B&B ImFoRmAkriom ImAmE M^m^=EmENT 300 @ow4ce n--*=iVn R=uLxv Upoosca M,%nLmomc2, MA Pro ZC'77Z 0 U MA 11 CXC 1) 2410-01 1 0 STENOGRAPHIC TRANSCRIPT DEPARTMENT OF HEALTH$ EDUCATION$ AliD WELFARE MEETING ON AIREAWIDI PLANNING S:Llver Spring' Maryl 8 Ju:Ly 196 3 -ACE. FEDERAL REPORTERS, INC. @O a I Reporters ffici K4; W Constitution Aven6 I!L D' .'Washington C. Telephone: 393@01 1 Craft/Renzi 1 DEPARTMENT OF HEALTH, EDUCATION, AND WEIYARE 2 - - - 3 MEETING ON AREAWIDE PLANNING 4 5 6 7 8 Room 921, 9 7915 Eastern Avenue Silver Spring, Maryland ,lo Monday, July 8, 1963 The meeting convened at 9:20 o'clock a.m., Dr. 12 Jack Haldeman presiding. 13 FR 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CO,'4STITUTION AvE N.W WAIHINGT ON 0 C. 2 I N D E X 2 Agenda item P@e 1 3 Discussion on implementation - Dr. C. Rufus Rorem 8 4 Discussion on implementation in Southern New York Mr. Joseph Peters . . . . . . . . . . . . . . . ... 48 5 6 7 8 9 10 1 1 12 13 FR 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE N,W. W ASKINGTON. D. C. 3 P R 0 C E E D I N G S - - - - - - - - - - 2 DR. HALDEMAN: I wonder if we could get on with our 3 hog killing. I guess everybody is here except somebody from 4 Blue Cross. McErner told me either he would be here or someone 5 from his office would be here. 6 I don't know whether we need any introductions. I t 1 7 think we might go around and just rapidly call off. -auctions were made.) 8 (Intro 9 I think the purpose of this is probably three-fold. 10 The first purpose, I think, is to get a discussion 11 of methods of implementation of areawide planning. George 12 and I argued over this term "implementation" throughout the 13 deliberations on the so-called Bugbee Committee,, and I don't FR 14 think we ever found, really, a better word. 15 MR. BUGBEE: The argument was on the semantics, an 16 idiosyncrasy of mine. I don't like the word "implementation",, 17 but I have given up. 18, DR. HALDEMAN: In the Bugbee Committee there was a 19 lot of difference of opinion,, and the report as it came out 20 contains very little in terms of specifics in terms of various 21 methods that might be used for implementing areawide planning. 22 Part of it was deliberate, I think, because we didn't. 23 feel we were wise enough to make recommendations in a document 24 such as this that would be applicable universally. 25 And secondly, I think there might be some real ACE-FEDERAL REPORTERS, INC. 26 1 CONSTITUT'ON AVE., N.W. W4."N.TQI, 0. (;. 4 I minority opinions if we had taken one side or another. There 2 were those on the committee that felt very strongly that there 3 should be franchising or the equivalent. There were others 4 that felt equally strongly in the opposite direction. And I 5 think both the Public Health Service and the American Hospital 6 Association that were sponsoring the committee had not taken 7 any particular position in regard to this. 8 It se@ to me like the time has come for setting 9 down and at least discussing various methods that are being usad 10 throughout the country to implement areawide planning, what ha3 11 worked, what hasn't worked, and get a general discussion of th-@ 12 subject. 13 I myself have mixed feelings on this subject because FR 14 it seems to me like it is an essentially negative approach and 15 a lot of our hospital planning agencies, a great deal of their 16 time is taken up in stopping construction of one kind or 17 another. 18 It seems to me like in the course of our discussions, 19 we might want to discuss what are some of the positive element4 20 in planning. I was right impressed with the recent article by 21 Bob Sigmond of Detroit in which he took off in depth on the 22 positive elements of planning. 23 The second general sub ect is one of priorities. 24 I would like to make an assumption in this part of the discussion 25 that the areawide planning agency is responsible for the ACE-FEDERAL REPORTERS. INC. 261 CO"STITUTION AvF N W. 5 I distribution of capital construction funds, whether they be 2 Hill-Burton or a modernization program,, Federal funds, or 3 whether they be capital construction funds raised in the 4 community such as in Columbus. I think this problem of priority is one which in the 5 6 future years the Hill-Burton program is going to be faced with muc 1 7 more than they are now because the current priority system under 8 Hill-Burton which is largely a matter of relative need is 9 fairly simple, end it works relatively well in rural areas, 10 but when you get into a metropolitan area, it obviously breaks down. 11 12 And if we get a modernization program, every State 13 Hill-Burton agency and every local areawide planning agency FR 14 is going to have a problem of priority, not only in the general 15 hospital category, but among categories. And so I would hope 16 that we would take a hypothetical situation, perhapsI, in a 17 community and see what we can develop in the way of priority 18 principles. 19 I have always felt that if we get a modernization 20 program -- Well, first, our specifications for a modernization 21 program do require the areawide planning agency be consulted, 22 but secondly, will not spell but in any detail priority principles, leaving that to the State Hill-Burton agency as well as local 23 24 Rill-Burton agencies. 25 I thought probably that the process would be locally ACE-FEDERAL REPORTERS, INC. 2 61 CONSTITUTION AVE N W 6 I a good deal like an NIH study section would be, pooled profes- 2 sional judgment based against certain general guidelines which 3 are developed. 4 Now,, the third thing I would like for us to take up 5 is whether it would be desirable to have what might amount to 6 a national meeting of personnel of local areawide planning 1 7 agencies. The American Hospital Association, Hi Sibley, and 8 Public Health Service have just completed a series of seven 9 regional meetings which were intended originally to be sort of 10 a field testing-for a cookbook that we had developed, based 11 largely on these committee reports, but going into more detail 12 some detail as to the data needed for planning, the analysis 13 of the data and what not. FR 14 I don't think any of these meetings really served 15 that purpose. And the reason it didn't serve the purpose was 16 that the groups that participatd were, not only people from 17 areawide planning agencies, but were a lot of people that were 18 broadly interested. And they served a useful purpose, I think, 19 in that it stimulated interest in areawide planning. 20 As I was saying, I think those sessions served a very 21 useful purpose, but it was not as useful in terms of people in 22 areawide planning agencies who are actually doing the work in areawide planning agencies, having an opportunity to get down 23 24 discuss more or less detailed questions and to discuss the' 25 gs that the staffs of areawide planning agencies are ACE-FEDERAL REPORTERS, INC. 2 6 1 CONST'TUTION AVE N W, W-@'llcl,ol L2@ C, 7 interested in. 2 So we wondered if there wasn't a need for a meeting 3 that would be pretty well confined to the individuals in 4 working an the staff areawide planning agencies and, if so, how should such a meeting be structured, when it should be 5 and what not. And I would like to take some time in this 6 7 area. 8 As far-as I am concerned,, the meeting these two days 9 is quite unstructured, and if you want to take off and consider 10 other things, that is quite appropriate. I am not quite sure what we will do with the proceedings, but we are having them 11 taken down so that we can develop some sort of a report if it 12 l@3 appears that many pearls of wisdom are being dropped. FR 14 George, do you want to discuss this from the standpoint 15 of the background as chairman of the Committee on Areawide 16 Planning? 17 MR. BUGBEE: I think you have covered it very well, 18 Jack. I think we are all conscious of some worry about how 19 far you go with legal sanctions, but I don't know that anybody 20 feels terribly strongly. 21 It is kind of an academic argument and probably not 22 the most important method of-implementation anyway. 23 So I suppose you go through the whole range. Even in 24 the informal conversation of last evening,, it seems to me people 25 are developing quite a little experience in how to put these ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AvE N.W. W.,@"G,oI0. C, 8 1 things in motion. 2 I like your idea of positive as well as negative, too. 3 DR. HALDEMAN: I think when we talk about implementation 4 we might try to bring in this element of positive action. 