over as Regional Advisory 12, Group Chairman and turned things around, but only at the timel 13 Washington was turning around, and this disillusioned them 14 totally. Doctor Zabatlyea resigned from his position, and I guess.is now donating some amount of time, and a doctor whose 15 name I don't recall -- a ddntist is filling in for him.. 17 The other problem in Louisiana is -that there are 18 two systems of medical care, and the two seem not to be meet- 19 ing. Although, as I have down here, there had been some 20 change under way when the- axe fell. 21 So the leadership is in question at the present 22 time. This report that @ have before us was prepared by a task force, signed by Doctor Zabatly'ea but obviously not the 23 product of his thinking. It is rather disorganized, it does 241 not follow any'sequence that permits ycu to see the program as 25 40OVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. D.C, 20U@2 1,11-ID154 a whole. 2 1 The staff has been reduced considerably; there are four and a half professional people listed with pres mab !a ly 4 as I mentioned -- the Regional Advisory Group began the turn-i 5 around, but I have the feeling that now they really developed phase-out plans and when this new concept came along! they 7 kind of even delegated this development they had not.expected', 8 tolothers. I am not sure from the narrative how often' the 9 10 Regional Advisory Group has met, and as I said.-, I dol feel 11 tha t probably their work has been delegated to staff! in some existing communities. 12. 13 The past perfor.mance of this has not been@good; they have begun some outreach programs in some of the rural 14 15 areas, they have begun some patient care program activities; they are proposing other's. -and --,in this present package. 17 They have participated in the established Emergency 14edi cal Service programs.in the state, the two direct efforts toward hypertension, quality assurance and outreach counsel- ing. 20 They do recognize, and I guess they have been 21 atturned to this for some time, that they may not get money 22 for more than a year at a time, as they have in the past, so 23 I guess it is nothing new to them. 24 Their efforts are reasonably feasible on a year's 25 HOOVER REPORTING CO, I NC. 120!,Iawchusetis AvenLe, ti.E. D,C. 20002 22 0 qliD-155 budget period. 21 One plus is that the state itself has finally il reorganized its health-care delivery systems, evaluation 4 systems, and has a centralized state agency which wi 1 take 5 on and direct, presumably, many of the things that ate going I 6 on in the Comprehensive Health Planning agencies, many of the 1 7 things that have been going on in the Regional Medic 1 8 Programs. 9 This was accomplished in 1972 when this cohsolid.a- 10 tion was under way, and it seems to be accepted; fun ed by 11 the state, at least partially, and for,that reason, if nothing 12. else, I would suggest that this request by Louisiana even 13 though we know the leadership is .not good, at the present time, 14 and that past performance has not been good, that there is some merit now that the state has begun to move in the focusdl 15 direction, in not cutting +-he rug out from under them, with 17 the hope that at least some amount of money will continue the 18 emphasis toward this simple direction of the health services. 19 That is the only justification I can find at all 20 for recommending any sum of money for Louisiana whatsoever. Some of their projects are adequate; a couple of-them are 21 rather biased, I think because the Director at the moment is 22 a dentist. They have a couple of 'fairly sizable dental pro- 23 grams, including a mobile bus that is going to go out and fix 24 25 teeth, I guess. HOOVER REPORTING CO, INC 320 t@,assachusetts AvenLe, ti.l. s We have another strange one, or at least it seem 2 funny to me; they are going to establish a Midway assessment 3!i Region at the Charity Hospital, and as I read some of the 4 comments, this is to move the patients out of the wards into 5 another place, because these are patients they can't get rid 6 of -- families don't want them back, they don't have any. 7 money to pay nursing care, and that is one way out. And 8 the Midway Assessment Region is for patients flowing the other 9 way, that come in@through the Emergency Room and can't be evaluated adequately, and they have to be placed in.this area 10 11 and then moved into the hospital or someplace eventually. 