*@001637* TPtANSC-,' lprl" OF PROCEED@INGS T ,DE, PAR Ti@lil, O@7 TMUCATI@l'.(-,'N A.iM Wl,Tff ARE Z)IVI,r)!C'.,,l Ow RF'-,GTOI"AL @IC[IL PROGRIliviS P40C CODUI41TTLIE PP-,NP.,L A Rocl,c,,7ill-e., Maryland j7 May 23,, 1 thru H 0 O'@, Ein, REPOPI'!,---,@'G COMIAr@,TY, INC. j@.eporters 546-6666 228A C 0 N T E N T 8 REGION BEGIN MOTION APPROVED 2 IOWA 231 235 236 3 MEMPHIS 237 251 266 MISSOURI 267 278, 280 5 NEBRASKA 288 297 297 6 7 NEW YLEXICO 299 312 312 NORTH CAPOLI@.IA 313 321 322 8 NORTH DAKOTA 323 339 341 9 NORTHLANDS 343 356 356 10 11 TEXAS 357 401 402 12, OHIO VALLEY 404 421 422 OKLAIIO'IA 423 436 437 13 14 SOUTH CAROLINA 440 455 455 15 SOUTH DAKOTA 4,57 466 475 16 TENNEESSEE MID/SO. 475 482 485 18 19 20 21 92 2.3 24 25 @@OOVER REPORTING CO, INC. @O faassachusetts Avenue, N.[. 1 DEPART14ENT OF HEALTH, EDUCATION AND 2 WELFARE 311 4 5 6 7 8 AD HOC CONSULTANTS MEETING FOR REVIEW OF 9 RMP APPLICATIONS 10 11 12 13 14 15 16 17 18 Conference Room H 19 Parklawn Building 5600'Fishers Lane Rockville, Maryland 20 8:30 A.M. 21 Thursday May 231, 1974 22 2.3 24 25 HOOVER REPORTING CO, INC. 22 3 5/23 am D/em P R 0 C E E D I N 'G S 8:40 am 2 MR. CII7-OIBLISS: I would like to say, first of -ill 3 good morning to the members of this panel, I indeed cor,,mend 4 you again for the diligence and the zeal that you tackled this 5 most difficult task we had yesterday. 6 I would like also to welcome to the panel,Dr. 7 Scherlis. Good morning, Dr. Scherlis. 8 'DR. SCHERLIS: The expression is "the late Dr. 9 -Scherlis". 10 MR. CIIAMBLISS: And say we are g lad to see you,, .11 and we are still waiting on Mrs. Wyckoff and Dr. Mi@ler; 12. but, if the committee so chooses, I think we can proceed. -13 We're halfway through with our task and today i-i-e 14 have fourteen regions yet to be reviewed. The order at I 15 woul d suggest, and certainly this can be changed, would be i(i along the following lines: Iowa, Memphis, Missouri, Nebraska, 17 New Mexico, North Carolina, North Dakota, Northlands, Ohio 18 Valley, Oklahoma, South Carolina, South Dakota, Tennessee and Mid South, and finally Texas. 20 DR. SLATERT Sir, I have to catch a 5:10 train at 21 the Capital Beltway,, so I have to leave here about 4:15 or' maybe a little later, if it's not raining; and I'm on Texas. 22 .I can tell you Texas won't take more than five minutes. 23 24 Jesse Salazar is the primary reviewer, it will take ten minutes. 25 IOOVER REPORTING CO, INC. ,20 Massachusetts Avenu,, N@E. 229 em2 MR. CIIAMBLISS: It y7ill take ten minutes. 2 DR. SLATER: We should be able to finish. 3 I-IR. CIIAIU3LIS: I could make the suggestion that 4 we take Texas now. It's too hot in Texas to start with Texas. 5 1 DR. SLATER: We're anxious to talk with each 6 other, because this requires some preliminary review by us 7 to be able to make a sensible presentation.- So if you could 8 do it after lunch, we'd appreciate it. 9 MR. Cl@4BLISS: After lunch? All right, we will .10 start out with Texas immediately.after.the lunch hour. 11 DR. 1,7IiITE: Bob, where do We stand in terms of 12. relationship with the other panel? ..13 MR. CHAMBLIS: The other panel, as of last night, 14 had completed nine out of 23, and we had completed 14 out of 15 28. DR. VTHITE: Some of us have suggested a target 17 of this afternoon's.joint meeting. Is there some way they 18 can be reinforced in the3r efforts? 19 MR. VMI WINKLE: We talked with Dr. Pahl just a 20 minute ago and he I s over reinforcing that right now. 21 MR. CHPJ4BLISS: A suggestion has been made that 22 the first panel that completes its work would go over and 2.3 join the other and help them speed-up. 24 DR. CARPENTER: I also have to leave about four, and 14orthlands is therefore a bit of a problem,, maybe,, except 25 HOOVER REPORTit4G CO, INC. 320 M3ssachusetts Avent, @, N.E. em3 1 if we finish on schedule it won't be. 2 MR. CIIAI-IBLISS: I think we'll get to Northlands 3 about near the lunch hour, just before or just after. 4 DR. CARPEIITER: Thank you, sir. 5 MR. Clil@lIBLIS: Then, shall we begin with Iowa, and 6 welcome Mrs. W17ckoff. MRS. TIYCKOFF: Sorry to be- late; I-couldfilt get a cab. 9 10 12, 13 14 17 18 19 20 21 22 2.3 24 25 !OOVER REPORTING CO, INC. 20 ?Aassachusetts AvenL, i, N-E. 231 em4 1 REGIONAL MEDICAL PROGRAM REVIEW 2 IOWA 3 MR. CHAT.ABLISS: In the casecf Iowa, Dr. McPhedran 4 and Mrs. Salazar are the reviewers and Mr. ziviavsky is. the 5 staff support, will provide staff support. 6 DR. McPHEDPAN: I am recommending that we give 7 Iowa the amount that they are asking for. I think this is a 8 good Regional Medical Program. 9 And to go through the categories that were suggested 10 on the review sheet, first of all, a little background from 11 me: I site visited Iowa in the past, it was several years 12. ago, but a lot of the direction of the program that was there 13 at the time is still there, and I've had occasion to meet 14 with Charles Caldwell on one or two times since then, and 15 he continues to impress,.me as an imaginative coordinator. From what is presented in the application, it sounds as though the Regional Advisory Group, for example, had great 8tength then and continues to be a strength, anticipat- 18 ing the form of the review sheet. To return to that, the program leadership I 20 21, classify as at least satisfactory, and the staff-as generally good in the Regional Advisory Grou ; a good group there. 92 p The kinds of meetings they have held in tbepast to deve op 23 programs and to monitor it as it goes along, seemed imaginative 24- 25 and very much to the point. HOOVER REPORTINO CO, INC. 32OMassachusettsAvenue,N.C. 232 em5 1 Past performance and accomplishments as satisfactor Y, 2 also. Satisfactory in all of the other categories.) 3. I guess that the program staff and the Re ional r I I i. 4 Advisory Group principally were the factors that ma ke me feel 5 that the over-all assessment of the region is above average. 6 It is a well-administered staff of generalists. Itils a 7 stated policy, that is, that persons on the staff retain 8 some ,general competency in various activities that they 9 conduct. 10 Therets a good deal of emphasis on joint Oecision -11 making on the staff members. This is gone over in the 12. current application. '13 I think that they have, as I say, a good Regional Advisory Group support. 14 15 The only sour,.note, I guess, for me, was that -the relationships with Comprehensive nealth Planning, which I thought previously iiere.quite good,, seemed to be somewhat less than satisfactory, as judged from some letters that I 19 think are included in our notebook here, which were not in the original application. 20 But, on the whole, I think that the general program 21- purposes and their past accomplishments simply weren't what 22 23 they have been asking for. And, according to this master 11 financial sheet, which perhaps I found more helpful than I 24 should what they are asking for constitutes only 80 percent 25 HOOVER REPORTING CO, INC. .12n Avenue. N.E. 2 33 em6 of what it was thought they could have in targeted available 2 funds. 3 And even if they are expecting to request in July, 4 it would only come to about 95 percent. I really think with the management and direction of!, 6 this program, it has been good enough in the past that it 7 certainly warrants that kind of support, without going into 8 further detail. 9 MR. CIIPJIBLISS: Thank you, Dr. McPhedran. 10 Mrs. Salazar. 11 MRS. SALAZAR: I subscribe to Dr. McPhedran's 12 views, and this is the impression that I gleaned from 'le 13 application. 14- Ho@vever, there are some concerns which I had an occasion to discuss with rank briefly about the CHP involve- 15 ment and some other comments. But the timing seemed to be 16 bad, that they just couldn't get to them. I would like to 18 hear from Frank, MR. CHAI-IBLISS: Mr. Zi'vlavsky, would you 20 MR. IZIVLAVSY..Y: Iowa,, from the beginning', had a very close working relationship with CIIP. They h ave maintained 21: that relationship throughout their program history. 2@ 23 14hat they have in the eapplication is actually one 24 non-official B Agency comment, that there are 15 CIIP agencies in the State,, fiv'e of the 15 are actually approved B agencies. 25 HOOVER REPORTING CO, INC. ri r 2 3 4 em7 The comment you have.here is a comment from one 2 of the non-CHP B agencies. They telephoned them i n to 3! Division P14P and requested a three-day delay in their 4 application. This was approved, and they submitted it on 5 the 3td of May instead of Play lst. 6 They just admit it's a breakdown in their machinery 7 for the CIIP to be processed, because they have always taken 8 into account the CHP comments, have been able to negotiate 9 their differences with CI-IP. They have submitted five 10 additional letters here,, but basically.two CIIP agencies have 11 delayed their review. One has favorable comments. One has 12. a recommendation for disapproval. And the last line, I just 13 state that the Iowa CIIP has not yet responded to negative 14' comments or questions due to the short timeframe. 15 We received tlie@e on the 20th of May, and inserted these into the books of the reviewers and the coordinator, and we have-not had an official chance to sit down and 18 negotiate on a one-to-one basis with each of the differences I& 19 of the CHP agencies. And I,usually they have a comment'in 20 there that it's a breakdown in their machinery. The staff is on top of it. 21- 22 I will be watching this closely, and that's really about where it is. 23 MRS. SALAZAR: One of the things that I noted in 24 reading the application is the resiliency of this staff to HOOVER REPORTING CO, INC. A Li r 2 3 5 em8 1 react and turn around and react to all kinds of crises, in 2 a very flexible manner. And I think that's very good. 3 MR. CIIPL@LISS: Someone has said that's based on 4 their youth, because they all are very go-go types, young,, .5 aggressive, they move quite fast. I simply throw that in 6 as an observation. 7 DR. McPIIEDRAII: So- I would move that they be funded 8 in the.aniount requested, which,, to reiterate, is $1,061,349. 9 MR. CII2U4BLIS: We have a motion on the floor that 10 Iowa be funded., recommended for funding at a level of 11 $1,061,349. Is that seconded? 12, DR. MILLER: Well, the yellow sheet says 249; 13 but maybe there's a mistake here. 14 DR4 WHITE: What is Mr. Caldwell's background? 15 MR. CIIAI.-IBLISST I believe his background is either in hospital administration or public administration. 16 DR. WHITE: He's about the third coordinator they have had, isn't he? 18 19 MR. CII@,BLISS: To my knowledge he is the second. DR. McPIIEDR2UI: Second. 20 DR. WHITE: Willard Prell was first. 21@, 14R. VAN WINKLE: That is 249. 22 DR. McPIIEDRAN: Okay. Amend that. 23 e 2,4' MR. CH7UI.BLISS: Do you amend the motion? Is there a second to the motion? 25 HOOVER REPORTING CO, INC@ ?J r 2 6 er.i9 1 MRS. SALAZAR: I second it. - 2 MR. PULLEZI: It adds up to 349. 3 MR. CIIAMBLISS: It has been properly moved and 4 seconded'that Iowa be recommended for the level of 5 $1,061,349. 6 It has been seconded, so we now may have discussion. 7 DR. SCIIERLIS: I note that one of the projects is 8 for emergency medical systems. I thought that was specifi- 9 cally exe.-,ipted unless there were continuing projects. Is 10 this a continuing project? It's for $74,50.0. L 11 MR. CHIU-IBLISS: It is a continuing project. 12. DR. McPHEDP-AN: Yes, I think it is a continuing 13 project. 14 MR. CHP14BLISS: Continuation of a previously 15 funded project. 16 Is there further discussion? 17 If not, the Chair calls the question. 18 Those in favor? 19 [Chorus of "ayes".] 20 MR. CliAlIBLISS: Those opposed? [No response. 21- 22 MR. CHAMBLISS: The "ayes" have it, and the motion passes. 23 24 25 iOOVER REPORTING CO INC. @ft A,I.@.., UrI 237 emlO REGIONAL MEDICAL PROGRAM REVIEW 2 MEMPHIS 3 MR. CH@IBLISS: So we will now turn our attention 4 to the Memphis Regional Medical Program. The reviews there are Dr. CarDenter and Mrs. 6 Wyckoff, with Mrs. Lorraine Kyttle providing staff support. 7 DR. CARPENTER: This is a region that I've had an 8 opportunity to visit. As many of you may know, it is an 9 interesting Regional Medical Program involving part of 10 five States and growing out of an existing health planning 11 body in the Memphis area. That body later became a 12, Comprehensive Health Planning agency for the area and that 1 "13 growth of the regional program, made a great series of State 14 and local Pd4P's, naturally, and probably it would have been 15 an iriDossible situation,.without that beginning. I But it really has worked well, and given the 17 Memphis Regional Program, I think, a particular characteristic 18 of its own. 19 In some ways it seems to me to behave like a very 20 broad planning agency. The nature of the Comprehensive 21 Health Planning agency, as much as it behaves like a Regional 22 Health Program. But I don't think it's all bad. 23 This is a data analysis that attempts to get into 11 h6alt.h care problems in the region. It is the latest in a 24 25 series of publications based on .data that was,demographic HOOVER REPORTING CO, INC. 'Of) L12tt2rhiltAttq AvenLi- N.E. 2 3 3 emll data that was available and re-analyzed to meet the region's 2 needs. Also surveys of health in various places in the 3 region. 4 usual, in the world, it's very difficult to 5 determine that the program has been guided in direct ways by 6 this kind of data analysis,, but I believe the ability of the' 7 region to generate that kind of data and to-reinforce and 8 talk about the health care needs of Memphis has provided 9 them with a kind of credibility leverageIthat has been 10 important in the development of the program. 11 Tlie region has a relatively stable staff. The 12, coordinator has been there, Culbertson, for a long tine. 13 And they have A stable -- well, they have had some changes 14 in their varying structure because we had legal questions about the original arrangements. They are now settled down 15 into a standard RAG arrangement, and that was not 17 terribly adversely affected by the regional catastrophes* 18 They are not terribly explicit in the way they 19 write their Application. They list, I guess, four goals- and 20 13 objectives; and, as I tried to analyze them, I come up 21 with what I really thin!: are seven ideas. And these are related nicely to the usual medical goals of the Regional 9-2 23 Program, and I don't see any problem there. e 24 They discuss priorities as though they were separate from their goals and objectives, which is a little discon- 25 [OOVER REPORTING CO, INC. 20 @iassachusetts Avene. @, N.E. 23 9 c., ml 2 I certing, but by the time one o'clock came around I had 2 solved the fact that they were really paraphrases, and one 3 can in fact group their goals and objectives into some range @4 of priorities. 5 The request is for about $700,000 in core support, 6 a million six for 28 con tinuing applications and a million 7 for nine new applications; $300,000 for developmental awar s. 8 The projects from the beginning of this region 9 have not had very specific goals. They have been very 10 general: Let's get together, sometimes plan; letlb get 11 together for general action@kinds of goals. And they've 12. not been evaluated particularly well. 13 I have great difficulty in this application in 14 understanding in some ways what they have accomplished. 15 On the other hand, they have brought in an enormous number of dollars from other so.urces to the region, or at 17 least have contributed to it, and because of this very close 18 working relationship between Comprehensive IIealth Planning, 19 experimental health care delivery systems, and Regional 20 Medical Programs in the area, it is very difficult to give 21 credit for what happens. IIhich is certainly ncit-a complaint at all, but it does make evaluation very difficult. 9-2 I believe that the Regional Program in that area 2.3 had a significant role in brin'ing something like a half 24 9 25 million dollars to the region in other support in each of the HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. VJ.@hinafnn n r. 7nnn9 2 4 0 eml3 last three years. 2 They estimate that they have served 200,1000 patient-),.. 3 in the last year, and about 21000 professionals have been 4 trained. So there are some kinds of program evaluation that 5 are available; but, again, the project evaluation is a 6 problem. And one almost gets the feeling that the projects 7 were ancillary to the main issue. 8 -lihich, again, I think is more an interesting 9 -different approach* perhaps; but there are some difficulties, 10 I think. 11 There is, for instance, $60,000 invested in a 12, project to improve death certificates. Tlhich reall@ turns 13 out to be an experiment by one of the pathologists who does 14 one and a half autopsies a week, and tries to see whether 15 X-rays and gastric analysis would add anything to his I ability to perform as a pathologist. 17 That was hard for me to see as a Region Program. 18 MR. T11014PSON: It's interesting, though. 19 DR. CARPENTER: It's very interesting. Of the million dollars, roughly, for the nine new 20 projects, half of it goes for area education centers in ten 21 hospitals, and really, this project, half a million dollar 22 project buys an organizer, a librarian, and provides space 24 rental to the hospital, providers a secretary and some books, 25 journals, and audio-visual material for the area. IOOVER REPORTING CO INC. ;20 Massachusetts Avenu i, N.E. Vashington, D.C. 20002 2 41 eml 4 And the outputs of that project are said to be 2 to list the educational and clinical resources in the area 3 f th- of these ten hospitals, to relate the leadership o e 4 clinical and educational resources to determine the need 5 for new educational programs, and to develop an over-all 6 manpower plan. 7 Ilow 1, I just believe that that's the work Df the 8 Advisory Committees, not $500,000 worth of staff. mind I 9 also -- I don't know, at a time when this program i going 10 to be phasing out, I wonder what the meaning of a 11 developmental aviard is. 12. flow, let me stop at that point and see whlat my 13 cohort would say. 14 14RS. IIYCKOFF: Ilell, I think I-lemphis has the 15 most beautiful case of euphora about PJIP than any of the 1(; PIIP,S. They have chronic optimism about how this thing 17 is going to go on, and they are just going to conquer all the problems in the world. And it's partly due to Dr. 18 19 Culbertson's personality. He carries the thing on his back. 20 pretty well. 21 They also operate as a.very peculiar -animal. They are different from any other RTIP,, because they're like a 22 23 family. They seem to telephone each other and keep in touch 24 with each other across State lines and across all the 25 terrible amount of paperwork and rules and regulations that IOOVER REPORTING CO, INC. 20 Massachusetts Avenui, N.[. lashington, D.C. 20002 2 4 2 eml5 exist. They rise above it all-and do it in an informal 2 fashion, and they seem to get together after hours and keep 3 the wheels very well oiled, and do the things that have to 4 be done. 5 It's an incredible thing, and they cannot believe 6 that they are going to be phased out. They just don't 7 believe it. 8 Instead, as you can see from this report, they 9 make all kinds of alternative plans, so they Ire going to 10 survive no matter what. 11 And-I really have a little faith in them. I 12. honestly think they may be able to do it. They have put it 13 together, they have got this experimental health systems 14 management agency, and of course their Comprehensive Health 15 Planning Groups, and the yj.IP, and.they are planning to.get l(i ready to jump in any direction when the legislation comes 17 through. They are going to be ready for anything. So I 18 think their development funds will be used to launch 19 whatever needs to be launched at that time. 20 They show more faith in survival, when the crunch 21. went on, they went right ahead with their plans, and they 22 are all ready to get their maximum amount of money with new 3 projects and everything wlicnthe funds cane through. 2. 24 They have only seven I think,it was out of, was it 18? They had only seven approved and unfunded request@ 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. 2 43 eml6 at the end, and I think they had 11 that way, succeeded in 2 putting through at the worst possible moment. 3 So I really think that they may be able to make a 4 go of this. 5 I would like to hear a little from staff on what 6 they know aboutihe new plans they have for this new@trustee-. 7 ship board. If there is an @tliing in there. 8 'DR. I-IIIITE: I wonder if Mrs. Kyttle mightlalso 9 -comment on this phrase "escrow accounts". Is that ti 10 substitute for keeping money after the thin g is ove ? 11 DR. CARPEIZTER: That's a catalysm. 12. MRS. KYTTLE: 1,7ell, you asked about the o ganiza- 13 tion that is forming and you are quite riaht. It's almost 14 incestuous, because N14CC's spawned IUIP, and PI.IP's spawned 15 HSM.' P14P responded to the RFP that R&D issued for experiment3.1 i(i health systems, wrote the application, pulled the people 17 together, set it under a corporative kind of stance, 18 because that's what the RFP requires, and Voila, there's 1!) Health Systems Management, Inc.,, which is right across the 20 hall from TU4P. 21 DR. McPIIEDRAN: I'm on the ropes, Mrs. Kyttle. 22 RFPF R&D sent out a request for contract.proposals across 23 the country. That's a request for.contract proposals, for 24 proposals onexperimental health delivery systems. Regional 25 Medical Programs in Memphis sat down and wrote one, but did IOOVER REPORTING CO, INC. 120 Massachusetts Avenui, N.E. Va-hinotnn D C- 20002 2 4 4 eml7 not send it in under their name, because they were not at 2 that time a proper applicant, They spawned IISII, Flfl@ and the 3 local B, which is one of the most active B's in the State of 4 Tennessee, not just west Tennessee but in the State of 5 Tennessee, had formed an umbrella trusteeship -- and tl-iat's 6 not a catalysri; that's theirs. They call it an umbrella 7 trusteeship. 8 It proposes the merger of the executive committee 9 of each of these agencies, and it is a straight-forward., 10 unabashed move to present the three of them. This is not an 11 area where one is more interested in surving over the other. 12. The three of them want to survive. 13 They did an inte3mting thing. They agreed that each 14 of th@se.three entities, if their full boards ratified it, 15 and since this paper was prepared all of the boards have ratified it, the full boards. -The body bringing the largest 17 turf to this umbrella trusteeship, and without doubt that's 18 RMP with parts of five States, would bring the turf or I!) cognizance of this new group, should the turf w ant that. 20 And so there is, then, the possibility that there would be an 80-county five-State Health Service-Agency or 21 2@ whatever might come out of the new legislation. 23 They thought that that would be the experiment, 24 and that's the purpose of that organization you asked about. 25 MRS. VIYCKOFF: They believe in survival. IOOVER REPORTING CO, INC. @20 Massachusetts Avenui, N.E. Vashington, D.C. 20002 2 45 eml8 1 MRS. KYTTLE: The three of them, not just R14P. 2 MR. TIIOI-MSON: It does@offer complications, 3 however. We're used to, you know, the one-on-one business, 4 whols on, whols off, between CIIP and RMP. 5 Now, they have substituted a menage a trois kind of 6 thing, to complicate it even more.. 7 MRS. KY".Ir."LE: I don't know if they look at it as 8 a complication in that frame. The possible complication is 9 @that Memphis RI-@IP has assisted, and that is from beginning to 10 where they are now, all other B's in west Tennessee all of 11 them. But the one that is operating in southeast I'llentucky 12, is a Memphis Pj4P, funded not any longer, but it was'. MRS. VIYCKOFF: And 14ississippi. 13 14 MRS. I'@YTTLE: Northern Mississippi and the boot- heel'of Missouri and eastern Arkansas. The five operating 15 B's are all B's that have been funded and initiated by 3.6 17 Memphis RMP. 18 Now, if Memphis RMP comes into this umbrella 19 trusteeship with the greatest territory, it will encompass 20 the territory of those B's, and they knout that, and they 21 realize that that will be the option. If those' 'local B's and indeed the legislation permits that t pe of arrangement, 22 y they thought that that would be the interesting experiment 23 24 to form a new Health Service Agency for that terrain, wit- subcontracts with existing B's, that they have already funded 25 HOOVER REPORTING CO, INC. 320 MassachusettS Avenu,, N.E. @p q@Anq 246 eml9 MRS. I,7YCKOFF: I guess you have to give Dr. 21 Cannon a little credit for also holding this organization 3 together. 4 MRS. KYTTLE: Yest mal DR. SCHERLIS: How much of the funding actually would be directed toward the setting up of such a group? How much of it is seed money? 8 MRS. KYTTLE: They seek no funds for that. The 9 arrangement they have made is that they are rotating for'the 10 first period of operation, the executive director of HIIS serves as the chairman of this new board. The staff is 12! provided by Pl,!P, and the leg work is done by CHP. And for the next ninety days, they first started 14 thinking of a year and they realized that that would be too 15 long a time, the next ninety days the coordinator of P14P 16 serves as chairman; the staff of IISM has to fund the money 17 to get the staff work done, and the CHP organization does the is regional communicating. l@) DR. SCIIERLIS: You"told us about that $400,000 in 20 escrow, 21 DR. VIIIITE: There's actually 800,,000.--There are 22 1 actually two different escrow accounts. 23i MRS. KYTTLE: This application seeks no money for 24 that organization. 25 DR. SCIIERLIS: Yes. But'where does the money come IOOVER REPORTING CO, lf+C. 120 Mamchusetts Ave nu % N.E. n r, 9rillp.? 2 47 em2 0 f rom? 2 Two things: how is it-labeled,, and how can a sum 3 of money be available? .4 MRS. KYTTLE: All right, that's the first question 5 you asked about. The $800,000, when you total the two, it's 6 a combination of five and three. Let's speak to the 500 7 first,, and that is the creation of local consortia to 8 develop health manpower needs and relate them to identified 9 health service needs, and relate them to health manpower 10 resources, 11 MR. CHAMBLISS: Is that to which the fun s are 12, going to be used? 13 MRS. KYTTLE: Five hundred thousand. 14 DR. CARPENTER: That's for ten hospital 15 librarians, ten secretaries, and ten planners, community 1(; organizers. 17 MRS. KYTTLE: You asked if that should not be the 18 work of the local advisory committee, because so many of if) these groups were formed from such advisory corqmittes; but 20 they have no local advisory committees. These are predomin- 21 antly in ares where there are not B's, and this-is how Memphis starts B's. 22 23 DR. CARPENTER: No, they.have B agencies now except in -- organized in eve@ area, but not 24 25 MRS. KYTTLE: They are not funded. HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington. D.C. 20002 2 4 8 em2 1 1 DR. CARPENTER: Two of them are not funded. But 2 they are two out of ten at most. 3 No, these are not B agencies, these are 4 MRS. WYCKOFF: Health Centers. 5 DR. CARPENTER: These are hospital libraries. 6 MRS. WYCKOFF: There's the seed money to start 7 things. 8 MRS. KYTTLE: I said they have no local advisory 9 committee in these areas, save Jackson. There.is one in 10 Jackson, and there's one ongoing there. 11 DR. CARPENTER: But they showed us a map of the B 12. agencies, right, and they cover the whole area except maybe a few outlying counties. 13 MRS. KYTTLE: These are areas that have no health 14 manpower committees working in them. 16 DR. CARPE14TER: Oh, okay. No manpov7er committees. 17 MRS. KYTTLE: And that's how tJ-,ey have spawned, 18 they have first developed some health manpower committees for B's. These are areas wh@e the B's have formed without 19 health manpower committees. 20 DR. CARPE14TER: That's the point I'm-naking. If 21 they had the manpower committees, they wouldn't have to spend 22 a half a million dollars. 2.,3 MRS. KYTTLE: liell,'for some reason, and I have 2,4 tried to research it and I don't understand it, the philosophy, 25 HOOVER REPORTING CO, IK. 320 Mamchusetts Avenvi, N.E. n r. 7(IW2I 2 4 9 em2 2 I the Memphis Regional Program thinks local consortia to 2 address health manpower needs should be seated in a 3 hospital. They feel the hospital setting is the setting A for an IISEA, and they have felt that way from the very 5 beginning. And that's where these are, ten sites. 6 MR. CIIA14BLISS: Dr. Scherlis. DR. SCHERLIS: Now we've gotten through the first -g gear, what happens to the second ten libraries# secretaries, 9 et cetera,, for the second year? They are being funded? 10 MRS. KYTTLE: The same thing that will happen for 11 all the otliers6 Some of them will make-application under 12. the new legislation as health service agencies. I mean,, .13 that's going to, happen across the country. Most of.then 14 feel that they are ready to make application. MR. THOITSOII,: Ten libraries are going to be certified as health agenciest as' I understand you? MRS. KYTTLE: One of the first things the local 17 area is going to have to do is to create its own manpower 18 committee. The librarian wirl not be -- even she's a part 19 of the system, but she is not the pivot. 20 DR. @711ITE: I'm suffering from an inability to 21 recall 1-7ebster's definition of "escrow". But it seems to me 22 it has to do with putting money aside for future use. 23. IIRS. KYTTLE: They want to impound their own 24 money. They want to put $500,000 aside now so that they feel 25 HOOVER REPORTING CO, IK. 320 14assachusettsAvenL@ i, N.E@ em23 250 by July they will have gotten these things ready to go to 2 contracts, or in the writing stage now of when, I think one 3 is in Kentucky and the other is in Crittenden Count in Arkansas. Rather than coming in in July with this proposal 5 of ten sites all worked up, they want to escrow the money 6 out of the total package now, so that it can begin n July 7 rather than make application to us in July. 8 MR. THOMPSON: So, in other words, they wa@nt to use 9 the escrow business as a substitute for a specific proposal. 10 MRS. KYTTLE: Yes, and they want to tell 7ou now 11 what they want to put it aside for. 12. MR. THOMPSON: Has this proposal been matched up 13 through the whole internal review process as a proposal? 14 MRS. KYTTLE: As a concept. 15 DR. CARPENTER: I think there are a series of i(i small proposals. Isn't that the way it got through the RAG 17 as small proposals? But it did it part, in $25,000 hunks 18 it went through RAG. 15) MR. THOMPSON:- $25,000 hunks up to $500,000? 20 That's a nice piece of business. 21 DR. WHITE: They have got $800,000 there. 22 MRS. KYTTLE: And it all went through at once. 23 DR. CARPENTER: They didn't hide any of it. 11 24 MRS. KYTTLE: It did not bleed through, it went through as a concept, and $25,000 apiece for ten sites. 25 IOOVER REPORTING CO, INC. @20 Massachusetts Avenu @, N.E. 251 em2 4 DR. CARPENTER: Can I, at this point, break into 2 the conversation and make a funding recommendation?, 3 MR. CIIMIBLISS: You may, indeed,, Dr. Car enter. pi DR. CARPENTER: I would, just to get theldiscussio 5 going, move a certain funding level. Their annua ized rate 6 now is a million and a half. Their targeted rate s about 7 two million three, and they request three million our now 8 and predict that they will ask for a million two later, 9 and that will get them at two times target. 10 I think that the region is pretty.crood, but not 11 in a position to go from a million and a half to four million 12. seven at the time of phase-down. I would suggest a' funding -13 level a little above the target level, of $2,600,000. 14 MR. CH7UIBLISS: Will you place that in the form of 15 a motion? 16 DR. CARPENTER: Yes, I do. 17 MRS. WYCKOFF: I'll second that. 18 MR. CH2UIBLISS: It has been moved and seconded that the level be established for -- be recommended for 20 Memphis at $2,600,000. 21 Is there discussion? 22 DR. WIIITE: I would like to pursue this further, and I am going to. We've talked about the 500,000. There's 2 t3 24 another 300,000 in escrow dollars, which I interpret as this, 25 Mrs. Kyttle, as underwriting the survival of these three in 40OVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. n r, qnnnl 25 2 em25 1 whatever form they're going to take. 2 It says that, I think.- 3 MRS. KYTTLE: It says that high priority out of 4 this developmental will be given to those agen .you know, cies, 5 in the total region. That's the PIIP region that I'm 6 pursuing, the logical kinds of things that the new legisla- 7 tion proposes. 8 There again that falls within the umbrella purview, 9 but the umbrella -- the organization that is the umbrella is 10 not seeking funds, but it seeks to fortify its philosophy 11 that it's a good umbrella, it hopes that the legislation .12! will speak to a State, you know, whichever one comes out first, 13 and it wants to have agencies funded within it that it can 14 contract with. 15 That's what the high priority is for those agencies. 16 DR. 1,7HITE: Now,, is that $300,1000 the same as the developmental fund? 17 18 MRS. KYTTLE: Some of those are B's. Yes, that's out of that. 20 MR. TH014PSON: I think what we see here is probably 21 the bald statement of the problem that you are finding more or less in the same degree in all of these, most of the 22 proposals, and this is an attempt to second-guess what the 2-.31' legislation is going to be as f'ar as, you know, whether 24 this is regional health authority or State health authority, 25 OOVER REPORTING CO, INC. ?O Massachusetts A-fenui, N.E. n 2 5 3 em2 6 and it's floating around in all these crazy bills. 2 Now,, I think we have a policy problem here, 3 whether our PIIP funds should be used to relate an agency, a 4 proposed agency for nonexistent legislation. And I think 5 that's true here, I think tliat's true in a subsequent thing 6 that I'll review to you. 7 In other words, when you, from RMPS sent the 8 message down: Fellows, get on the ball with your,CHP and 9 no kidding this time. We've seen a lot of getting into bed i 10 with CHP, and it's -- in fact it now looks like a plot by 11 the two of them to survive, whatever happens. 12. Noiql I don't know what's going to happen if this '13 legislation setting up this envisioned Regional Health 14 Authority is delayed by two years. You know, all this 15 money that we're pourihq @n here to build these various 16 elaborate umbrella agencies, the consortia -- they have about 17 six names for it -- it's going right down the old,tube. 18 MR. VAN IIINKLE: I would like to. point out that 19 they have been encouraged to start various programs with'CHP. 20 MR. THOMPSON: That's what I'd like to know: who 21 has the crystal-ball authority that they can tell me-that the Regional Health Authority is going to be established 22 23 by the end of PI.Tls life, and take'over RMP's staff or skills e and start in business. Who the hell has got that inforratioii? 24 25 1 don't have it. HOOVER REPORTING CO, IK. 320 faassachusetts Avenu @, N-E- @4 em2 7 MRS. KYTTLE: Mr. Thompson, you know it would be 2 beautiful if that were the case,-but no region has had that 3 word, and they are all trying to take the most logical and 4 1 - flexible stance that they can, trying to provide for the 5 possibility of State structure as well as providing@for the local structures, until they see what the legislate n is. 7 MR. TIIOMPSON: V7hen you cover all the bets on a 8 racehorse it costs a lot of money, and that's what ese 9 'people are doing. They're puttincT two bucks on eve or 10 in the race, hoping that somebody will come in and ey will 11 be on it! As long as it's not their money, that's kay. 12. MR. CIIAIIBLISS: This is one of the policy questiois 13 that we alluded to earlier on when the committee was convened, 14 and this is one of the issues that will be dealt with as the 15 review goes forward. I would like to acknowledge the presence of Dr. 17 Margolis here, our former Director. And since this is a is policy issue, I'm wondering if he would say a few words.on 19 this point. 20 DR. SCHERLIS: I was just going to make one 21 suggestion. I think that Memphis really shows some good judgment with the idea of an escrow account for $800,000 and 22 I would think that some of the wisest judgment that this 2:3 24 Review Committee could make is 'to have an escrow account of 25 a hundred, a hundred and tvienty to 'forty thousand dollars HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. n 11 )nnn-) em2 8 that we would have available, and say, let's save that for 2 some decent health planning as of July lst, 1975. 3 Vlhile 'I wasn't here yesterday, which is a 4 calendar error that I apologize for, I spent, really, as all 5 of you did, a very difficult time reviewing these, because 6 v7e're doing it on promise and hope and faith and, frankly, 7 charity. 