5 Suppose I just go around the table and comment what you are- 6 doing in this area and what you would like to do, what has 7 worked and what has seemed not to work. 8 Rufus, do you want to lead off? 9 DR. ROREM: Yes, I would be glad to be first to 10 speak because I-am going to be the first to leave. I have a 11 9:00 o'clock plane tonight so I wonft be here tomorrow. 12 Well, I think that we like to characterize our effori:s 13 as primarily being interested in stimulation of individual FR 14 hospitals to do planning on their own account and then stress 15 in that the fact that the self-interest of an individual 16 hospital means that they must be familiar with and aware of 17 what the other institutions are doing. And we have urged 18 every hospital to appoint a long-range planning committee for is its own institution, composed of representatives of the manage- 20 ment, of the trustees, and of the attending staff and, if they 21 wish to cooperate, community members -- it is all to the good -- 22 as well. 23 Conversely, we work with community groups particularly 24 in areas where there is no hospital to study the characteristics 25 of their own area to see whether and what kind of a health ACE-FEDERAL REPORTERS INC. 261 CONSTITUTION AVE N.W. wAstieNGTON o@ C. 9 I facility may be needed. 2 Now, one of the things that you will have to take 3 away with you is our work document or guide for the use of 4 long-range planning committees of individual hospitals. And 5 in this, there is a tabulation of the results of our resident 6 survey applicable to the year 1960 which shows in tabulations 7 of 29 districts where the people of that area with hospitals 8 go as inpatients7of each of the 29 districts. 9 In other words, when a person wants to say: Where lo do the people who live around me go? -- the tabulation shows 11 where each of the 29 districts that are classified here were 12 hospitalized and, conversely, the planning committee of a 13 hospital can see where its patients come from. FR 14 We will find, for example, that they might get 40 15 per cent of their patients or some other figure from a particular 16 geographic area. Yet, they may only serve 10 per cent of the 17 people from that geographic area. 18 Our idea is that this would serve as the basis for the 19 hospital to plan ahead and as to what areas it wants to be more 2o active in, the areas where it will encounter already entrenched 21 position on the part of other institutions. 22 This is strictly superficial. It does not devise 23 the services in terms of medical, obstetrics, pediatrics, and 24 in this particular guide does not deal with outpatient service 25 or nursing homes or many of the other important facts. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTICON AVE., N.W 10 I I mention this as a method because we use this as 2 a backdrop for appraisal of any projects for expansion or for 3 new institutions strictly as a guide and as a backdrop and 4 try to keep this interest going. 5 I might say that all of our general hospitals have 6 now established long-range planning committees and four of our 7 eight nongeneral hospitals, nursing homes, and things of that- 8 kind and rehabilitation centers and home& for crippled childrea, 9 have also done so. 10 Just as far as implementation is concerned we use no implementation except that of persuasion and the announcement 12 of an official position which our organization takes after 13 going through a series of hearings which we call nonlegal FR hearings. 14 15 If a hospital has a program on which they would like 16 to have our opinion, it,goes through four steps. They first 17 have a conference I call a conference of the hospitals most 18 likely to be affected. 19 Now, after three and one-half year4,, those are very 20 lively discussions and the insttitutions now are getting so 21 their representatives -- these are administrators -- speak up 22 frankly in their own self-interest which for a while they were 23 very self-conscious. It was a log-rolling affair. 24 Then, it is brought formally between a committee of the 25 administration and hospitals involved. The institutions are ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AvE N,W, WIIIIIIIIA, D. C@ 11 I always there, and that second group actually take a vote as to 2 whether they think it is a good idea. 3 DR. HALDEMAN: What is the difference between the 4 composition of the two groups? 5 DR. RCREM: The first group is the hospitals most 6 likely to be affected, which means those are probably contiguous 7 areas. The second is a representative group of all the 8 hospitals in th6'area elected by them --'seven people. Then, 9 that recommendation goes to all the hospitals in the area. 10 Euphemistically, I guess I would say that every 11 hospital administration is a member of an advisory committee tD 12 us whether he likes it or not. He just is. And that group 13 hear a statement description of it, and they take a vote. FR .14 MR. BUGBEE: In a meeting? 15 DR. ROREM: In a meeting. 16 DR. HALDEMAN: Open meeting? 17 DR. ROREM: Open meeting. And they take open votes 18 up to now. We are talking about making it private, but it 19 isn't now. 20 MR. SIBLEY: How often do you meet? 21 DR. ROREM: About twice. We meet in between times tD 22 hear committee -- 23 MR. SIBLEY: This group meets twice a year? 24 DR. ROREM: We have met twice this year because of 25 special things that have come up. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE:., N W, a C. 12 1 DR. KLICKA: May I interrupt you? 2 Is this meeting structured in such a way that you or 3 your organization makes its recommendations on the basis of your 4 guidelines to this group? 5 DR. ROREM: That's right.. 6 DR. KLICKA: Before they start their discussion? 7 DR. ROREM: Not at these points. 8 DR. KLICKA: What do they base their consideration 9 on? 10 DR. ROREM: Well, on the merits of the case. 11 DR. KLICKA: This is what I mean. Who presents 12 the merits of the case in a so-called scientific way? Do you 13 do this or do you permit the hospital that wants to do something FR 14 to present its case alone? 15 DR. ROREM: The hospital is present. The hospital 16 really takes over and questions are asked in terms of the 17 standards. 18 DR. KLICKA: But you don't evaluate this first for 19 the group on the basis of your studies as to whether you think 20 this is good or bad. 21 DR. ROREM: In the sense of in writing? 22 DR. KLICKA: No, it wouldn't make any difference, but 23 it would seem to me that the group who were to be affected 24 would first like to have the opinion of the Planning Committee 25 relevant to how this would fit in the scheme of things. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE N.W 7. C. 13 DR. ROREM: By the time it gets there, they know 2 how or staff understands. 3 DR. KLICKA: How do you do this? 4 DR. ROREM: The first meeting, I introduce. The 5 first meeting is really a go-around, just a general talk. 6 The second meeting, by that time, I have an opinion which I give 7 a tentative -- no, it doesn't crystallize until after the thirl 8 meeting. Then, It crystallizes definitely. And it still is 9 a wandering discussion the first three times around. 10 DR. HALDEMAN: What is the third one? 11 DR. ROREM: Then, the third one is with the entire 12 group of hospital administrators. 13 And then, the fourth is with the Planning Committee FR 14 of our Board of Directors. 15 MR. BUGBEE: But each of the three groups has an 16 official vote they pass On to the next one for examination. 17 DR. ROREM: The very first one has no vote at all, 18 but the representative committee, the advisory committee as 19 a whole., and the Planning Committee, and it goes to the Board 20 with a specific recommendation that is very short. And as it 21 goes along, I make summaries of these which are acceptable 22 to the institution, one-page-statement of which they might have 23 had 20 pages. And they accept it as to whether or not it is 24 factual, but not analytical at that time. But after it goes 21 through the third one, we take a very definite position. The ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AvF N.W@ C. C. 14 1 recommendation goes to our Planning Committee. And this is 2 consistent with sound public policy and coordinated planning 3 in our area. 4 DR. HALDEMAN: What is the composition of your Planning Committee? 5 6 DR. ROREM: The Planning Committee is selected strictly 7 from the Board of Directors. It happens to be seven members; 8 it could be eight. 9 DR. HALDEMAN: What is the composition of your Board 10 of Directors? 11 DR. ROREM: Our composition of our Board of Director3 12 is all laymen, some of whom may be hospital trustees. They 13 are the presidents of large corporations -- that is, financial, FR 14 industrial, and mercantile plus several clergy and plus soma 15 educators. 