12 But anyway -- they are at least making some efforts 13 at bringing some services to people who are denied services at the present time. 14 Another one at the Earl K. Long Hospital -- they 15 indicate that there is a,-60-day waiting period for patients to be seen in the clinic, and they are asking a modest sum 17 of money to open up night-time clinics and weekend clinics so that this waiting period might be shortened, and I guess that is reasonable. 20 DOCTOR SLATER: Well, that is straight operational 21 patient-care delivery. 22 DOCTOR WHITE: Well, it.i@.going to support some 23 staff work to help administer that. 24 MR. THOMPSON: You can't do that with a modest sum 25 HOOVER REPORTING CO, INC. 320 Massachusetts Averiue, N.[. 'ila@ilifigtofi, D.C. 2C,.Of,'? (;'02" t ID157 of money. 2 DOCTOR WHITE: Well, I get through saying these .'3 things; it's a bad bag all around, and yet I don't feel.tliat 4 it should be denied survival for as long as the rest,of them 5 are going to survive, in the hope that one more year@might 6 see something turn around even more. 7 They have asked for $985,000, which is only 77 8 percent of the targeted funds, which would go to them ona 9 formula basis. 10 Mr. Zivlavski, maybe you have some comments before I come up with recommendations? 11 MR. ZIVLP.VSKI: There are several negative'comments i 12. i I' 13 which you made, and I hop e I can cover these comments. The phase-out of the Louisiana Regional Medical 14 15 Progr. am was taken very seriously by their Board of Directors; as of July lst of 173, Doq;tor Zabatlyea was only part-time, and a business management was basically left to the Board 17 staff. 18 19 This was a non-profit corporation, by Louisiana 20 law; they have to notify the state 60 six months in advancer before terminating the corporation. 21 At that time Doctor Zabatlyea did reduce his staff; 22 he was on approximately 20-25 percent. He remained as a part- 23 time coordinator. 2,4 In late June things did change. In September, things 25 HOOVER REPORTING CO, INC. 320 taassachusetts Aventie, N.[. "ia- D@C. 20002 223 IIDD158 1 looked a little bit better when $17.1 million was released 2 from the Division of Regional Medical Programs. The Board i 31;@ of Directors, instead of submitting official notice to the 4 state that they were going to termina te, kind of put the cor- 5 poration in neutral gear and decided to wait. 6 It sounds like some story, but I am trying to get it in the right sequence so that you will understand. 8 As more money was released from DRMP, Doctor 9 Zabatlyea had hired several people to the program staff; when 10 it became clear that the lawsuit was won by the Regional Association, the Board of Trustees again, for the corporation gave Doctor Zabatlyea another nod to go ahead and hire addi- 12. tional staff members 13 14 During this.time we made a site visit; Mr. Posta 15 and I, in November 1973. I- The National Council was concerned 1(; about that; we made a site visit, we discussed this with 17 Doctor Zabatlyea in February of this year. lie indicated t at 18 he was going to resign from the corporation; two months ago 1!) he handed in his resignation and the grantee would not accept it. 20 He has increasedlis time back to 50 percent; he has 21 rehired several of his staff. Several of the staff have been 22 Project Directors with the Louisiana RMP when they worked 23 for the CHP agency and have 30'ned the staff, and what you 24 see here basically are eight or nine maybe ten people; I 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. '@iashiiiv.ton. D.C. 20002 WliDl59 1 think it is 8.6 full-time equivalents,, LIICIL. L.Ilt=_Y J.LCLVIZ tlW- 2 and they are asking for $1.25 million. 3; Doctor Cook, the Deputy Director, is 100 percent; 4 he did come back to fill in the gaps when Doctor Zabatlyea 5 was not there. 6 So it has been slow; the staff has been slow in - building up. The present situation now is -that he is going to remain 50 percent. For how long I am not sure. 8 I would rather not comment on,anything else. 9 MR. CHPIIBLISS: I would if I may just make this 10 observation to the Committee. You should know that the staff,has been very much 12. 1.3 concerned about this Region for some time, and that there is 14 a concern beyond the staff as it relates to the CHP-RMP issues. in Louisiana. 15 This has been one of the Regions that both Doctor Paul and Mr. Rubel have be ,pn concerned about the CHP-PIIP 17 18 relationships in, and I say that only to give, perhaps, Staff an opportunity to comment on those relationdips betweer J!) PI@IP and CHP and this Region. 