8 And all the old judgments that we have used have 9 had to go down the drain completely in reviewing thesb; and 10 I think that if Memphis gets approved for an escrow account, 11 that my next suggestion will be that we vote an escrow 12. account of a hundred or eighty million dollars for July lst,, 13 to be used if there will be health planning then. 14 I don't think that putting this into some thirty, 15 forty, fifty little different projects, that wOlre begged out and saying, Come on in, 1(; for and scrounged for by going 17 we have this last chance to get it. A lot of them read that 18 way. That that is really the equitable way for us to use government funds. 19 20 I have the serious questions that all of you have 21 had, and we're operating within a very difficult framework, to reach equitable decisions. 22 I am all for escrow accounts, particularly of most 2tl 24 of that one hundred and twenty 'or hundred and forty million dollars. 25 HOOVER REPORTI K CO, INC. 320 Massachusetts Avenui, N.E. Washington, D.C. 20002 256 em2 9 I didn't mean to pre-empt you, but I wanted that 2 stated somewhere along the line.' 3 DR. IIARGOLIS: V7ell, my most positive word is that 4 I an delighted to see my good friends here again. 5 I am delighted to see that you are tearing at things as 6 usual. 7 I don't understand,your concern, John, in not 8 knowing how to spend money on nonexistent legislation. 9 After all, money was appropriated, impounded in 173 to be, 10 spent in-17.6; when the authorization would expire by June 11 30th, anyway., 12. So it's.a perfectly clearcut situation! 13 I would like to address this question, because I 14 think the points you raise are important, and rather than 15 matters of policy, although.they certainly involve policy, Al 1(; there are also senses of timing in judgment, which will have 17 to replace, as they often have in this program, some kind 18 of policy base. In all of the discussions on planning, 19 legislation, developed both some kind of unified health 20 planning proposal, there has been more dissatisfaction - an 21 not very well hidden -- than satisfaction with everybodyis proposal, as you implied. 22 23 The administration is not wildly enthusiastic about what it has proposed. The Rogers Committee feels about 24 the same about its own proposals. 'Theice is ojreat uneasiness 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. em3O 2 5'11 about what would occur. Time is running out. And some 2 of the basic problems remain. 3 The problem which everyone has looked at, usually 4 defined so poorly, that it is looked at plainly, is the 5 meaning of planning, the relationship between planning and 6 implementation; and the relationships between planning and 7 management. 8 Traditional questions which have been up for 9 consideration time and time again. .The difficulty involved 10 in all the pieces of legislation and in the debates which 11 really don't get around to this is that'no one isirea-dy to 12. say what that relationship ought to be. Nobody is willing ..13 to come down hard, although there are indications that a 14 position has been developed.. 15 For example, it is now felt that whatever these 16 health service agencies will be,, or whatever name they come 17 out under,, they will be private, nonprofit structures within 18 the State. There will be an uncertain kind of support for iq State structures. The planni@ng process will be kept from 20 State implementation, however, there will be some small 21 amount of money for implementation, a larger amount of 22 money for implementation based on whose bill you're looking 23 at. 24 Vihat is missing in the process is something which can produce, in the health delivery system, a cooperative 25 HOOVER REPORTit4G CO, INC. 320 hiassachusetts Avenu @, N.E. @t'ithincinn Df' 9nOfl? 25 8 em3l 1 structure which allows people to operate in the private and 2 in the nonprivate systems in such a way that they are able 3 to do together more effectively those things which they wish 4 to do than they can do them separately. Which is an early 5 description of Regional Medical Programs. 6 It creates a real problem. And in many ways what 7 our reviews are attempting to do is being approached under 8 other names, with different kinds of understanding, and with 9 a variety of methods. 10 But the debate has not been joined, I don't think 11 it will be joined, And when you' re through with this 12, session and we're through with the review session which is 13 coming up after that, there is still going to be great 14 difficulty in making a judgment about what is IU.TP going to 15 do in relationship to CIIP, what will the planning function actually bel what will the relationships be between planning 17 and implementation; and, furthermore, what is going to be 18 the role of the State government in this? Because, in general, the role of State goverment 20 has been downgraded,,almost lost sight of,, there have been 21. serious objections to it from outside and from within. And 22 we're going to be entering the fall season whether using an, escrow account or not, with no more certainty about what 23 that relationship is tlaan exists at the present time. 24 25 What we have been saying'is a'consequence, and it's HOOVER REPORTING CO, INC. 320 Massachusetts Aveniii, N.E. Washington. D.C. 20002 259 em32 about the only v,7ay out, navl)c not too bad a one, is that the 2 most proved factor IDeyond a Regional Medical Program, and 3 it's novi my job in addressing all these programs, it applies 4 to others as well, certainly the CIIP; but beyond the CHP, 5 the other kinds of federal programs which are in the 6 States which have sort of opted out of this activity, 7 the rqost judicious, thing for. them to do is to get together 8 with one another as rapidly and as fully and as enthusiastic- 9 ally as'possible,, and decide what they're going to do together, 10 regardless of what the legislation is going to look like. And between the passage or nonpassage, which is a 12 good likelihood, of the legislation, its approval, its 13 appropriation, its regulations and its administration, 14 so many things will occur that if the people who are out 15 there quit trying to decide who is going to be in charge and decide hot they are going to ru nthe thing together, they 17 are going to move rapidly ahead. 18 Now, sometimes this is interpretative on the part 19 of R14P people, if I'm talking to them, as some of the MIP's 20 are, is that they should quickly move to take over. 21 Now,, that wouldn't work. Clip takes the same 22 response when they are listening to their own partisans; 23 it's for you to take over. 24 And if they will get just a little smarter, they 25 will move together; but they are going to have to move with HOOVER REPORTING CO, INC. 320 Massachusetts Avenu -, N.E. Washington, D.C. 20002 260 em33 other programs. Maternal and Child Ilealth Service, Community 2 14ental Ilealth Service, which, for some reason, along with 3 others,, have never been considered a part of the general 4 concept of comprehensive planning. 5 Migrant program , all of them have each -een looked- 6 at separatelyt and all the conversations have been itFP and 7 CIIP as if those were the only actors in the game; ,,hen, in 8 fact, they'are some of the actors, and in many ins nces 9 rather minor actors. 10 Novi, I think the additional thing which isi going 11 to make a difference, about the time we get started @ith it, 12. is the gro.wing concern with the regulatory function "I-7ithin -13 the State which will produce an entirely different enviroh- 14 ment for the total relationship between planning and 15 implementation. Because,.the regulatory function will throw I/ I(; in a new responsibility which must be a State responsibility, 17 almost by definition. 18 That regulatory function already app lies to if) institutional development. It's going to, in all likelihood, 20 involve cost control, because we get national health insurance. 21 and tj-iere is freer and freer conversation now about a complement to certificate-of-need legislation for construction' ->2 ol 23 and that will be some kind of certificate-of-need for man- 24 power. 25 Now, when these kinds of things occur, people who iOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. Alachinatnn f) r. 2nfln? 261 em34 have been vying for responsibility may find themselves vying 2 for getting out of sight; because it's going to be no 3 child's game4 .4 And yet by looking at the total structure, as it 5 will be much faster than many of us have expected, the 6 relationships between the planning, the implementation, the 7 operational and the regulato ry functions can become clearer, 8 and the responsibilities for the various parts will begin 9 to fall into place. 10 But to try to assume full mana ement or full 9 11 authority for any one of them is injudic"ous, it won't work, 12. and I don't think anyone would really want it when they get .13 all through with it. 14 The real struggle, in all sincerity, will be on 15 the part of those who are determined that the regulatory 16 function,, particularly control of rates and fees, be placed 17 anywhere but where I am. Nobody is going to want that. 18 And yet it is going to be the part of the system which is 19 going to have the greatest power, and from which most of. 20 the strength is going to flow within the States. I think it @-iill go in the States gradua lly. 21 The otaier big debate is whether the National Health Insurance 22 23 is to be more federal or State directed; but that's a e very fundamental issue. 24 Novi, I know that's not a policy thing, but at least 25 HOOVER REPORTING CO, INC. 320 hiassachusetts Avenu,, N.E. n r 7nnn) 262 em35 it's a statement cfsome kind of dynamics which will work 2 well some place;and not others. 'The concept'of escrovi,, I 3 would certainly agree with you, is certainly -- if you're 4 going to consider the setting aside of funds for an@,uncertain 5 but realizable goal in the immediate future, that should be 6 a programmatic kind of action across the board, rat@er 7 I than.limited to any one program, to come up with that kind of an idea 9 And even then, it is a risky kind of thin to doi 10 because you don't know what the situation will be w en those funds are released. 12. I don't know if that helps or not. .13 MR. CIIMIBLISS: I.-Tell, thank you, Dr. Margolis. 14 There may be some questions that the panel would like to 15 raise in addition to --,. Dr. Vaun? 16 DR. VAMT: Getting back to this, not with regard 17 to Dr. Margolis' comments, the only thing that concerns me is about the escrow is that, does this place any of the I!) other P14P's that have seen fit to come back in July, at a 20 disadvantage? 21 In other words, are these people gambling that all 22 money is going to be doled out on the first round, and, reall@, 23 whatlpulve been saying is not so there won't be any money 24 left for the second round, so they're putting their little 25 nest-egg in escrow. iOOVER REPORTING CO, INC. 120 Massachusetts Avenu i, N.E. me, nnnn,) 26 3 /2 64 em3G 1 Has that thought occurred to anybody? Is this 2 what they are trying to do? 3 MR. CIIAI-IBLISS: There will be a sum of moneys 4 - remaining for the second round. 5 DR. VAUN: so as you envisage it, this would be 6 not placing anybody at a disadvantage? The other PIIPIS. 7 MR. CHAMBLISS: Well., the total-amount is limited, 8 so therefore what is ultimately awarded to Memphis comes out 9 of the entire amount available. 10 DR. MILLER: Isn't it true that ly" previous 11 except for developmental fund awards, which has not been 12. mentioned in the current directions no region was allowed .13 to just apply for escrow funds,-by lump of escrow money. 14 You got it another way. But you couldn't Apply for escrow 15 funds. 16 And now you do not have an authorization or 17 direction for regions to apply for a development award, 18 either; do you? 19 MR. CH7U.IBLIM We cfo not. 20 DR.MILLER: Well, isn't it appropriate that this 21 review committee specifically record in the record that we 9.? do not recommend funding for that activity or that kind of 23 an award, that part? MR. C117UIDLISS: That would be a problem, and we 24 are looking to this committee for its judgment on that. 25 HOOVER REPORTING CO, INC. 32OIAassachusettsAvenL,i,N.E. @,@.@himofnn nr. 7nfwig em37 265 DR. I.IILLER: Do you want that in the form of a motioi? 2, MR. CIIAMBLISS: A motion is not in order at the 3 present time. There is a motion on the floor, and that 4 motion is-that the level of funding for Memphis be recommender 5 at $2,684,000. 6 MRS. WYCKOFF: Well,, v7hy don't we do it? 7 MR. CIIIUIBLISS: You may so-indicate that, and the 8 staff people will take due notice of it. 9 MRS. WYCKOFF: Should we amend the motion that the 10 escrow funds be taken out of this? 11 DR. WIIITE: All of the escrow'funds are on the 12. yellow sheet, they are not on the application. The awards. @,13 Treat you see on the application-is a developmental award and 14 a project, and I believe we are not supposed to get so deeply 15 into the region's management as to reject a specific 16 project. 17 I guess I have the feeling that if we reduce the 18 requested funds by an appropriate amount, the region will 19 probably behave fairly well.'OAnd I would be satisfied just 20 to reduce the funding amount and then proceed. 21 Does that make sense to anybody? DR. McPHEDRAN: Then how about, as a separate piecE 2 23 of business that does not have anything to do with this particular consideration of this program, that we could have 24 25 this motion that Dr. Miller suggests. Could we do that? IDOVER REPORTING CO, IK. ;20 Massachusetts AvenL,,i, N.E ,,- - : - - - - r, (I 1) nr@.1) em3 8 266 Just as a general part of the proceedings of this 2 committee. If we could do it that way. 3 MR. VA14 WINKLE: But the staff can also express 4 your concern about these two items. 5 MR. CIIAMBLISS: Then I call the question. 6 Those in favor please indicate by the usual sign 7 in voting. 8 [Chorus of "ayes".] 9 MR. CIIAMBLISS: Those opposed. 10 [.No response.] 11 MR..CIIA14BLIS: The motion is carried. At two 12. million sixi with the concerns of this panel being conveyed 13 to the rt--glon in the advice letter and by staff. 14 I must say that the privilege that we've had of 15 having Dr. Margolis, the Deputy Administrator of the 16 Health Resources Administration, come in just at this key 17 moment, when we were discussing a very critical issue having 18 to do with Memphis, was most timely. I would endeavor to ask the staff to set the 20 whole question in sorie type of framework, and then we would 21 like to have Dr. Margolis comment on those issues,, be 22 conveyed to the staff and to perhaps some of the regions. 23 I think this is very timely, what he has done. 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. nil I)nnn) 26 7 em39 REGIONAL MEDIC@ PROGRAM REVIEW 2 MISSOURI 3 MR. CHA14BLISS: We shall now then turn our 4 attention to a review of the application from the Missouri 5 Regional Medical Program. The reviewers here will be Dr. McPhedran and Dr. Miller, and staff support will be provided@ 7 by Mrs. Resnik. 8 Thank you, Dr. Margolis. 9 'DR. MCPIIEDR2UT: Yesterday Dr. Miller and I got 10 some additional material on the Missouri application, and 11 I cite this now not to beg off, because I have read it, in 12. fact, but it was interesting because it was a staff visit 13 to Missouri and it was suggested to me that maybe I ought 14 to change my views to some extent. In fact, the value 15 of this program and the..merit of the application, specificall@- But I must say I think it hasn't changed my views 17 a whole lot, and, while I've got more to say about it than is I did, it really remains about the same. 1( To go through the review sheet: program leadership, 20 I was unable to classify one of the categories, and have 21 checked "satisfactory to poor" because I thin}-, that it is variable, without mentioning particular persons. I think 22 23 that it really is uneven, and I'm basing this on the fact 24 that the leadership seems to me very much the same as I recall it from at least two -- because Ilve been there twice 25 iOOVER REPORTING CO, INC. i2O Massachusetts Avenui, N.E. tir, )nnn,) 26 8 em4O two previous site visits, and a lot of discussion at various 2 National Advisory Council.meetings. 3 I really think that what has happened in @is- 4 - application reflects this leadership to a considerable extent. I have no'criticism to make of the program staff, 7 and never did, except that I'think it used to be very large, and the proposal suggests enlargement. I can't -- pnless 9 they postpone the marking of that enlargement, it is 10 currently 30 with a proposed addition of 45 staff. 11 The program staff in the past we used to @riticize, 12. maybe this should have been more a criticism Iof the,@leadershi:), 13 for its lack of initiative in helping people in the region 14 to develop parts of the program, develop projects and 15 develop other component parts of the program. 16 According to the most'recent visit, that is not a 17 problem now, but it certainly used to be. 18 I am persuaded by the recent visit, I have said 19 that at least it's satisfactory, but I really wonder whether, 20 if it's satisfactory now, it is justified to consider all 21 the additional staff to such an enormously large-staff that 22 is proposed. 23 The Regional Advisory Group which, until a couple of years ago, numered only t@,7el"ve, has been increase4, I thin.@, 24 25 by two stages to a total of 55 members, and it appears that HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. flashington, D.C. 20002 em4l 269 I it is satisfactorily supervising the activities of the 2 program. In the fourteen months before this application 3 there were four Regional Advisory Group meetings, I think 4 eight of the Executive Committee, and several of the various 5 technical and standing committees. 6 So the committee structure has continued to function 7 And the Regional Advisory Group also said that there is a 8 fifty percent attendance rate at these several RAG meetings. 9 Past performance and accomplishments, 1 think.ate 10 mediocre for the most part. I found it difficult to either 11 say satisfactory or poor or inadequate. 12, Considering the amount of money that this program 13 has gotten in the past, it is difficult for me to be more 14 generous in my assessment of this. 15 In the past there was a very large investment made in a lot of computer centered activities, and I guess that 17 this still remains with me, although it's all gone from the present application. 18 We thought..,those of us who visited it, that there 19 20 was bad judgment and even, perhaps, appropriate for the State 21 of I-lissouri,, mulishness about following the direction and guidance that we attempted to give. 22 23 The objectives and priorities sdemed.to be satis- 24 factorily stated. 25 I think that the proposed'activities, and I can HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.E. Washington, D.C. 20002 em42 270 summarize briefly the categories are satisfactory but not 2 imaginative. The feasibility, that is, the likelihood that 3 the activities proposed can be accomplished in the Lim-e that 4 they anticipate the program will continue is, by th@eir 5 own statement, likely in some and unlikely that the 6 manage in others. 7 For example, they state that all the EMS activities 8 that they-have proposed, and I will come back to this, ther 9 is a question pertinent to the one Dr. Scherlis rai ed 10 earlier, whether or not these are new E@IS dctivitie,s; but 11 they say that they feel these activities can be up raded 12, in the next year. I really wonder whether that is so* 13 The cooperation with CHP seems to be quite 14 satisfactory. 15 My over-all assessment of the region is that it is only average. 17 I am afraid I have more comments and remarks to make. In this Regional lledical Program there appears o be no serious problem in the relationship of the gran tee, 20 which is the University of Missouri, and there-never has beer, 21 22 and that continues to be,-,I gather, a satisfactory relation- 23 ship, 24 MR. TIIOI.IPSON: You'don't shoot Santa Claus.. 25 DR. McPIIEDRAN: No, not intentially. HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. Washington, D.C. 20002 em43 271 The major thrust that they have stated for them- 2 selves are five: emergency medical systems; health; 3 manpower; education, and under that category especially 4 training people to deal with the problem of high b,Lod pressure, and training seminars to be conducted for many 6 categories of hospital personnel. 7 Third is listed as integrated health care delivery 8 systems, with especially heavy emphasis, as I see i@, on 9 supporting hospitals in developing JCAII type criter--.a, and 10 also a problem of oriented records for local practitioners. @ulatory care systems, particularly con erned 12. about availability and of care. 13 The purposes, the major thrusts are as general 14 I'm quoting from the application tjiere; just general, as I'm 15 stating them to be -- sXstems for-end-State --- kidney manage- ment, 17 Their fiscal year 175 suggests that their E,?,IS 18 role will be completed, and the local communities will be 19 able to take the developed programs and projects and handle 20 them on their own, although I don't think that my reading of 21 the application particularly supports that. 22 Then I went through the request for funding, 23 including changes in core staff. I. spent less time, I must say, on the continuing projects, but a good deal of 24 3 25 time on the new projects, and tried to dig out for my own iOOVER REPORTING CO, INC. @20 Massachusetts Avenu i, N.E. Nashington, D.C. 20002 em44 272 I purposes what I thought was a necessary expansion of core 2 staff. And what I questioned might be new E14S projects, and 3 I realize the staff might have gone through this and may want .4 to, perhaps, dispute my judgment. 5 The excisions that I performed enabled me to cut 6 their proposal from $3,010,113 down to $2,295,113. I felt 7 that there was $713,000 that could and in my. view should be 8 removed from the proposal; and it happens to coincide with 9 what staff, in the person of llrs. Resnik, has recommended; 10 and I uess it also coincides to some extent with the 11 targeted amount. 12 But I think it is worthwhile to suggest what .13 specific things, there were. 14 There were, for example, requests for what amounted, 15 I think, to increases i@ core staff. They have six district 16 consultants, and the recent staff site visit suggests that 17 they should be continued. I have no quarrewl with that, 18 But there is a suggested sum of $31,000 by sub region to 19 increase staff support for the distrist liaison to $186,QOO; 20 and I will quote from the application what the ultimate 1 justification is. 2 22 It is said that the specific outputs would be a 23 plan and method of implementing the plan to operate un r 24 the new legislative athority. If no legislative authority is forthcoming by fiscal year 176, this year's effort will 25 HOOVER REPDRTING CO. INC. 320 Mamchusetts AvenL,@, N.E. Washington, O.C@ 2GTj2 em45 273 have been one of which the Missouri Regional Medical Program 2 can well be proud. @le will have'brought together at the 3 working level members of principal federal and State health 4 agencies, to work toward a common cause of improving the Statewide health care system, and I think that I would really 6 have felt that even in a Form 15 something more specific than that could have been given me as a peroration to convince 8 me that that money ought to have been spent. 9 There are other things in there that I feel are 10 similarly if not worthier of support. I won't bother you witi 11 the details, but I do want to mention that I thought that 12! there were about around twelve, as I see it, new projects, @.13 no EMS, twelve, roughly, totaling around $245,000, that I 14 just don't think are in the guidelines, are they? 15 MRS. RESNIK: We're treating them as sub-components 16 of already existing and ongoing EMS projects, which is 17 essentially what they are. They are dealing with training, 18 but in different locations. And they tell us that they 19 understand that tl-iat is within their authority under the. 20 present guidelines. 21 They are applying to the EMS bureau, but they 22 don't foresee any giants. 23 DR. McPHEDRAN: This looks to me like new EMS, 24 and so that's 245,000, and then going through some other 25 projects, I noticed this, but I did it anyway, I thought there HOOVER REPORTING CO, INC. 320 Mamchusetts AvenL; @, N.E. Viashington, D.C. 20002 7 4 em46 were several things, like there's a quality criteria 2 pro]ect in a hospital in Jefferson City, and it looks to me 3 as if that really is PSR activity, and I wonder if that 4 similarly should be excluded. 5 And several other things that also seem to me un- suitable. 7 So that, in summary, what I did was I felt that 8 at least $715,000 could come out of it, and I came.out with 9 a recommendation, as I say, of $2 295,113, which is obviously 10 unreasonably precise, but it is approximately where the targeted sum is. I would have no quarrel if we said the 12. targeted sum would be satisfactory; and I would like to know .13 what Dr. Miller thought about it. 14 MR. CHAMBLISS: Dr. Miller. 15 MR. MILLER: .This is an interesting experience we 16 all go through. I pursued a rather different and more 17 devious route of arriving at the same conclusion. 18 I have known the Missouri Regional medical Program for a long time and many of the staff people on it, and. 20 perhaps it is worthwhile to mention a little of the background 21 on this. 22 Ilhen I?14P got started, Missouri was really ready, because Missouri was more regionalized in the medical 23 241 establishment than most any State in the'union, having their 1 25 medical school in Columbia, which is a small, a relatively HOOVER REPORTING CO, lfic. 320 Massachusetts AvenLi, N.E. Washineon, D.C. 20002 em4 7 275 small city, and therefore, having had to farm. out clinical 2 medicine for a long time into other communities, which is 3 almost never done in most of the other medical centers in 4 the United States, and which was extremely repugnant to them, 5 as you may all remember. 6 So Missouri was, its time had come, and the mule 7 characteristics recognized tl jis, and they proceeded with 8 vigor. 9 They also had some people in the leadership ositio-i p 10 who have,considerabl.e skill in recognizing political 11 expediency, and when it is popular at the national level 12. to spend money oh electronic computer equipment and remote 13 control things, they were in there for millions and got them. 14 @,7hen it is politically expedient to turn th,6m off, they 15 turn them off like it w4s a water fauceti Ilhich they have I(; now done, because something else is politically expedient. 17 I have four applications that are mine that are is coming up today, all of them are somewhat similar. And 19 Dr. Schleris' comments previously have bothred me, yesterday 20 and today and last night, and even losela little sleep over it. 21 22 Because the principles formally ascribed to 23 Regional Medical Programs of quality programs, well evaluated 11 24 demonstrations that are woth the.money, seem to be all gone, and I suppose it seems a matter of political expedience, but 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu-, N.E. WashinLrton. D,C. 20002 2 76 em48 1 it looks like wevre stuck'anyv7ay. But it is bothersome. 2 And in these four programs that are coming up, they all have 3 applications, they are going gung ho for election, it's 4 politically expedient to get the money and they're out to 5 get it. And by whatever most clever mechanisms they felt 6 could be used to get it, regardless of whether it is cost 7 effective or will be continued really, or what the ultimate 8 goal is. 9 No@,7, Misso uri has done it to a rather great degree. 10 It has -- it doesn't have an escrow item in here, a develop- mental fund item, but its method will give it a nice big one. 12. There are separately described staff component .13 projects, 26 of,them in this application, either with a dolla@ amount none of which is excessive by itself; but 14 together is nice. 15 There are six district liaison systems with a total 16 17 budget of $186,006. They went all out on EMS without 18 having a general State EMS plan, which is forbidden, so there are five continuations and elc@ven new EMS projects, or a 19 20 total of $518,000. It wo uld be some little job to keep them coordinated. 21 Maybe they will need those district guys to keep all those 22 different outfits working in any kind of a rational coordinating 23 way. 24 1 could go on in more details, but I think I will 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D,C. 20002 A 0 277 em ;, 1 say, first,, however, that a little bit in contrast to Dr. 2 McPhedran's view, I feel that the basic questions that we're 3 supposed to answer on this review sheet, most of them 4 relative to other PIIP'S, you'd have to grade Missouri as 5 good to excellent. 6 The program leadership, you may not like them, but, 7 they've done a good job in Missouri. The program staff is 8 equally so. 9 The Regional Advisory Group, they get along with 10 very well. It's a little funny, but it works. 11 Their past performance and accomplishments, they 12, have been a leader in Missouri without any question. They 13 have lead regionalization in Missouri to a phenomenal 14 degree, and they have more general acceptance than many 15 other regions. Their objectives and priorities I would interpret 17 as political expediency, and they have done it extremely 18 well. The feasibility,, of course, is,very low, because we are theoretically supposed to grade these things on whether 20 they can do this in one year# and they obviotisl@-can't 21 possibly do what they've got in this application. 22 They get along fine xiithCIIP, they,support- them in 23 many ways. So they will get 'good'acceptan&,e by them. 24 The total picture, 26 staff component projects and 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenul N.E. Washington@ D.C. 20002 em5O 278 27 continuation projects and 19 new projects. 2 Much of this is overambitious for one-year concept" 3 and it looks like it cannot be accomplished. My conclusion: Irecommend funding, h-..-,ver, at 5 the targeted level, which Ithink it is a wav out f the 6 dilemma of coming up with adollar figure. 7 MRS. RESNIK: They are coming in with a -.OO request 8 July 1, they indicate. 9 DR. MILLER: We will address that ti-7o months from 10 now. -11 MR. CHPIIBLISS: All right, each of theireviewers 12. has come up with a different amount here. -13 DR. McPHEDRMI: Well,, T really didn't make that'in 14 the form, of a motion. I have no quarrel with 15 ---,Ohl I w6fildn't mind if he wanted t6l- I)R MILLER: figure out how you can 3p§tify d'orqing out with $2,295,113. 17 I'll go along with it. 18 DR. McPHEDRA14: I will move the target amount, 19 which is $2,364,333. 20 MR. CHAIIBLISS:. Is there a second? 21 DR. MILLER: I will second. MR. CIIAI-IBLISS: It is moved and seconded that a 22 23 recommendation for Ilissouri be the-targetect amount of 24 1$2,341,490. 25 DR. 14cPHEDRAN: I know you %-;ere probably semi- HOOVER REPORTING CO, INC. 320 Massachusetts Avenu 3, N.E. Washinzton, D.C. 20002 em5l 279 facetious, Dr. Miller, in saying that the changing in the 2 computer or the electronic program direction which had 31 developed so many electronic aids to care that was turned, 4 off like a water faucet. In fact, that really wasn't so. 5 It was damn hard to turn them off. I mean it really was 6 hard. It took a great deal of effort and persuasion, and 7 determination,, and repeated visits, 'and Bob-Toomey -- 8 DR. SCHERLIS: It has not been turned off, the 9 output has been changed. 10 DR. MILLER: Excuse me, I should make a comment. I have been through this with several other PI.IP'sl some of 12. which I made site visits on also as a coordinator. @13 I agree with you. The' electronic fanaticism in 14 our society is extremely difficult to turn off. We had it 15 in many others. Georgia was a good example, when I was down 16 there. 17 But it has been turned off now in almost all s MR. C112U4BLISS: May I restate the recommended. 20 amount for Missouri as..being P2,364,333.. 21 Is there further discussion? I call the question. 22 23 Those in favor of the motion, please indicate by 24 the usual sign of votina. 25 [Chorus of "ayes".] HOOVER REPORTING CO, INC. 32OMassachusettsAveni:i,N.E- Washington, D.C. 20002 em52 280 I MR. CIIAI-IBL ISS: Those opposed? 2 [Iqo response.) 3 MR. CFIA-MBLISS: The motion is carried. 4 DR. SCHERLIS: I ask one question now that you've 5 voted on it. 6 This relates to the fact you said they had a great 7 many different types of EMS activities, and you questioned 8 coordination. Is that correct? 9 DR. MILLER: Very difficult to do' this with this 10 many separate components. 11 DR. SCHERLIS: You mean they are making no .12. effort to coordinate it? Is there any umbrella EMS for the 13 region? 14 DR. MILLER: No, no. They would hope to get one. 15 But in the meantime they are going to have all of these various sub-components @,,7eidh are allowable. 17 MR. THO@IPSON: Mr. Chairman, would you transmit our 18 unease about the EMS situation in 14issouri to the EMS people? 19 MR. CI17U.IBLISS: We 47ill, indeed. We are much aware of the discussion here, and we will be in touch with 20 21 the EMS people, DR. SCHERLI8: I would almost suggest that we give 22 no EIIS funds if they are to be used in disparate programs. 23 24 In the State of Maryland we have had examples of @hat is now a large State support of some $2.4 million through 25 HOOVER REPORT114G CO, INC. 320 Massachusetts AvenL, @, N.E. Washington, D.C. 20DO2 (7fVl %4@ em5 3 281 t,'-ie Governor. In the face of what are already small EMS 2 activities and some not so small',, and you will spend endless 3 dollars trying to coordinate what are program that begin- 4 with noncompatible equipment, noncompatible standards, 5 noncompatible operations. 6 And I would think that if we perpetuate such 7 support, that we will be causing an excessive amount of funds 8 to have to be spent later on. 9 Some training programs will differ, criteria for i 10 State certification will differ because you will be training 11 at a different level. 12. I think part of the insistence that we should have 13 would indeed be that these be coordinated, 'regardless Of 14 what the ground rules are. Otherwise, we should not support 15 any EMS activity whatsoever. 16 I feel very strongly about that, having spent a 17 good part of my energies in Maryland, because of the very 18 reasons that we have had different types of funding, 19 different community structur:s and different involvements. 20 lle would be undoing a great deal of,what has been done in the 21 past. 99 MR. CIIAMBLISS: The EMS people are moving towards 23 State plans and State systems, Statewide systems. 24 DR. SCHERLIS: But if you give money to that group, 25 they will do their thing. The history of our society is HOOVER REPORTING CO, INC. 320 faasmchusetts Avenu,, N.E. Waship.zton. D.C. 20002 2 82 em54 that everyone does his thing i-f he has the wherewithal to 2 do it, and I would assume that by mal@ing separate structures 3 administratively,, with our own means of support, they will .4 do their own thing. I hope this vion't be true of I-,Iissouri. 6 MR. VAN 1,711@KLE: 1,7e did that in kidney, you know, 7 Len. If that did meet with within the State plan itself, 8 nothing was approved here. 9 DR. SCIIERTIS: But we have this leverage over 10 these programs, I gather from some of the feeling that we 11 don't. 12, MR. TIIOIIPSON: You see, the problem is that many 13 of the States do not have State.management. 14 MR. CH2U-IBLISS: A good amount of our previous 15 funding for El-IS has resulted in the,development of State i(i plans. I can assure you of that., 17 DR. I-AILLER: Can I make some comments? I have 18 been connected with this at the local level. Althoug I 19 don't pretend to know it alll I know quite a bit. EMS systems started ou 20 t with an Office of 21 Transportation funding, which is very large and many have 22 them -- there are many of them in the United States. I-le happen to have a very large onein Minnesota. And they're 23 24 buying ambulances. They are h6aded by ambulance drivers, 25 by and large; they're buying ambulances and training arbulan e HOOVER REPORTING CO, INC. 320 Ma@husetts Avenu @, N.E. Washington, D.C. 20002 t,)"% "r tr" em55 283 attendants, and setting up standards for their performance, 2 and that funding is precluded from doing anything with the 3 patient except delivering him to the door of the neiires 4 hospital. It cannot go any further. 