16 We have an advisory committee, this representative committee that I spoke of,, of hospital administrators. The 17 18 chairman meets with our Executive Committee and Board of Directors 19 the Advisory Committee of Hospital Administrators and an 20 advisory committee of the medical society, the profession., but it is appointed by the president of the medical 21 society, six 22 people, with the president always ex-officio. And we have 23 quite a few meetings on the side. 24 A3 far as priorities are concerned., I might say that 25 priorities are f ound on page 11 of this report when we get to ACE-FEDERAL REPORTERS. INC. 261 CONSTITUTION AvE N.W. C. C. 15 I it,, and these are the ones we have used. They are a little 2 bit generalized if you want to call it that, but the highest 3 priority with almost no quibbling at all is to any programs 4 which will contribute to greater coordination of patient care 5 within the community rather than mere sanction of existing 6 types of facilities and services. 7 The second program goes to those which will achieve 8 more effective tae of existing plant and personnel. Moderniza.. 9 tion, of course, would be a part of that. 10 The third is something like the second,, those which 11 will prolong the useful lives of existing facilities without 12 jeopardizing the standards and efficiency. 13 At the bottom of our list are programs which will FR increase bed capacity because we are caught up. We are dealin@, 14 15 from a position of surplus rather than of scarcity. 16 We all know it is easier to plan for scarcity than 17 it is for surplus. It is like the sailor says with the rope. 18 He was really in a terrible jam because he had a rope that was 19 too long. He didn't know what to do. He said, "If it was too 20 short, I could splice it, but it is too long. I don't know 21 what to do. I don"t know where to st!trt. 22 So for what it is worth, that's what we do. I didn't 23 mean to take so much time. 24 DR. HALDEMAN: I think we ought to ask questions so 25 we thoroughly understand how it works. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE N.W@ W4'@ll"@' C C, 16 I Does your Planning Committee ever override your 2 committee of administration? 3 DR. ROREM: It has not yet; it might. 4 They have approved ten projects up till now expressly and disapproved one. And all of those up till 5 now were 6 recommendations of the advisory group. 7 But I might say that we haven't been brought into 8 court as one of the people last night mentioned they have. 9 We have been brought into the court of criticism and public 10 dissatisfaction on the part of the client that wasn't happy, 11 and they have used up till now their response and method of 12 expressing dissatisfaction as being what the lawyers would 13 call "ad hominum.11 FR They put it, not on my Board of Directors but on 141 9 15 the staff as being unreasonable and intransient. 16 MR. COUSIN: Jack, may I ask a question?. 17 DR. HALDEMAN: Yes. 18 MR. COUSIN: Rufus, what does it mean to a hospital 19 in your area if your group gives its approval or turns 20 thumbs down? 21 DR. RUREM: It means they can quote wherever they se(! 22 fit the fact it has been approved by the Hospital Planning 23 Association. MR. COUSIN: Does this have any real impact? 24 25 DR. ROREM: Yes, for both small and large contributixisl ACE-FEDERAL REPORTERS, INC. 261 Cot@STITUTION AVE., N,W. 17 1 particularly for large and somewhat small. 2 MRS. COLEMAN: Has any hospital elected to not ask 3 your opinion? 4 DR. ROREM: Up to the present time, we haven't moved 5 in and given it anyway, but we are thinking of doing that. 6 If they don't ask our opinion, we are very likely to adopt the 7 position of giving it anyway. 8 MRS. @MAN: How big a projedt? For small things,, 9 I suppose they have no obligation to consult you at all. 10 DR. ROREM: No. but the Hospital Council of Western Pennsylvania which works very closely with us has expressly 11 12 and by resolution suggested and admonished the hospitals to 13 report and ask for approval whether or not the public campaign FR 14 was contemplated and whether or not the amount was large. 15 We are not defining the word "large." 16 MRS. COLEMAN: Suppose they just wanted to put in an 17 intensive care unit or something like that. Would that be 18 something they should bring to you? 19 DR. ROREM: As a matter of fact, one hospital did 20 exactly that about $125,000 they wanted to spend. They did 21 bring it to us. And in the condition like that, it doesn't 22 go through all the channels. It goes straight from the staff 23 to the representative committee and Planning Committee. The 24 Board never hears about it. 25 MRS. COLEMAN: suppose it was something that di< ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AvE N.W@ C. C. 18 1 cost very much money, but was a vital change in scope of the 2 hospital like they wanted to take out pediatrics or put in 3 pediatrics or something like that,, but they weren't increasing 4 the beds. 5 DR. ROREM: The hospitals that want to do anything 6 like that generally take the initiative and want to get some 7 approval because they know they will, probably. And so there_ 8 is no special peoblem. And in a few cases, they have done so. 9 We have a hospital which this week on Friday will 10 announce that it is closing its obstetrical department and thaL 11 all obstetrical services will be going to a hospital two blockg 12 away as of next Monday. It is a 300-bed hospital with a 36-bel 13 obstetrical unit. And the hospital that is going to pick it FR 14 up is a 550 bed, mainly maternity hospital. And the doctors hive 15 been on both staffs all the time. 16 They are going to close it. And on that,, we worked 17 with them all through this. I can't say we were more than an 18 influence. That hasn't gone through two channels at all. It 19 was applauded from the beginning, and it.- is now a reality. 20 MRS. COLEMAN: So whether it goes through channels 21 or not depends pretty much on the amount of money involved. 22 Is that more or less true? 23 DR. R@: I would say so pretty much and whether or not there is to be a public camp# 24 ,ign, the two combinations. 25 One hospital has announced by 1970 it plans to build ACE-FEDERAL REPORTERS, INC. 2 6 1 CONSTITUT'ON AVE N W. 19 i a doctors' office and interns and residents home and expand 2 and improve its emergency and outpatient department which 3 obviously would be improved. They have got the money. But 4 they can't spend it until the urban redevelopment association 5 has declared an area that is blighted. So they had to make 6 this statement of this policy in order to help the urban 7 redevelopment., 8 There -is a case where the facts have been known to 9 us, but no formal application. We are just a little bit io embarrassed that it broke in the papers, and I have told peoplB I think in their self-interest they ought to have their 12 program on record with us as it develops. 13 All isn't perf ect with us. FR 14 DR. HALDEMAN: You say that in ten instances,, they 15 approved the contemplated action of the hospital and in one 16 instance they did not, is that right? 17 DR. ROREM: That's right. 18 DR. HALDEMAN: So usually, they go along. 19 DR. KMEM: Usually, the institution goes along. 20 As a matter of fact., we turned down two. But 2i before it came to a vote of our board, the hospital said, 22 "Would you mind if we just withdrew the application completely 23 which they did. They came back a second time six months later 24 and it was approved. 25 DR- HALDMAN: If you had it to do over again, ACE-FEDERAL REPORTERS, INC. 261 CONST TUT ON AvE N.W, C. C. l@ 20 I would you use the same mechanism or a different one? It seems 2 to me it has the element of a little bit of back scratching 3 if the decisions are pretty well made by administrators. 4 MR., BUGBEE: Does it? Or if you have 26 of them or 5 25 always supercritical of the 26. 6 DR. ROREM: I might say that this last one, the one 7 that is now coming through a second time, is one that decided_ 8 to ignore -- Thi-s is one that was turned down, went right 9 ahead anyway. It happened they got Hill-Burton money and had 10 that to go on. And they went ahead anyway. 11 And, incidentally, the two we turned down both 12 received Hill-Burton money because of the particular gerrymand.-r- 13 ing at that time of the area. And the one that recast its FR 14 program, we approved. The other one, we haven't approved, ani 15 it is well along. 16 Off the record. 17 (Discussion off the record.) 18 MR. BUGBEE: Rufus, to this point Jack raised, thoUgIL, 19 would you find the 26 administrators when you get to that stag(,, 20 or as they filter up from representatives,, are they fairly 21 Judicious, or do they log-roll? 22 DR. ROREM: Let me tell you what happened this last 23 time. Usually they are unanimous. 