20 DOCTOR WHITE: I shoiild.have mentioned that, too. 21 That is apparent in the application, at least the communica- 22 cations from someof the CHP agencies, ftt people there are 23 trying to stake out territories. They want to be the surviv- 24 ors and not @IP. They impose conditions on RMP, or try to, 25, DYER REPORTING CO, INC. 16 14 i KliDlGO 9 1 which I thought were totally unrealistic, in demanding that 2 they come and present their pro'osals for review, and they p 3 were going to go after technical merit of the whole thing, 4 as we were trying to avoid. 5 All that sort of thing instead of trying to determine 6 -- yes, this is consonant with what we should be doing. 7 So I guess I &so got up on my hind legs on that 8 thinking, that I have invested time and effort in RMP and I 9 would rather see them survive then CIIP, and I shouldn't say 10 that. MR. ZIVLAVSKI: I would like to add some comments .11 12. on the CHP comments. On the yellow sheets we have two para- graphs; one speaks to the New Orleans Health Planning Council, 13 14 and the other speaks to the Northwest Louisiana area Health 15 Planning Council. The concern thiit,,Doctor White discussed concerning the New Orleans area; they notified the Project Directors 17 the Friday evening before the CHP Monday morning meeting 18 this one, their meeting on May 28th. Doctor Cook, the Deputy 19 Director is meeting with the CHP agency, trying to resolve 20 this. 21 The second concern is the Northwest area, which is 22 madeup of eight parishes in the Northwest part of the state. 23 There is a three-page summary from this agency; basically it 24 is probably the most negative letter in the whole application, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 t2O2) 546@66,36 111)161 1 but when you read the whole letter you realize the territory 2 that the Northv7est area takes into account. 3" They have-Usted 12 projects here which the receiveO, 0 4 and they are all negative comments for these project None 5 of these 12 projects' fall into the area which their dHP 6 agency has. 7 It is a mess, in that they received a b unich of project grant activities, which they really should not.have 8 9 received. 10 This will help you alleviate some.ofthe c ncerns about the Northwest area. In addition, the Deputy cpordinato 11 12, Doctor Cook, is also meeting with this group on Play /r-n".L. believe, to'get this Area straightened out. 13 14 They were favorable in three of the arthritis proposals, which this group is not reviewing, and they were 15 favorable in another project, which again was not in their area anyway. 17 18 The two projects which head into the Shreveport 19 area were continuation projects, and these were projects 20 Number 42 and Project Number 44. These were continuation projects in this grant request in the Shreveport CHPH agency 21 voted for approval for these two projects previously, and 22 this is in the $71.1 million that was awarded for octobPr 23 to December, so I hope we can take care of Mr. Rubel's 24 concerns in addressing the RAG and the CHP areas. 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.C@ @44a@ . 20002 ington, D.C ID162 1 I think we have taken care of these ma]or concerns. :00 PM 2 MR. CIIABIILISS: Thank you. 311 We would now entertain a recommendation, Doctor 4 White. 5 DOCTOR WHITE: Well, unless you would prefb,r further 6 discussion of the CHP issue, though I don't know that there 7 is anything further to discuss. There is an obvious,linfluence- 8 of some kind there that has to be resolved. I donitilthink tis Committee can resolve it. We have already ident@fied..it- 9 anyway. 10 I think that RMP has done some good work down there; 11 12 Doctor Zabatlyea was a dedic. ated fellow, andIthink he has done a lot of work the CHP should have been doingi and there 13 14 are some things to be completed, and I think it would be a shame to terminate it at this time, and therefore I would move that this be approved at the requested level, at $985,212. DOCTOR MILLER: Second. MR. CH701BLISS: 'It has been moved and seconded that 18 the level to be recommended for Louisiana be at $985,212. 19 Is there discussion? 20 I hear a call for the question. All those in favor? 21 (Chorus of "Aye") 22 Opposed? 23 (No response) 24 The "Aye's" have it; the motion is carried. This 25 HOOVER REPORTING CO, (NC. 320 Massachusetts Avenue, N@l, D.C. 20002 A 9C. f, R :)163 1 panel has completed one-half of its work. I wish to commend 2 it for its patience, its stamina and its participation, and 3 I would also like to say to the Staff and to our Recorder 4 that we appreciate your patience and stamina'also. 5 (Whereupon, at 6:10 P.M. the Committee recessed 6 to 8:30 A.M. May 23, 1974) 7 8 9 10 12 13 0 14 15 .17 18 I!) 20 21, 22 2 t3 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.L. Wastiington, D.C 20002