5 When EMS incentives started with M@IP here a couple of years ago, why, the focus was to try to get comp ehensive, 7 planning for comprehensive care of emergency cases,land to face the issue about @.ihat happeneA to the patient a@ter they got inside the hospital-door. And so many IZI@IP's un rtook 10 to do this, and many of us supported planning for c rehensire emergency system development in the States. 12, Then EMS bill came through, and it seemed,like -la that this was going to take over, the over-all coordination; 14 but @is, as usual, has not happened. 15 And the leadership there doesn't seem to have the I(; capacity yet for attacking tl-ie whole problem. 17 So at the local level the possibilities of local 18 B agencies or regions or districts within the State of 19 getting funding through the new EMS bill was really quite 20 remote and they came back to RMP in most of the local levels 21 to do tJiis. 22 So there are three separate fragmented kind of 23 prograris for EMS in this country right now, and they're not 11 24 coordinated at the national level, and the attempt of RTIP's 25 is to try to get coordination at the local level, which we HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. VVashington, D.C. 20002 @.e tree en, 56 2 84 have always been challenged to do in the IUIP management 2 system. 3 l@IIL'3. I-IYCKOFF: But if you offer tJien money and .4 say, If you will make a State plan and you have thi6 money, 5 would this create a climate? 6 DR. 14ILLER: That's exactly what we did two years 7 ago. Many of us did it two years ago. 8 -We paid for the deve lopment of some kind :)f a State 9 plan. 10 DR. SCIIERLIS: Not necessarily. I was ch irrian 11 of the EMS Committee nationally that reviewed all @e 12, projects that came in, and these iieren't, exdep.t in@ rare i 13 instances, State plans. And I'd say.if you look at the whole 14 United States now, there are very few States that have any 15 semblance of a State plan. Maybe two or three. DR. MILLER: Now, there's a good difference between 17' a good State plan and a State plan, so I'm not saying they're good; I'm just saying 18 if) DR. SCIIERLIS: My only concern here is that I hope 20 in whatever letter goes out indicating funding that one proviso of that letter states that each of tl-iese-areas have 21 22 set up compatible systems, that there has to be a plan 23 utilizing all their forces. I don't think that this State 24 is large.enough to have individual areas designated as they 25 have, unless there is some over-all State compatible plan of HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em57 285 communications and everything else that goes into it. 2 I would think that unless vie put that into whatever 3 support letter we send out, this will be something that will 4 have to be dismantled later on and will have to be 5 fragmented. That's the only point of my observation. 6 MR. CHAI-IBLISS: We do appreciate these observations 7 that the panel has made. 8 We have at the table Mr. Mike Posta, who coordinated 9 the EMS activities for the P14P's, and he indicates to me that 10 of the 23 site visits that were made by staff over the last year that the majority of them had, as an effect of the PI@IP 12. support, the development of State plans. la And we will keep in mind your admonitions for 14 lessening fragmentation and more coordination between the 15 three federal agencies that are supporting EMS activities. 16 I want to assure you that PIIP has already been in 17 contact with the Emergency Medical Service Program here, and 18 agreements have been reached as to what we probably might I!) 0 fund and what their area of responsibility is. And I assure 20 you those discussions viill continue before these funds are 21 awarded. 22 I would call to your attention 23 MRS. RESNIX: May I add-one word about the Missouii 11 24 EMS program and the thrust in this application? 25 It was stimulated, by and large, by the passage Of HOOVER REPORTING CO, INC. 0 Masgchusetts Avenu i, N.E. Washington, D.C. 20002 2 86 em5 8 State Law 57, which set forth standards and requirements for 2 equipment on ambulances at various training levels, to the 3 extent that these programs involve programs with little 4 training, and that is the majority of the new activities, 5 it is not new in the sense that they are treating a new aspect of EMS. The training at various levels,' to y are 7 conform, or their existing training to conform to the 8 state requirements as described in the law. 9 And that is why it looks fragmented but it is part 10 of eventually a total training system. 11 I raised the question with them about eq@ ipment 12, and various items .of that sort, and there was st3ll@ a 13 considerable number of dollars that has to be looked into. 14 But there was a ma3or point in establishing these as separate 15 activities to conform to the State law. MR. CH2UIBLISS: I think we have already had a vote 17 on Missouri, and the discussions we have been having is an 18 add-on. I would simply suggest to the committee that it 20 may wish to take a coffee break, at this time; and, if so, 21 maybe we could return at 10:30, 10:33 with our -coffee and 22 resume. 9 ti [Short recess. 24 MR. CIIA14BLISS: May I call the panel to order again please, and indicate to you'that I gather that the 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 ,@-I rAt CI:CC em59 287 other panel is moving quite well -- and so are we -- and 2 suggest that we might take a look at the application from 3 Nebraska Regional Medical Program. 4 Yes, Dr. Thompson? 5 6 7 8 9 10 11 12. 14 15 17 18 1!) 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.E@ Washington, D.C. 20002 em6O 288 REGIOI@AL I-IEDICAT, P,@OGIWI @t VI.Ul@7 2 NEBRA Sl'\A 3 MR. TIIOMPSON: I guess I am tJ-ic only one. 4 MR. CHAMBLISS: Yes, you are the reviewer, and the staff support will be provided by '-'ivlavsky. 6 Will you proceed? 7 MR. THODIPSON: I Will. 8 Nebraska has not been the most flaming IUIP among 9 the 53. It's relatively small in amounts of money granted. 10 It never.achieved triennial review. Its status has always 11 been on an annual basis, although there were indications, 12. I understand from staff, that they were going to apply for 13 triennial review one month before the famous letter zipped 14 down to tell them to phase out. 15 They have a new man there who has only been there, i(i I think, a couple of months, abo ut half time. I expected with 17 his history a far less professional job on that proposal 18 than the one I find before me. 1!) Actually it indicates to me far more strength in 20 the region than has ever existed before.- I don't know exactly 21 what happened to cause it. 22 I wish that every report we ever had did what 23 Nebraska did very early in their proposal. There is E@ibit 1, 24 qoals/objectives, and they are fairly well spelled out. Both the goals and objectives. 25 HOOVER REPORTIfiG CO, INC. 320 Massachusetts Avenu @, N.E. Washington, D.C. 20002 2 'j' 9 em6 I M at li ap letter, opened was that when they got the 2 the original PAG began to fall off and they then reappoint 3 a committee for the phraseout, which consisted of selected 4 people within RAG, and they began the phaseout operations, 5 and then when the breath of life came back into the program i they selected from this committee, the phaseout committee, 7 thirteen people from RAG, so'they only have thirteen people 8 in their RAG at the present time. 9 Ilowever, when you look at the makeup of this 10 committee it is very widely represented. They have a lot 11 of public representatives, and they do have one Indian 12. representative among the t-vielve, so there Pas .an attempt 13 to retain at least a Statewide representative RAG in this 14 small group. 15 I think what we have to think, to regard this, we have to remember the goals, and the goals are not all that 17 innovative, but they are good solid goals, and I think they 18 are within.their reasonable capacity of Nebraska to carry I$) out. 20 One of them is kind of unusual, in th.at their 21, Goal No. 3 has the specific objective to stimulate the 22 development of comprehensive home health care systems. 23 In other words, they have really gone al 1 out for home healt-IL care systems. 24 25 Their goals, roughly, in broad terms, there is a HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washinaton, D.C. 20002 em62 .290 planning goal, there is manpower training goal, there is 2 this goal of home health care systems. There's the data 3 reporting analyzie kind of goal. And then the last goal is 4 the facilitator, coordinator, gathering people together kind 5 of goals. 6 But in each one of these broad goals there are 7 specific program type objectives. 8 And one must say that there is a very close 9 relationship between these goals and the kinds of programs 10 that we see coming up in the proposal. 11 Ilow, at the present time, they have been operating 12. at a level of 502,000. I said they are one-of the smaller 13 s, I think they are one of the four smal program lest programs,, 14 as far as money is concerned. 15 Their target would be some 868,000. This package here is 962,000 with an indicati on that they will be coming request 17 in with an additional/of $150,000. 18 So we then have a program, that is kind of climbing 1.1) up beyond their original base level support. The program 20 that probably would have gotten triennial approval, if the 21, funding thing hadn't changed. 22 Noxi, in general, they -- the most recent change in 23 this program, as it has been with most of the other programs 24 we've seen today,, was their relationship with CIIP. They 25 decided to start working with the various CIIP agencies within HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. Washington, D,C. 20002 em63 291 the State, and they have more or less r(@Cefined their 2 mission within -- still retain their goals. 3 Therefore, on liebras]4-.,i Regioyiil lledical Program,, it mission is tO'v7ard cooperative work with A and B agencies in 5 Nebraska State Department of Ilealth, in an attempt to match 6 those health care providers who have a need for service 7 with those resources capable.of responding with services 8 with the ultimate purpose of improving the health care, for 9 all Nebraska citizens. 10 So that this is kind of a redefinition of its own 11 mission, vis-a-vis the CHP agencies. It is not all too 12, clear from the proposal how well this is progressing. 13 Several otlier projects that we will be talking 14 about actually came from B agencies, and in one B agency 15 right off they said it @iould be unfair for us to write off on this, because actually we were involved in gathering the 17 proposal and designing the proposal. 18 There are other sections where there is an absence 19 of a writeoff or a signoff by B agencies or A agencies, and 20 others where the A agencies and B agencies in particular indicate a very positive view toward the projects" 21. So it's kind of spotty. I will try to have the 22 23 staff elaborate on this, because, although it's evident they are trying to cooperate, how successful they are is a whole 24 nother question, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. Washington, D.C. 20002 em64 292 1 Now, when you look at the proposal, and it's probably 2 the thickest one in this go-around, it seems rather awesome 3 until you realize that it is a fairly simple proposal. 4 They put their money on two things, an A hex kind o@ a busineks 5 which they believe should be, like Memphis, to cover a fairlyt 6 smallregion, and if you were concerned over the fact that 7 some'of these area community health-education conso@tia, 8 as they call them here, or hospitals in Memphis, yo will 9 find some of them are nursing homes in Nebraska, be@ause 10 their primary concern is with that level of trainin 11 So, of all the projects we're talking abo t, therb's 12. these two main thrusts, the A hex type thrust, %,fit.hia 13 nationalized learning -- I mean.a Statewide learning 14 resource center, and then some one, two, three, four, five, 15 six specific regional agent type outfits. Surprisingly in this proposal, there are eleven 17 different home health proposals, home care proposals, some 18 of them defined in one way, home health satellite or the 1.0 day-care service for elderly and disabled; and they have 20 these scattered throughout the State, mostly based in nursing home type places. They are trying to get nursing 21 homes for whatever few little bits and pieces of visiting 22 nurses' associations they can find, and beginning to design 2.3 a global home health backup pro"ram, for the elderly in 24 9 various parts of the community 25 iOOVER REPORTING CO, INC. 320 Mamchusetts Avenui, N.E. Nashington, D.C. 20002 29 3 em6 5 And of course this is, as I said, these two thrusts 2 are in line with-their Goals No.'2 and No. 3; and the rest 3 of this rather large list of variety of programs, nurse- 4 physician programs in the cities, shared hospital resources, which are not unusual, they are all small. They run from 6 12 to 33 thousand dollars. It's obvious they're shoving this money into programs that are in existing institutions. 8 There is this problem of their renal program, 9 which is the largest of all these non -- Ahex non-hoire healt.q 10 related outfits. 1,4hich I will allow Staff to respond to, because it looks like a fairly shaky business, all in all. 12. I'd like to hear from staff. I'm going to use .13 him, if you don't mind, as kind'of a secondary reviewer, 14 because my secondary reviewer isn't here. And let him 15 particularly elaborate on the problems of the interface with CHP's and with the kidney problems, and any other comments 17 he may have on Nebraska. 18 MR. CIIAI-IBLISS: Mr. Zivlavsky, will you comment, please? 20 MR. ZIVLAVSKY: The Nebraska.application is 21 576 pages. Dr. Iless, three years ago, made a site visit 221 out there, followed up by a site visit approximately a year 23@ and a half ago. 24 There was,a major shakeup out-- there. They followed 251 up on,,riany of the concerns from the first site visit. They HOOVERREPORTINGCO,IRC. 32OMassachusettsAvenLri, N@E. Viashington, D.G. 2OW2 29 4 em6 6 st as any increased their program viability and they were 3u 2 upsweep to come in for a triennial anniversary application 3 when our phaseout letter hit them right between the eyes.. 4 Some of the good things that they have been able to do have been their efforts in indirect costs, for example, 6 have been less than five percent of their total costs. over the past two years they have really been able to doa 8 good job in this relationship. They receive a few stars for 9 that, at least. 10 In the area of minorities, the State has approxi- 11 mately 2.7 percent. They have worked in.the area of sickle 12. cell screening for the entire black community of Lancaster @.13 Cou tv, which is in the Lincoln area. T n hey have worried 14 with a mobile cancer bus in terms of screening the Indian 15 population. The program staff has provided assistance to the 17 Panhandle community.action, which involves the migrants and 18 Indians out in western Nebraska. In their phasein they l@) have hired an additional min@rity -- I should say they lost 20 one minority person in their program staff. They were able 211 to hire another minority person on their progra-m'staff. 22 I am not sure -- they come in with an application 23 requesting no people. Pres@ly they have 11.5 full-time 24 equivalence. I think they can use a couple of people to help them in the monitoring area. 25 HOOVER REPORTING CO, INC. 320 Masuchusetts AvenL,@,N.E. Washington, D.C. 20002 em67 295 I don't know. That's up for discussion or gralis, 2 guess. 3 I like the comment on the negative CIIP comments, 4 and on page 345 of the application, specifically commenting 5 on Mr. Thompson's CIIPA comment, the reason the CEIPA agency 6 withheld comment was because they developed the proposal 7 and they were actively involved, and I believe they felt it .8 was a conflict of interest. So they backed-off, and this was one of the reasons that they did not comment. 10 The second negative comment is on project No. 47, 11 and again the CHP agency has commented that this project 12, lacks specificity. 13. The program staff is following up on this particula@- 14 project, and it involves the Omaha and Winnebago tribes, 15 and basically there's a,lnisunderstanding that the outreach I(; from the community health representative in the community 17 population, the CHR'S, they assume that you have much more 18 time than really is available; she has a half a day a week 19 for outreach activities, and they didn't really get this 20 clarified before they submitted the proposal to the RAG. 21 The RAG again is following this up with' program 22 staff and I think they can negotiate this. difference. 2tl The renal project, DRkIPS,.Dr. Mathis, the present e 24 coordinator, if he would not seek out of-State technical 25 consultants,, and he agreed to do this because all the people HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. VVashington, D.C. 20002 29 6 em6 8 within the State of Nebraska have been involved in IL-1-ieir 2 project. 3 Yesterday we received a letter from the a@sociate 4 coordinator for program services, attached to tliree'comments basically from the technical reviewers. All three had negative technical comments, reducing the budget frbr,. 7 approximately $51,920 down to 15 or 20 thousand do.Liars. 8 These comments have not been submitted tol@their 9 @regional advisory group, however. The Regional Adv:.Sory 10 Group will be meeting this following Friday, reacting to 11 these negative comments. 12. Basically what you have is a questionabl e@stance. 13 We are trying to as],, the community for some suggestions 14 or recommendations on what to do with this particular project. 15 I think I have ansviered, 16 MR. T11014PSOI@: my funding recommendation, they ar@ 17 now.502, the target is 868. This comes in at 962. There's 18 a possibility of another 150,000, because there is really no if) slush fund or escrow, however, designed in this program. 20 All the money is carefully identified in this, these little 21 small programs. It is very difficult to cut much of this, but I 22 23 would make the recommendation they.be funded at $912,000, 24 which is $50,000 less than they now have, which reflects their-- 25 cost of that Izidney program, which'I have some doubts about. HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 29 7 em6 9 'ing to tell them that this is against the kidney I am not go 2 program, but they've got to read'. The kidney program has 3 cost 50,000, we're cut 50,000. And they still will be the 4 third smallest program in the country if they get all this. DR. WHITE: Well, in the past we could say t ese 6 technical experts came out. If you go ahead and insist on 7 each of these, inspite of our advice and their advice, 8 next time around;they can thumb their nose at us this time, 9 because 10 MR. CHM@IBLISS: Would you speak.just alittle 11 louder, please? 12. MR. THOtl@PSON: I think the technical comments on this I can't see how the RAG'can step around them.. It was 14 unanimous, and I think the RAG will just drop that. 15 So I think we,can put a little hint in the advice 16 letter. 17 I move then, $912,000 for the Nebraskd proposal. 18 MR. TOO@IEY: Second it. MR. CHAIIBLISS: The motion has been properly 20 moved and seconded. 21 Is there discussion, please? Question. 2211 231 Those in favor? 24 [Chorus of "ayes".) MR. CIIPIIBLISS: Those opposed,> 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenv,, N@E. Washington,D.C.2OFj2 em7O 298 [No response.] 2 I-IR. CIIA.IIBLISS: The "'ayes" have it, an(-l t.,-ie T-@,cticii! 3 carries, at a reco,-imended level for l@ebraska of @912,00,0.. .4 6 7 8 9 10 12. .13 14 15 17 18 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 3-)O Massachusetts Avenu @, N.E. Washin,zton. D.C. 20002 29 9 em7l RE, GIOIIAL TIE, DICAL PROGRAIL REVIEW 2 NEW MEXICO 3 MR. CIIMIBLISS: Shall we then move to New Mexico? 4 The reviewers here are Dr. Miller, and Dr. White, with Mr. 5 Zivlavslzi as staff support. 6 Will the record so indicate that II.Irs. Jesse 7 Salazar is not a part of these proceedings,, and has absented 8 herself from the room. 9 'DR. MILLER: The Ilew Mexico application is another 10 of the umbrella type PIIP applications. 11 It is an extremely ambitious one, and has an 12, application for $2.77 million, when the current level of 13 funding is $1.2. 14 Iloviever it does not plan to come in with another 15 application in July, so,.this is its total application for the next year. 17 The New Mexico RMP had has a new coordinator, @lk8 and who starts,, let's see,, May lst. Dr. Gaye, who has been, I!) in my opinion, an able coordinator in the past, is resigning 20 as of the 30th of June, but will remain,as a consultant to 21 Dr. Walsh, the new c ordinator. 22 Otherwise, the program leadership seems to be good, 2.3 and I presume that this arrangement looks like it will still 24 provide a continuity and a fairly stable@program leadership. 25 The program staff seems to be adequate, and capable HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. Wathinoton- D.C. 20002 300 em7 2 in general. 2 The original Adviscry,Group, I don't quite know 3 what they did -- why they did what it did. I coul@n't-find 4 it in there, but they recently padded the Regional ',Advisory 5 Group, increasing its membership to 120 people. And we've seen that in reverse a number f times 7 in the last few years. I don't know what will motivate 8 it doing this. 9 But, of course, it forced the development of sub- 10 committees to then run the program, and at least i seems to 11 be reasonably satisfactory. 12. The past performance and accomplishments have some -13 bright spots, and some that maybe aren't quite so bright. 14 But in general they seemto be satisfactory. As I felt 15 their objectives and priorities were, also. 16 And the proposal is congruent with the explicit 17 objectives and priorities as given. 18 The feasbility is another one of these where, 1$) with the tremendous proposal for a year,, it doesn't seem ven 20 likely that it can carry out well the projects that i t 21 proposes. CIIP r 22 elationships apparently are quite good. 2.3 So, over-all, I felt the program is above average. 24 And I felt that the -- that if P14P was' going to be continued 25 for another three years, this region, like two or three HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.E. Washineton, D.C, 20002 em7 3 30 1 others welvb had yesterday and today, would be really well- 2 established for going gung ho ahead on a three-year program. 3 Most of the projects in this application are really A projects for the staff. There's some confusion in my mind 5 as to what constitutes a staff program in New Mexico and whati 6 constitutes an extramural project, since, in most of the 7 projects, why, the RI.,IP is th e, apparently the sponsoring 8 organization, and many of the staff that are going to be 9 working on the project are staff people of the Regional 10 Medical Program. 11 So I interpreted all except two of these projects 12. to actually be essentially staff activities. Which, in this .13 case, would mean, then, that almost the whole program in 14 New llexico is a program staff management system of staff and 15 projects run by the samp people. There are two projects that are extramural, which 17 they list as the lowest priority, in which it received some 18 unfavorable comments. So that which are for a neonatal 19 regional program and -- I fo37get what the other one was.. Genetics. Oh, yes, genetics regional program. 20 There's one huge emergency medical service that is 21 22 an expansion staff project, continuing -@ it's a continuation 23 project, but it's a huge expansion, with a budget of @911,000 24 Same kind of problem,we had before. 25 I don't know what it was last year. Does the staff HOOVER REFORTING CO, INC. 320 'Wswchusetts AvenLi, N.E. W;i,zhin,-nn DC 20002 em74 302 1 knovi? 2 DR. WH I TE We' re trying to determine that 3 right now. Th at kind of information is not in any of our .4 research. 5 I think since the program is funded to July 172 for 6 $520,000. 7 DR. MILLER: $528,000? Well, it isn't such a huge 8 expansion. 9 DR. WIIITE: Well, that was for to7o years. .10 DR. MILLER: That was a tvio-year program. 11 DR. 1,7HITE: That was two years? 12. DR. MILLER: That was two years of funding? 13 DR. IIHITE: Yes. Oh. this is one year, $911,OOOT and another one of 14 15 their projects, health education for the public', was expanded to $303,000, and I don't know what the previous level of 17 that was. 18 MR. VAN WII@lYxLE: Project 25, DR. MILLER: No. 25, health education for the public. 20 21 MR. ZIVLAVSKI: There is another substantial increase. They had $175,000 in there, and then about 70,000 22 for the past six months. And they put approximately 225,000 23 in there. 2,4 DR. MILLER: I have some,philosophical feelings 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em75 303 about health education for the public beamed through every 2 possible communication mechanism for one year for $,300,,ooo,, 3 as to what are the cost-benefits, and hoei would youi,ever 4 know? And if you can't know, what the devil do you@do it 5 for? 6 ller, I think in a 1 candor, MR. CH7UIBLISS: Dr. Mi 7 ad staff with the reviewers, it should be noted that we h presentation of that proect, health education to -Eae public, during the last year. We were not overly impressed with 10 what came out of it. 11 I say that just so the committee may kno@,;@that that 12. presentation had been made to the staff. .13 DR. MILLER: I think I can complete my statements 14 now with the feeling that this is an over-ambitious., largely 15 staff programs in an @IP that is fairly good, and therefore I(; my feeling is that we ought to hold our funding to the 17 targeted level. MR. CHAILLISS: Dr. White. DR. VIIIITE: Well, I noted that Dr. Gaye was 20 retiring. I don't knovi Dr. Walsh.- I knovi nothing about New Mexico. This is the first time I've had anything to do with 21 New Mexico, other than the site visits as a reviewer. 22 23 Dr. Walsh is an unknown quantity, to me at least. 24 The staff seem to have the credentials. 25 My interpretation of the Regional Advisory Group is HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. Washinkton, D.C. 20002 30 4 ern76 s t that it was ex panded to 120 people in.1971,, at whose behe 2 I don't know, but possibly to get the minority group in, 3 or one thing or another. 4 But, in any event, when the phaseout came out, they 5 then began reducing-by' attrition, and beyond that they 6 also began not meeting, to my interpretation, in delegating 7 their authority to an executive committee and I think this 8 is reflected in the fact that the proposals, as I read them, 9 are enormously impossible. 10 If they had trouble spending.-- I think it .-ays 11 in here the number of people they trained in two years in 12. the EMS program for approximately $250,000 a year, they have no earthly hope of spending 900-some thousand in a year's i4 time and getting their money's worth out of it. I thin]-, also that health education to the public I(; is a hopeless proposition by the avenues that they propose. 17 I don't why we can convince people to take aspirin by using 18 mass media, but we can't convince them not to take it. MR. T110tIPSON: Well, you know, Bayer's advertising 20 budget Iis far beyond anything we put out. 21 DR. @,711ITE: In any event, beyond that, I would 22 agree with Dr. Miller. I would consider,this an average, -9,3 neither bad nor good; and I think it's entitled to its fair 24 share of whatever money is portioned out, and I would agree to the targeted fund minus whatever is reserved for July, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N @E. 30 5 fHD46 and let it go at that. 2 I,IR. CIIARIBLISS: Dr. Scherlis. WD fls 3 DR. SCHERLIS: I looked at the Emergency Medical 4 Services, which constitute a great part of their budget, and 5 in reviewing it, I asked some serious questions about it. It 6 looks at what is the'easy side of the Emergency Medical 7 Service, the trainee and the vehicle end of it, but in terms 8 of looking at a system of care, there are some serious 9 questions. 10 Maybe I could just spend a minute or two on this. .11 Under objectives, it looks at training and corununi- 12 cations, which really consisted of developing a statewide 13 emergency communications system linking all hospitals and 14 ambulances together, then-to create a crisis center to inte- 15 grate all communication links. I guess the question I'have is something that maybe 17 they have not included in this, although they have about 40 18 or 50 pages devoted to it, and I would rather see that than 19 all the individual sources, arrd that is, are they are talking 20 about characterization of care? 21 I see the reference that this is an important aspect, 22 but if you are going to have people talking to people, they 9@3: should talk to them about somethbg aside from the fact: 24 "We're coming in'in a hurry; we've got some sick people aboard." 25 HOOVER REPORTING CO, lftc. 320 Massachusetts Avent, i, N,[ Washington,D.C.20 2 3 06 WIID47 1 I don't know if they provide in there, and perhaps 2 Staff can comment, whether they have provided medical communi- 3 11 cation at one end or whether this is administrative communi- 4 cation. Also, if they are under all of these funds proposed, for centers in the state for treating more specifically cer- 7 tain types of catastrophic events, if they are talking about 8 one or twenty burn centers, one or twenty trauma centers, one or twenty cardiovascular centers -- so what is "Training 9 and Communication Evaluation," and I would have to review 10 tnis carefully, but I would think one would like a great deal more in the way of evaluation than what they have 12 included, if they are going to get some answers in terms of 13 what they want to do. 14 15 Continuity -- they are going to ask the Governor for money, which seems to"me the-b'est way to continue all forms of care, at least by going through the appropriate 17 18 motions. But I don't see adequate emphasis in here on what I would think seem to be the real problems despite the fact 19 they are putting in an awful lot of money. 20 They are talking about basically new and,.bett.er 21, ambulances, about communications, about training, and I think 22 the other end of it, in terms of what happens when these 23 people get to a center? I don't, know if they are talking 24 about by-passing certain areas, or if they are talking about 25 HOOVER REPORTING CO, INC. 32OMassactiusettsAvenue,N.C@ V4ashington, D.C. 20002 3 07 WlID48 really having hierarchy type of care and really a regional 2 type of emergency system. It does not seem to come out of, 3 at least, the document that we have, and I question hether w 4 or not this is really an adequate pres.entation-or whether 5 you know more about their plans. 6 Maybe this does not do justice to the plan they 7 have. I don't think that this warrants the price-tag placed 8 on it, at least from the minimal review I have giver it. 9 Perhaps you can comment? 10 MR.-CHMIBLISS: Are there Staff comments 11 response 11 to Doctor Scherlis's query about New Mexico? 12 MR. ZIVLAVSKI: Why don't I just start from the .13 top and make a few comments? In terms of the RAG and the number of the RAG, when 14 15 Doctor Gaye became Coordi,nator, it was his decision to involve 1(; more people in the decision-making process. He increased the RAG 220 members, broadly representative and including minori- 17 18 ties and parts of the state, and the whole thing. 19 In this application it seems like a conflict of information, but in the RAG report it-mentions 120 still being 20 there, but actually they have decreased it to 73 members. 21 There is a lit-de confusion in interpretation; it 22 depends on which page you look at. The in terms of the 2,3 of Doctor miller's comments on whether there is confusion over 24 staff projects, and are they essentially control projects, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 3 08 WHD49 1 four or five of 4:,@se activities were out originally with 2 CO numbers. The last review we had, in a site visit we had 3 down there, we indicated to them that what they needed to do was to place these projects in independent status, provide 4 5 them with a project number and make sure you give them the 6 -- the information to the Project Directors that these are 7 unlimited activities and they-can't crawl back into the wings of the university once the project phases out. 8 Just in the last six months, they have typed these 9 10 CO type numbers and have been:.able to communicate these to the people. 11 12 These are free-standing, they are centrally located in the headquarters of the RMP, physically right in the same 13 area. However, they are operating as project directors, 100 14 percent type of activities; when the project ceases, they 15 are going to have to find new employment, whenever that 16 happens. 17 DOCTOR MILLER: But they are staff of the RMP; 18 they are listed under the personnel lists for each one of 19 those things as the New Mexico RMP staff. 20 MR. ZIVLAVSKI: There is no duplication,.in terms 21 of salaries on the Form 6, which is the core staff salary 22 budget, as well as the Project Directors' salaries. There 23 is no duplication of funding; each of the moneys are coming 24 out of different types of activities. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. nn nnnn) I 3 09 WHD50 1 Yoii can look at Project 32, the community health 21 resource development, Project 33,,the health resources 3ij registry, and Project 34, regional health resource plan and 41 development; each of these three projects are leaning toward 5 the future of health resource planning. 6 These are not in escrow, there is not -- these are 7 defined moneys and they tell you exactly what they hope to 8 do in these Areas. 9 Staff did there.was a presentation by Project 10 No. 25, which is the health education for the public; ..'it has 11 substantially increased their requests. -This is a statewide project; the former project director of this is now a Deputy 12. Director of the P24P. 13 14 It presents a problem; maybe the alternate sugges- tion is to have a technical review committee, site visit from 15 out of state consultants to come in, people that don't have a bias, and maybe we could send this message back and then 17 vrrite an advice letter to the program to have somebody from 18 out of state come in, let the*RMP pay for it with their own 19 funds, then give the report to the Director of the program 20 hot to Walsh, not the Deputy Director, who is thb-previous 21 Project Director. 9-? Project Number 18, EMS, there is a heavy emphasis 23 they have done a lot of things in here; I don't know how to 24 tackle some of your questions, but You mentioned the fact of 25 HOOVER REPORTING CO. INC. 320!,iassachusetts Avenue, ii.l. 310 WHD51 1 categorization; the Deputy Director, Doctor Ilanratty, has 2 been working on a computerized system for it. 31 Their position is that they,are not happy with any 4 of the national plans for categorization, AMA or any'-of these. 5 They would like a modification of each of these plans, and 6 @they would like to have a computerized categorization of 7 the hospitals. And they are working on that right now; they 8 started out slightly on their surveys, the form has been pre- pared. I can't tell you what modifications have been made 9 10 in the categorizations of all the hospitals, but there is an 11 obvious gap, because one or two hospitals in Albuquerque, one 12 in Santa Fe, and then you have the rest of the state, and they haven't completed this. They have the survey form .13 developed. 14 15 It is a modified form, and what the results will be have not appeared yet. In area medical comrqunica tions they work closely 17 with the State Department of Communications. Everything they 18 19 do there is pretty well basedoon a total effort, because there are a lot of scant resources. 20 21, They have done quite a job in terms of-training. No @IP funds have gone into the purchase of vehicles; the PL@IP 92 Doctor Walsh, by the way, the present Director of this 23 Program, is also the Director of the EMS project. If he is 24 finally selected as the final Coordinator on July lst, his 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n r innn) 31.1 WlID52 1 Deputy Director, Doctor Hanratty, will -- it looks likely 2 that he will take over as Project'Director. He has been 3 1 Deputy Director on the project for one year. MR. CHA14BLISS: I wonder if that sufficiently covers 5 the query about the categorization and so on? 6 DOCTOR WHITE: I might point out that if you take 7 the targeted fund -- I was a little more charitable in 8 approaching their EMS; I think they o ave some compatibility 9 in terms of their training programs, and by',legislation thdy are,going.to be uniform. Communication as I read it was between am bulances 12 and hospitals, where there are enormous distances to get to. 13 DOCTOR SCHERLIS: The average.run can be 50 to 100 14 miles. 