24 This last one is going through the channels a second 25 time. And of 18 out of 26 that could have been present, 11 ACE-FEDERAL REPORTERS, INC. 261 CONST'TUTION AVE . N@W. C. C, 2 1 I voted to let the old disapproval stand. Four decided that it 2 ought to be changed. One of those votes was the institution 3 itself. And four decided they didn't want to take a position 4 and abstained. So it is not always unanimous. 5 DR. KLICKA: As you evaluate this kind of a situation, 6 what is their reasoning based on -- a prett 7 sound analysis of 7 the material that you presented to them? 8 DR. R@M: I would be willing to say yes. 9 DR. KLICKA: You agreed with it, didn't you? 10 DR. ROREM: @Yes. 11 Mr. Willis was present at all of these. 12 Dave, why don't you get into any points as long as we 13 are discussing this? You are at a distance now where you can FR 14 think back where we could have done something different. Is 15 what I have been saying somewhat similar to what you might hitviE 16 said? 17 MR. WILLIS: Yes. 18 DR. RMEM: Up to now? 19 DR. HALDEMAN: First, I think Jack Cousin had a question. 20 MR. COUSIN: I wanted to know,, do you work with ostec- 21 Pathic hospitals andt secondly., how does Government react to 22 this? 23 In Other words, if there is a city, State or a county 24 institution, or even if there is a health problem involving the 25 cityo State,, and county, Federal Government. We don't have ACE-FEDERAL REPORTERS, fNC. 61 CONSTITUTION AVE N W. D. C. 22 1 much luck except with Hill-Burton, but the city, State and Coulty, 2 for example, if it is a city hospital and they want to cut out 3 pediatrics, does this get to you either from the hospital or 4 from the city council or the Board of Health? 5 DR. ROREM: 'Let me say first of all, and this makes 6 us unique, this happens to be a trading area in which there is 7 no local government hospital, the largest one in America by far. 8 Secondly, there is one 25-bed osteopathic hospital in 9 this whole area. 10 And the third is that there is no proprietary 11 hospital in the whole area. It makes the issues a little 12 sharper. 13 Another fact is that at the present time we don't FR 14 know of any M.D.s who want a staff appointment that donle have 15 one. 16 Now, the osteopaths, however, they have a nice 17 hospital, and you,go 25 miles out or 30, osteopath hospitals 18 start up again. But in Pittsburgh, they haven't up to now. 19 MR. COUSIN: What would you do if you had a request 20 for an osteopathic hospital and you could pretty well develop 21 that the osteopathic physicians had much fewer beds available 22 to them than the M.D. hospitals, and they wanted to put a 23 hospital up where there was a surplus of beds, but not of 24 osteopathic beds? 25 DR. ROUM: I know. I don't know what we would do ACE-FEDERAL REPORTERS I NC. 261 CONSTITUTION AVE . N W. W@ ........ 0. C. 23 1 at this point. I suppose after we got over the faint, the 2 faint of the first time, we would see what could be done about 3 taking care of these people because our State is very similar 4 to Michigan except that here the M.D.s have the lily-white 5 concept which is pretty well accepted in the general community. 6 That is strictly M.D. 7 I don't know of any institutions in the immediate 8 area that have any M.D. hospitals that have osteopaths only- 9 not a single one. 10 MR. COWIN: We have something like 2,000 osteopathic 11 beds out of 17,000. We have one county where something like 12 15 per cent of the people in the county are being cared for b 13 osteopaths. FR .1.4 DR. ROREM: We have less than 50 out of 8,000. 15 MR. COUSIN: And you are not going to change that; 16 we are not. 1.7 MR. BUGBEE: I don't want to stop at the osteopath, 18 but I want to ask you, you have been a little elusive about 19 who presents the brief for the hospital. 20 In fact, as you are describing it, the hospital 21 presents its data and you and all the rest question the data, 22 but it is really the applicant's responsibility to present all 23 the data. 24 DR. ROREM: Yes. 25 You understand that this has all reached them before ACE-FEDERAL REPORTERS. INC. 61 CONSTITUTION Avc N.W, W a c 24 I they come to the meeting. 2 MR. BUGBEE: That's right, but still, it is their 3 presentation rather than the planning staff. 4 DR. ROREM: Up until it reaches our Planning Committae, 51 then I am in there giving my opinion pretty strongly. 6 MR. BUGBEE: Or you might question them or ask them 7 for new data or bring in your own data. 8 DR. R@: That's right. 9 MRS. COLEMAN: Do you tailor their program somewhat? 10 Do you modify it? In addition to approving or disapproving, 11 do you change? 12 DR. ROREM: I would say it is fair to say that most 13 of the programs by the time they even reach the representative FR 14 committee have been changed materially. 15 Wouldn't you? 16 MR. WILLIS: Yes. 17 I think it is part in answer to your question and Mr, 18 Bugbee's to note that there is a working schedule set up. Eveiy 19 hospital must have its long-range planning committee, which 20 committee must announce long in advance of the time it comes 21 to these official committees what its tentative plans and 22 programs are. And then the staff works with them. And most 23 of the modification and so on occurs there in the early 24 planning stages before it ever comes to the committee. 25 DR. ROREM: I might say we have Postponed I would sa]p ACE-FEDERAL REPORTERS, INC. 61 CONSTITUTION AvE N.W. W45.1,@'ON, 0. C 25 at least a dozen projects, not disapproved, just postponed. 2 And just they were out of this world and weren't to be considered 3 at all. One project was for complete rebuilding of a mental 4 hospital. Th ey were going to spend money for renovating first and $5 million for a nonprofit unit of about 300 beds and it 5 6 looks now as if they are going to just drop it completely and 7 'go out of the-nurses home business and set these people up over 8 in their big nufges home. And this is an illustration. 9 DR. KLICKA: In these meetings, Rufus, is there a 10 complete agreement on the accepted bed need for an area between 11 your organization and the State organization that is responsible 12 for the administration? 13 DR. RCREM: And the Hill-Burton. There is now. FR DR. KLICKA: Do they accept your figures or you 14 15 accept theirs? 16 DR. ROREM: They are the same figures. 17 DR. KLICKA: You are not answering my questions. Are they yours or their f igures? 18 19 DR. ROREM: We gather the figures for them. There 20 is no conflict as to what the mathematics is. 21 DR. KLICKA: Who computes the beds? Do you do it 22 or the State do it? 23 DR. ROREM: For the State plan? 24 DR. KLICKA: No. for these regions that you are 21 talking about where a hospital comes in and says, "We want to ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE N.W@ i7. C. 26 I develop a program that will add 200 beds. Does that 200-bed 2 figure come within your purview or is it the State plan? 3 DR. ROREM: It isn't cut that fine, really. We typi- 4 cally would accept as available beds some that might have been 5 thrown out as non-fire-proof which ate in use. The State' 6 uses a strictly mathematical formula for engineering for 7 acceptable and nonacceptable beds. So we would be inclined to 8 have on balance -included in the list of beds some that we 9 know to be closed down, for example, which the State wouldn't 10 know because they don't go behind that., and some which the 11 State would regard as nonacceptable. 12 DR. KLICKA: All right. There is a problem there, 13 but I am talking about the overall bed need for a region. Who FR 14 compiles that bed need? Do you do it or the State do it to 15 sItart with? This is a fundamental thing. 16 MR. WILLIS: The State does it. 1.7 MR. BUGBEE: Who said you are f lush.7 in beds? You i8 started out a while ago saying you have more beds than you ig need. Who said that? 20 DR. ROREM: We assert that on the basis the beds 21 are not used to capacity and on the assumption we keep current 22 records of bed use. And on this simple principle, if beds areIL't 23 used to reasonable capacity, there isn't a need for more in 24 the totality. And this isn't just a single figure. The bed 25 vacancy is a composite. ACE-FEDERAL REPORTERS, INC. (51 CONSTITUTION AVE . N.W o@ C. 27 Whatever the bed vacancy, maybe more than half of 2 those are maternity and pediatric and something else, less 3 than half are medical and surgical. And one of the things that 4 we work toward and are trying to bring about is the transfer 5 of medical, obstetrical, and pediatric facilities for use'for 6 general beds. And if that were done, it would relieve the 7 need completely even in periods in the winter peaks. 8 MISS ANKINS: You mean for medical-surgical,, diverting 9 O.B. and pediatrics to medical-surgical? 10 DR. ROREM: Yes, and we are trying to get more 11 hospitals to drop this obstetrical entirely. 12 I hasten to say the hospital that is doing this isn't: 13 doing this as a matter of abstract theory. It is a very FR 141 practical administrative decision on their part. We don't 1 15 hope for anything more than enlightened self-interest, at least 16 I don't. I hope every hospital would be guided by what it .17 thinks is best for itself, but would also know what is going or. 18 around it so it would be an enlightened self-interest and 19 Inot a short-sighted one. 20 MRS. COLEMAN: Do you have very much difference in 21 quality between your hospitals? I mean, do you have very good 22 ones and very poor ones? 23 DR. ROREM: Yes. 24 MRS. COLEMAN: This presents a real problem. If a 25 good hospital wants to add beds, but there are enough beds if ACE-FEDERAL REPORTERS, INC. 261 CONSTITUT ON AvE., N W@ a C 28 1 you count all these raggedy beds around, what do you do in 2 those instances? You say you can't build any more beds 3 because we have enough beds in this area? 4 DR. ROREM: You asked what do we do. We do the best 5 we can. But what do we think or what do we say? 6 MRS. COLEMAN: Yes. 7 DR. ROREM: We try to take a look at the particular_ 8 need. 9 For example, one hospital adding beds for research 10 work in metabolism, we don't consider that as having to competB 11 with the medical-surgical cases. 12 Likewise, another hospital has added which we approved 13 just recently a building program which is going to add eleven FR 14 intensive care beds and a few more for rehabilitation. They 15 don't have to scramble for our office's priority concept. 16 And another one is going to put up, which we approve4l, 17 a 78-bed chronic care unit right on the grounds of the 18 institution. We don't regard that as being competitive with 19 the addition of general care beds. 20 MISa' JENKINS: Rufus, do you examine those parts sucli 21 as the chronic and long-term care units and so on on the basis 22 of the hospitals justification, will it be financially sound 23 if they want to do a certain type of research? Do you discuss 24 with them are they going to utilize this facility? It is goini 25 to be a charge to the general patients to underwrite it, or dc ACE-FEDERAL REPORTERS, INC. 261 Co STTTUT ON AVE N W 29 I you go into this at all? 2 DR. R@: The only place that research has come up 3 has been in connection with the university medical school and 4 affiliated institutions. 5 MISS JENKINS: That's enough said right there. 6 DR. KLICKA: Do you think that's the role of 'the 7 Planning Council? 8 MISS J M INS: To some extent. 9 DR. ROREM: We get into the operations, if you mean 10 by that -- 11 DR. KLICKA: I wonder if we could put this on the 12 agenda. I think it is a very important question. 13 MISS JENKINS: Do you think it is basically wrong, FR Carl, if they are going to put a particular special service in 14 15 which they have not well programmed? 16 DR. KLICKA: We are talking about research? 17 MISS JENKINS: Oh, no. I am talking about research 18 where it involved beds and what the financing of that research 19 will be. I am thinking only in terms of beds -- that is, beds 20 that would support research. 21 DR. KLICKA: This wouldn't be very many beds. You 22 are talking about a small 7- or 8-bed ward to support a 23 specific research. 24 MISSJENKINS: I would not be involved in that. I 25 thought Rufus was talking about something a little bigger than ACE-FEDERAL REPORTERS, INC. 61 CONSTITUTION AVE . N W, 0. c 30 i that. 2 DR. ROREM: We do have one 24 beds. 3 MR. WILLIS: I would like to add something to Dr. 4 Roremis last three comments, first, to Dr. Klicka. 5 When Dr. Rorem was just getting started, the state 6 agency computed bed needs simply on bed population ratio. And 7 all of their ratios were much higher than locally was believed 8 to be necessary.- And this created, you can well imagine, some 9 problems. Money was dangling there and plenty of empty beds 10 around. 11 Two things occurred to change that situation. 12 First and most important was that the state Hill-Burton began 13 to modify the bed population ratios by direct inclusion of FR 14 utilization data in their concept of need. 15 The second was the Hill-Burton areas themselves were 16 redefined so that the city boundary was broken. 17 Now, in Pittsburgh, as in most cities, there was an 18 excess of beds to population. Once you broke down the city boundaries as arbitrary limits of an area, you throw those 19 20 excess beds into the suburb calculation and you imediately 21 watered down that need, too. 22 So both these things happened at the same time. And 23 interestingly, the local hospital when presented with the idea 24 of changing the Hill-Burton areas this way, knowing in advance 25 that this was going to virtually wipe out any Hill-Burton ACE-FEDERAL REPORTERS, INC. 26 1 CONSTITUTION AVE. N@W W@LH@NGT @, D@ C. 31 I priorities for general beds, still went along and voted for 2 it. And the express comment was, 'We better learn how to use 3 what we have before we ask for more, it which was pretty good. 4 I am not sure all of them really knew what they were 5 voting for, but they did. And the Hill-Burton agency adopted 6 the same areas. 7 Then'the matter of quality. When these areas were 8 redefined, a big teaching hospital and a good hospital was 9 put at the core @f each area. So every area has got at least 10 one good hospital and every area has got at least one bad ii hospital. So the good hospital begins to protect the interes.tii 12 of that area, and it will always be given a higher priority to 13 try to protect that way. FR 14 On the matter of getting involved in program and 1 15 1financing, I would like to point out a difference that has 16 impressed me between the way this is happening in New York and 17 the way it happened in Pennsylvania. 18 In New Yorkp statistically, there is a great unmet 19 need for long-term care beds and virtually every hospital in 20 the Rochester region is putting in an application for nursing 21 home beds and chronic disease beds and so on. This was quite 22 a marked contrast to the situation in Pittsburgh where C. Rorem's 23 group had gotten so involved with each institution pointing out mmin 24 the difficulties in financing and in staffing and in progra & 25 and how this will relate to the short-term care and so on. ACE-FEDERAL REPORTERS, INC. 26 1 CONST'TUTION AVE N.W W@ ;HINIIQN 0. C. 32 I There were very few tears because they anticipated the 2 problem, whereas in New York they were doing it simply on the 3 basis of beds and available money and nobody is really terribly 4 concerned about how this is going to be financed or what the 5 program is going to be. 6 One, you have a plethora, and the other one a dearth. 7 I don't know which is better. 8 MR. C6@IN: Rufus, if I understood you correctly, 9 before a project comes to your attention, each hospital has 10 to have a long-range planning committee and a long-range plan. 11 DR. ROREM: That's right. 12 MR. COUSIN: Now, has your Planning Council okayed 13 all of these long-range plans because it is conceivable -- FR 14 DR. RCREM: We haven't even received them all. 15 MR. COUSIN: It is conceivable to me a hospital coull 16 come to you with a short-term project that fits in very nicely 17 with a hospitals long-term planning, but the long-term planniig 18 doesn't tie in at all with the long-term community planning. 19 DR. ROREM: Right, it could be. We do the best we 20 can. 21 For one thing, we just continually repeat in variatiims 22 on this theme that it isn't the first cost, it is the upkeep 23 that causes the most of the problems for the institution and 24 the community. A $4 million hospital is going to cost $60 25 million before it is discarded. Somebody is going to have to ACE-FEDERAL REPORTERS, INC. 261 Co"45TITUTION AVE N.W w@lh(II-1-01 0 c 33 pay t divided by three for the annual operating budget for I hat, 2 rough-and-ready purposes and figure the length of life. 3 And so you aren't just committing yourself to $4 million; you 4 are committing yourself to $64 million, assuming no change in 5.the price level. 6 MR. SIBLEY: It sounds like marriage. 7 (Laughter.) 8 MR. COtbIN: Do you intend to eventually O.K. all of 9 their long-range plans? 10 DR. ROREM: We aspire to that, yes. I don't want 11 to give the impression that this is -- You know, a guy always 12 can talk more freely away from home. I imagine the rest of yoii 13 are doing the same thing. FR 14 (Laughter.) 