15 DOCTOR WHITE,: They need to communicate with the 1(; interim stations along the way just in case something happens. 17 18 DOCTOR SCHERLIS: This is why I asked about-the categorizations, because I don't know how they are going to 1!) react to passing certain ones if they have to, and this is a 20 key feature to astate that large, with a long haul-. 21 DOCTOR WHITE: But regardless of the quality 22 MR. THOMPSON: This is rather ironic. Unless I am 23 e mistaken, the first proposal that-ever came in from New 24 Mexico, altogether in the old, old, old, days was on emergency 25 HOOVER REPORTING CO, INC. ti r 312 WlID53 1 medical services. They did a ratl-ier large study and they 2 found out that the primary cause of death downthere was not 3 heart, stroke and cancer; it was Indians spread out over the 4 highway in these old cars. 5 We did not give them any money because they did not 6 fit into the categories of heart, stroke and cancer. 7 DOCTOR WHITE: It still doesn't solve the prob em 8 of the Indians, because they point out in here, there are no 9 areas in which the Indians are terribly ],,een about participat- 10 ing in. 11 MR. CHAMBLISS: Is there a motion and a recommended 12. level of funding here? DOCTOR MILLER: I move.that they be funded at the 13 target level: $1.64 million. 14 DOCTOR WHITE: Second. 15 MR. CHAMBLISS: It ha's'been moved and seconded that 16 New Mexico be recommended for funding at a level of $1,644,000. 17 Is there discussion on the motion? 18 All in favor? (Chorus of "Aye") 20 Opposed? The level is recommended at $1,644,754. 21 22 DOCTOR WHITE: They will get th e message @out staff appraisal of educational efforts-, won't they? 23 MR. CHAMBLISS: Your don.cerns will be passed along, 24 indeed, regarding EMS and education for the public. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. ID-1 1 RE-GIONikL l,iEDICAL PROGRAM REVIEW 2 NORTII CAROLINA REGION 3 1 MR. CHAMBLISS: Shall we go on then to Notth 4 Carolina? 5 Doctor Miller, Doctor McPhedran, and Staff; will be 6 represented by Mrs. Parks. 7 DR. SCHERLIS: We should have Mrs. Salazar. come 8 back, shouldnvt we? 9 DOCTOR MILLER: This is another large application. 10 North Carolina has a current funding level of $1.67 illion, it puts in an application for $3.26 million, and plans to sub- mit another ap lication in July for $400,000. 12 p Targeted level is $2.78 million, and the composite 13 of th@ present application with the proposed additions in 14 July-will be 132 percent of the target, or $880,000 over the target amount. 17 The Region is a good Region, in general, has done a lot of things in the past that are quite outstanding. They 18 have a change in the Project Director and Coordinator, which 19 20 I can not assess. Perhaps the Staff Ican help us with that. The new Executive Dire ctor, Ben Weaver-,.was Deputy 21 Director for five years, so it is presumed thatlis leadership 22 should probably be adequate. 23 The program staff approach looks all right; the' y 24 plan to increase it quite a lot during this next year, but 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Wa@hini,qon, D.C. 20002 31 4 WHD-2 I they have- a fairlygood nucleus anyway. 2 The Regional Advisory group assessment is all right.1 3 The past performance, as I men@ned, is good; 4 their objectives and priorities are good, and the proposal 5 fits in with their objectives and priorities. 6 Their CHP relationships are good. 7 This, in my opinion,-is one of the extremely needy 8 areas in this country, where you can hardly design anything @t, and 9 that would not help, because their needs are so grea 10 they are really deprived of health care. There are any -11 areas of health care deprivation in se rvices, and they have 12. been working toward these and have made some outstanding achievements, I think, in this area. 13 So I think they deserve a recognitio n of those 14 things. 15 @i-s application, 45 projects. A lot They have, in th of them are not very good in principles of feasibility or per- 17 formance, and are not in my opin ion, justification for the 18 costs. 19 20 One continuation, one which bothers me terribly, but I guess it's just one of those things, is a medical air- 21 operations, which is $50,000, which is a continuation, so I 22 suppose they have been doing it, which is solely for the -- 23 the money is spent solely for the purpose of flying faculty, 2,4 students and staff around the state in private planes in 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.I@ nr )nnfig 315 IHD-3 support of the area health education center project. 2 Of course, all kinds of,faculty -- as-we-11 as 3:i students and staff -- would like to fly in private airplanes 4 almost anywhere if you give them that,luxury. 5 Another one, they have a project in here for the 6 medical foundation they have in the state for a PSRO develop-, 7 ment for $125,000. I think this is inappropriate; PSRO's 8 are going to be funded, and as near as I can tell from that 9 application, it is a pure PSRO project development. 10 Then there are multiple rural health clinic supports. 11 There are supplementary support to state-clinics or state rural health clinics, which undoubtedly are needed, and are 12. 13 supported by the state. But the amount of this support amounts to $243,000 altogether. i4 15 And then anoth.er.supportive project for supporting the area health education center activities in the state, which is funded outside o@ RMP, to develop a library network 17 18 for $363,000 in community hospitals throughout the state. 19 Although I 6on't question their statement that community hospitals have no library facilities that amount to anything, 20 and when you want to educate health-care professionals in 21 rural communities, why, one of the things you need is a -92 library, but it seems like an overly ambitious approach with- 231 out any guarantee that it will 'be.continued. 2-4 Another of the fundamental things, of course, in a 25 HOOVER REPORTING CO, INC. 32C, Massachusetts Avenue, N,E. WHD-4 1 place like North Carolina, which I think is probably true 2,1 in some of the other similar types of states, there is very 3!1 little guarantee that these -- any of these activities will 4 be-continued after RMP funding, probably because, however, 5 that their potential for funding things is so poor that tey 6 are quite dependent upon Federal funding programs. 7 In general, I regard this as a superior program, 8 and it is a terrifically needy area, wh ere they a composite 9 application which is over-ambitious, and some of it is 10 inappropriate, and my recommendation would, again,@be a fund- ing at the target level. 12. MR. CHAMBLISS- Doctor McPhedran? 13 DOCTOR IMC PHEDRAN: I agree. I really have nothing 14 to add. 15 DOCTOR MILLER: 1. I'll make the motion, then. DOCTOR MC PHEDRAN: I'll second that. 17 MR. CMIBLISS: It has been moved and seconded that 18 North Carolina be recommended for funding at the targeted level of $2,775,522. 19 Is there discussion on the motion? 20 21 DOCTOR MILLER: Their present funding for the. current year is $1,175,000, so they will'get 22 MR. VAN WINKLE: About $1.1. 23 DOCTOR MILLER: They Vill get $1,100, 000 more 24 ii money; they probably can't spend that either. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Awenue, N.[. ,Yas,hington. D.C. 20002 qHD-5 1 DOCTOR WHITE: Well, I guess that is what bothers 2 me,,in terms of losing out on a million dollars. 3i Even though you said it was a superior Region, yet 4 I look at -- what? 45 new projects, which 5 DOCTOR MILLER: Very needy. How do you really 6 decide on deprived areas? There is no way to solve those 7 problems without pouring money into them. 8 MR. THOMPSON: They are going to come in with 9 another $4OOiOOO. 10 DOCTOR WHITE: Let's not get people used to some- 11 thing why get the poor people but in the hills used to 12 something they are going to lose next year? DOCTOR MILLER:. Reminds me of a site visit I went 13 on a @ouple of years ago to West Virginia. Have any of you 14 been to West Virginia? 15 We were questioning a lot of these things, And one of the physicians said: 17 18 "We depend on Federal money for a living; we 111) will do anything -- whatever the Federal money resource 20 requires, because we are totally dependent upon Federal money.11 21 22 DOCTOR SLATER: They are not the o nly group that says that. 23 MR. CHAMBLISS: Doctor Miller, may I just ask a 24 point here, about the PSRO? Did you say that was out and out 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. WashinEton, D.C. 20002 WHD-6 I PSRO? 2 DOCTOR MILLER: Nearly as I can tell. Does the 3 Staff have any other interpretation? 4 MRS. PARKS: We thought the.same way. 5 DOCTOR MC PHEDRAN: I agree. 6 DOCTOR MILLER: I think it is totall' inappropriate y 7 at this time. DOCTOR SCHERLIS: I have some concern, because I think in your description of the various projects, programs,anl 10 so on, I was detecting a certain note of lack of enthusiasm, and then Ihad your conclusions, which reflected, in a way, 12, a disparate approach. You know, the need is there, I think we would agree; 13 the R@ has a' pretty good track record, and again I would 14 assume that, given an area that is impoverished in many ways, 15 these funds might eventual@y-do-some good. I do have a significant concern, though, in terms 18 of all that money, in view of what I think were very apt cri:- ticisms of the ability to really spend this wisely, and I 19 20 would think, particularly in view of the fact that they are 21 coming back for at least additional funds at $400,000, and in view of the fact that we doubt very much that all of this can 22 be @- not just efficiently spent, but let's say inadequately 23 spent, that you might then entertain some reduction from the 24 target figure, understanding that they are going to come back 25 DOVER REPORTING CO, INC. 20 Massachusetts Avenue, N.[. lashington, D.C. 20002 @n9@ FlArl.urr, WHD7 1 for more, alt hough I know that is not a constraint, but I 2 just have some difficulty, as I view the large array of pro- 3 jects, particularly the one for, say -- well, I guess it 4 would be $362,000 for a statewide network of hospital librar- 5 ies. 6 I wonder if you might not entertain-the possibility 7 of reducing that some, because I don't think they could really- 8 effectively utilize this support level. DOCTOR MILLER: I judge on that library business 9 they are going to staff those libraries? I could not tell 10 in the application, but they are probabl y going to set up 11 libraries in every one of these hospitals, which has nothing 12. 13 now. Is that true? 14 15 MRSI PARKS:. Right. They will be tied into the nine area health-education cent,6rs, but I don't think that the 17 supportive personnel will solely be funded through the North Carolina RMP. 18 DOCTOR MILLER: Well, it costs a lot of money to 19 set up nine libraries. 20 DOCTOR.IIHITE:- Doesn't it cost a fair amount to 21 keep them going, in termsce personnel? 22 DOCTOR MILLER: It is a terrible problem. She says 23 they are going to keep them going; will the hospital undertake 24 the responsibility, or the AHEC, or solely someb ody else, for 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. waship,gtc,n. D-C@ 2&302 i7ri9@ HD-8 1 the operation of these libraries after one year, a fter the 2 PJIP is gone? 3 DOCTOR WHITE: If nothing else, somebody has to dust 4 the books. 5 MRS. PARKS: I am not really sure. The only infot- 6 mation I have is what is.in the Form 15, and it was not clear 7 as to how many would. e a lot of 8 DOCTOR MILLER: It does not say; there ar unanswered things as you read these. 10 DOCTOR WHITE: Did you find contributions from the Appalachian Regional CommissioA? Matching funds and things 11 12 of that sort that look as though they might be substantial? DOCTOR MILLER: I don't think they have that in 13 here,d'o.they? 14 MRS. PARKS: No. 15 MR. THOMPSON: @at I-can"t understand; they have been working specifically with hospital libraries,, hospitals 17 18 and quality control for all these years. What the hell have.. they been d oing? All those small hospitals; that was the main 20 thrust of the project -- quality control and libraries. DOCTOR VAUN: The objectives of the National Library 21 of Medicine is not to perpetuate the old concept of libraries. 22 It does not cost a lot to build a library that can function 23 through the National Library of Medicine network, and if we ?,4 pour this amount of money into creating a lot of old-fashioned 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[.. Washington, D,C, 20002 ,qAl\ EAC CCCC 321 drain. fHD-9 1 libraries, you might just as well flush it.down the 2 MR. VAN WINKLE: Staff.had flagged that for that 3 1 consideration. 4 DOCTOR MILLER: Well, I think cutting the budget, 5 even to the target level, willIput the pressure on t@em for 6 some of this kind of stuff. 7 MR. CHAMBLISS: That is the motion, to rec d 8 funding at-the target level. 9 Is there further discussion? 10 DOCTOR SCHERLIS: May I move an amendment to the motion? MR. CHAMBLISS: You may indeed. 12. -13 DOCTOR SCHERLIS: T withdraw my motion. MR. CHAMBLISS: Those in favor of th e motion, let 14 it be known by the usual sign of voting. 15 16 (Chorus of Aye Those opposed? (No response) 18 May we have a show of hands on that vote, please? 19 (Show of hands.) 20 Three in favor, and the "Nay.'s" have it and the 21 motion is not carried. The Chair will entertain a new motion. 9-2 DOCTOR SCHERLIS: I would move that the target 2.3 figure be reduced by $400,000, 'as the level of funding for 24 the coming fiscal year. ')5 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. @,VA@hincrtnn D r, 20002 @1ID11 1 the vast array of projects, particularly that one, and to 2 think in terms of what will happen to a statewide systems 3 when you have libraries in individual hospitals, and@wha't will 4 occur:-at that time. 5 I think there is a lot of fat in this budg@t. I 6 don't think this is going to affect their overall pr)gram one 7 iota, and I think to fund them at their target level now, 8 when they .vill be coming back for additional funds, they 9 aren't bound to ask for only $400,000; I'm sure they will be asking f-or a significant sum more I'd like to gi e them 10 11 that latitude. Now, if you asked me if I reached a tation@l feeling,, 12 -13 I think that I tried to express myself rationally, but I. would suggest to you that the input to that wa s about 95 per- 14 cent'gut reaction. 15 Is that a fair.apprai@al? That's what you thought, 16 -didn't you? 17 DOCTOR MC PHEDRAN: That is what I thought. 18 MR. CHMLBLISS: Shall I call the question again? Those in favor? 20 (Chorus of "Aye" 21 Opposed? 22 (No response) 23 The motion is carried'. to recommend a level of fund- 24 ing at $2,375 522. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Wa@hinRtan, D,C. 20002 HD10 1 DOCTOR WHITE: I'll second that. 2 MR. CHAMBLISS: The motion is now that the recom- 3 mended level be set at $2,375,522. 4 It has been properly moved and seconded. Is there 5 discussion? 6 DOCTOR MC PHEDRAN: I supported the previous motion, 7 and I really feel it is important for me to say that this is 8 another arbitrary choice -- so was the previous one. 9 I don't really know how you decide, and it is 10 obviously arbitrary and I don't know how it can' ever be intelligently decided. In fact, it can't be withoutla more 11 detailed review of the projects. 12. 13 So I think that I would like to know whether Doctor 14 Scherlis would acknowledge that this is a really arbitrary amount? 15 DOCTOR SCHERLISt/.Let me tell you the rational way 17 inwh.ich I reached my decision. I sit here and listen to the reviewer with a great deal of care, because he is going 18 has gone through the document more than any of us have, 20 and must really have some expertise. And I get a certain flavor which I file away, I assume, somewhere in my brain. 21 Really, it is a gut.reaction, and then as the dis- 22 cussion goes on and I try to relate what I have heard at 21 previous meetings, to a particular state, what I did in this 24 instance was to look at the sum they have asked for, look at 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 (7n2i VIHD12 REGIONAL MEDICAL PROGRAM REVIEW 2 NORTH DAKOTA REGION 311 MR. CHAMBLISS: Now we will move to North @ako'ta. 4 The presenters here will be Doctor Slater and Doctor 5 Scherlis; Miss Resnik will represent the Staff. 6 DOCTOR SCHERLIS: North Dakota, Mr. Chambl'ss, is 7 the smallest budget RMP in the nation, of $367,746, and are 8 coming back in with a request for $774,057, which is 132 per- 9 cent of the anticipated target. 10 I would like to make a comment that there ust be 11 -some kind of a leak in this agency, because despite our pro- 12, testations that they don't know what the targeted fl ures are, North Dakota is so honest.that they said: 13 "There has resulted a grant application figure 14 that exceeds the target figure." 15 Which doesn't bother me very much. 17 DOCTOR SLATER: North Dakota also makes a point which I think will rectify that and I am abstracting here,:. 18 19 @"We have considerable.difficulty attracting physicians to North Dakota. Our image is ridiculous in 20 view of the.national situation." 21 I think theyhave some problems in this proposal 22 which reflect that self-image. Quite honestly, I am concerned 23 about their priorities, ana@ there is not a thing, I believe, 24 that we can perhaps do about this. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. @li,A@!iington, D.C. 20002 'qAq% LP.C 3 2 4 WHD13 1 Their-image, in fact, is based on the fact that 2 they have about 146 primary care physicians per 100,000 3 population, which is the lowest on the national scene, and their concern is that they need to upgrade their medical care 5 system, primarily going in the direction of producing more 6 manpower and increasing the education of those individuals, 7 both professional and lay, who are already there in North 8 Dakota. As you know, there has been a major press to develop- 10 a four-year medical school, and I had the opportunity to 11 visit North Dakota after the original feasibility study, to 12 determine whether they would become a Region, and recommended 13 to you -- what? In '67, I guess; Doctor Scherlis has been ,4' thqre'mor-e recently, so his information is better than mine but they now have been accredited for a four-year school, and 15 are searching for ways to @implement this. well, to get back to what they have been doing, they have, from what I can make but, a small, reasonably well- organized, active staff, and I will have to rely entirely upon other people's inputs to determine how effective they 20 are. 21 Their program thrust, as I said, was in education 22 and manpower. 23 Past accomplishments include Emergency Medical 24 Care System; they have been able reproduce 1,000 Emergency 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. Washingtor,, D.C. 20002 i,)rt,jx rAc cacc 325 WHD14 I Medical Technicians, which has produced a number of one per 2 600 population, which is the highest ratio on the national 3 scene. They are proud of that; they feel it makes a very 4 effective dent, at least on attending to accidents and emer- 5 gency problems. 6 In the second area of activity, the University of 7 North Dakota, working their EXtension Service through the 8 Medical School, and working in conjunction with the Public 9 Health Department, And the IUIP i have really been able to'get 10 engaged in a great deal of data collection and professional education -- continuing education programs. 11 There are four AHEC areas which are actively 12. @13 involved in thelarrangement of local.-teaching programs for 14 lay.and allied health professional teaching people, and 15 associated with this havIe been the arrangements for a great deal of travel by nurse educators as well as the bringing in of local physicians to become engaged as teachers in their own 17 special areas of capability, for not only lay but allied 18 health professional people. i.q 20 So that by and large, I think they have concentrated a great deal on blanketing the state with a.great variety of 21 types of-continuing education and special types of therapy 9 -2 for coronary care, renal, chronic renal disease, problems 23 g rehabilitation of the'handicapped and the like. 24 requirin Now, where are they going-, against this kind of a 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. @@ashint@n, D.C. 20002 WHD-15 1 background? 2 They have presented a series of activities here 3!i which -- in which I would like to indicate to you where they 4 see their priorities, on page 16. 5 Their RAG is made up of 47 people, with ni e repre- 6 sentatives from Comprehensive Health Planning. I believe 7 they work very closely with CHP, but I don't have an direct 8 evidence of it from this proposal, except in the sen e that the CHP people are involved in reviewing and helping set 9 10 o through. .priorities on the proposals that g They are askim for a series of projects, a@d I will 11 just run through them and give you the commentary o.n,ithem. 12 First of all, they are-intereseted in feasibility '13 14 study to look into the development of,a residency proIgram in internal medicine. This of course is oriented to getting the 15 medical school off the ground. $13,775; this will put tog the- committees, consultants and site visits. 17 They are particularly anxious in looking at 18 Pittsfield, Mass., Rutgers University, Muncie, Indiana, I believe it is, who have been able to develop residency program 3 20 at community hospitals. They would like to develop a conso'r- 21 tium of hospitals for the residency programs that emanate 22 from the University of North Dakota.. 23 The second project, small -- $9,620 a feasibility 24 study to look into the potential for graduate programs of 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[ r% 11 327 ilID16 I behavioral science related to family practice, and they 2, are looking to the possibility of developing a Master's 3 degree in behavioral technology as a graduate program, and 4 also set up resources for marital counseling, child-rearing, 5 sex counseling, addiction, dying, and fty will do this 6 through statewide meetings and consultations and this kind 7 of activity trough AHEC. 8 The third type of program is $400,000, a biomedical communications system connecting the four AHEC'S, phase A 9 10 and B are.to go on during this fiscal year, first of all to 11 study the feasibility and costs, and mechanics of this, and secondly to purchase the equipment. 12. After they purchase the equipment, by the end of 13 Fiscal Year '75, they will then present a fiscal study to 14 see whether or not it impossible to continue to fund this, 15 .and that will go to the legislature, later to be in fact picked up and operated by the University of North Dakota. There is really no mention o the -- apart from 18 microwave connections and a few general words there is no 19 mention of the kinds of equipment, how the terminals will 20 operate, what the details are, how the people will fit into 21. this -- now many specific types of programs will be function- 2i) ing through the learning centers that will be located in these 23 four places. 24 By and large, I don't understand this and am very 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue@ N.C. Wn,zhinoinn I) P. 2nnn9 WHD17 I d about concerne this type of expenditure of money. 2 I bring this up now because it is a tremendous 31' chunk of money to spend when one could put this into the pro- 4 duction of personnel who will go out and improve the-home carei 5 treatment, and so on. Fourth, they want a computer lab. They really are 7 anxious to be able to program the health data that they are 8 pulling together and improve their computer laboratory capa- bility. That is $36,000. 9 Satellite hemadialysis unit they want they have 10 one five-bed unit presently, operating at Fargo; fty want a three-bed unit put together at the United Hospital in 12 Grand Forks, which would give them two 'in the state. 13 14 A project review program for North Dakota certifica- 15 tion and need law a.nd the Federal capability expenditures; $25,000. They want to bring in a consulting firm, John, to tell them what the capability of a certification of need law 17 is. You will have to comment on that for us. 18 They are talking about a human services center, for 1!) $41,700. 20 They have developed a medical park, with two new 21 hospitals going up; I believe it -is in Grand Forks, and they 22 would like to put up a separate facility in which all of the 231 other health and human services,agencies are placed, so that 1)41 :I everything is placed in one area there, and they can inter- 251, HOOVER REPORTING CO, INC. 320@AassachusettsAve,,!ue.h-[. W,s.@ington, D.C. 2f!,.@,02 3 29 HD18 I digitate more-effectively- for the coverage of people being 2 serviced by that area. 3!i It sounds like a good idea; they put it on the 4 bottom of their priorities list. 5 Number 8 is a data analysis two of these have 6 been withdrawn. The last one is development and teaching 7 health data collection forms, to be done by the Department of 8 Health in Bismarck; $25,000. 9 I am very concerned, personally, about the amount 10 of time that is spent up there collecting data and analyzing it. I don't quite understand what they are doing with all 12. this data; they were talking about this back in 1967. It seems to me they should have been able to get some kind of 13 14 an operational base on what can be dote in North Dakota, with all these years of RMP activity, so someone from Staff or Doctor Scherliswill have,'to fill us in on that. 16 I would like to suspend further commentary on this at the moment. I can't decide whether or not to suggest that 18 we hold them to the targeted funds, or.to wack out the 19 $400,000 entirely, as we just did on that project. 20 IIR. CHMIBLISS: Thank you, Doctor Slater. Mr. 21 Doctor Scherlis? 22 DOCTOR SCHERLIS: I don't know if I can be'helpful 23 !(I in this. When I was in North Dakota, I guess I share the ,@4 concerns that other site visitors have had previously; this 25 HOOVER REPORTIFU CO, IK. 320 Massachusetts A@verlue. N.C. Washingle,i, D.C@ 2C@-@"!2 33 0 rlHD19 1 has been a State which, at least in my experience, has been 2 rather unresponsive to suggestions from out of state. 3 I remember as I was leaving, going to the airport,, 4 a finger was thrust at my chest and I was told that: 5 "You people from Washington just don't know 6 what we people out here really need and should do." -1 And I only resented it becaus e I wasn't from-Washington. 8 Their Executive Director makes this a 25 percent 9 effort as far as his time allotment, and there is no Deputy Director, so that is a blank. And I think.this is indicated 10 11 in a way by the type of projects that we'see, because these do not really indicate any homogenous presentation 3n terms 12 of addressing what many people who come to that state feel 13 the real health needs are. 14 When I was there the thrust was mre toward 15 Physicians' Assistants and Emergency Medical Technicians, on the bais of what has been there described as far ffi the ratio 17 of physicians to the population of the state, and it concerns 18 me that they are going at theocomputer approach rather than 19 20 through the people approach. Two of the projects have beenwithdrawn, two wh3ch 21 9-2 were given very unfavorable ratings by their local CHP agency, so this reduced their overall request by, I think $28,000. 23 DOCTOR,SLATER: Both of those were data collection, 24 again. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. WlID20 I DOCTOR SCHERLIS: Their staff is small; they have 2 a 25 percent Executive Director, an Assistant Director for 3 Administration that's another that is a full-time person,, 4 and they have two individuals in Program Evaluation,.Which is 5 a person and a third, and a full-time person in Health 'Education, who is a nurse involved in health education, so 6 7 they do suffer from lack of staff, as,a great.many of these 8 projects appear to derive from the university. 9 When we were there there were some hopes of having 10 areas outside of the larger population centers, and let's 11 face it -- North Dakota does not have many large population centers by out criteria, but these do not seem to have been 12. .13 implemented, and I think -- and are affected in the present report. 14 15 As you look at I- the individual programs, you can fault them. I think in terms of'using MIP funds for residerr-y programs at a medical school, you know, if you can't get your money anywhere else, RMP can be approached, and yet you could 18 say that in North Dakota., if &iiey can attract physicians that 19 com e to their state under any guise, this is a wholly worth- 20 while way of improving health care. 21 I am impressed with the fact that this has a little 92 different flavor than it used to have; at least they are 2.1 interested in more ways, in heal:th care delivery, and the 24 North Dakota project, at least in my experience before, was HOOVER REPORTING CO, INC. 320 Masuchus--Its A@ter!ue, H.[. 3 3 2 ician and provide 'HDQ.21 1 very much from the top and not totally phys r 2 oriented. 3 am concerned, as Doctor Slater was, abou that 4 biomedical communications system for $400,000, and also irto 5 the application of computer technology, which was ar.I-)ther 6 $36,000, and this was to have health care professionals in 7 the state as they said it: 8 ...affect an evaluation of the application 9 of computer technology in health care fields." And the way they would do this would.be to have the Physician 10 -11 apparently located in different.communities to have access 12 to the computers, in order to improve the delivery ol@ health 13 dare, and as I read this, I don-'t quite know what they say. The speak of the "seldction and implementation of 14 process for computer programs or software will require con- siderable investigation of computer systems now in,operation, and therefore considerable travel, study and collaboration 18 with other investigators throughout the United States. will be necessary." And I guess what they will be looking for are pro- 20 grams that will help physicians improve the level of health 21 care. This is how it comes out,' and I would think that, 22 Number 1, the funds that they ask for won't be helpful in 23 that regard, and Number 2, a lot of these programs are readil@ 24 accessible by getting in touch with other areas and utilizingi, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N,E. WHD22 I the mail, and I wonder how much acceptance there will be by 2 North Dakota physicians in this,.and I don't sense from this 3ii that the homework has been done. 4 If you talk about a state that asks:for three and 5 a half million dollars and you cut it down to two and a half 6 million, I don't feel very badly. 7 But when you take a state that is asking for a 8 relative pittance it is already the lowest-funded -- and then ou begin carving out big chunks, you leave it with 9 y very, very little, if anything, to move on. 10 So one rational approach that-I also should have 11 mentioned in my discussion before is inconsistency, which is 12. again, one of my chief virtues. .13 So I don't feel constrained-.to be consistent in 14 any recommendation that I make, and one thing that this Review 15 Comittee has always impressed me,with is its great ability 16 to be consistent. This has been, if anything, the most con- sistent feature about it, includ ing the directions that we 19 get on top, about what RMP means this year, at this meeti.ng and this has been true of every meeting I have ever attended, 20 and I think that I won't have to defend consistency any longer 21 in ftt regard. 22 So I would support your general comments; I guess 2:3 it is a question of coming up with a sum of money to recommend, 24 ii and perhaps you could have some discussion before we offer HOOVER REPORTIN6 CO. INC. 320 It'iassachusetts Aver,.ue. h-E. D,C. 20@-g2z' 33 4 HD23 that motion,'if that is within the purview of the reviewer. 2 MR. THOMPSON: Has there been any Staff input on 3;iii this $450,000 thing? 4 MISS RESNIK: Yes, there is one letter in response 5 to a question which I asked a Doctor -- did he need to do 6 all of this at this time? It is tied to the four AHEC's at 7 the four big cities -- Grand Forks, Minor, Bi-smark,and Fargo. 8 He suggested yes, they probably would not tie in 9 with all of the facilities as originally planned. The letter 10 which I guess I just havenl-t had a.chanc.e to duplicate, is 11 from the project Director, Doctor Christopherson,-who suggeste 12. that he could reduce the equipment by about $80,000, and man- .13 power by $24,000, leaving a total of a little over 300,000 14 for the Droject. 15 That still is Very large, and I believe what may 16 have happened is that they approached the AHEC.'s and @,they couldn't get additional funding. They are funded fo r five 17 18 years out of the old Manpower grant, and so they are just trying to do something with to'his, although ivy are 'ustifyin 19 3 9 it on the basis of the educational programs in the medical 20 schools. 21 MR. CH2U4BLISS: Doctor Miller? 22 DOCTOR MILLER: I don't think I have a vested 23 interest, so I think it is all right for me to make some com- I-)4 ments. 2.5 HOOVER REPORTING CO. INIC. 320 iiassachusetts Av@rLe, k@E. nr 11ID24 I have been a big brother to the Norti, ""@akota Pl@4P's for a long time, and we really need to understand the 2 Dakotas in the center of the country, in a program like 3 this; you know, the Dakota.Territory was a territory and 41 5 when they finally became a state, which was a long time ago,, 6 but it was one of the latter-ones, and North and South Dakota are typically pioneer American rugged, independent indivi- 7 dualists, everybody doing his own thing now in his own way,, 8 and to heck with his neighbor, and they never 'could get 9 together. 10 -11 They still can't; they are divided between North and South Dakota, as different as though they were a@ch- 12. enemies, though it has modified somewhatlately. -13 North Dakota medically of course is very small; 14 the population is 500,000, MInnesotals is one million. They 15 have 50 hospitals in Nort@ Dakota, whereas Minnesota has 286. They have 500 physicians; Minnesota has 5,000. They are arch-conservatives, rur al America, independent; they have some justifications for it, incidentally. They have 19 very small amounts of medical personnel and hospitals, by 20 population ratio, but do you know where the longest length of 21 life is in-the United States? Northern North Dakota. 22 They have the fewest number of health care faciliths 23 in the United States, by population Northern North Dakota. 24 So maybe there is something about health that is 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. @qas,)inp.ton, D.C. 20002 WHD25 1 more important than medical care. 2 Now, they are beginning to change, and the change 3@ is motivated by the very great need for them to have a com- plete medical school. Nowadays, their two year school, which 5 incidentally was a superb one -- their graduates could choose 6 almost any othEr medical school they wanted to go to in the. 7 United States and get admitted, because they were very,, very 8 well-trained two-year men. 9 But that is not an option now, and they really 10 desperately need to develop their own medical school. T ey have a big AHEC grant, and have these four units which have the potential of developing a clinical tie-in, multiple sma 12. places, with the medical school and still maintain quality 13 14 in medical education at the clinical level. Now, they need support in every way they can get it in order to carry out this rather ambitious plan. They 16 17 alsolpioneered in the training of medics, and were one of the first ones, along with Duke but a different approach, 18 i.q of trainig Physicians' Assist@nts, which has gone very well in North Dakota. 20 21 So they are moving into a coope.rative approach, -9-2 they are cooperating with each other in t.heir viciously com- petitive adjacent towns better than they have before, and I 23 would put in a plug for --- let!,s give them a little push. ,@4 DOCTOR CARPENTER: Is it really true that people in 25 HOOVER REPORTING Co, INC. 320 flassachusel@ts Aver.@le, fi.l. Washingtor@. D,". 2,,,'@'2 337 WHD26 1 North Dakota live longer, or does it just seem longer? 2 (Discussion off the record) 3 DOCTOR SCHERLIS: Anecdotally, North Dakota is the 4 only place I have ever been to where the home that we went 5 to, which is one of a series of apartments, instead 6 (Further discussion off the record) 7 We do have a number we have arrived at. MR. CHAMBLISS: All right. We would like to have the recommendation of the presenters. 