15 DR. HALDEMAN: Rufus, behind your whole discussion 16 and the effectiveness of what you have done, isn't this the fact 17 that there are relatively few major sources of capital construc- 18 tion funds,, a few industrialists provide a fairly large bulk? 19 DR. ROREM: I would like to answer that. That's what 20 'I thought when I came there. 21 DR. HALDEMN: But it isn't true? 22 DR. ROREM: It is not true. Big industry provides 23 in the gross something less than -- I thought in the aggregate 24 about a third of all capital funds, corporate contributions. 25 It isn't true. It is not more than 20 per cent, and it is AGE-FEDERAL REPORTERS. INC. 261 CON-TITUTION AVF N.W@ K@ 0. C, 34 1 concentrated in the areas up till now where the big industries 2 have their concentrations of employees. And suburban hospitals, 3 just for general purposes and convenience of travel, have a 4 very hard time getting big corporate support. I mean the 5 new residential suburban hospitals. 6 Now, a town like Homestead or McKeesport or Sewickley 7 where there are heavy concentrations of employees, they 8 continue to give-very, very good support once a thing has gone 9 through. 10 DR. HALDEMAN: Conversely, if your organization did 11 I'not recommend that there be an addition to a hospital, would it 12 be very difficult for them to raise the capital construction 13 funds? FR 14 DR. ROREM: Yes, it would -- has been. 15 DR. HALDEMAN: In other words, in the last analysis 16 DR. ROREM: Even if they weren't going to give an 17 awful lot anyway, it still throws a pall over the campaign, 18 no doubt about it. 19 DR. HALDEMAN: But you do in a situation wheteyour 2o real implementing force is the influence on the givers of 21 capital construction funds. 22 DR. ROMM: Especially big givers. 23 MR. BWBEE: The thing you brought out last night 24 that is important, too, you say 20 per cent big givers and 20 25 per cent small givers, your small earners and bank loans and ACE-FEDERAL REPORTERS, INC. 61 CONSTITUTION AV E . N@W@ 0. C 35 I bank loans are affected by sanctions$ too, you see. 2 DR. ROREM: That's right. 3 MR. BUGBEE: I don't know as much as they should be 4 but didn't you and Jack both say that the loaners are beginning 5 to talk about what the recommendation is? 6 DR. ROREM: That's right. 7 I might say also that we haven't had a general hospital 8 even give any tCought to a big program unless they got Hill- 9 Burton money. 10 MR. BUGBEE: Unless it got? 11 DR. ROREM: Yes. And up to now, some are starting 12 to talk about it, but it is all for expansion or for non-bed 13 activities and no bed expansion has even been thought of FR 141 except in terms of Hill-Burton support. 15 And up to the present time,, there is no difference 16 of judgment between the Harrisburg office and ours. 17 MR. BUGBEE: You mean from the present on, not up to 18 the present time. 19 DR. ROREM: No, actually, the very first six months we 20 were there,, we disapproved two plans. Both of them a month 21 after we disapproved them were approved by Hill-Burton, both 22 of them. And we are still wrestling with that fact. 23 We later approved one, and we still haven't approved 24 the other. 25 DR. HALDEMAN: Off the record. AGE-FEDERAL REPORTERS, INC. 261 CONSTITUTI(ON AVE N.W@ 36 1 (Discussion off the record.) 2 DR. KLICKA: I hope we can come back to this. 3 This question is beginning to be a real problem in Illinois. 4 DR. HALDEMAN: Well, I don't mind opening discussion. 5 Well, we will put it on the agenda to discuss. 6 MR. BUGBEE: Let me ask, Rufus, has Hill-Burton 7 designated you? Do they before they grant money now ask your_ 8 recommendation?-'Is there any official or unofficial agreement 9 DR. ROREM: Yes, in writing, and I have to quote it. 10 They will make no final decision on a request for Hill-Burton 11 funds until they ask our organization whether it is consistent 12 with the broad plan for Allegheny County. 13 MR. BUGBEE: It hasn't gone long enough for you to FR 14 tell except those rec ndations. 15 DR. ROREM: After those first two went through, there 16 has been no difference of opinion. 17 MR. BURLEIGH: What kind of a time interval elapses, 18 Dr. Rorem, the time you first have a project until the time the 19 Council -- 20 DR. ROREM: First brings it to our attention, put it 21 that way. 22 We don't always live by, but we have set an eight 23 months time lag, eight months lead time'. And we have spent 24 that particularly with respect to Hill-Burton recommendations. 25 But sometimes it is two years. Sometimes it is quite a while. ACE-FEDERAL REPORTERS, INC. 261 CONST'TUTION AVE N.W, W@,.:N"ON 0. CI 37 I I know I am taking up a lot of the time, but I am 2 getting my money's worth in here because I can't be here 3 tomorrow. But I might say that we had two hospitals that were 4 all ready to go. They were going to apply for Hill-Burton. It was pretty clear they weren't going to get it, so they 6 relaxed. So they are now getting down to the merits. They 7 can get it now. 8 They we're four miles from each other. They had 9 almost identical short-range and long-range problems. The short- range problems, they both had unsuitable facilities being used, 10 11 One happened to be the obstetrical department which 12 was in the prime location and was too big and the medical and 13 surgical facilities needed to be replaced. FR 14 The other had exactly the opposite. The obstetrical department was in bad space in old buildings and medical and 15 surgical was running high. So they both had to do something 16 7 quick within five years, also in three years, but also something 18 quick. 19 So we focused their attention, each one, upon what 20 they could do without -- using the expression -- doing anything, 21 what administrative decisions could be made. 22 And in cooperation with the Hospital Council and a 23 physician on their staff, we made administrative and space 24 utilizations of what they now got. As a result of the 25 inspection, we turned up the equivalent of about 25 beds in ACE-FEDERAL REPORTERS, INC. 261 CONST TUTION AVE N.W. 0. c 38 I one institution that could be had just for administrative 2 decisions. 3 For example, a certain segment of pediatrics could 4 be used for medical and surgical. That's one illustration. 5 The director of nurses had herself and her assistant; 6 right in the middle of the patient care area with empty space 7 in the nursing home 50 feet away. All she had to do was move- 8 out and there were eight beds. 9 Another was an introduction of a discharge timing 10 which by announcement,curiously enough was accepted by the 11 'doctors and had the equivalent of opening up another eight 12 or ten beds as far as this total was concerned. 13 So they are back to normal again, but still need to I FR do something. 1.4 15 And the other hospital wasn't full except in the 16 medical and surgical. 17 The point I am coming to is this simple that at 18 several meetings, I finally got the representatives of the 19 boards of both hospitals together, Willis with me. We had a 20 long session and I talked freely. When I wrote up the minutes, 21 I called it a su ry. I even gave it a title -- "Challenge 22 and Opportunity." And the challenge and the opportunity was 23 to work together. And I recommended that they have a list of 24 about 20 things in which the hospitals were alone and seven 25 things that they could do together and recommended they have a ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AvE N.W. D. C. 39 I joint consultant on a program. 2 And they have agreed to this and are going to pay 3 out cash for a joint consultant. And it will be a physician 4 in our area. They have agreed on someone. It looks now as 5 if it is going to be one of the members of the school of publi: 6 health, Dean Clark, you all know him. 7 So we get neck keep into operation and into operatin@ 8 finances. And w-e have the advantage that there is nothing 9 except sympathy and understanding from the Hospital Council. 10 And Mr. Sigmond's -- who is so interested in this -- main 11 criticism of us is we don't do enough, we don't get deep 12 enough into operations. We should be doing more; we should 13 be pressing harder. FR 14 So the criticism we get isn't that we are interfering 15 too much, but we aren't interfering enough, which as a short 16 round is a good criticism to have. 17 MR. PETERS: I am inclined to say -- you mentioned 18 eight months and as high as two years for a proposed study -- 19 in New York there is a proposed bill which hasn't got a committee 20 yet, but it will probably have a committee this year which says 21 that the regional council should make c nts on establishment: 22 of new construction in 45 days and 60 days on expansion of 23 facilities. And this has bothered a lot of us because we won- 24 dered how with our particular committee structure we could get 25 an opinion out in 45 days that represented anything than an ACE-FEDERAL REPORTERS, INC. 6 I CONSTITUTION AVE . N,W. WA,qr@c@@N D. c 40 I off-the-cuff opinion. 2 George can comment on that because George was 3 chairman of one of our committees for years and knows how 4 difficult it is to extract an opinion in 45 days. MR. BUGBEE:' He is probably right Eight months 6 is about what it takes. 7 MR. PETERS: That's pretty much our experience, 8 about eight montfis. 9 MISS JENKINS: This is consoling, Joe. We had one 10 demanding an opinion next week,.,and it has been four months 11 now, and we are taking a beating over it. And we are not 12 about to render an opinion yet. 13 I will go back and quote you. FR 14 DR. ROREM: A3 it goes forward and the other describe 15 their procedures, I would be very much interested to know what 16 reactions you folks have to getting the administrators and 17 representatives of other hospitals involved because as far as 18 I know, we are the only ones that get the other hospitals 19 involved with anything like this depth. And I might say this 20 was written into our bylaws, this advisory committee of 21 hospitals, before I came and at the insistence of the hospitals 22 at that time. 23 I say "hospitals," the presidents and management. 24 MRS. COLEMAN: What is the range in size among the 25 hospitals? ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AvE N,W. 41 1 DR. ROREM: Our smallest hospital, general hospital, 2 short-term hospital, is 119 beds. 3 MRS. COLEMAN: And the largest? 4 DR. ROREM: About 650. We have four of those. 5 DR. HALDEMAN: I don't want to prolong this. There 6 is one other area, though, I think we ought to get into.in 7 relation to each of the communities we are going to talk about. 8 And that is the @entral city versus suburban problem and what 9 the problems are and how you are meeting it because it seems 10 to me like an areawide planning group, this is one of the hardest 11 problems to tackle. 12 You may have a surplus of beds in a central city, bul: 13 you have suburban areas growing up which are going to, in many FR 14 instances, get proprietary beds if you don't let them have their 15 own beds. 16 You might speak to that point. 17 DR. ROREM: We take the position that suburban, 18 through statistical facts which are true which we point out., 19 a number of statistical facts, one is that at the present time 20 there are not many specialists living in suburban areas having 21 offices in suburban areas. They haven't come out there in part 22 because there haven't been hospitals.- 23 But we have suggested that the principle of the 24 satellite hospital be used and even if it is a,bed facility that 25 it be an offshoot or be sponsored by one of the larger ACE-FEDERAL REPORTERS. INC. 261 CONSTITUTION AvE.. N W, wqs@'Na@ON, 0. C. 42 I institutions in order to reduce overhead costs and duplication 2 of facilities. 3 There is an emotional appeal in the new areas, of 4 course., for an institution that will be identified and be a 5 part of it. But when the chips are down for money, they don't 6 come forward with the money. And even this institution, thi-S 1 7 $4 million institution, that is going forward, after three 8 years, they hav4-'raised and have got $1 million in pledges, caith 9 some portion of it. And it is not identified. We tried to 10 get them to identify it whether it be an offshoot or branch 11 of one of the other larger hospitals, but it is an old institution 12 with a good name, and they wanted to continue it. 13 They are moving away from an area of great need, but FR 14 also an area quite uninteresting to the institution because it 15 is a blighted area. 16 MR.BUGBEE: You know, Jack, on this issue you raise, 17 it is like the question of the administrators conference, I 18 think. One of our major problems is trying to establish 19 procedures and principles that apply to different sized metro- 20 politan areas. 21 I suspect New York, Chicago, probably Detroit, 22 Pittsburgh, is probably the size where you can do it, Cleveland, Rochester, Columbus. 23 24 DR. ROREM: That's right. 25 MR. BUGBEE: For the administrators council, but i ACE-FEDERAL REPORTERS, INC. 26 1 CONSTITUTION AVE N.W@ 0, C. 43 I think the questions of suburban versus central city are 2 almost equally separated. And we talked last night, and Rufus 3 got this page where he has five regions. 4 Well, you could make an argument about central city 5 serving the entire area much more validly than you could in 6 Detroit, I would guess. I think your issue is: Do you. want' 7 your beds spread that way? The old Hill-Burton geography a points towards sireading, but I don't know that the travel 9 anywhere here is prohibitive. 10 DR. ROREM: There isn't anybody who is more than 11 one half-hour from a hospital. 12 MR. BUGBEE: You at least by travel have the option 13 Of having the hospital in the center or outlying. Then, the FR 14 question comes where it should be and that's the part I don't 15 DR. ROREM: I used statistics that I am sure I call 16 attention to in one item of the travel. 17 One, I point Out that after all, these fine roads 18 that cause people to move out to the suburbs run both directions. .19 So, you see, it is just as easy to get back as it was to go out. 20 And the other is that as far as bed cire is concerned 31 21 on the average, a person is bedded down at the advice of a 22 doctor about once every eight years. But on the average, he will 23 see a doctor about live times a year. So only one out of 40 that 24 see a doctor. So the important thing is to have doctors in the 25 community that are handy and quick. ACE-FEDERAL REPORTERS, INC, 61 CONSTITUTION AvE N W. W@.",NG,ON , D, C, 44 1 We had a situation in our area where a man . a 2 department head of one of our large corporations, worked his 3 heart out on a drive for a hospital that was only going to be 4 a half-mile from his house. He thought, "How wonderful when 5 you wake up in the night and the kid has a cramp and rush him 6 to the hospital." And just before the ribbon cutting, he wa@ 7 transferred to Milwaukee and had to start all over again. 8 (Laughier.) 9 So this idea of convenience to a hospital. 10 And another case, one of the fellows working on this, 11 j'his wife got sick while up in Butler County and had to come 12 back 20 miles. 13 MR. BWBEE: Rufus, you are talking about the five FR 14 visits versus once in eight years. 15 Jack, even that little research you did or your 16 department did pointed out that parking was the crucial thing. 17 See,.even for the five visits a year, if you had your doctors 18 where there was ample parking, probably the half-hour isn't 19 prohibitive to take the child, leave out the emergencies. 20 DR. RMEM: In the study of emergencies. we found thiLt 21 the people that are medical emergencies or psychological 22 emergencies where they travel fast to get somewhere, they waited 23 longer before they were seen than they did the time traveling 24 to get there. 25 MR - S IB LEY: I w.ant to follow.Rufus' point a little ACE-FEDERAL REPORTERS, INC. 261 Co"ST'TUTION AVE N W. 0 c 45 i more because it leads into a broader subject perhaps which you 2 just ended by saying you are planning for the location of 3 physicians and you are not using physicians at all in your 4 procedure by which you review hospital plans or patient care 5 facility plans. You are using only hospital administrators. 6 And at this point, the question comes,, is the hospital 7 administrator capable of speaking for his medical staff, or 8 are medical staff's willing to abide by the speaking of the 9 administrator when the review takes place? 10 DR. ROP-EM: It is up to the institution to have 11 cleared all of this before it comes to us. And some of these 12 bring physicians along to these meetings. 13 I might say further that we propose from now on because FR 14 of the interests of this committee of six doctors to use them. 15 They have even said they would be willing to go on record as taking a position on plans. 16 17 MR. SIBLEY: So this would be another planning 18 procedural step- 19 DR. ROREM: It would be a parallel one or participating. 20 MR. SIBLEY: You gave us four steps. Would you put 21 it in here some place in the four steps? 22 DR. ROREM: It would be a parallel one. The six 23 doctors are invited to all these meetings. A couple of times, 24 they have come. 25 MR. SIBLEY: So up to now, your physicians, the ACE-FEDERAL REPORTERS. INC. 261 CONSTITUTION AvE N.W t. c. 46 1 representatives of organized medicine, because I presume this 2 is what they are, have not felt threatened, so they have not 3 begun to appear. 