9 10 DOCTOR SCHERLIS: I,would not be prepared to defend 11 it, but that is for a number of $500,000, which is midway 12 between, actually, what they have asked and what is targeted, and the rationale that we have used, which is not offered as 13 14 a means of defense, is that they now have a level of $367,OOOJ" 15 they requested $774,000, .and actually reducing that by what ,they have indicated they can, Ohich is $104,000, plus eliminat-- ing two projects.-- which is not a significant decrease it comes to a total of $100,000. 18 19 I would think at this particular time, with the medical school coming in, that within the constraints that 20 they have-duting the coming year, this would be -- I would 21 assume the values of the programs they are looking at, and 22 certainly they can come back in July for more. 23 The major reduction'i.4 what they have indicated they 24 can take. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 WHD27 1 MISS RESNIK: They are not coming back in July, 2 according to their suggestion. 3 MRS. WYCKOFF: Can they come in now, or is it too 4 late? 5 DOCTOR SCHERLIS: Well, even if they are not coming 6 back, this reduction, $104,000 -- what they have indicated 7 they can make by dropping two.projects, again this is not a 8 significant reduction but I think it reflects on some o their well, computer services that the other additional 9 reductions have made,. so this is $500,000, which is over 10 their present level of funding. DOCTOR SLATER: It effectively takes out the bio- 12. medical program. Since the $360,000 was put into microwave 13 sending and receiving equipment, it makes it possible for 14 them, though, still to spend somewhere between $20,000 and 15 $40,060 to put in four audio-visual learning packages in the AHEC centers, which could be used locally to improve teaching 17 techniques for various types of personnel. 18 By suggesting this, we have taken $224,000 out of 19 the request, so we have effectively killed off the biomedical 20 system. 21 MISS RESNIK: Yes, they still have a start, and now 22 we can go ahead, if it is agreeable.,, to suggesting limiting 23 the locations where they are going to try out this Medline" 24 microwave. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. commend? V4HD28 1 MR. CHAMBLISS: Would the Committee so re 2 Did we have a motion to-tha@ effect, or was that 31 a recommendation? May we have a motion, please? 4 DOCTOR SLATER: Motion by Doctor Scherlis, seconded 5 by me. 6 MR. CHAMBLISS: It has been moved and seconded 7 that the level of funding for North Dakota be at the level 8 of $500,000,. Is there discussion? 9 DOCTOR SLATER: I would like Mr. Thompson to refer 10 11 briefly to that questbn before we go on. MR. THOMPSON: There are 24 states that have certi- 12. ficat6 of need legislation. -13 DOCTOR SLATER: To spend $25,00.0? 14 DOCTOR VAUN: The importance of certificate of need 15 legislation in a state that,is -@ that has only two dialysis units escapes me, but what I wanted to make was the observa- -17 tion that the knife seems to be getting sharper as the day 18 wears on, and I am especially sensitive of this when we have been dealing with other Regions whose requests are in the 20 millions. 21 We have arbitrarily landed on the target figure, 22 and when we are dealing with a small state-like this, that has 23 a very small $80,000 makes a iot of difference, and in lighi-. 24 of Doctor Miller's comments, I really would like to see us 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 34 0 qfID29 1 give them at least the target figure. 2 MRS. SALAZAR: Mister Chairman, I endorse that. 3 Is discussion still in order?. 4 MR. CHAMBLISS: Certainly. 5 MRS. SALAZAR: I used to have some administrative 6 responsibility for the state of North Dakota, and of all the 7 Regions I have ever dealt with and I have dealt with quite 8 a few the state of North Dakota has a long history of being 9 very penurious in their applications. They spend money, 10 wisely and they spend it well, and they are very fiscal, 11 they are very accountable to every dime.. 12 I am looking idown the list of the RAG and I see 13 a lot of old familiar names, and.I also see some on the staff, and I also note that they are trying to recruit a 14 Deputy Director, which is one of the things that I recall is 15 an old problem, and I am wondering how much we would damage the.program if we reduce it by a relatively small.figure? 17 How attractive this would be to somebody they are trying to 18 19 recruit for leadership, which is verv much needed in this area. 20 DOCTOR SCHERLIS: We would like -to withdraw our 21 motion and sugget that it be the-@targeted figure. 92 MR. CHAMBLISS: The amount mentioned in the motion 23 is withdrawn and the target figtre is substituted, and that 24 figure is $582,217. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. W35hingtOn, D.C. 20092 341 WHD30 I DOCTOR SCHERLIS: I would also like to just note 2 for the record -- it is interesting to note, and we should 3ii have mentioned,this in what I think is a very active motion 4 on appeal -- they never ask money for overhead. Isn't this 5 true? They are the only state in the Union that refuses to 6 ask for.overhead of RMP, and maybe this is a way of refunding 7 some of that overhead. MR. CHA14BLISS: Question? Those in favor of the 8 motion? 9 (Chorus of "Aye") 10 Those opposed? 11 (No response) 12 The "Ayels" have it; the motion carries. 13 DOCTORSLATER-.. Will the Staff advice going back on 14 this indicate the concern over the priorities of communication 15 .and so on? MR. CHAMBLISS: Yes. 'PR. THOI@IPSON: And the certificate of need thing? MR. Cl-UU4BLISS: And the certificate of need thing. 19 DOCTOR SLATER: This concern is coming from people 20 who have spent time in the-rural areas. 21 MR. CHAMBLISS: Will the Staff note that? 92 I would now like to ask the Committee to make a 23 decision as to how we could proceed during the lunch hour 24 here. We have completed the review of eight regions this 25 HOOVER REPORTIN6 CO, INC@ 320 Massactiusefts Avenue, N.[. gHD31 1 morning, we have eight left; we could, if you wish, complete 2 one.more and then -- Nor.thlands, and that would free Doctor 3 Carpenter, and then after that immediately start in on Texas, 4 and that would clear Doctor Slater. 5 I stand open for.suggestions from the Committee as. 6 to how we should proceed4 7 MR. THOMPSON: Let's get going on Northlands. 8 9 10 12 13 14 15 18 19 20 21. 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washingtof), D@C 20002 ,nni@ cAL 34 3 WHD32 REGIONAL MEDICAL PROGRAM REVIEW 2 NORTHLANDS REGION MR. CIUU4BLISS: All right, let's move forward to 4 Northlands, and let the record show that Doctor Miller, the 5 former Coordinator of Northlands, has absented himself from 6 the room. 7 The reviewers here are is Doctor Carpenter. 8 Staff support will be provided by Mr. Jewell, on Northlands. 9 D,OCTOR CARPENTER: Well, this is a -- sort of the, 10 same problem. The Coordinator, as is perfectly obvious to 11 everyone here, has left, and I think he left quite a hole. 12. The Region has given u its own priorities, or if p it hasn't, at least it doesn't mention them in the applica- 13 tion. 14 15 The stfff is --,.it simply lists the Feddral words .and then says what it might do after that. 16 The staff is tiny,@ there are four eople, with three p professionals. They have in mind enlarging to five, I believe. 18 But I see no evaluation of any significance, an d again, the 19 20 pro@jects don't seem to me to have any specific goals. They are talking about area health education centers 21 but it is not clear that there is local support for these, 22 and it seems more a question of bringing in Mayo-produced 23 software to be displayed to hospi tals and staffs who undoubtedly 24 will be busy elsewhere. 25 HOOVER REPORTING CO, INC@ 320 Massachusetts Avenue, N.[. Washinkton, D.C. 20002 34 4 rHD33 1 They don't have any activity in primary care, and 2 I was pretty concerned at that point. That was my f rst 3'li time through, and I -- after I went back through it 'gal iti 4 is a triennial application; this is the third year. 5 Their mechanism, except for the staff, I giess 6 tair mechanism is intact. The RAG was inactive for i while, 7 but it seems to be back again. 8 The man who took over was the Deputy DirecLor for 9 a.number of years, and he puts together a very,mechaiical 10 application. It is beautiful, you know? All the -- every- thing is color-coded, and you can find your way through it very nicely, but I just don't find any substance there. 12 The contracts through CHP and the state agencies 13 will apparently lead to the designation of Emergency.Room 14 15 facilities by classification and a better communications system between the various agencies . providing emergency care 16 in the state, and this will be something which I believe the 18 original Coordinator started, and it is going to leave a 19 legacy that I suspect will be useful. The definition of levels of training for various 20 21 kinds of emergency personnel and performance standards.have been elaborated, and-for the continuation and development of 22 this emergency project, they are asking for $140,000 for local 2.3 plans, And $120,000 for the state coordinating mechanism. 2,4 Then there is this network of community-based health'i 25 HOOVER REPORTING CO, INCI 320 Massachusetts Avenue, N.[. nr )Annl WHD34 I education centers; they do have local councils, and at least 2 a pdrt-time staff now, in each of-the areas. 3i Continuing education was has.always been, I guess 4 of importance to them, and they have continued that. They they have a series of these AHEC'S; they have a 5 are 6 standard description on each of the projects, which is goals 7 that I think were set sometime ago, and then on some of the 8 projects, there is typed in with a different typewriter some additional ideas. 9 10 For instance, some of the they have a managemen training program, and some of the AHEC'S, but not all of them, 11 will take advantage of that. 12 One of them is going to get involved in public educa- 13 tion, but no particular information about exactly what t.hat 14 means. 15 Altogether, this program for the community based 17 health-education centers will cost about @636,000-$640,000. Then there are -- they are interested in the PSRO, 18 business, and they are not coming at it in a way which I 1!) would think -- or, I would think they probably should have 20 not started this way; they are interested in quality evalua- 21, tion, and they know that they are laying the groundwork for 22 a PSRO, but I am not surd that they are going to I am not 23 sure how you look at it. 24 They are going to set criteria, but they are going 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. W2-iiington- D-C. 20002 alto WHD35 I to develop nine pilot programs, too. And all in all, they 2 will invest $190,000 in something.called the "Poundation for 3 Health Care Evaluation," and I hope 4 MR. THOMPSON: It sounds like a PSRO to me. 5 DOCTOR CARPENTER: I hope we can have some descrip- 6 tion of what that organization is. 7 They have managed to pull together- some people who 8 don't ordinarily work together in quality care; the., got the 9 Medical Society and the hospital group together, and that 10 must have been a challenge, and then they got the Ma o Clinic to go along, too, so there has to be something good oing on 12. there. Well, we have a state they want to coordinate a -13 state hypertension control program, and that will cost 14 $133,-OOO for clinics -- for a clinic in one hospital, and 16 then $87,000 for software for public education programs. There is $120,000 to sell the idea of organ procure- 17 ment to both the public and the professionalst and a p art of 19 that program is to find out why heptatitis is a problem in 20 transplantation. There is $69,000 to start the last two CHP's that- 21 the state thinks they need. 22 Some of the projects are so vaguely described that 23 the state A agency expressed concern in regard to two of the 24 projects, involving the specificity,of the plans, and I guess, 25 HOOVER REPORTING CO, INC. 320 MassachusettsAvenue, N.[. Washingtop., D.C. 20002 WHD36 1 that I am on CHP's side. 2 Can we hear particularly from Staff about the nature 3i of that foundation for health care evaluation? 4 MR. JEWELL:. Doctor Carpenter, I questioned Mr. 5 Wilkins when he was in here, on this, and it is a fund-holding 6 company. No, not a fund-holding company; I am trying to think 7 of the words he used. 8 I really can't answer your question; I could not get 9 a satisfactory answer at the time he was in there, and I did 10 question him on this. 11 DOCTOR CARPENTER: All righti 12 The number of that project -- well, it.is hard to 13 find the projects because they are under-several categories. .MR. CHAMBLISS: Is that 107S? 14 DOCTOR CARPENTER: We can find it by the dollar .value. MR. CHAMBLISS: 107S and 107? Would that be the activity? 18 DOCTOR CARPENTER: That is, probably. 19 20 MR. JEWELL: That is the hospital association. (Discussion off the record) 21 MR. THOMPSON: They say there is $326,676 in 22 quality assurance; how did that number get arrived at by 2 tl .Staff? 24 DOCTOR CARPENTER: Well, it is hard., I'll tell you. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C, 20002 WHD37 1 I spent a long time last night trying to do that, but you 2 can add up the various projects in that area. 31 MR. THOMPSON: Well, there is 17S, which is 4 $158,000; then there is 107, which is another $73,000', so 5 evidently Staff, or whoever made up this briefing sheet,'Must 6 have combined those projects that had something to do with 7 quality assurance, to come up with the fact that 20 percent 8 of the budget is on quality assurance. 9 MR. JEWELL: That is from their.wotds, Mr. Thompson. 10 It is on the purple sheet in the front. MR. THOMPSON: I only got the yellow sheet. 11 12 DOCTOR CARPENTER: There is some blurring, too, 13 because there is a hypertension program that was well, there are several of them. One of them is a quality assurance 14 15 program in hypertension.,. So some of this quality assurance business, I think, has a little bit of pizzaz to it. There is a guy from the 17 Mayo Clinic who is working pretty hard at it, and he started 18 19 with a single disease and workwed out criteria and applied. them, and now wants to expand it to a couple of others. 20 MR. THOMPSON: Beverly Payne did that a couple of 21 years ago in Michigan. You know, and he started out with 22 more than one disease. 23 You know, it is awfulfy difficult; these guys are -)4 just rediscovering the wheel. 25 HOOVER REPORTING CO, INC. 320 t@chusetts Avenue, N.C. D.C. 20002 WHD38 I DOCTOR CARPENTER: It is awfully difficult to match 2 and'meet these. Ile is matching the relationship between 3 the ability to meet the criteria and the outcome, or trying 4 to in a hypertenson pro3ect. 5 And I think that you know, that is a significant area that requires more innovation. 6 7 Let me you want 'a funding level, or do you want to talk a while? 8 MR., THOMPSON: Go right ahead. 9 What about the kidney thing.7 Is that going to be 10 legit? DOCTOR CARPENTER: I don't think, very; no. 12. MR. THOMPSON: I'd like to pursue legitimate pro- 13 jects here; I've got 20 percent wrapped up in quality assur- 14 ance and I'm not sure that is not a PSRO basis. 15 I have $149,000 or 9 percent of the total budget wrapped up in kidney disease. Then I have the payoff to CHP, which I'll roll 18 b Y. MR. CHAMBLISS: Let me speak to the CHP issue* 20 MR. THOMPSON: I didn't include t e Cil 21. DOCTOR CARPENTER: The quality assessment, there is 22 about $190,000 going into what might be a PSRO, and if it 23 is not it is so vaguely described it would be impossible for 24 me to support it. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. w..h;..i.n n r. gnnng 350 WHD39 I The rest of that $326,000 -- you know, I think it 2 is not unreasonable to suggest something will come of that, 3i and it certainly will not be a complete PSRO; it will be, 4 you know, an opportunity to try to lead people beyond Beverly believe is terribly important. 5 Payne's criteria, which I 6 The renal project, I don't thin]-,, is very good. 7 Are you suggesting though, John, that we are not supposed to 8 fund renal projects at all? And I guess the issue then is 9 this is hot a ccrtinuation. 10 .MR.. VAN WINKLE: That is not a fact'.. The only ting we need to do is flag the kidney so 11 it can be discussed with Doctor Goodman in the end-stage 12 renal program. We have to make sure that they are in compli- 13 14 ance, and this sort of thing is not something you fund without 15 checking. DOCTOR CARPENTER: The main thing with that kidney program is that they are talking about procuring organs, and they don't tell you for what. 18 19 I assume they don't plan.to bank them indefinitely, but I don't know. 20 MR. VAN WINKLE: Could I speak to that 21, Doctor Fred Shapiro is the Director of the Renal 22 Program in Minnesota and probably one of the leading nephrol- 23 ogists in the country in terms of setting up what we con- 2,4 sider to be one of the better programs that we have seen. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 9nnn9 WHD40 I HE-does have true regionalization; he has been 2 taking care of the Dakotas, too, as well as Minnesota, and 3 those satellite units you see basically are coming out of 4 Shapiro's units. 5 DOCTOR CARPENTER: Does he do enough transplants to 6 have an impact on things? MR. VAN WINKLE: Absolutely.. 7 MR. THOMPSON: I guess my concern is the kind of 8 field you have for the project which is not'matched with at 9 least my idea of the resources that are available in the 10 state. 12 DOCTOR CARPENTER: You mean you think they could do more with what they have? .13 14 MR. THOMPSON: I amItalking about -- you know, there are some very good people in that state. 15 DOCTOR CARPENTER: Well, you know, I can't argue with you there. M. VAN WINKLE: Mr. Thompson, I don't think there 18 is any'@question that after DoGtor Miller left, most of the 19 other staff left also, and at on e time all we had was Mr. 20 Wilkins, his Deputy, and I believe one other person. Is that 21, dotrect? And one part-time individual, and I -- Mr. Wilkins '22 is excellent; I am hot questioning that whatsoever. It is 23 n just so thi' 24 MR. THOMPSON: in the old-days, we used to get some 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, B.C, 20002 TIID41 1 real flaming-projects out of there. 2 MR. VAN WINKLE: That i.s right. Their RAG and 3 their Executive Board are excellent. They are very good, 4 but they went into -- as I heard someb ody mention earlier 5 !to neutral, and they informed.us at that time that they were 6 making no moves or any decisions or moving forward in any 7 way until they got some answers from us, and we informed 8 them back-. "You may have a considerable wait," because we 9 didn't have any at that time. 10 So there was a period of time there was very little happening. 11 DOCTOR CARPENTER: Our idea now, at a $1@,250,000; 12. 13 the target is $2,170,000, the request will, by July, amount 14 to $2,500,000, and I would think we might start now at some- where around $1 600,000. DOCTOR WHITE: Can I interject a comment? According to the yellow sheet, at least, all but 18 $226,000 is for on-going activities. They only ask $226,150 for new projects. I don't knew what percentage of continua- 19 tion projects are being augmented, financially, but if You 20 cut them too drastically you may noteven allow them o con- 21 tinue what has already been started. 22 DOCTOR CARPENTER: Well, it is not too clear. 9,3 @R. THOMPSON: They mdy be supporting them, but -)4 their annualization funds now 25 HOOVER REFORTIK- CO, INC. 320 hiassachlisetis A,@erue, N.E. Vi@ington. D.C. 2CaD2 71ID42 I MR. CHAMBLISS: Did you have a comment on that, Mr. 2 Jewell? 3 MR. JEWELL: Well, Doctor White, I don't know if 4 it is unusual but it is probably unique. For-example, on EMS 5 they will set a limit of perhaps $25,000, which are funded 6 through the CHP B agencies. You don't -- it isn't grab-bag 7 here; tey set a fund and if you can comply-- they set a fund 8 for a certain amount, and if you can comply with what they set out as their goals and objectives, then that set amount. 9 10 is all you get. 11 MR. THOMPSON: I think it,is too drastic. DOCTOR CARPENTER: Do you? All right; I had $1,700,0)0 12, 13 I was anywhere, all over the map. If you were to say well, give them what -- there is no way that those three guys 14 -are going to bring home the bacon and a $1,700,000 worth of 15 pro3ects, even if some of them are now under way, I don't think. 18 But I don't know; what do you want to do? Give them @half of their new projects, and what they had before? 19 DOCTOR WHITE: Does anybody know at what percentage 20 their old projects have been inflated? 21. MR. CHAMBLISS: Do you have any idea? 22 MR. JEWELL: It is not a great amount. I am sorry, 2..l I don't have that figure, but augmentation of $10,000 would be 24 a lot. 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 HD43 DOC-TOR CARPENTER: It has to be augmented in a bunch, 2!.l doesn't it, because they went from MR. JEWELL: Well, I meant on the individual. There 4 are some of them, Doctor Carpenter, that are larger. 5 DOCTOR CARPENTER: $600,000 increase; their request 6 is $600,000 larger now than what their annualized amount is, 7 and they are reduced in staff, and they have $200,000 worth 8 of new projects, so there must be a $400,000 increase in their continuation $300,000 or $400,000.or something like 9 10 that. MR. CHAMBLISS: All right. Are-you prepared to make a new recommendation, or does your former recommendation 12. hold? 13 DOCTOR MC PHEDRAN: I have an observation to make 14 that may be beside the point; it is on a matter of detail. 15 I think that this matter of developing standards for care of common problems in different hospitals and office prac- 17 tices and so forth, that it is to me an argument of no effect 18 that somebody else has done itvin the past,.Beverly Payne or 20 anybody else. 21 I really think that people's behavior in the manage- ment of these things will never be changed until they are doing 22 it themselves on a local level. I think that it is worthwhile 23 to avoid the duplication of effor'ts in various parts of the 24 .1state. I don't think it is an inapproprite expdnditure of 25 HOOVER REPORTING CO, INC. 320 Mawchusetts Avenue, N,E. Viashingto,i. D@C. 2C-002 WI-ID44 1 money. 2 Now, I don't know whether it is within RMP guide- 31 lines; I haven't really gotten that far in thinking about it. 4 But I really think, from what I have seen since I have moved 5 to Augusta, it makes me feel that the efforts which are being 6 made the staff of this community hospital to develop 7 they are doing GCAH types of preparation for audit purposes, 8 is probably going to be of more value to us than almost any" 9 thing else you may have done, and it really did not help them 10 a lot to know that somebody else had made some recommendations in the past. I know it sounds like God and Motherhood, Duu i 12 .13 really think it is true; I don't.t@ink there is any point in 14 bringing anybody else's recommendation in except as it guides you in making your own. 15 MR. VAN WINKLE: Well,,that is certainly something that,,can be checked'out by!taff. 17 DOCTOR CARPENTER: I don't think if that is the 18 start-up project that that isea problem. It is this non- 19 20 sIpecific -- whatever it is $190,000 for the foundation for 21 health care evaluation, that we just knownothing about.. I don't think that is the problem. 22 The other half of that money is for quality assur- 23 ance, and I agree with you. I think it is the best thing 24 they are doing, and ought to be supported. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington. D.C. 20002 .5 3 t) iHD45 1 So -- would you believe $1,700,000? That is a 2 motion. 3 DOCTOR VAUN: Seconded. 4 MR.-CHAMBLISS: It is moved and seconded that the 5 level be set for Northlands at $1,700,000. 6 Is there discussion on the motion? 7 Those in favor? 8 (Chorus of "Aye") Opposed? 9 10 (No response) The motion carries. 11 The Committee has done all its work assigned for 12 the morning, and I would say we can have lunch and come back 13 and start with Texas. 14 15 (Whereupon, at'.12:45 P.M., the Committee recessed for luncheon, to 1:36 P.M.) iti 18 20 21. 22 23 24 25 HOOVER REPORTING CO, INC. 32OMassachosettsAvenue,N.E. Washington, D.C. 20002 TEXAS REGION @357 1 MR. CHN4BLISS: May I call the panel to order and 2 indicate that first, I have been-in contact wi th the, Chairman 3 of the other panel and they are moving along with sneed. 4 We are looking forward to the joint meeting of thl 5 two panels so that we can have a view of what they hiave been 6 doing and they in turn can see where we stand and we are not 7 at the moment certain as to whether this groun can meet either 8 this afternoon or tomorrow. I am more or less incli@ed to 9 -believe that it may.be in the morning. 10 I would then suggest to the revi ewers th t you 11 may begin to consider amending your plans with that @n mind. 12 I do know that doctor -- let's see, who @as to -13 leave today Or. McPhedran. DR. SLATER: I am sorry, I am irreversibly 14 15 committed to leave. MR. CHAIABLISS: Dr. Slater has already indicated previously. Will you leave today, Mr. Thompson? 18 19 MR. THOMPSON: Yes, I have an important meeting to make. 20 MR. CHA14BLISS: Dr. Vaun? 21 DR. VAUN: I have an appointment tomorrow after- 22 noon. 2.3 MR. CHAT-IBLISS: I think that willnot be a problem,,- 24 DR. SCIIERLIS: Would it'be advisable that we meet 25 HOOVER REPORTING CO, INC. setts Avenue, N.[. 320 Massachu D.C. 20002 358 1 at 8:00 o'clock instead of 8:30? 2 MR. Cli7a4BLISS: I will get that to the other parties. 4 MR. TOOMEY: What is the purpose of the other 5 meeting? 6 MR. CHAMBLISS: Since we have been split in two 7 groups to coordinate the work-of both of them, so that we can 8 have the joint recommendation covering all of the all of 9 the funding levels opposed by the two panels known to and 10 enforced by the entire review committee. 11 DR. McPHEDRADI: Is that something that you need as a pro forma matter? 12. MR. CHA-@,IBLISS: It it a pro forma thing. 13 DR. McPHEDRAN: We can't just give you a blank 14 15 check? MR. CHP24BLISS: Since Dr. Indicart has said that this should be a quality review, I think whatever semblance 18 we can maintain of making sure that all of the requirements are met for such, I would hope that as many as can stay over wo uld do so. 20 21 I would call to your attention also the fact that we have a new Reporter present. 22 Shall we then begin with a review of the appli-. 23 .cation from Texas and the reviewers 24 DR. WHITE: I hope you all will know I am excused. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. W;ithinatnn n c 2nnff2 MR. CIIAIIBLISS: Mrs. Salazar and Dr. Slater and, 21 for the record, we note that Dr..T,7hite has absented himself from the room. 4 1 - Miss Murphy, Miss Mary Murphy, one of o@ir 5 operations people will be the staff person on this r gion. 6 MRS. SALAZAR: At the outset, I must say.at the 7 time of the New Mexico deliberations were 19 minutes[, so I 8 am making a push for equal time and a little beyond that, -I hope vou will bear with me. I am eager not to be 10 discriminatory towards sexes. I thou .ght it would be helpful 11 to go into a little more detail because I found the application 12, extremely hard to understand and perhaps some of yo have -13 had the same difficulty. 14 Texas is rounding out its first year of triennium 15 status, funded at $775,832, which covers 14 project activities, a co-staff of 7 professionals,, 5 commercial. 17 This request continued funding for six on going 18 programs and five new areas of health education, health economics and systems demonstration, health manTDo@,7er, health 20 care quality, and management of major diseases, amounting to $3,239,000. 21 There is also a staff development component 22 requested in the Amount of $287,000, The.present director 2t3 e 241 has served his Icapacity since November 1973. However, he has 25 had MIP experience siiice 1970, having served as a deputy HOOVER REPORTI Co, INC. 32OMassachusetisAvenue,N.I. Washington, D.C. 20002 1 director from June 1971 until August of last year when he 2 became acting director. I 3 1 The remainder of the corps staff has wide 4 experience from 1-1/2 to 4-1/2 years. The total nuler of 5 staff was reduced from the time of phaseout from 32@to the 6 present 14. And the various disciplines are impressive. 7 But, I do have some concern about the re ion's 8 ability to'mount the very ambitious program that the. now -propose without active day to day surveillance and participation 9 10 by physicians or more immediately related profession 11 I have other misgivings about the regioni's ability 12, to deal with the broad State-wide medical programs as they propose in the application with a delegation of authority- -13 and responsibility through the project's contract conditions. 14 Especially since these issues are addressed in the proposed 16 very highly sensible position, access, utilization, organi- 17 zation, manpower and so on. The regional advisor group and the board of 18 19 trustees of the Texas IUIP, Inc., which is the grantee, appear to have excellent lines of communication. Although it is the 20 same time noted that the executive committee,met only once 21 in 1973. 22 2t3 This committee of RAG which I will hereafter refer If to as RAG has added two minority m@6-rs, one of rural and one 24 urban base. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washin&n. D,C. 20002 361 I it is interesting to note that although the 2 program committees were only reactivated in early April of 3 1 this year, meetings are already scheduled in June with only 4 three replacements out of the 70 members requiring space. I 5 think this is a test to the continuing interest in the State 6 and especially in the RAG-IUIP affairs. 7 The RAG has obviously been very participative 8 in the program development which evolved into this present 9 application. It had a sneci.al planning committee in November 10 of 1973 and it met subsequently three times; to address.internal 11 and external health influences and significant legislative 12. thrust. @@13 The RAG is also moved into the direction of 14 strengthening relationships with the health planning agencies 15 and has met with medical,.agencies as well as other Federal 16 and other related associations. several of the projects seem 17 to emanate from these sources. As a result of the joint Arkansas Council, a 19 proposed rate for high new born death rate is under the 20 Texas X,,IP for joint funding. This is I think a real break- 21 through for Texas in view of the fact that they seem to be 22 responding better to local needs and demands which cross 23 traditional State lines. With the CIIP involvement in the application, there 1)4 is some very familiar names with longstanding experience in HOOVER REPORTI Co, INC. 320 ',IassachLtsetts Avenue, M.[. n r )rlr.,I,) 1 health planning, are rather obviously alert and informed to 2 the new thrust of Texas PIIP. 3it I notice that Sister Marian Strohmever is 4 actively involved. She has been involved in the health 5 planning in the lower Rio Grande Valley, which is one of the 6 depressed and under-served medical areas of the State. 7 However, the time frame for the preparation and 8 submission of this application imposed very serious limitations in my view on community involvement and review. 9 10 And to me it at least created a vacuum in the application in order to review the CHP report. It appears planned. It is 12, so olanned that it is almost meaningless to me. There were four letters of endorsement with two @13 14 to follow and there was somelexpressed reluctance from local groups to comment on State-wide programs. They felt thev 15 didn't have a bearing, that they'were not capable of that, 17 There is also an element of inconsistency in this is vacuum. In February of this year, the second annual meeting- of health planners of 22 councils of government was sponsored 19 by the Texas IU4P. The purpose of this meeting was to solicit 20 21 assistance in information about successful projects funded by the Texas @IP since 1968. Another such meeting is Dlanned 22 for next month. 23 i I think that perhang it is time to inquire about 24 i present status and cooperative efforts in view of this, as HOOVER REPORTING CO, INC. 320 Massac,@uselas Aienue, N.[. D.C@ 20,,.,02 363 well as other pending proposals and the RAG reports. That 2 they are under consideration like the Arkansas-Texas joint 3 council. 4 As to feasibility, the contract approach to these 5 proposals seems to have some advantage of concise language 6 and subject presentation, the goals and objectives are clearli, 7 defined, easy to read. 8 However, the same economies of language do impose 9 specificity and detail. I have no criticism of contracts 10 per se as a mechanism but I have some oroblems with the 11 personal nonhuman approach to fulfilling the prov!isions of 12. the contracts. .13 There is a quality throughout here of saneness 14 of the language. 15 It is common-to all the projects and it is 16 difficult to determine the inter -phases and the -- the network, in other words, of the relationships of one project to the 18 other. 19 The.language is good and it is lofty and it is 20 worthy and it sounds like they can do it. But once again, the 21 impression that these views that vou are looking at, all of these throw a thin layer of professional systems who are 22 23 unquestionably skilled in such presentation and I have trouble 241 with the understanding of it. I have trouble with understanding the programs commitment to address themselves to these 25 HOOVER REPORTIliG CO, INC. 320 hiassachuse',Is Aven@ue, N.[. r) r' ')Arjl7 -3614 I problems. They don't come through in these little 2 descriptions of the request for contracts, That is my own 31 bias. 4 There is an intangibility about it that I find 5 is very difficult to deal with. Let me just quote one 6 little paragraph. Description of one of the programs. 7 To develop and demonstrate educational approaches 8 for barriers to health care. 9 So much of the contracts and the effectiveness 10 of the contracts, I believe depends on the language, that I 11 find it impossible to get an understanding from what I read 12 in this application of what Texas is going to do with these 13 contracts. I have some concerns about giving contracts to 14 profit organizations and who will monitor them and I will 15 spell those out later. 16 I would not at this time like to make a recommp-nda- 17 tion'until we hear from Or. Slater about that. MR. CHAJIBLISS: Thank you, Mrs. Salazar. 18 Dr. Slater? 19 DR. SLATER: I thought you were going to be going 20 for 19 minutes? 21 I would like to sav, Mrs. Salazar and I met just 22 23 briefly at lunch, is the first time-we communicated on Texas. 24 And I will simply reiterate for vou what my statement was for her. 25 HOOVER REPORTING CO, INC. 320 thssachusetts Ave,,ue, N.[. was deeply impressed with the objectives as 2 shei has quoted them of the Texas,orogram and felt that as 3 i long as looking at health education, qualitv State-wide 4 disease projects, health manpower concerns, that clearly 5 there is plenty of room to move. 6 And that one cannot fault under any circumstances, 7 this kind of -- the set of ob jectives. 8 Miat I simply cannot get a handle on, reading 9 Texas, was what was really coming out of it and I came 10 prepared to say that,I am impressed with the range of 11 activities that are going on and feel that, from what I read, 12. that they apparently do have very good review by an involve- 13 ment of the comprehensive planning group. But Istill could 14 not understand it because there is too much, there is too 15 broad a range of activity explained into few words, which I 16 believe you say lack any color whatsoever. I think that perhaps Plrs. Salazar put a figure 18 on it by saying there doesn't seem to be any medical pro- 19 fessional input into this that gives the sense of the priority within the framework of the humanity aspect of it and I am not 20 21 saying that that comes through that strongly in the other proposals but this is a little too perfect in some ways. 22 23 What I am saying is that-I am impressed with what 24 they are attempting to do and if one takes-a look at page 24, 25 the project status report, contract No. 73-1, continuing HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. Wa,4hinatnn D C- 20002 366 I education for registered nurses providing community health 2 services, is on schedule. 3 Comments: Extended 60 days for additional effort 4 Progress excellent. 5 That is fine. 6 And there is two Dages of this type, or 2-1/2 7 pages of this activity and we.simply have to accept the fact 8 that everything except the two projects is on target and doinc 9 well. 10 on- the basis of that, there is a request for 11 continued activity of, I can't get here, I would say some- 12, thing like, maybe $300,000, $400,000 extension. 13 Now, when one goes beyond that one gets into the matter of what do they plan to do in the future? 14 As Mrs. Salazar pointed out, because they are in 15 1(, a tight time frame, they have decided to follow the general guidelines of their thrust, their objectives and sent out 17 proposals for, send out requests for proposals. 18 Do you want me to go on with this? 19 20 Mrs. Salazar. Y.es. 21. DR. SLATER: And let me, if I can find my way in again, let me give some sense of what they are doing here. 22 They have an access committee of their RAG, 23 24 oriented, an access committee concerned about getting into the health program. It is asking for $286,400 for what is 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. Vi'ashinp,ton. D.C. 20002 367 called the Texas health education project. Within that 2 there are a whole series of objectives which are fine. 3 Objective 1 is develop and demonstrate a coordinated approach 4 to individual health education in a selected area. .5 Then there are Work Activity A. Apply @ose 6 guidelines developed in RMPT Contract l@o. 74-14 thr ugh a 7 coordinated approach to individual health education,lin,a 8 specific conlmunity, town, county, multi-county region. 9 $45,000 is available for that. 10 Two, determine health education requirements and -11 develop effective means of meeting those needs. 12. There are four work activity suggest-ions here -13 sent out, widely distributed throughout the State. They 14 range from.Work Activity A, analyze cultural barriers to 15 adequate health care and"%,17-velop methods for overcoming the I(; barriers through education at $48,000; Work Activity B, 17 develop an outline form that can,be used in rural poor 18 communities to assess health status and informational needs i.q at $40,000. 20 Work Activity C, study the legal barriers to healtl 21 care as perceived by the consumer and provider and recommend educational approaches to overcoming those barriers at 22 $63,400. 2.1 And, Work Activity D, demonstrate and evaluate the 24 use of upper division nursing and medical students as remote 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. I area community health educators during non-school periods 2 at $35,000. 3 Objective 3 is imorove health care and reduce 4 overall cost through education. 5 Work Activity A, analyze areas of greatest 6 consumer abuse in the health care system and suggest educational 7 programs aimed at overcoming same at $55,0004 8 All of those activities add up to something 1 ke 9 $@86,400. 10 Then, under the general rule book of the utiliza- 11 tion community, the Texas Health Economics and Systems i 12 Demonstration Project are indicated. That is a figure of ..13 $636,340, and I think I would lose you if I read over all 14 the objectives and work activities. 15 Needless to say 16 MR. THOMPSON: That is a five-year project ii conservatively speaking. I just reviewed it just for you, is Bob. 19 DR. SLATER: Than]7 you. I didn't even speak to 20 you about it. Health P4anpower Committee of the RAG is to assist, 21 ordinate and cooperate with those who wish to perpetuate, 22 CO 23 expand and improve the quality and output of health manpower 24 in Texas for $160,000., and a very laudable group of objectives laid out here. I don't think anyone is finding any u t 25 HOOt'ER REPORTING CO, INC. 320 Massachusetts Avenue' N@l. .3b9 I with this. 2 The report on current distribution and trends in 3 Texas is -- work activity, none is required at this time. 4 They were satisfied at a excuse me, that an pears to be .5 in here under what they were going to fund and I have been 6 misled. 7 But they have a series of'objectives under 8 attempting to define better health manpower. Here is a very 9 specific one. 10 Encourage the development of a responsive and 11 timely State-wide health mannower data base for use by health 12 educators, policy-makers and others. -13 tiork Activity A, a six-month s tudy for this 14 purpose, with Governor's Office of Information Services, is nearing mid-point. This,.is already under way. 15 (2) Continuing Education Committee is wanting to identif encourage and assist those health care professionals y interested in finding new and'more effective methods for 18 19 providing continuing education in the region, and thev require 20 $308 . 700 for that. MRS. WYCKOFF: Is that PSRO? 21. 22 DR. SLATER: I don't think so. 23 MR. THOMPSON: There is-a quality that is laying the base for that. 24 DR. SLATER: Can you identify that? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.I. hp lnhnq 1 MR. THOMPSON: Project No. 111. You mention PSRO 2 specifically in the nroject, but.although it doesn't make it 3 directly 4 DR. SLATER: Objective 1 is assist in the 5 development of new approaches to upgrading quality health 6 care in response to identified needs of the professional 7 community. 8 Tlork Activity A, establish a quality review task 9 group comprised of physicians and other health Professionals 10 to provide leadership and decision-making functions for the 11 project. 12 Work Activity B, select a technically qualified, 13 unbiased organization capable of providing research, analysis,, 14 evaluation and other work support to the task group. 15 The analysis evaluation, in other words. MR, THOMPSON: I was Ion the PSRO task force and I can take this and lay it out and say to the PSRO, here you 18 are, go. 19 DR. SLATER: The final one is just for $6500 20 I don't think I dropped a zero -- I did, $65,000, excuse me, regional disease management program. 21 That is oriented to the management of major 22 categorical disease awareness and treatment program in Texas. 23 And the goal is to design and test effective mechanisms for 24 25 developing and managing State-wide disease programs. HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. 'tvashington, D.C. 20002 1 Now, they have several objectives. 2 To document the methodology in Texas for a 3.1 coordinated State-wide response to major disease awareness. 4 and treatment programs. 5 Work Activity A, to evaluate the major disease 6 programs supported by MIPT since 1960, heart, cancer, stroke,, 7 hypertension, renal, to identify successful and unsuccessful 8 features. 9 Now, that is evaluating the major disease programs 10 supported by RKIP since 1960. That is a.lot of work. 11 Develop a methodology for a comprehensive, 12 coordinated State-wide approach to major disease programs. .13 That is to be sublet to somebody or maybe multiple people 14 for $65,000. There are some other objectives here. 15 Monitor the Tnajor disease proarams currently being 1(; funded through RI.IPT. objective 3, recommend to the regional advisory group concerning the efficiency of participating, or continuing 18 19 to participate, in major disease programs. 20 I am saying that I support this type of activity. 21, I think it is very necessary and we have to move increasingly to it in this country. 22 2t3 What I don't get a feel.for, either from this IF 24 brief description as,it appears here or of the more extensive write-ups that appear in the book and they are not that much 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. n p I)nnno 372 1 more extensive, they are simply almost the same thing laid 2 out on the dollar street activities, required pages required I by RMP. I can't get a feel how long it takes to do these.. T@ether there are groups in Texas to do them and what is 5 the quality of the work that is going to be done. I can't 6 seem to get a professional sense of this. 7 I am concerned that they are asking for a great 8 deal to be done in a very short period of time. 9 Now, I gather against this background that,the y 10 expect many, many proposals to come in and.in fact having 11 something in the range of 90 or 100 from which they wish to 12. choose about 25, and I am anticipating obviously that their .13 staff and RAG group are going to screen out those that are 14 technically capable of being done in one year. 15 I come back to the concerns that Mrs. Salazar i(i had, which Ibelieve should be reviewed here and that is the 17 matter of what kind of assurance do we have of the monitoring 18 that can be done by essentially nonprofessionals, non- 19 physician professional staff aond it may be that they need. 20 other kinds of professionals on activities that are essentially 21. contracts. The question I have is when one Duts contracts 22 23 out, are they all to profit-making organizations? 24 Does the contract carry any concern for the 25 conflict of interest between those who are on a profit-making HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. Ilashinaton, D.C. 20002 I basis in providing the kinds that we want in compared to the 2 usual grant system? 31 I think that I don't want to go any further 4 at this point. 5 Do you have any follow up? 6 MRS. SALAZAR: No except for this letter. 7 MR. CHIU4BLISS: Yes, let me introduce the letter. 8 There has come to the attention of Dr. Pcihl 9 what is marked as an urgent piece of correspondence rom 10 Texas. It arrived during the break and the reviewers have 11 had a chance to read it. 12, I would simply submit that the panel.ma@,'wish to -13 know of its contents. 14 DR. SLATER: Yes, I think the Texas people were 15 concerned that they had out a proposal into us in which they 16 were really asking us to take on faith the fact that they were -17 going, following the program thrust that you have described 18 and had submitted a request for proposals to be submitted to 19 them and that these proposals are now just coming in and that 20 they are planning to have their RAG staff group act finallv on t ose proposals on June 28 or something like that, which 21 22 is something more than a month After we would have funded 2.3 them to do it. 24 So that we are in fact funding them in advance of the time that they actually make a decision for the proposals. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N @l. n r, I)nnnl) 374 T,Ihat they are suggesting is.that their proposal 2, as submitted to us, be modified to the extent that they'take 3 their 25 top priority proposals and submit them to the PI.IP, 4 staff here who would review them and make a decision on 5 whether or not these satisfy, in essence, the goals of IU4P 6 and the thinking of this Committee is the staff could 7 interpret that. 8 Is that a fair display of what they say? 9 MR. POSTA: Yes, sir. 10 DR. SLATER: TheV are concerned that 11 DR. SCHERLIS: Could you translate that? 12. MR. POSTA: lqhat their picture is, that by going ..13 the contract route they would like to have as long a Deriod 14 as possible, meaning 12 months. 15 If they had to wait until July 1 to get their I(; 15's and 16's in more specificity, by the time it got through 17 all counsel, they would have a maximum 10 months to do the 18 activities vroposed and their whole concern ist on the in the past, through their 19 contracts that they had funded 20 evaluation process according to Texas representatives, the 21 ones that have been funded in the least amount of time,'have 22 not been as successful as those that were-given a full year's 23 duration. 24 MR. THOMPSOIN: Do we have any idea to whom these 25 contracts are going to be let? HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, ti.l. 375 1 MR. CIIAM13LISS: Miss @lurphy, can you comment on 2 that? 3 MISS t@IURPHY: I think in the primary and 4 secondary review, a summary of contracts funded from 1972 5 through 1974, and just reading down to the peonle that they 6 were contracted to: 7 Texas Hospital Association -- these are the past 8 ones and probably some of these same will be included in this 9 round. 10 Texas Hospital Association. 11 Texas Medical Foundation. 12 Chamber of Commerce, Tyler. Coordinating Board, Texas College and University 13 System, Austin. 14 15 Scott and Ilh,ite Memorial Hospital and Scott, 1(, 'Sherwood and Brindley Foundation-Temple. Human Resources Development Foundation-Houstoh. 17 18 Bexar County Medical Foundation-San Antonio. 19 Cameron County Board of Health-Harlingen. 20 Texas Hospital Association, Austin. 21 Texas State-Department of Health, Austin. 22 St. Paul Hospital-Dallas. Texas Medical Foundation, Austin. 2.3 The University of Texas Health Science Center at 2,4 San Antonio. 25 HOOVER REPORTING CO, INC. 320 Massnhusetts Avenue, N.[. Southwest Research Institute, San Antonio. 2 1 And I could go on. I have another page and a half. Those are the 4 types of people that they were contracted to. Theyisent them 5 to a very select group. 6 I have the sheets where they are checke off, 7 how they had selected them and according to their expertise. 8 Five hundred. 9 MR. THOMPSON: I am concerned myself, olly fairlv lo knowledgeable in the area ..of health care economics,lthat .11 this project that they have laid out here is verv well done, 12. but the problem is that work, the way 't is laid outl,-work -13 activity A has to be completed before work activity B can- 14 be begun and C. When I said.it would take five years, I was being 15 slightly facetious. It would take three years. 17 But, I don't know where they are going to find 18 the people down in the hospital association, because I now 19 the people down there who are going to be able to do this. 20 This is a fantastic -- it is a well laid out, fantastic idea. MISS MURPHY: Thev are only going to let 30 to 35 21 contracts out of this whole group. 22 23 DR. SLATER: I assume they are going to operate 11 in the future on the basis as they onerated in the past. If 24 one takes project status reports and accepts their very brief 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 377 1 indication of how they are proceeding, one says they are 2 satisfactory, I just don't have a feeling for this and all 3 we can do is assume on how they are going to operate in the 4 future as they have in the past. 5 MRS. SALAZAR: They seem to be convinced that 6 the contract mechanism is the way they are going. 7 MISS MURPHY: That is the only way they feel they 8 can go.. 9 MRS. SALAZAR: "They feel that their experience 10 with thel.contract is.very good., 11 DR.. SLATER: I will accept that.- 12 MR. VAN WINKLE: Thev have 130 letters of intent 13 out. 14 DR. CARPENTER: Did the regional advisory grouo 15 approve this? MISS MURPHY: Yes. 17 DR. SLATER: I think it is difficult to have done 18 more than this, because of the reporting that will be 19 necessary to get A graso of-the reports. Either that or 20 they might have been able to give us an appendix of their 21 status reports which would give us some indication of what was coming out of the projects that are already funded and 22 23 the implications. MISS MURPHY: This is what the form I referred 24 25 to do summary of contracts funded. Very small print. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n I, )Ann) 378 I MR. CHAP4BLISS: There have been some concerns 2 on'the part of staff expressed about the 16's and the fact 3 that they have not gone into anv detail. 4 We would certainly want the views of the committee 5 on that aspect of the application. 6 MRS. TIYCKOFF: Does this mean that they are goina-, 7 to reach out beyond the walls.of the great elite establishment 8 in Texas and try to get into the uncovered areas that really 9 been touched? 10 MR. THOMPSON: These are the same old boys. 11 These are the same old boys. 12 DR. SLATER: I would like to take exception to 13 Mr. Thompson. 14 They really are making an effort to look at the 15 mortality rate in the area. 16 MRS. I%TYCKOFF: I think the physicians are really on the job. 18 MRS. SALAZAR: It is very difficult to say, Mrs.- Wyckoff, from the reading, the kind of thing Dr. Slater has indicated, it is very difficult from the reading. 20 21, This is why I have problems with the application being completed that it will indeed begin to cover these 22 areas. 23 Mary, maybe you can tell us at the time of phase- 24 out, where did Texas go? How far down the road did it go 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.I. f 379 I back? 2 Maybe I can get some Meaning from it. 3 MISS MURPHY: They went from 35 veople and now 4 they have 7professionals, B-1/2 5 MRS. SALAZAR: I am not speaking so much of staff. 6 MISS MURPHY: They closed all of the sub-regional -i offices. No more sub-regional offices. 8 Like these RMP's were sent to El Paso, so many 9 of their old staff that the@? had, that they knew were distri- 10 buted throughout the State to try to get a good coverage 11 MR. TH014PSON: I don't think seven people can 12 monitor these. 13 MISS MURPHY: Say that you pick a good project director, why would some person have to go out and do it? 14 15 MRS. SALAZAR: How can you monitor yourself? DR. SLATER: I think'what needs to be clarified is whether or not there is functionally any difference between 18 a contract and the traditional form of grant mechanism that the @IP follows in the sense of professional quality and 19 20 monitoring and judgments that are made. 21@ I think if the committee can satisfy itself, that 2-? contracting is just as good functionally.. MR. VAN WINKLE: Dr. Miller has had some ex 23 perienci@ with that methodology. 24 MR. THOMPSON: Before you go, because you are goin(i 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washiqgton, D.C. 20002 380 I to have a lot more to say about this than I, when we had a 2 project we,had a man, an identifiable person who we sometimes 3 were disaopointed but we knew his background, we knew wnat he 4 was good at and bad at and we could judge the contract, I 5 mean the project. The contract, we don't have the man. 6 DR. MILLER: It depends on how you do iti. it 7 depends on how vou do it and my experience with it was 8 essentially halfway between what you traditionally think of 9 -as a contract and what we traditionally think of as nrojoct. 10 And by that mechanism, wh ,y you know not nly the 11 man but you know the institution, you know what you want 12 them to do and you have a lot better control oIver it@than .13 you have over a project. All the way around. 14 MR. THOMPSON: it takes a good monitoring system 15 to get that. 16 DR. MILLER: It takes a good system, yes. Bat 17 it is not an open-bidded contract kind of a thing. You don't 18 just publish it and give it to the lowest bidder without regard, 19 to who it is. You can do 20 DR. SLATER: They are not going to do that here. 21 They are obviously going to look for quality projects or iiork and then contracts. 22 So would you agree to that in terms of what I 23 24 understand the system here to be, they are simply using the 25 contract method to finance? HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washingtt,p., D.C. 20002 I DR. MILLER: It hasn't any positive attributes. 2 I am thoroughly sold on the contract approach to project. 3 It really puts vou in the driver's seat with regard to 4 management. 5 MRS. SALAZAR: Tqhy did Texas elect to go this 6 route? 7 MR. CHAMBLISS: That had to do with the change of 8 organizational structure. 9 Will you clear that up, Mike? -.10 MR. POSTA: I guess it was December of '72. ur3 11 to that time the Texas system was the grantee agency which 12, was composed of 17 educational institutions. Then they broke 13 away and formed a name and a board of directors and of course 14 by that time we had gotten word that February '73, that we were going out of business'. 15 So the regional advisory group got together and said., if we are thinking about feasibility, short-term pav- offs, we had better think in terms of a period of a vear. 18 19 Their whole administrative mechanism was to build a device 20 whereby they could call the shots, set up the instructions for the contracts, choose the reople and pay them for the job 21 done and they, quoting verbally, "have felt that they have 22 done a better job especially in short runs." 23 24 They probably would not agree -if they had a three- 25 year funding period. But I think their whole premise is based HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C, 20002 @82 on that approach. 2 DR. CARPENTER: Did they use the contra t I mechanism to get the grants written? 4 MRS. WYCKOFF: You mean the IUIP? 5 MR. THOMPSON: I think I know who wrote some of 6 these grants. I think that is a facetious question. 7 DR. SLATER: Well, I think again, given the 8 material that we have in front of us coming from a p g am 9 that has been site visited and has been a r)art.,of the 10 endeavor here for years and for which many peonle have Dersonal @ll knowledge of the individuals, one has to give the benefit of 12, the doubt. -13 I think there is another major question that 14 comes UT) and that is whether or not we feel it is appropriate or some of the monies for the new 15 to consider allocating all,,. iii projects which have been requested prior to the time that 17 those projects have been-chosen. They have requested that 18 they do this with the proviso that we, appropriate the staff 19 here, the responsibility of reviewing those 25, and 20 representing us and the advisory council, that it is appropriate 21 for them to proceed to carrv out. 22 MR. VAN WINKLE: I believe I am corrects Larry, they cannot sDend any money until you have 15's or 16's, is 23 24 that correct? 25 DR. CARPENTER: 1,7hatlis the 15 and 16? HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. (3) 1 MR. VAN WINKLE: The budget forms. 2 DR. SLATER: They won't be able to start until 3 July 10. As soon as you clear the air and the money will be 4 in the bag. .5 Otherwise, they won't get through until the 6 Advisory Council meets in August, which is too short and 7 will 8 MR. THOMPSON: Are they talking about this or 9 the next one.coming down the pike? MISS MURPHY: They are sending nothing else in. 10 11 Otherwise the contract will have to be approved and met in 12 July. 13 DR. SLATER: To get something done. MR. THOMPSON: Ile are examining this one right 14 now; is that righ4@--> -15 1(; DR. SLATER: @at is-right. We don't know what the 25 projects are going to be. 17 All we know, are the guidelines being used by 18 applicants who already submitted 130 proposals?' 19 MR. THOMPSON: If they can do it, why can't every- 20 body else do it and we don't meet in July? 21@ DR. SLATER: Well, I think 22 DR. MILLER: Isn't this a slush fund> That is 2t3 what we turned down yesterday. 24 MR. CHA-MBLISS: Ile need -the judgment of the 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 384 1 reviewers here. 2 I would say there is.a fundamental issue here and 3 that is, I think Dr. Pahl would be very much concerned here 4 and so will the Council, and that is the local decision-makinc 5 process has not had a chance to work its will on what you 6 are being asked to make a recommendation on today. 7 MRS. IIYCKOFF: It is a blanket request. 8 MR. CHAMBLISS: I would I wanted to, wanted 9 the discussion to go forward as it has, so that.we would 10 thread out of here some advice for counsel and for Dr. 11 Pahl. MISS MURPHY: Could I ask something? 12, MR. CHAJIBLISS: Yes. .13 14 MISS MURPHY: Each one of these proposals as they are being worked out before they are submitted to the 15 16 RMP, are to be brought to the attention of the CHP. A comment is going to be made prior to coming to the RM P. 18 MRS. TQYCKOFF: Did they make the comments on the- 19 P14P that went out? Or on what companies? MISS MURPHY: They have companies on all of this. 20 21 DR. SLATER: I think if the usual history of all 22 the other Dro3ects were being followed Iby.this one, we would 23 have 25 more clearly identified, ve@ briefly described .projects which we would look at"and we would say, yes, that 24 is what they are going to do next vo-ar and they only requested 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. W.,4@iiinortnn D C- 20002 385 1 7 percent of-the funds that are targeted for them and it 2 sounds good because they have been producing in the past and 3! so let us go ahead with it. 4 I think that is what we are likely to say as we 5 pick holes in the taraets. 6 MR. THOIIPSON: He would have some evidence that 7 Clip 8 MISS MURPHY: You will have it. They will have 9 reviewed them before thev get to the RMP.. 10 The proposal is, you know, that is the direction. 11 MR. THOMPSON: Ilhat is to stop it even if they 12. get an unfavorable review? 13 DR.,SLATER: I think what they have done is wire us.and put us on the record and said that the 25 projects 14 that they send up here would only come on the basis that 15 16 they went through the usual vrocess and then they put this staff in the position -- put us in the nosition of defending 17 18 on the staff to legally or to put their names on, agreeing that these are apnronriate. 20 MR. THO,@IPSON: This is going to come up in South 21 Carolina. The same kinds of business, although not so blatant. 22 I just have a vague feeling that I am getting 23. 24 had. DR. SCHERLIS: The question is, for how much. HOOVER REFORTitiG CO, INC. 320 tilassachusl-tts Avenue, N.C. D.C. 20002 _)OO 1 DR. CARPENTER: There are certain things which-I 2 will not nut. 3 DR. IIILLER: You have been getting had all day. 4 MR. CHA-P4BLISS: I would assume those comments are 5 off the record? 6 DR. SCIIERLIS: No, sir, I would like those to be 7 on the record. 8 MR. CHMIBLISS: All right. 9 DR. SLATER: -I.think it clearly breaks a 10 precedent, the past, as well as good operations, to approve 11 this kind of thing without some committee review inputs. 12. Mrs. Salazarts question is whether or no,@ it wouldi .13 be sensible in this case to have a site visit by some of.the 14 review committee and the staff to take a look at the situation 15 herein view of the -- in view of the problem. 16 MR. CH70,IBLISS: I would recognize Dr. Scherlis fi rst. 18 DR. SCHERLIS: You are obviously looking for 19 some way out. Perhaps we could give a tentative approval, giving their approval by July 1. 20 21 I for one, although I know that a great deal of' 22 what we are doing at this session is really looking at inadequately submitted proposals and making what in time may 23 24 be inadequate decisions, I stilf think we should go through the opportunity that I think vie must have and that is exercise'! 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. ',Vashin@or,, D.C. 20002 ing our right of approval or disapproval and not telling the 2 region you can do what you want'on any basis that you choose 3 to and I for one am not that overly that any region, 4 including Texas, once it receives this sent of money will 5 decide that it is going to do anything more, is minimally 6 necessary to have the project operate. 7 Novi, my faith may-be less than others because ovex 8 the years that I have been had, including site distances and 9 I would suggest that we have tentative approval but only. 10 contingent that we have approval in July to review the .11 contracts. I offer that as a con tract. ,12 DR. MILLER: This contract is a bit of semantics 13 as a sort of semantics. It is trying to get approval for 14 slush fund projects without approving the project. By callina 15 them contracts. 16 So I support what you do, that we not fund it ii now but give them the opportunity to come in with their 18 proposals in July for how many ever contracts, projects, 19 whatever they wish to call them, as long as they are submitted 20 in the usual way. 21. DR. SLATER: I don't understand what has happened 22 here. I thought you said you would find it provisional upon 23 the receiDt? DR. SCIIERLIS: I offered potential ways of trying 24 to meet this. 25 HOOVER REPORTING CO, INC. 320 Massachusptts Avenue@ N.I@ W2qhinatnt, n c 2non2 1 1 think we need more suggestion on this. I most 2 strongly do not support the concept of giving them funds at 311 this tire for what they have asked for and I am trving to 4 seek a way out. 5 Any suggestion as a way out 6 DR. SLATER: The question at this point is whether 7 we will guarantee some sum of money up to what they requested 8 that will be held in escrow here until our requirements are 9 satisfied, which is their submission of whatever the proposal 10 they want as a result of these request,s.that have gone out 11 and the ratification of those proposals by the staff and now 12. we are adding to that, either a site visit or some members 13 of this committee to get these proposals and talk on the 14 conference, call or come to Washington and do so. 15 Such things that keep our process intact. If we I(; do that by July 10, we will avoid another whole review cycle 17 which they want to avoid in order to be able to do the. viork. 18 I-IR. THOMPSON: One of the beautiful things about- 19 a contract, you can specify time. Therefore if it is 10. 20 months or 12 months, they let the contracts. Tlhat is the 21 difference? 22 DR. SLATER: Because the only way we can do it 23 is to bring it back for the next review cycle and it will be .1 - later part of August, and it will add two months. 24 25 MRS. IIYCKOFF: They add it to the other end? HOOVER REPORTING Co, INC. 320 ?,',assachosetis Avenue, N.[. 389 1 MISS IIIURPIIY: No, they can't. 2 MR. THOMPSON: They change the contract and 3!1 MR. CHMIBLISS: Ile have known for some time th@t this application presented something of a dilemma. I have 5 just talked with Dr. Pahl on the point. 6 Dr. Pahl, would you care to make an expression as 7 it relates to -- the contract activities coming in about the 20th of June after this committee 9 MISS MURPHY: No, the 28th. The RAG are going i 10 to meet and approve them and he said they would be in here 11 by the 10th complete. The 30th of July. 12. MR. CH704BLISS: Of July, that is worse. 13 DRi PAHL: I really feel -- I don't need the 14 microphone --.I really feel that we prefer a definite decision 15 not based on staff canabil ity early July for the following 16 reasons: 17 Normally I think we would be happy to accommodate that kind of recommendation but we are laboring under some 18 19 difficulties internally, namely as soon as legislation is' 20 passed and none of us know when that is going to be, the 21 department is then going to make its decision as to just how many of our staff are going to be departing on the decentrali- 22 23'; zation basis and I am not sure who is going to be here in July to do the work, very frankly. 24 I think that it is rather clear issue in the HOOVER REPORTIliG CO, INC. .390 I sense that Texas has had and does have as much of a 1 ifetime 2 as any other RD.IP. It happens to be a free-standing organi- 31 zation, it is not the only one that we have. 4 I think that they have chosen to go a certain 5 route and that is their choice, but the other RMP's have been 6 under the same time limitations and are under the same time 7 limitations and I would suggest that you not treat them 8 speciallthan from the other RMP'S. 9 if you can find it appropriate to arrive at a @io decision on the. basis of the information provided, which 11 leaves you comfortable, we will take that recommendation to 12 Council. 't 13 But I do not prefer to have i come back to 14 Committee the staff, because I really don't know our 15 capability to manage thityesponsibility and it would be really a disservice. The other thing is: I am and you should know 18 this, working with the Office of the Administrator to try to- get an agency policy statement developed which will be sent 20 to grantees pointing out what the FederallresDonsibilitv is 21. for monitoring activities which go beyond the lifetime of 22 PJ@IP's, just trying to look to this eventuality and Dr. Margolis is very sympathetic. 23 Vyp- have drafted a statement and if this were to 24@ occur, for example, then some of the time pressure would be 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 391 off of free-standing organizations. You have to realize that the Government always has programs terminating and continuing activities within those programs. 4 All I am trying to do is to formalize a Federal 5 responsibility at an agency level which would assure Texas 6 and its affiliates, as well as all other grantees, that shoul@l 7 another monitoring device beyond the Rt4P be necessary, perhap,@ it could be this agency or the regional offices that could 9 assume that responsibility.' 10 If that were the case, then the fact that an.' 11 activity got started later, that would not be so detrimental. 12 Because that is the thrust of Dr. Ferguson's point of view. 13 In essence, I don't believe that we can accept 14 those kinds of workloads projected into the future with what 15 I know to be our own situation. I feel Texas has a right to choose its method of handling its funds and grant appli- cation. 18 I do not believe that it is in any other positiot 19 than any other IU.IP or will be treated differently. 20 To that extent then, we leave you to your own 21 considerations. But perhaps it does give you some guidelines. MR. CHAKIBLISS: Thank you. 2 Dr. Vaun? 2t3 DR. VAUN: I think we are playing semantics here. 24 It is unfortunate that Texas picked the word 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[ - n r, )nof)g 392 I ficontracts. I think we awarded slush funds in the last day 2 and a half and I don't see any reason why, because hey- 3 selected the word "contracts," that we should treat them any 4 differently. 5 lie talked about slush funds up to $800,0'00 un to 6 OiL this point, with very ill definition of what was g g to 7 happen to that money, besides it was being tucked aivFLy or 8 future legislative proposals. 9 DR. SLATER: May I make a motion to get 5omethincr 10 on the floor and that is that we, I find it possiblelto make 11 any decision on how to cut back on what they suggested, so 12, I make the motion that we fund them to the amount that they 13 requested and that 14 MR. THO!.IPSON: After all this, you are going to 15 do that? 16 DR. MILLER: Go ahead. 17 DR. SLATER: 'Subject to the contingency that the 18 proposals that they submit are reviewed by a technical 19 by the staff and bv a technical site visit. 20 1 think the point'is, I don't think that we can. 21, bypass this committee if the committee will have to give the 22 responsibility to some members of the committee and staff to go to Texas and it is just one dpLy, to get a grasp on this, 23 24 to see if we are fulfilling our Federal mandates. t I don't see this as a slush fund for Texas projects',. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. I think that the technique used has just been delayed bring- 2 ing projects to look at. 31 MR. VAN WINKLE: Who would the site visitors 4 report back'to, doctor? This group or Council or t 5 DR. SLATER: Back to this group who will be 6 sitting here in July. 7 MR. CHA.IIIBLISS: Ithink Dr. Pahl has, if I may 8 make the point, has stated that we are uncertain as,to the 9 -status of our staffing after the first of July:and w,e have 10 no indication as to what our ttaff availabilities will be 11 to help decide this question. 12 DR. SLATER: You have another round.of you -13 have another review cycle to handle. 14 MISS MURPHY- July and August. 15 MR. VAN WINKLE: Another group has laid on us -1(i that visit here, right? @17 DR. PAHL: I think there is a different question 18 than what I heard coming up before. 19 Ile do have a July meeting of this committee, an 20 early August Council meeting.. If what you are doing is recommending approval 21 22 subject to your reconsideration in July and then notification 23 of the region and if the Council would buy that, they would thereby in reality have a mid-July approval from you for the 24 full amount. 25 HOOVER REPORTING CO, INC. 320 ?Aassachusetts Avenue, N.E. Vl;i@hingtf)n D C- 20002 I DR. SLATER: Ile met here on July 18, which is one 2 week after they are going to submit it. 3 DR. PAHL: That gives them three weeks. 4 I understood you to say that staff to do-it July 5 20. You may recommend approval with -- contingent upon it 6 coming back and confirming it at the July meeting but basical:.y 7 that does not give the money to Texas. and they can't go ahead 8 and spend it until July 20 or thereabouts which is three 9 weeks different than if they take more time to describe it 10 in their July 1 application. 11 I don't know whether that is.a good thing or 12. not. 13 DR. SLATER: Is it technically possible for this 14 to be approved by the Council and not have to go back to the Advisory Coun cil? Could they aive this-review committee final right 16 17 of approval? 18 MR. THOMPSON: If we make that recommendation. 19 DR. PAliL: We would take that recommendation to the Council. If thev accept it, then we could implement it. 20 21 DR. CARPENTER: It seems to me that we can. accomplish the same thing in a much more standard wav. I sunDose that if we are right, that these people do have the 23 o-,)Portunity to develop a good selection of projects, an we 24, want to get them started on that, we can approve an amount it 25,1 HOOVER REPORTING CO. INC. 320 Massachusetts Averue. @i.E. Vias,@i:@ngtcr,. D,C, 2C,,@-12 3 9 1 of money now. 2 For instance, we v7ould want to support their 3 corps staff right away. We could support something around 4 $1 million which would set them well past July and if they 5 have the confidence that their program is reasonable, they 6 can assume that when we have a complete description in July 7 we will approve such addition al funds as will be necessary 8 to carry out the program. -have is a region that is now. 9 I think what we operating $348,000 worth of projects, a very small number of 10 11 projects. 12 They are saying that within a year they can 13 productively spend nearly $1.5 million on new projects. I think that I will require additional convincing. 14 So, I think that you get.-them started and they have nlentv 15 .of money to go on, until we have a chance to see their detail- ed nroposal. 18 MR. THOMPSON: May I ask a question, because I am confused at this noint. This dann telegram that keens zipping in, we 20 should have taken it up this morning. 21 role are talking about 25 additional projects, is 22 that correct? 23 e DR. SLATER: No. 24 MR. TIIOMPSON: You are talking about these? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[ - 396 1 DR. SLATER: They requested the program staff 2 money and then they have also requested in this package, 3 money to continue and complete that which is alread under 4 way. Something like $348,000 there and then they sid we 5 need about $1.5 million for new studies but we have It got 6 the projects yet. Vie have the areas and we put out to bid 7 but we don't have the project yet because we haven't had 8 enough time to get them in. 9 We would like you to give us the right to spend 10 up to $1.5 million which is what the.budget boils do to, 11 to support these contracts when we, when our RAG haslreceived 12. them and decided what are the high priority ones and bv -13 some mechanism this review committee likewise approve them. 14 We ate simply being asked to approve in advance ,what they are behind in.,, I don't see it as a slush fund 15 .16 because it has to be reviewed by their RAG and reviewed by us in some way. 18 MR. THOMPSON: Let us just take this crazy, damned economics of the whole delivery system. $656,000 DR. SLATER: Those are guidelines for proposals. 20 Those are not the projects. you haven't seen a Project 21 22 description there. You have seen guidelines for proposal. 23 MR. THOMPSON: O.K. Then I understand I buy .Dr. Pahl's proposal that we request Council to permit us at 24 our next meeting to review some of these contracts. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 397 0. K. DR. SLATER: 2 DR. CARPENTER: They'haven't even chosen sites 3 for these projects. 4 You look at the site selection sheet, they are 5 blank. 6 DR. SLATER: Because they have come in. The 7 whole reason to come in now instead of the next route is 8 based on their argument that they have one year left like 9 everybody else in the,program and they haven't asked this question about any other rojects6 10 p 11 They said, we really need a whole area if we are 12. going to contract and try to do what we are doing. So, we 13 would like to give you a new advance. MR. VAN WINKLE: Dr. Pahl indicated that three 14 15 months from now or four months from now, contracts for a full 12-month period. It is just that the end product will be monitored 17 18 by somebody else. They can let a contract. 19 DR. SLATER: They can do it up to the.last minute as far as the monies are soent. 20 21 MR. THOI.IPSON: Why can't we separate the thing 22 out? Give them a certain amount of money, writing RMP's 2.31 and then request counsel to permit this Committee to review i 11 the hard proposal at the next meeting and approve or disapprove 24 them without going through Council. 25 HO@IER REPORTING CO, INC. 320 Massacht;set@,s Aveniie, N.[. 398 1 DR. SLATER: That sounds like a good idea. 2 I just had a question strike me like a bolt'of 3 lightning. 4 This is the first time it has happened. ilho is 5 going to monitor any of these things? 6 All of this work that we are farming out, Dr. 7 Pahl, who is going to be look ing at the reports that are 8 doming in? 9 DR. PAHL: That-is what I was alluding to. 10 MR. THOMPSON: We brought this up yesterday, about 11 what is the 12. DR. PAHL: In practical terms, it may not be as 13 bad as it always appears to be. 14 For example, the chronic disease control program 15 disappeared, but I remember RMP for about 3-1/2 years matching contracts as a result of the Federal commitments. The whole 17 kidney activity that we, have been doing, is the fold-over 18 and so forth of that activity. I sat with Dr. Margolis about -- well, a week or more aao and again pointed out to him that it would seem nice 20 21 if we could get this agency kind of policy statement which 22 could be sent to all grantees and we now have drafted one at 23 his request which will be looked at.every carefully and I 24 am not sure what will eventually happen to it. 25 But it would be nice if we could tell grantees HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Vlashinzton. D.C. 20002 399 1 that we recognize the program and that there are continuing 2 operations and that the Federal Government, hopefully this 3 agency or regional offices, will monitor and that we won't. 4 all have to get out contracts again. I can't make the commit- 5 ment. lqe are trying. That is no4@- a problem., It will 6 happen. DR. SLATER: We can pass this over to the next 8 review-cycle. 9 There is only one problem. When they are overatirq 10 by contracts, they withhold a certain percentage, I think 11 20 percent of the funds until the contract is completed and 12 then they make the final payment. If they start late on. 13 a one-year contract, then we are past the fiscal year ending 14 and they will have to pay out the funds for the remainder of 15 the contracts before the,-contract is completed and thereby lose whatever leverage they have on the contract. 17 MR. THOMPSON: Miv don't we just hold the thing? 18 Why don't we just buy MRS. IIYCKOFF: Put it in escrow. I would like to hear from Mrs. 20 DR. SLATER: 21 Salazar, Mr. Chairman. 22 MRS. SALAZAR: I don't feel that that is a real 23 factor in that the Texas INIP has a board of trustees, so I 'assume that will have some fiscal responsibility to hold 24 these people accountable; am I correct in that? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n r innng 40o MR. POSTA: Yes, but at the present time they 2 plan to terminate it. 3 DR. PAHL: You are in the never, never land of' 4 grants, Federal legislation, and there is no one in this .5 room who can honestly state what will happen next June 30 6 and there are a lot of people concerned and working and nobod'@r 7 in this agency can tell you and I really say'that-in all 8 seriousness, because we lived with this whole activity, this 9 is the same set of discussions we had internally last year 10 when the program was going to end, Jerry Gardell,.Larry 11 Parker and others have been concerned about it a year ago 12 and we are in the same position this year and somehow R-MP's .13 are here and as a Federal manager, I am trying my best to 14 smooth the way to get a transition but I can't get a commit- 15 ment. I would say, make your decision on the merits ii of the case and don't worry about the tail end payments of 18 contracts. Somehow it will work out. Do what you think is appropriate for spending 20 the money effectively in Texas on the basis of the information 21, you have. And you have to arrive at that decision. But we will worry about the continuation. 22 JR(4)fls 23 24 25 Hoov@8 REPORTING CO, INC. 320 Massachusetts Avenue, N.[. MP nnl)nq c) ers/mi 4ol ape 4 1 DR. @fILLER: I submit, in antagonism, I guess, 2 against the motion, that it isn't g'oin- to make that much 3 difference with these activities, whether they start he 20th 4 of July or when does the council meet after? 5 DR. PAHL: 9th of Auaust. Awards would go cut 6 effective September 1. 7 DR. l@aLLER: It isn't going to mat-,e that much 8 difference, and Ifail to see a reason why we should make a 9 special procedure for Texas. Even though, I kno@@ they are 10 accustomed to such treatment. -11 DR. SCHERLIS: What was the motion you made @n hour 12.ago? 13 MR. ClWfBLISS: Was that a motion? DR. CARPENTER: A motion with a second on the floor. 14 15 DRi SLATER: I will withdraw my motion. 1(; MR. CHAMBLISS: The motion is withdrawn and the chair ,Will entertain a new motion. 18 DR. CARPENTER: What I was suggesting is that what 19' I move, is that we fund Texas whatever the sLu-a of $319 and program existing. plus the continuation project, $348,000, plus 20 another $350,000 to give them wiggle room. 21 22 So that is $700 -- $1,100,000. NRS. 1,TEIKOFF: I second the motion. 23 11 MR. CHAMBLISS: It has been moved and seconded that 24 Texas be funded for this round at the level of $1,100 000. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avertue, N.[. 402 Are you ready? 2 Is there discussion? 3.1 @S. SALIZAR: Yes, does your motion, Dr. Carpenter 4 include the rest or your first condition? 5 DR. CARPENTER: No condition, and I ho pe th y will 6 be back in July 7 DR. SLATER: We have another cycle to consicer. 8 MRS. WEIKOFF: Let them come back in July. 9 MR. CHAMBLISS: -With the prov3-sion that the) will 10 come back in July with a clearer application. 11 DR. CARPENTER: No provision, but just recommend that 12. they tell us all the good opportunities that they have@ in the .13 July meeting. 14 DR. @aLLER: I will second the motion. 15 MR. CHAI-.IBLISS: It has been moved and seconded. @16 Is there further discussions DR. MILLER: Could I ask the question from the staff's 18 viewpoint, the fact that they said they were not going to come- back in July does not mean they can't now change and come back in July. 20 MR. CHA@-IBLISS: They still can come in July, ye-s. 21 MR. TOO@FEY: Question. 22 MR. CHAIFBLISS: All those in favor? 23 (Chorus of ayes.) 24 25 MR. CHA@IBLISS: Those oppos6d? HOOVER REPORTING CO, INC. 320 Massactiusetts Avenue, N@E. 'V,IashinEtoti. D.C. 20002 (No -response.) 2 MR. CHAMBLISS: There is.no opposition and the 3 motion is passed. 4 DR. SLATER: The next round, all we are going; to do 5 is take a look at the 25 projects if they do it.' We, in 6 essence, covered the basic text of this Texas program. MR. CHAMBLISS: Let us take a short recess. 8 (Recess) 9 10 12 13 14 15 17 18 19 20 21 2-@ 23 24 25 HOOVER REPORTING CO, INC. 320 Mamchusetts Avenue, N;E. Washington, D.C. 20002 4o4 OHIO VALLEY MR. CHAMBLISS: Shall ge resume? 2 our next region for review is Ohio Valley. 31 'Vaun The presenters for Ohio Valley will be Dr. 4 and Mr. Thompson, backed u by Mrs. Parks from the staff. p 5 There are, in this region, a couple of nuances, 6 having to do with the two regions formerly in Ohio that are 7 no longer in existence. There'have been some special arrange- 8 ments made permitting activities from,ohio to be incorporate 9 into the Ohio Valley application. 10 I wonder,, before the reviewers make their presentation 11 if you would just like to highlight those issues, so that it 12 may be before the Committee as a whole. 13 MR. VAN WINI 1, 25 if HOOVER REPORTit4G CO, INC. 320 Mass3chu@'@ts Avenje, N.E. 414 1 DR. VAUN: I think this is what John was trying-to 2 raise in his point. 3 Now, they have been four years in the process and 4 they are asking $200,000 again. So. the likelihood is that 5 much of this is going to remain under-funded at the end of 6 this year. 7 DR. SCHERLIS: The other two items that trouble me, 8ambulatory care, aga3-n, a developmental component of $150,000, 9and developmental for one of their sohmets or for at least the five additional sohmets. Their suborganizational response for health manpower care and training, I think they have the .12.very interesting, very long and very,,varied list of proposals. But my concern even more here than elsewhere is what 13 14 happens when that year ends? They will have built up needs, people and no vestige of opportunities, I think, for a great 16 many of these to be supported, particularly, home care. 17 We have all been involved in the home care projects for a limited period of timL-. @,hen they die, they die. There- 18 is nothing to fix them up and they were going down the road with 19 $500,000. 20 MR. THO@IPSON: Except management of the projects 21 that we picked up in the past. 22 DR. WHITE: I am still 6ot sure about this fourth one. 23 chere is some money that would be earmarked for them. 24 MRS. PARKS: For what? 25 415 MR. CILAI%IBLISS: For Ohio-. 2 MRS. PARKS: Toledo, Ohio. The funds requested in i27(d). 4 DR. WHITE: That is the developmental complex. @as. PARKS: Yes, it is to provide funds for the 6 development of sohniets in certain defined georgraphic areas. 7 They included in here some potential sitesthat they 8 Ian to start them. The Toledo-Lima-Dayton ones would also 'oe p 9 included', but they do not have the application from that 10 particular group of people, as yet. 11 DR. WHITE:, This $150,000 is again an escrow account? 12.' MR. CHAMBLISS: It is for future project activities. 13 DR. VAUN: But., it would appear on the basis of some 14 commitments by -- that 3'.s,not totally an escrow. They were led 15 to believe that they would have some access to the Ohio Valley program. 17 I am.asking it again. Suppose it is awarded at the 18 level you recommended instead of what they asked? Isn't there 19 :)Ption to say to these other people, sorry, we didn't get all 20 )e asked for, therefore, you are out of luck? 21 NR. CHAMBLISS: We would have to give them specific 22 Lnstructions on that and we would await your judgment on this 2t3 )oint. 24 DR. MILLER: iqr. Chairman, there are three projects I m asking the reviewers, there are three projects that are liste@d 25 416 developmental awards. 2 Are these projects is'this another way of havinc, 3 $500,000 of a developmental fund which they can use as they i choose7 4 5 one of them is home care developmental awards, 6 $200,000. one of them is sohriiet, $150,000, and one is 7 ambulatory care and developmental components, $150,00(. 8 $500,000 of developmental funds. Is this all open? DR. VAUN: It is not open and that is how I arrived 9 at some of my reduction. 10 DR. @FILLER: You are saying, essentially that those are things that we disapprove of in engaging in? 12. DR. VAUN: That $200,000 care thing, as John pointed 13 Out, this is the fourth year. Now, how developmental can you 14 be? 15 MR. CHAI--fBLISS: Is their specific recommendation on 17 that particular part of the application from the committee? MR. THOMPSON: I don't think we can tell them that we were concerned about, but if they want to give that, that is their prerogative. We need instructions to the region. 20 I think we can say that we were concerned about the 21 odd coincidence of equal requirements for the same kinds of 22 desperate towns, and the second thing we ought to tell them,, 23 e we just really don't know how developmental the -fourth year 24 25 agreement can be. But that is up to them. HOOVER REPORTING CO, INC. O,)n N r 417 1 MR. CHAMBLISS: Thank you. We will note your 2'concerns and we will entertain a motion. @.3 DR. VAUN: I move that the request of the Ohio 4 Regional Program be reduced by $514,900, to a figure of 5 $2,305,636, with instructions to the region that the specific 6 project that involves development components -- is that 7 27.(b), Jean? MRS. PARKS: Yes. Is that the sohmet activity 9 yes. 10 DR. VAUN: May not be less than $100,000, may not be 11 less than $100,000. 12 MR. CHAMBLIC-S: Is there a second to the motion? DR. MILLER: Second. 13 14 MR. CHANBLISS: It is moved and seconded that the level be for the Ohio Valley, $2',3'05,63'0, with the additional 15 provisions cited by Dr. Vaun, applying to the region. DR. l@IHITE: This 27('D), I understand, has not been through a review process. 18 DR. VAUN: No, it has not because this region phasing 20 out of one regional medical program has been given access to this regional medical program,, and I guess they just didn't have 21 22 time to do it. MRS. PARKS: No, that i6 not -- the process of handlin 23 1 24 Developments of activities as been approved y t e regional 25 dvisory group. they do have some areas identified that they 418 intend to fund. The Toledo-Li-ina situation., now, that has'not 2 been approved by the RAG, simply because they do not have the 3 1 -,!application yet. But, the process of providing funds to 1 4 certain areas, provided they meet the guidelines', has been 5 approved. 6 DR. WHITE: My point is, therefore, we cannot say 7 no less than $100,000, unless we appended that, and'they 8 approve it as being a project they would otherwise undertake. 9 The regional advisory group has to have the preroga- 10 tive of approving thi§. 11 MRS. PARKS: Yes. 12. DR. VAUN: That is why I indicated no less than 13 $100$000. 14 DR. WHITE: If they say it is no good, we don't want 15 to do it 16 DR. VAUN: How are you going to protect this region 17 Which is out in the cold right now, having been told they 18 haven't access to this prooram?" 19 DR. VAUN: And they would not be penalized because 20 they e;ere doin- this out of the goodness of their heart and 0 21 they also handled two arthritis proposals, and they agreed to onitor, evaluate and carr on all grantee activities for those 22 y rticular projects. 23 MR. CIIAMBLISS: As add-on's. 24 DR. VAUN: There is a way to obviate the criticism. 25 1 419 That is to guarantee the.$100,000. 2 I think if they do not award up to $100,000 to this 3 iproject, their request will be further reduced by $100-,000. 4 DR. WHITE: This $100,000 can be used for that or 5 nothing. 6 1,RS. PARKS: I am sorry, let me get this clear. 7 In other words, the money that you are approving for 8 27(b) can only be used for the Toledo-Liriia pr.ojects, if it. 9 comes in and is approved? 10 DR. VAUN: Right. 11 IIRS. PARKS: They cannot use it to start up 12. activities in some other sites? DR. VAUN: No. 13 14 MR. VAN WINKLE: Would you award them 2205, whatever 15 it is,, and in the ottier.,mat-,@e-an Additional award if it comes throuc,h? 16 17 DR. VAUN: If you tell me that i@ the best way to say it, that way, and I will s@, it that way tell me what 18 19 the rules are, and I will subscribe. 20 Now, I think you know what I am trying to say. DR. CARPENTER: I guess if I understood, he said let 21 us award them $100,000 less in July than if they come in with 22 this sohraet up north, and we xiill,give them another. 23 24 DR. VAUN: Is that what you are saying? 251 @IR. VAN WINKLE: Your concern seems to be over this -420 sohmet, $100,000, whatever' it is.' 2 Let us say, in the award, that the 22 is for Ohio 3 lValley and the X amount is for the other. 4 MR. CHAMBLISS: Making a total of @2,305,000, just 5 as you have proposed. 6 DR. VAUN: I will revise my motion to accommodate 7 that statement. 8 DR. SLATER: I wonder if Dr. Vaun would revise his 9 position since he is within $10,000 of the target figure, and 10 in view of all the criticism, why are we giving them more t an 11 100% of their target figure? 12. DR. VAUN: Because I think I have arrived at my 13 figure in a far more rational way than they arrived at their's. 14 I have no way of knowing how they arrived at their target :15 figures. DR. MILLER: Which is the correct target figure? We have two. -ieet is the 18 MR. CHA@E3LISS: The one on the long st 19 laid-up one and the more correct one. 20 DR. MILLER: 35291 -- which is 45,000? 21 MR. VAN WINI@LE: I would like to point out that the target figure is for Ohio Valley. 22 DR. MILLER: Their developmental project includes 2,-l 24 @;hat they are going to give to Ohio Valley. So it is all in 25 Lhere. 421 MR. VAN WINKLE: I am only sayin@ 2 MR. C@,"IBLISS: Your point is well taL,,en,, but the imotion as presented by Dr Vaun includes not only Ohi Valley, 4 but the additional $100,000 to take care of Project 2 ti is 5 correct? 6 MS. PARKS: Yes. LNIR-. CHA@IBLISS: Now, question from Dr. Sche..lis. 8 DR. SCHERLIS: As I recall we had a great .eal of 9 fun@. and games in all of our previous review committees 10 designating the various quadrants, or portals, in which we 11 place various regional medical programs. 12, Could you refresh my memory and tell me where Ohio i3 Valley was? 14 MR. CHAMBLISS: If I recall correctly, Ohio Valley Al 15 was in the upper quadant. MR. VAN WINI@E: You know, this particular project 17 you are speaking of is $150,000. 18 MR. CHA@E3LISS: We understand that. It has been 19 reduced to $100,000. That is the point that he is mat HOOVER REPORTING CO, INC. 320 MassachusettsAvenue, N.[. n r I)nrlnl) programs, that, as I total it, come to something lit-e $500,000 2 for the total number of -five or six which they have requested 3 and perhaps to give you a flavor of what these would tike to do@ 4 -together I can read from one of them', and many of them are put 5 ust exactly the same way. 6 This concerns one of.their medical product 4ervice 7 groups which is under regional'h6alth development pro Iram. 8 This was-created for the purpose of achieving the following 9 lon--range goals: 10 Promote area-wide participation of hospitalr., other 11 health care providers and consumers,, in exemplary programs for 12. effective cost containment. -13 Improve the availability, accessibility and quality 14 Of health services throughout the area through a more sophisti- 15 cated health care system in concert with State and area-wide 16 health plannino, efforts. Attract and better utilize health manpower in rural 18 communities. 19 Promote expansion of shared services voluntary 20 hospital organization concept. 21 They are the -eneral ones. 4D 22 Cost containment services will be pursued through the 2.3 following activities: group-purchasing to initially include 24 drugs, I-V's and selected hospital supplies; shared services 25 to include microfilming and printing; shared personnel, HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washinvton, D.C. 20002 428 1 commencing with dietary and medical record consultants. 2 They put them into each one of these area A S.1 3 !whole wide range of programs which, if effective, would 4 obviously accomplish a great deal. They point to a complement 5 to their pharmaceutical, drug costs, 50%, I-V equipme t by 6 40%,an'd so on. In each one of these areas where they have 7 planned or existing systems, they point out that they,liave 8 been able to-reduce costs, or will reduce costs. 9 They have stated specifically in their gene al 10 description that they are provider-oriented and certa nly this -ii has been one of their main thrusts, has been in that .1 i rea. 12,Other p.rojects include program staff which is $3,,7,OOJ,, EIIS raining, $100 000 -- so they are asking for a total of 13 t 14 approximately $1,380,000. This exceeds their estimated 140% $1,000,000, by a total of $350,000. 15 tarcre t They have, as I ointed out successfully developed some remote coronary p .1 rograms. Their emphasis is obviously now on their regional 17 p health development area pro-rams, which, if these work, can be- 18 lIq very effective. 20 Much of the effort appears to be in really reducing costs by mutual purchases, the hospitals, and the others, as 21 19.:) II have indicated, appear to be essentially.continuation 6f the 23 projects. 2,4 I will Iwithhold any motion until there is further 25 Discussion, and we have had staff comments on that. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 429 I MR. CHAMBLISS: All right, thank you. 2 Mr. Toomey? 311 - MR. TOOiklEY: I think it is interesting that the thrus@ 4 of the Oklahoma program has moved from their early,cooperative 5 programs in the clinical field and evolved as coopera ive 6 efforts in the management and the hospital operation. 7 I suppose the three major -- three or four 'f the .8 major efforts in the hospital field today have to do itil 9 shared services, mergers, contract management and tliic kind io ofoperation. The people in.the hospital business look -- they 11 look at this kind of evolution as being something really 32, tremendously desirable because it takes many of the problems .13 and many of the isolation factors related to small hospitals 14 operating as autonomous individual institutions that are 15 essentially uneconomic,because with small hospitals having 16 to purchase things that they purchase and hire the kinds of eople that they hire, in a small hospital and expensive -- p 18 for example, a dietician-, or social worker in a small hospital- 19 may not have enough outlet for her capabilities or her capa- bilities in that one institution alone. Whereas the sharin- of 20 21 people, the sharing of resources, whether they be financial 22 resources or personnel resources or equipment resources, has 2.3 to be, as far as I am concerned, it has to be the move of the e future in order to create some kind of an institutional health 24 ,are system. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Now, I really only differ with them in the use of 2 some words. For instance, to call-it a health delivery system, 3. I think it is probably wrong. I do agree, certainly, that it ii 4 an institutional kind of melting of services and sharin of 5 services. 6 I look upon it really as a thrust in two are s. One 7 is economics and the other is the enhancement of the ma powe 8 or the professional personnel who are basically in short 9 supply and,certainly if they can be shared it is desir3ble. 10 Soi I can't help but be very much in favor o this 11 kind of move in terms of the services, it enhances the services 12.rendered to the people; it enhances the problems, the ost of 13 containments. It has a very strong economic thrust in terms of 14 value to the community and value to the institutions and value 15 to the patients who use these institutions. 16 I think that it is an extremely desirable kind of 17 thing and I think that it is certainly interesting, that it 18 springs from the initial sharing going on in the heart disease, 19 2ancer and stroke and they moved over into the institutional 20 -ields, and I suppose part of the reason, I don't know whether 21 !)onnell, however, you pronounce it, is a physician, if you call lim a doctor 22 MR. VAN WINKLE: Hb is a hospital administrator. 23 24 YR. TOOIEY: Well, I remember that he was Donnell,iNI.H.@., 25 HOOVER REPORTING CO, INC4 32OMassachusettsAvenueiN.E. 'N.i@hinvtnn DC-20002 1 which is a Master's degree in hospital administration, so I 2 think it is, perhaps,,just as logical for this guy as a 3 Ihospital administrator to move his Me in that direction as it 4 is for a physician RMP directed to move his RAG in the 5 direction of clinical services. 6 In either way, I think there are values to be gotten, 7 and Oklahoma, as a rural State, as far as I am concerned, with 8 this kind of thing, is a very large degree, I would say, at the 9 present time, you could look-upon them as almost a model.@ io What could be done from the institutional point of view with 11 other institutions. 12. So. the only other question that --.the only 13 question, really, that I had was the -- it is a small staff, but if you put it on a percentagewise basis, it is about a 70% 14 15 increase in the staff that they are asking, This is one place, Mrs. Resnick, where I think we havc 16 17 to lean on you to find out if that increase in staff, with the fact that their programs are under way, and they are just 18 expanding them, rather than building in a lot of new ones, 20 whether that is justified. 21 MISS RESNICK: I think they need some strengthening of staff. But I felt at first it was a little too much at this 22 time. 23 24 The regional healt development programs are wel alon- as far as the models are concer.ned because Enid and 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. I Bartlesville have been successful. Enid and Bartlesville 21 were initiated just as a pilot last spring ,@ith '74 monies an 3 they do want to expand and probably will follow the 4 Bartlesville approach. They are getting very good reactions 5 from the communities. 6 You are right, they feel this is an excellent 7 mechanism for the rural area outreach and that is what it 8 will prove. 9 As for this new staff, I can't speak to it exactly- 10 I haven't been in the area and talked to 14r. Donnell. I think 11 he needs some strengthening, but I am not-sure that he needs 12@ that many people. Seven new positions are proposed. Four @13 professionals and three clerical,.administrative and that sort of thing. 14 @IR. THO@IPSON: Have you had any more definite 15 16 relationships with CHP? When you'get these programs, then CHP usually starts screaming. @SS RESNICK: There are four funded eastern area 18 CHP "b" regions which were extixmely laudatory of the program. 20 One of the projects, if you will notice, is to assist in western Oklahoma. Actually, it is two programs in 21 1 iwestern Oklahoma will eventually go on their own, but right now -2 Ilit is a very weak area and they have had arocky history with 23! ,Ithe CIIP acency and even the "a" a,4ency. @4 lir, Donnel.4:I think,i@as with the "a" agency and he is 25 HOOVER REPORTING CO, INC. 320 llassachusettsAve,-,.e, ti,c, 433 well aware and sensitive to this development in connection with 2 the CIIP "b. 3.i He feels that it is helping to strengthen t@e 4 relationship. 5 Now if that answers the question 6 DR. SCHERLIS: I have tried not to put too Much 7 a qualitative feeling when I presented it. I come away quite 8 001 to this- c 9 Ithink a good many of these projects shoul( have 10 been done by the Oklahoma Hospital Association withou having 11 any semblance of involvement whatsoever, of any consLu =.L groups or other regional cooperative ventures'. .13 I did.nbt know that he was a hospital administrator. 14 If I had, perhaps I would have so identified him in the 15 presentation and it would,,have been covered fully by that. 16 I say it only because I'don't think this reflects 17 a regional cooperative venture. I think it reflects the swing away from what they used to have. 18 When they formerly were 19 heavily oriented towards education., who was it, Dr. Dale Dromes, 20 and I was very concerned because it was totally professional education and we spoke then rather prosaical ly of this or that 21 22 medical program, having turned the corner,.and Oklahoma seemed at that time never to find 'the correct corner or a correct 23 corner to turn. 24 25 Now,, they have turned and are still heavily provider HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n p 9nan9 oriented out now it is a different group which is providing 2 that, and that is the hospital-based need and they are spinning 311off cooperations which are looking at what I think are very I 4 important aspects of mutual purchase of equipment, sharin- of 5 facilities, and I see that the thrust that they .point to 6 under proposals, are one thing.. When they get progre s, they 7 can point to the facts that they are now reducing the,cost of 8 I-V equipment and now have joint niicrofilriiing,and so on, but 9 these are the progress notes. 10 Under their whole area health programs, muc broader ii thrusts are envisioned. But, I think they are doing 3-rsc 12. things first. Everyone does his own thin&i and I think he is 13 doing his own thing very effectively. 14 I would like you to react to that. 15 MR. TOOIIEY: I react two ways. One is, you could conceivably say either the medical'societies or the various 17 medical schools, and all of the States have been involved in the contribution or dissemination of medical information to the 18 I!) outlying rural areas before RMP came in with its medical thrust. 20 You say the hospital association should have done it. 21 Well, the hospital association is a collection of individual institutions just as the ust as the medical society is a 22 23 Collection of individual physicians, @nd I think that each one aas its own thing to protect. 2.4 .1 think that they are trade'associations, either way, 25 HOOVER REPORTING CO, INC. 320 Massactiusetts Avenue, N.[. Wa@iiinvtnp,. D-C. 20002 435 and to sa that in the profession of institution management y 2 the hospital association should inflict its desires for areat 3'ldevelopment of an' integrated health delivery system utilizing 4 all physicians is any different from saying that the hospital 5 association should indicate all hospitals, so th .at yo@ have 6 hospital systems. 7 You can argue one way and I think it is jus as 8 inappropriate, really, for me to say about that, abou the 9 medical association, just as it is for you to say it bout the 10 hospital.association. I think it is a major breakthrough in insti utional 12.management, which is for the benefit of large numberslof -13 individuals. Granted it really is to the benefi,t economically 14 and in terins,of quality of care. It provides these things 15 that were not provided befo@.. It is in a different context of clinical -- but it 17 Joes provide an excellentllan increase in enhancement of the -aliber of care within those institutions, and I think that, I 18 -hint,, you are going to be interested in what medicine does ,@jhat nursin- and dieticians and x-ray technicians and what the 20 21 other people do. Because each has a bearing. 22 So, I think that, we are both talking from different 23 points of view, but from my point 11 of'view, this is great. DR. SCHERLIS: I don't mean this to be a debate. it 24 25 is obvious we didn't get together,at lunch. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 1 IIR. CHA14BLISS: A brief comment by i@liss Resnick. 2 14ISS RESNICK: The origin-of these area development 3corporations was a manpower development device to begin with. 4- It is not emphasized quite as much in this presentation as it 5was the last time and that is still a component of their 6operation. It is not just sharing costs and containments. It 7is manpower seminars, workshops, development of -- they will 8have a conference that is being spread out throughout these 9hospitals so it is a little ziore than meets the eye. 10 I don't think it is exclusively a hospital management .11 MR. VAN WINKLE: You would n't believe the community 12 involvement in this program. Never saw such enthusiasm. 13 @IRS. WEIKOFF: This is just a piece of the whole 14 thing. 15 MR. CHAI@IBLISS: .I wonder if the representatives I(; are ready to make a motion? DR. SCHERLIS: Recognizing that hospitals are 18 important,, I would move that we fund them to the level of their 19 target, which is $1,033,000. This reduces what they asked by 20 $150,000, which I do without conecience,really. IIR. CHA@IBLISS: If you will look at your spread 21 sheets, you will see the more current target figure@is 22 $1,062,337. Would that be covered in your recommendations 23 24 DR. SCliERLIS: I would'move -- ye s. 25 @IR. CHAIIBLISS: Is there a'second? HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 437. TOO@Y: I will second it, and then just as an 2 aside, tell you that you gave $62,000 more than I was going,to 3 a s 4 I-a. CHAMBLISS: All right, it has been moved and 5 seconded. 6 Is there further discussion?. 7 Dr. White? 8 DR. IMITE: Is there some concern on the yellow page 9 about the duplication? E14S activities? 10 DR. SCHERLIS: We have oeen assured this is not a 11 factor. 12. @SS REC-KICK: It is just a continuation of what 13 they have been doing. Very little additional money, training, 14 and, apparently, it is acceptable. 15 1-fR. CHAYIBLISS: Call the -question. 16 NRS. IIEII@OFF: Question. 17 @IR. CHAT@IBLISS: Those in favor of the motion? 18 (Chorus of ayes.) 1.9 @a. CHA@IBLISS: Those opposed? 20 (No response.) @IR. CliA@fBLISS: The ayes have it. 21 I would simply wish, if I may indulge in the preroga- 22 23 t,ives of the chair, riake the observation that not only is the coordinator of Oklahoma an administrator, I understand that @4 25 his RAG chairman is a hospital administrator, one of your HOOVER REPORTING CO- INC. i I - I 438. reviewers, lir. Toomey, is a hospital administrator. 2 Your staff assistant is-a hospital administrator and 3 @lso is your chairman. 4 And, I would say it is about time that hospital 5 administrators became more involved. We have sou-ht to get 6 their participation over the years, and it now comes at a 7 rather late date. 8 DR. SCHERLIS: Nothing succeeds like success. 9 DR. CARPENTER: Could I ask one questions, 10 I.s l@. @ysor involved in the regional program in 11 Oklahor,-ia? You didn't see the name in the application? 12 @fR. TOOiNiEY: No, I didn't notice.. 13 @a. CHAMBLISS: I would like to note one thing for 14 the record if I may, that at this late date in our review 15 process, that all of the reeiewers,are still in the room. 16 I would like the record to show that. And,, it shows 17 certainl the commitme nt that our viewers have had to this y 18 process. 19 lqe do, indeed, appreciate the support that you are 20 oLvinc, us in this review, and I will say that I hate to spoil 21 what I have said. Off the record. 22 (Discussion off the record.) 23 IIR. CHAIIBLISS: Now, ige,are back on the record. 24 Our last region -- our next.region for review is Iouth Carolina. After South Carolina,, we will have only one 25 HOOVER REPORTifiG CO. I,C. 439 1 additional region to come before this panel 2 DR. MILLER: You have tw o. 3 MR. C@IBLISS: Thank you for correcting me, we 4 have two after this. 5 6 7 8 9 10 12 13 14 15 17 18 19 20 21@ 22 23 24 25 HOOVER REPORTING CO, INC. ----- I.. -I- fd r- 440 SOUTII CAROLINA REGION 2 @IR. CHAZIBLISS: Let the record show that Mr Toomey 3i has left the room for this review. 4 The reviewers here are Mr. Thompson and Dr. Vaun, 5 supported by Mrs. Kyttle, who represents the staff. 6 @IR-. THO'i%IPSON: South Carolina contains many of 7 the problems that we have been discussion here today, suchlas 8 slush funds. 9 Previous approval of contracts have not been 10 completed and so let me just start out with a positive point. 11 There is on page '@8 of the application, a thing entitled achronology to boggle the mind. That reviews the 13 history of the poor South Carolina project from 1972 back up 14 to 1974, and it is true, it was a -chronology to boggle the mind 15 The program wasin the first year, I think, its triennium review program wLien the axe fell. Its RAG has maintained itself, although I have many problems with the RAG. 18 I went throu-h it and I find out that the RAG, there 19 is a total of 5F, people, 24 of whom are physicians, ten of 20 whom are educators, four of whom are nurses, four of whom are 21 hospital administrators, ten of whom are other professionals. 22 One dentist and there are four ci@ilians on their RAG. 23 Now, whom they represent. Eight represent $--he State 24leducational system, seven the voluntary health a(-encies, three 25 n -en - -e 4 %I n f-.o 1.4 T) I CZ i I I 1, t- i-44 4Ltl 1 official health agencies, four of them pu,.)lic State agencies, 2 two in health planning. 31 Om afte Down on the bott r you go through, seven from 4 hospitals and medical centers and, finally, six public 5 representatives which makes one kind of wonder what kind of 6 direction this program has gone -i.nto. 7 The proposals, then, are very clear and logically 8 presented. I will try to sLm up what this is, 9 The objectives are in six Roman numberals. The regionalization of service,' health manpower development improvement, strengthening of quality assurance 12. efforts, special categorical interests, primary health care @13 and advanced resources planning. 14 These reflect both inputs from the national and 15 some 3-nputs from the local,6i2ene. Each operational project is hool@ed directly, or indirectly, to one of these Roman 17 numerals of overall priority areas. 18 However, do not be mis.l-,ed@ by the logic of this .9 19 presentation. BecauIse when one looks at the budget proposal 20 which, by the way, this is now funded at $1,250,000, their taraet is $2444. Their request for this is $3,000,000 even 21 22 and they have put us on notice that they are going to come slidin- in with another $500,000 which is a pretty big growth 23 Ifor aprogram that has been operating at a rate of $1250. ,@4 14hen one examines their request, one finds that 25 HOOVER REPORTING CO, INC. 442 Roman numerals, six Roman numerals, and the staff accounts for 2 67% of the total requests. 3i Now, in their defense, they have indicated several 4 future projects that are in the pipeline of eacti-one o@- the 5 Roman numerals, and they are not. They did not like Texas 6 sayinc,, "Give us some money and we will put some of th@se thin-s 7 into effect." 8 on the other hand, they have asked an inordinate 9 amount of money for the support of these Roman nwneral3, which 10 are not connected at this time to specific programs. 11 When one looks at the specific pro@rams eve thouch CD .1 0 12 they only require -- only consist of 33% of the to tal budget, 13 they are' consistent with the main goals and they are consistent 14 4ith wLiat little I know of health problems in South Carolina. 15 In other words, tt-iere is-a nurse wifery project 1(; Cor example. There is a great deal of attention to quality 17 --ontrol. 18 As you probably know, prenatal quality is a real 11) )roblem in South Carolina and the prenatal death rate is very 20 high, and they have paid attention to it. 21 I have some problems that some of the other qua lity 22 control or mec3-cal evaluation systems. They are institutionally 2..3 based. Those hospitals that have'i)een doing their job should 24 iave paid attention to Quality Control lon(, before this word 25 HOOVER REPORTING CO, INC. 443 became stylish to PSRO or to any other kind of way. But, I 2 can't argue with this specific project. 3il Now, as far as the CHP relationships, something very 4 interesting has happened. Evidentally, the CHP agency and 5 the IU.IP agency got together and said "What are we going to 6 do with this unknown legislation that might be cominy sliding 7 down the p i'Lre . 8 So they decided to get too-ether to talk about an' 9 advanced health resource planning group. They are supposed 10 to have the "b" agency, the a agency and IU4P and $164,000 11 was allocated to this advanced health resources group. 12 cr 11, Evidentally, they were going alon. when one D 13 ac,ency, I.think it was the "b" a-ency of Charleston, zipped 14 in on this proposal. Since it seems peculiar that one agency 15 would scream, and the other didn't scream, I tried to find out from the staff if there was a funded MO down there. That somehc@q that "b" agency was the fault of the DRMP, because Dr. Margolis 18 signed that grant and although they were no longe r with RMP, 19 it might have helped.. We are very much in a problem then 20 that they are requesting to approve what is roughly $1,092,000, 21 in these six Roman numerals, which really represent a lot of 22 specific projects that have not been advanced. 23 Now I understand they have told the staff that if we 24 ive them this money, they will not come back in the next round. 25 In other'wordsl they would take the money that we rv;oul unnvCI?Rrpn;?TlNrr.n INr 444 give, for example, to quality assurance, and give it away-to 2 some of the projects that they have in the pipeline of quality 3 assurance., 4 I am very reluctant to do this, althou@h I can see 5 the rationale of it b ecause I think we would, in essence be 6 giving them one liell of a 'oicy slush fund. 7 It isn't that I don't trust them, but we haven't had .8 anybody else recently tried that big a structure. Let me close 9 then. 10 It is a well-written project. Probably the best 11 written project I have ever seen from South Carolina. The 12. priorities are carefully spelled out. The projects do relate 13 to priorities. They are making a real attempt to get together 14 with CHP and solve this. The health authority problem. 15 But I can't see c,,iving' them all this money for proi-ec:s i(i that are still unapproved. 17 1 will close. 18 MR. CHAIIBLISS: Thank you, Ilr. Thompson. Dr. Va-un?: 20 DR. VAUN: I don't think there is much doubt that the 21 leadership program has come through on this.very well. I'think 22 John has identified the makeup of RAG, I am not sure that it e lias made any difference in the thrust of the 2t3 program, at least 24 Lis I surveyed the projects. They don't meet too often, 'but ,Ipparentiy, they s- i 25 eem co -et the job done. The staff, in my 1145 I opinion, looks c,,ood, and I think-it couches the realization 2 with CHP, in ,eneral terms. It is difficult, at this point, 3 Ito forecast whether the divergence are good, whether they 4 are checks and balances or forceps that may prove to be 5 counterproductive. -That may say a lot of it may not say 6 too much. 7 .1 must admit that I was more confortablo with this 8 proposal.before Texas -- and I mean that very sincerely. 9 I think I could have been very comfortable coming up with 10 some kind of recommendation before I saw what we-did specifical y 11 with regard to'bxas, and'that is even more so here because two- 12, third of the request is in this never-never land of advanced 13 health resources plannin,-. $164,000. Primarily, health care C7 14 to be defined in contracts, that is 194. The other was 164. 15 Special categorical inter6's@, $404,000, etcetera. I think John has identified this. There is no need for me to belabor it at this point. I think perhaps 18 l@s. Kyttle could help us. NR. CHAMBLISS: kliss Kyttle, would you proceed? 20 MISS l@-YTTLE: Going back to RAG, RAG has evolved 21 and is still evolving into what it is now. It was a 72-mem'ber 22 Dody with '0'3 physicians on it, not too long ago, and they 2t3 listened to get that RAG in a better balance, and as memberships 24 wrote it, the balance is coming, it is not there yet, but it 25 is comin-. HOOVER REPORTING CO, INC. Ro,,,, e r s /ni 446 Buty South Carolina is -and has been for some time 2 'divided into ten very precise medical districts. They are 3.1 planning districts. They are economic districts, and they are 4well-settled'districts for many matters.in the States. 5 When re.gional:medical programs Degan., it had a very 6toucyh time gettin- off in South Carolina, until it assur ed each 7 district that a physician from each district would sit on 8what they thouaht would then be the governing body, but which c; 9 turned out tc, 'L)e,,the recional advisory group and they have notn,oved away from that promise. So. whatever evolves from the RAG, you are go3na, to 12 have ten representatives, one each from its medical district. 1 13 They call them civilians down there,, too. 14 THOIIPSON: I knout,, I took it richt off your 15 checklist. end tape 6 -ontine on tape 7 18 19 20 21. 22 2,3 24 25 HOOVER REPORTING CO. INC, JR-7 MISS KYTTLE: The actual submission, that is not 1 dm 2 quite right in that they have not promised us that they will not come in. But we put the regions on a bit of a spot. 4 Before they heard words from this revie cycle, Wi 5 we asked them to look what the next cycle would lik@ and 6 South Carolina dodged and said, depending on what comes out 7 of this cycle, we will do this.or this or this. 8 We had their proposal and it sort of boaaled our 9 minds and we hit the middle, the $500,000 is a.-middl 10 contingency and for the purposes of producing this right, but 11 not correct list here,-we hit $5,000 out of all of e 12. contingencies that South Carolina proposed right back to us, 13 14 If they get full funding they do not Dlan to come 15 in. If they don't get fiiIA.funding, and it is this or this 16 or this and that is the kind of contingency this July 1 is. With respect-to the kinds of institutions that 17 18 they are dealing with, South Carolina had, about two years 19 ago when its hospitals got into accreditation and certifica- 20 tion trouble and that has fostered some of.this activity in 21 some of the categories that you mentioned. CHP, --le comments 22 on the velloiq sheet do not relate only to CIIP. In South Carolina there'are at least five forces 23 241 that have been-active in their own rights and very active in watching everyone else. It is AiDpala,chia, well-funded and 25 HOOVER REPORTING CO, INC. 448 dm 2 1 strongly provincial. CIIP, both A and B, external and internal 2 problems. INIP, the State Health Denartment in whic the 3 A" is se eded and the Governor has created a Health e are 4 and Environment Council which is beginning to move S ate 5 money around from ever,%,,one into everyone else and in o the 6 Governor's Office. 7 And South Carolina is politically, healt,,Iwlse, 8 in quite a turmoil right now. 9 I don't know whether it is that.they are farther along in some States and they are getting to the range like 10 11 that other States wIill get to or whether it is the a@proach, 12 I just don't know and that is why I say I don't know whether 13 they will be good checks and balances or counter productive. 14 There.is a lame duck Governor. 15 This Council that he,has created has made two 16 attempts, neither Of which was successful, to get legislative life. It is just a dotted line out of the Governor's office 17 18 and everyone wonders when the Governor goes, will the Council- go. It is a political arena right now healthwise in So uth 20 Carolina, to have pulled as much constituency together as 21 South Carolina did, is remarkable. MR. VAN WINKLE: Doesn't Westmoreland sit on that 22 Council? 23 MISS KYTTLE: No, not on the Council, he is runnino 24 for Governor. 25 449 1 MR. THOMPSON: My official recommendation was dm3 2 that $2.2 million which is just under $1 million more than 3 they havenow, but is some $800,000 less than thev requested 4 and most of that money, I would suggest could be turned into 5 the second review when some of these programs in the general 6 areas were more specific. I-am not making this as almotion. 7 I am just saving this is what I came out with. 8 I would not be adverse to recommending the 9 $2.4 million but I don't think that we can'give them in all 10 due respect, all this money, these slush funds that they are 11 requesting. 12. MR. CHIU-IBLISS: All right. .13 MISS KYTTLE: I alerted you that the pages of 14 the application do show the people with whom they will be doing business with, the sites with whom the will be doing 15 v 16 business with and the money that will be involved. Unlike Texas, these have been received, identified, 17 18 negotiated, some of the budgets have already been negotiated. down. 19 20 There have been preliminary studies bv CHP. CHP promises and that is Part of the hang uD there, their staff 21 has to get through things,that require the time, some even 22 2I3 said we won't even need 30 days'-- some of the submitters are B's and they can get by late June their internal process 24 finished on these specific ap _plications. They could have 25 dm 4 put a 15 in for everyone of them. They could have @ut a 16 2 in for everyone of them but they.are not through their final 3i review process and South Carolina is very precise about their 4 review process with respect to their regional advisory 5 group. 6 They would not put the 15 in this application be- 7 cause it hadn't gone through the second round through RAG. 8 It has.been through the first. 9 MR. THOMPSON: My problem is if it ain' in the book, I can't grab it. MR. CHA,'14BLISS: Are there further points of 12, discussion? 13 Dr. Miller? (8) 14 DR. MILLER: Dr. McPhedran and I, after yester- 15 day's discussion and much discussion about slush funds, discussed about whether we should put a motion in that would establish the principle of the review committee not to approve 18 anv slush fund components of applications and we discussed it a little bit and decided maybe it wasn't going to come up 20 and maybe there wasn't much point in putting up a motion that wasn't going to come up again and I just commented to him, I 21. guess it has been inappropriate. It would have been a good 22 idea to have the motion put in, because it seems to keep 23 coming back, doesn't it? 24 ,)5 MR. THO@,IPSON: In their-defense, everybody is HOOVER REPORTING CO, tNC. 320 Massachusetts Avenue, N.C. W@chinafnn 1) r 7nnn? 451 dm 5 1 laying $2 on the horse race and covering all 2 MR. CHPJ-IBLISS: Is there further discussion? 3 Dr. Ilhite? 4 DR. WHITE: Miss Kyttle, you are implying that 5 if this money was restricted at this time, in these numerical 6 categories, that they would by July have these thinas in 7 form which we could see, is that correct? MISS KYTTLE: Yes, they wore trying to obviate 9 the necessity to come into the July cycle and come in 10 September. 11 DR. WHITE: They were trying to.save us a trip? 12 MISS KYTTLE: They were trying to save themselves -13 two months, too. 14 They have made inroads with MUSC on contracts, 15 affiliation agreements ere tough for a year. Not too many I(; of us have sat around and said that. 17 That is one of the beauties of a contract. In 18 addition to it, contracts as Dr.,Miller said, give you I() opportunities to do things that when South Carolina discovers 20 the control of the contract, they like it, they have used 21 them sparingly through MUSC, because they.had to educate their grantee. Having done that, they propose the contract method 22 e 2t3 with these. 24 These are -- and in that, it is merely a physical mechanism and I think the group got hung up on the differences 25 452 dm 6 between agreements and a Project and a contract and they are 2 all the same thing. They wanted to let them as of July 1. 31 Also in their application they said they.would 4 hope for July 1 beginning dates on the use and they will be 5 ready to go by then,, they tell us, because they will have 6 had the opportunity to capture several things. They will havi. 7 their full staff complement to monitor them for that full 8 year in South Carolina and they do that precisely too. 9 They will have the opportunity to come through 10, the review group here with the staff at its highest comT,)lemeni 11 here in DRk4P because they see the erosion coming to staff 12 that Dr. Pahl mentioned, later, and they see the bodv that is 13 meeting herd today that they are not so sure that there will 14 be the continuity of it in July. 15 MR. THOMPSON:,/ -What is the incidence of hyper- 16 tension in children, does anybody know what the incidence @ii of hypertension is i n children? 18 Dr. Schetlis, do you kno@q? GP DR. SCHERLIS: No, I would assume vou would be 20 dealing with blacks as opposed to whites. You would have a 21 much higher incidence but I don't know what the incidence would be, 22 23 MR. THOMPSON: Theyhave a specific Program for 24 hypertension in kids. 25 MR. CH@IBLISS: I can comment briefly on that. l4OnVFRREPORTING CO- INC. I 453 dm 7 That is the incidence of hypertension in black chil-'--- does 21 not seem to increase until the stress mechanism get to work- 3 ing and that is towards adolescence and above. 4 DR. McPIIEDRAN: I think it is quite significant 5 gh@ it is. in black adolescent children. 1 don't know how hi 6 MISS KYTTLE: Part of the interest of that 7 activity is to nab beginnings of renal disease. As us.ing 8 hypertension in children, female children considerably. 9 DR. IIHITE: Ilhat is a special categorical interest? 10, Have vou an idea what they mean by that? 11 MR. THOMPSON: The priority areas. 12. DR. WHITE: No, special categorical'interests 13 for MR. THOMPSON: That is IV. 14 15 DR. 1,7HITE: Ik4ow what it is called. 16 MISS KYTTLE: Because the others deal with heart, 17 stroke 18 MR. THOMPSON: Hypertension, is their big one 19 because they have a high black population. MR. CILk'14BLISS: Yes, but they don't develop the 20 21 mechanisms to take care of the hypertension once it is 22 discovered. 23 DR. SCHERLIS: Just screening. MR-. CHA.14BLISS: The mechanism is not there, I 24 think in all candor, that should be said. 25 HOOVER REPORTING CO, INC. 454 dm 8 1 MR. TIIOI-IPSON: Diabetes is another one Beat is 2 specifically mentioned in this, emphysema, arthritis, heart 3'1 disease, cancer, they cover the whole categorical thing that they had in hypertension, that in the Dipeline there are 4 5 some peculiar ones, esophogean cancer. 6 MR. CHP-r@IBLISS: I would like to met a sense of 7 the committee's feeling on this application and call for a 8 notion if I may. 9 MR. THO?i4PSON: My second reviewer has a comment. DR. VP.UN: Jesse, in the Texas write up, how much 10 did you see where these contracts were going to and where? MRS. SALAZAR: None. 12 13 DR. VAUN: My mentioning Texas, I think was un- fair. 14 15 Miss Kyttle, think-you did mention the who and 16 where? 14ISS KYTTLE: And the budget and that is import- 18 ant. 19 MR. CHA.',.,IBLISS: The basic thing, would this Committee in its judgment wish to approve these before these 20 issues are in fact settled there? 21 MR. T11014PSON: That is why the recommendation 2,2 MR. CHA:,IBLISS: Would you put that in the form of 23 Index 1 a notion? "Recoram- 2@4 g-ndation" il MR. THOLIPSON: $2.2 million. dm9 1 MR. CHAP-IBLISS: The recommendation for a level 2 of funding for South Carolina is $2.2 million, 31 DR. SCHERLIS: I second that. 4 MR. CH2U4BLISS: It'has been seconded by Dr. 5 Scherlis. 6 Is there discussion? 7 Dr. Vaun? 8 DR. VAUN: John, I don't understand your sub- 9 mission. This is the award for South Carolina, period. MR. CHA14BLISS: They can still come in, 11 MR. THOMPSON: There is $500,000 coming in. 12. MISS KYTTLE: There will be more than the $500,000. 13 MR. CHAIIBLISS: There will be funds available 14 at that time. 15 MR. THOMPSON:-The $2.2 million is arrived at by taking out some but not all of these non-program areas. 17 MR. CH2UIBLISS: Would you like that instruction 18 to go to the region -- all right, we have a motion, we have a' 19 second, we have discussion. Shall I call the question? 20 Those in favor? 21 (Chorus of "ayes.") 22 23 MR. CH2UIBLISS-. Those opposed? 24 (No response.) 25 MR. C.HA-P-IBLISS: The ayes have it and the level is -;-lt56 1 set at $2.2 million. dm 10 2 I would call upon the' Committee again to ask 3 how we should spend our time for the balance of the after- 4 noon? 1 an given to understand that the other panel will 5 complete its work today. They will met at 8:00 o'clock, they 6 will be available for a joint meeting with this Committee at 7 9:00 6'clock and I would like. to know if you would like a 8 break for a moment or would you like to continue? 9 DR. McPHEDRAN:' 9:00 a.m.? 10 DR. SCHERLIS: Do we have any reason to meet 11 from 8:00 O'clock to 9:00 o'clock if we complete these two 12, regions? lihat would we do if we meet at 8:00 o'clock? 13 MR. CH.LMBLISS: We would have no basis unless 14 the Committee wished to look over what it has done and we 15 would have a listing ofall the actions that we have taken and a showing of the current levels annualized, the target 17 amount, the request and the actions coming out of this groun. -@,le can look at our work product as a whole. 19 DR. MILLER: Let us finish uD. 20 21. 22 2 tl 24 25 HOOVER REPORTING CO, INC. -I,- A..--..- %i r dm 11 SOUTH DAKOTA 2 MR. CHA-@IBLISS: All right, I would then ask,you 31i to turn ,,our attention to South Dakota. 4 The reviewer there is Mrs. Salazar, staff support 5 by Miss Resnick. 6 Mrs. Salazar? (9) 7 MRS. SALAZAR: In the interest of moving along, 8 I Will.try to shorten this. Ipromise not to do as much as 9 I did on Texas. 10 MR. CHA.NIBLISS:A little louder, please. 11 MRS. SALAZAR: The application is requesting @12. 6 continuing activities and the RAG has 11 of them, with 5 13 new ones. 14 Perhaps it would be better if I start in the back 15 of the summary that I see as a summary of this application. 16 That the RAG and the staff are obviously addressing the ii peculiar needs of this State,.very large rural area with 18 limited man and woman manoower and resources in various remote 19 locations. They propose a consortium of educational insti- 20 21 tutions and health institutions to very innovative and 22 creative aDnroach to South Dakota's health needs. Regionalization of the core of the center concept 23 is what thev are proposing, is Oell supported and the region 24 is making every effort to bring supported activities to the 2,5 HODVER REPORTING CO, INC. 320 Itiassachusetts Aven,@, N.E, CI.C. 21,',-,,@2 45 8 dm 12 1 point of self-sufficiency. 2 As most of you remember, South Dakota T-UIP pulled 3i away from Nebraska-South Dakota which was the original 4 planning grant as far back as 1969. The first program for I 5 South Dakota as a separate entity was extended through Augusti 6 of 1972. It gained operational experience immediately and 7 submitted its first triennium application effort la't year S 8 but because of sending phase out, it was never revi wed; 9 is that correct? 10 MR. CHA-.MBLISS.: That is correct. -11 MRS. SALAZAR: it was extended again in arch of I 12 1973 through January of 1974 and approved through June of 13 this year. 14 I am telling you this because South Dakota seems 15 to have an awful lot of tt@rting and stoppina and yet there is a great deal of continuity through the whole application, which is amazing. At the time of the staff implementation crisis 18 this vear, a couole months ago, the region was found to be 20 viable and energetic and it was certified,.I believe it is 21 excellent in its review criteria and procedures. It naturally has a great emphasis on rural out reach with a focus on man 22 and woman nower development through'the process of regional- 23 ization. 24 There is an integrated Drocess with CHP plannina 25 HOOVER REPORTING CO, INC, N r 459 dm 13 which is very remarkable, in that the CHP board is the RAGI 21 the one and the same body. 3 Manpov7er training, the distribution and utiliza- 4 tion of manpower are primarily important to the region and 5 these elements are found throughout all of the proje'cts. 6 I find this proposal a very exciting and@well 7 organized Western Plains, no nonsense languaae. It sets 8 forth what it wants to do verv matter of factly. into two 9 general categories of projects. 10 One, those that are designed to achieve their -11 objectives within the 1975 framework of funding and; 12. Two, those with interim P,@@IP support, and I-think 13 that is very significant that they specifically say this 14 interim report can-be given impetus beyond '75 to attain 15 their specific goals or tQ/achieve permanent status either I(; independently or under other funding sources. 17 The staff appears ready to move into new avenues 18 of health.resource planning. There is already good chemistry- that exists between the other health agencies. Coordination 20 of efforts and cooperation with other aaencies is very 21 apparent in the application. A quick review of the projects did emphasize the 22 South Dakota commitment to improving health services that are 23 t .41 not now adequately covered. Yet at the same time the appli- cation is realistic, it is very local, it is very regional andi 25 HOOVER REPORTING CO, INC. .46o dm 14 in response to the Geographic handicaps and that verv rugged 2 climate.that exists out there. 3 The in tandem operation of the CHP aqcncy is 4 quite visible in a State of 600,000. Of course the social 5 and political and business interrelationships is more apparen 6 than in under-nopulated areas. The regional medical program there is blessed with 8 a capable and dedicated staff and it has verv enthusiastic 9 and energetic support and I believe ongoing continuing @io support through the University of South Dakota. 11 The application states that this will be augmented 12 by two additional Program staff Persons who have planning -13 and evaluation expertise. It was a little unclear to me why 14 the application, in the application, why the Indian involve- 15 ment in the corps staff, en so.many of their programs are 16 based, have Indian Populations, verv large Indian Populations 17 in the State and out-reach. There is no more active involve- 18 ment of Indians on the staff. Especially in view of many 1!) significant Indian problems in South Dakota. 20 MISS RESNICK: Staffing with Indian Personnel 21 well, they are using their Indian outreach through their 22 RAG. There are four members representing the Indian reservation 23 population and they are taking the service out to the reserva- tion in those corps components, working Very closely with the 2.4 Indian area office in Aberdeen. It is Vermilion and I think .Antlro br*nl2.rikjp (In fur 461 dm 15 1 their resources would be extremely limited. That is where 2 the program is based. 3 That is the only explanation I can give for it. 4 I think they take it out to the reservations rather than try 5 to bring an Indian professional in where they have so few. 6 MRS. SALAZAR: They have some very talented Indiar 7 people in that State and that is why I was wondering why 8 they,weren't involved more at the corps level. 9 MISS RESNICK: I think it c6mes,through only at 10 the RAG and they take it out to the reservation areas from 11 what I can judge. 12. MRS. lqYCKOFF: The staff out there, there is other 13 area staff. 14 MISS RESNICK:,/There is eight components from the 15 staff and three or four deal with Indian reservations, .I(i precedtorship, allied health, a summer training program and 17 they are very close to the Indian program. MRS. V7YCKOFF: I think Mrs. Salazar's question 19 is, who is getting the jobs? 20 MISS RESNICK: I know she asked if there is an Indian person, rofessionals on the staff in Vermilion.. The 21 p answer is "No," but the only explanation I can give that there 2-@ 23 are few resources around Vermilion and thev carry on their 24 activities right on the spot in the Indian reservation areas. MRS. SALAZAR: They are used, in my estimate, for 462 dm 16 instance, are using some Indians as consultants to come in 2 when there are deliberations that involve projects and 3.1 planning for Indians. It is very important to have an Indian there to find out if he wants to be planned for. 6 MISS RESNICK: There.are four Indians on t e 7 RAG and it is through them that they are having the direct 8 contact., as- I understand it, with the Indian reservation 9 problems. 10 MRS. WYCKOFF: Thev do the planning. 11 MISS RESNICK: One or two have made certain 12. proposals but they have come from the Indian reservation or hospital Program. 13 14 I.thought you meant staff. There was -- there is 15 no Indian staff. MRS. SALAZAR: Yes 17 14ISS RESNICK: They are very much involved. The 18 Indian health facilities and Programs are very much involved- a in the Chair's activities and they have asked for help from 20 the Oahe and the Lewis and Clark,wherever they happen to be 21 close. 22 MRS. SALAZAR: I don't mean to imply that the program leadership is not energetic and well motivated. 23 '-14 MISS RESNICK: I think they are actively engaged with them. 1)5 HOOVER REPORTING CO, INC, 463 dm 17 1 MRS. SALAZAR: The RAG is also very strong and 2 active and has organized into several, what is obviously ver_v 3 productive committees. 4 The Chairman, interestingly enough is an author, 5 rancher, farmer. He is well informed of State Problems and 6 involved in many community and educational health efforts, 7 which is probably one of the reasons in the health'education 8 corununit concent. fie is an active facilitator and I gather .y 9 gets great respect throughout the entire State. 10 At the same time he is very adequately successfully 11 '-representing all of their interests, of the CHP, as well as 12. the RMP. MR.,THO@4PSON: Is he on the CHP board as well? 13 14 MRS. SALAZAR: Yes, it is the same board. Forty- 15 one members. MR. THOMPSON: Fifty-one percent on the board? 117 MRS. SALAZAR: I think it is interesting to note 18 that the executive committee of the RAG met six times in the. 10 last 12 months with almost 100-nercent participation in spite of that rugged winter out there, weather and the climate 20 too. 21, They seem to be very proud of the fact that their 22 members also serve without remuneration. 23 24 miss RESNICK: They have project consultants who serve without reimbursement. 25 HOOVER REPORTING CO, INC - 464 dm 18 1 many of them in this Particular program. 2 MRS..SALAZAR: Just to wind up, the highest .orlority,rating gf the RAG was assigned to the emergency 4 medical services. That program they-have is very small and 5 they are onlv asking for the training efforts, about $50,000 6 for that. 7 I presume that this means that there will be 8 another. application in emergency medical services :after thev 9 try this one out. MISS RESNICK: They are-planning to and thev are 11 also going to come in here again in July 1. 12 The thrust is manpower development again. 13 MRS. SALAZAR: That is the next one. The two 14 health committee based centers. 15 I believe bascvd-on the past experience of South 16 Dakota, that the goals and program are achievable and the 17 current momentum of the program indicates that they have a 18 fairly good chance, I believe, a fairly good chance of settina out what they set out to do. Laudable, I think the CHP joint 19 efforts are commendable. 20 21 I think that their efforts toward trying to bring Indian populations more actively into the program also are 22 very commendable efforts and I recommend -- may I make a recommendation, Mr. Chairman? 124 MR. CHA14BLISS: You may indeed, Mrs. Salazar. 25 4b5 dm 19 1 MRS. SALAZAR: That we approve this application 2 as requested. 3 DR. SCIIERLIS: That would exceed their target by 4 $531,000 by $198,000. 5 MRS. SALAZAR: Yes. 6 DR. MILLER: Being a neighbor and having had 7 much to do with the Texas, I thought'it might be worthwhile 8 to say-a little what I know about the South Dakota program 9 and its relationships. 10 As it started out with South Dakota and Nebraska 11 together, incidentally, the reason Northland was mentioned 12. was before I ever came on board our big medical centers in Minnesota figured that we would have the Dakotas in Montana 14 and a good deal of the upper Midwest and so I have had a lot 15 to do with them -- it is,.a different story. But they have, they couldn't join with North Dakota because thev never get along so they joined with 18 Nebraska, but they couldn't get along with Nebraska either 0 because Nebraska tried to dominate them. So they are imneding 19 20 movements which could have aotten started in South Dakota.- 21 But then Dr. Haves, who was the South Dakota associated' 22 coordinator of the South Dakota-liebraska program moved, left 23 the PI-IP to become Commissioner of Health in the State and 24 although I don't knowi I suppose he is -- is he? MISS RESNICK: Yes, very actively involved. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. -466 dm 20 DR. MILLER: He is completely attuned to this 2 whole movement. And Mr. Brecken is an outstanding leader,. 3 staff leader and so forth, so that actuallv this region would 4 if it had gotten going sooner, would have had the potential 5 to achieve much further than it has now and we wouldn't have 6 this limited taraet estirqate'which is based on this very 7 late start. 8 MR. CHA.MBLISS: All right. 9 MISS RESNICK: The target estimate is $571,000. 10 I am sorry the vellow sheet was not updated. (10) MR. CH)VMBLISS: Xle have a recommended fund of .@12. $571,000. The requested level of $724,417. 13 I don't have a motion yet to that effect. 14 MRS. SALAZA@; I said it was requested. 15 MRS. l@CKOFF: $729,714? 16 MR. CHIU-IBLISS: Would vou restate your motion 17 since there is some question about which figure vou had in is mind? 19 The taraeted figure? 20 MRS. SALAZAR: $729,714 as requested. That is my motion. 21 DR. VAUN: I will second it. 22 ,MR. CHA-MBLISS: It has been moved and seconded 23 that the level for South Dakota be 'Set at the requested amount 2,4 OIL $729,@. 25 467 dm 21 1 Is there a discussion on the motion? 2 DR. SCIIERLIS: Yes. At the risk of antagonizing 311 people who like my-,elf are hungr,,,, there are two specific 4 programs that I have question about. 5 One ig the PSRO activitv of $100,000. 6 I was wondering if that is what we really want to 7 support? 8 The next-question relates to the medical genetics 9 program which is a total of $46,000. 10 As I-read their nrogrami which is a very ambitious 11 one, in States manv times that size, I was wondering whether 12 that is one of the prime needs for the State of South Dakota. 13 IIISS RESNICK: They reduce the number of possible 14 trainees and this is tied to the medical school, a point I . which I think Mrs. Salaza@failed to make. A four-year 15 medical school recently approved by the State legislature and how going up for approval bv the National Association. We met this professor and doctor in genetics she 18 has had support from a number of sources including a little 19 bit from PI%IP last year to get started on this genetics 20 21 program. She is looking for other funds and at the moment 22 nothing is coming through. They think the States will support 23 it within a year. it is for this reason that they would like very 24 much to have this continued and not lose what she has already 25 i4nnuPR RFPnRTINf, CO- INC. 468 dm 22 1 accomplished and she is getting a lot of sunnort from the 2 medical Profession. 3 !I MR. CHA-MBLISS: TkThat is the purnose of the 4 project per se? 5 MISS RESNICK: It is a primary care, really, 6 activity with a referral, a resource for referral of patients 7 to professionals and to specialists. 8 MR. CHAMBLISS: What are they looking for? 9 MISS RESNICK: They are starting with @io MR. CH@IABLISS: All the chromosomes where you .11 screen for genetics are abnormal'> 12. DR. SCHERLIS: I think it is one of the programs in looking at many Sta