4 DR. RMEM: That's right, but they say now they are 5 willing to and would like to. There is no provision for them 'to 6 take an official position, but the chairman has said they 7 would be willing to take an official position. And I have got- 8 to'bring that to my board and see if we want them to. 9 DR. HALDEMAN: Jack. 10 MR. COUSIN: I was going to ask something else, but ii this physician discussicnchanged it a little bit. 12 When we did a patient distribution study, the same 13 as you did, we also did physicians. FR 14 DR. ROREM: We did, too, but we can't analyze it 15 statistically. It is too vague. 16 MR. COUSIN: We are going to do this over again-about 17 every five years. But meanwhile, we have done it-from time to 18 time in certain study areas for certain specific purposes. 19 DR. ROREM: You mean just the facts where the doctors 20 leave their offices? 21 MR. COUSIN: Yes. 22 DR. ROREM: We have done that. 23 MR. COUSIN: We have discovered a great many more 24@pecialists out in suburbia than you seem to indicate. 25 DR, ROREM: We are getting more, too. The last three ACE-FEDERAL REPORTERS, INC. 26 1 CONSTTTUTION Avc., N.W, W45HII-I@N 0. C 47 1 years made a difference. 2 MR. COUSIN: Getting back to the central city versus 3 the suburbia and probably the size of the city metropolitan 4 area has a lot to do with it, but besides, what about suburbanite 5 not wanting to come downtown because of the parking, and not 6 only because there is this terrific emoticqal play in having 7 a hospital in X,, Yo Z suburb, many of the patients and 8 perhaps even a higher percentage of physicians do not like some 9 of the social changes that are taking place in the metropolitan lo hospitals. 11 You could give them the world's best parking lot and 12 you could have all these beautiful highways running back and 13 forth, but they just don't like going to some of these formerl3 an( FR 14 still well-known top-flight institutions where the complexion 15 of.the patient load is changing rather drastically. 16 MR. COUSIN: The nice people want to be in the-country. 17 MR. BUGBEE: Be sick with other nice people. 18 MR. COUSIN: And some of these hospitals out in the ig country are having a higher percentage of specialists than they 20 had previously. And gain of the top-flight run at the Harpers 21 and Graces and Mt. Carnals and so forth -- well, Mt. Carmel is 22 semi-suburban -- but saw of these top-flight @town hospital 23 are losing a@ of their better men, particularly the follows 24 50 years and under who &re moving their offices out into the 25 Birmingham's and the Grosse Points and so forth. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUT'ON AVE . N@W W, 0. C. 48 I So that I am not so sure that the roads and the 2 parking are all the answers. 3 DR. ROREM: Oh, no. 4 DR. HALDEMAN: I think we perhaps ought to move on 5 to Southern New York. I do this with a bit of anxiety, you 6 might say. 7 During the Bugbee Committee deliberations, we had 8 four representat7ives of this metropolitan area on the committee 9 and we finally had to pass a rule that New York City couldn't lo be mentioned in this-committee -- (laughter) -- that we would ii never come up with a report on areawide planning. 12 In recent weeks, I have had a chance to talk to a 13 number of the people in New York interested in this metropolitan FR 14 planning group. And that is to the coaching by lbvg Coleman. i5 I think I was assured that something could be done in this area. 16 So, Joe, I wondered if you would lead off, and-Georg(@ 17 might like to speak, anyway you want to present it. 18 MR. PETERS: Again, we seem to be outnumbering the 19 rest of you three to one, although George is a Chicagoan now. 20 MR. BUGBEE: Alumni. 21 MR. PETERS: But a very important alumni. 4b 22 Actually, as far as New York is concerned, you have 23 got to think in terms of two distinct organizational structures. 24 First is the 24 years continuous existence of the Hospital 25 Council of Greater New York. And then, more recently, during ACE-FEDERAL REPORTERS, INC. 261 CO@NST'TUTION AVE,. N.W w@sHt,qG,QN, C. C. 49 1 the past year and a half or so, the Hospital Review and 2 Planning Council of Southern New York. 3 Even though there is a tie between the two, they are 4 structured somewhat differently, although a good deal of the 5 history of the former has been inherited so far by the latter. 6 Let me talk first about the Hospital Council of 7 Greater New York which I said had 24 years of existence and 8 which was the first planning council which purported to 9 represent the community and which had a community-based board 10 of directors. 11 We devised a master plan when Dr. Pastore was there 12 in the middle 140's. This master plan, as you all know, and 13 I won't go into it in detail, is based on the bed-death ratio FR 1,4 and established a certain number of beds and made some arrange.. 15 ments for distributing these beds primarily by teaching functions. 16 Over the years, we found that it was of little.use t4) 17 us. And during Dr. Nickelson's regime, we pretty much discarded ,8 it, although we have still continued to use a modified figure 19 based on the bed-death ratio. And I say, "modified". we modif], 20 it pretty much the same as,you all do on the experience of 21 demand,, use. If we find facilities aren't being used, quite 22 obviously, we have a sufficient number of beds. 0 23 In New York City in general, I am talking about the 24 five boroughs of New York City, we have a sufficient number of 25 bedsl although as is true of probably all of your areas., they ACE-FEDERAL REPORTERS, INC. 261 CONSTITUT ON AVE N W, I( WASHIIGTON. D. C. 50 i are very poorly distributed. Manhattan has many, many more 2 beds than it needs and roughly about 60 per cent of all the 3 patient care rendered in Manhattan hospitals is rendered to 4 Manhattan patients. The other 40 per cent of the patients 5 come from all over the'city and all over the region and even,. 6 from all over the country. 7 So our big problem in gew Yor@ which parallels 8 pretty much what-br. Rorem talked ab out here, we have an area 9 where we have enough beds. We found out that the population 10 'of New York City.has gone down since 1950 and little change is 11 expected in the next 20 years. 12 In fact, we have just published, and I am sure all 13 of you have a copy of it, a monograph dealing with the future FR 14 population of our region. We find that in New York City, as I 15 said, we expect little or no change in numbers of people, 16 although we expect at least a 2 million growth in the other counties outs ide of New York City, primarily Nassau, Stiffolk 17 18 and a few of the ones up north of the city. So this presents 19 a new problem for the new Council. 20 First of all - what do you do with New York City? 21 And secondly, what do you do to meet the growing needs in the 22 suburban Counties? 23 We haven't done much about the latter, and one of the 24 big things we have done during this first year of our new 25 existence has been to .spend as much time as our small staff ACE-FEDERAL REPORTERS, INC. 61 CONSTITUTION AVE N,W. 51 I would allow to get familiar with the problems and the character- 2 istics and the hospitals of the other nine counties outside of 3 New York City. And this is a tremendous job. We are talking 4 about now outside of New York City more hospitals than probably 5 any of you have except Dr. Klicka. We are talking about 100. 6 hospitals outside of the five boroughs of New York City and 7 140 general hospitals in the five boroughs of New York City, 8 a total of 240 tf6spitals with roughly 115,000 beds, I believe. 9 We are talking about a huge complex. 10 I dreadit)o think what would happen if our present 11 staff got the long-range plans of every one of these 240 12 hospitals. 13 (Laughter.) FR 14 I wouldn't know how to file them, much less how to interpret them. It isn't a problem. 15 16 Ours is a problem of dimension to a great extent. 17 So let me talk about how the old Council operated and then go 18 into very briefly how the new one hopes to operates 19 The old hospital council did not get involved -- 20 correct me if I am wrong, George, because you were on the 21 policy end, I was really on the staff end -- the old hospital 22 council did not get involved in studying hospitals or giving 23 advice unless it was formally asked. This is pretty much like 24 you said your early days were. We did not do any studies. We 25 did not render any opinions. We did not make any recommendations ACE-FEDERAL REPORTERS, INC. 26 1 CONSTITUTION AvF N,%Iv 52 I unless the group or the hospital or the agency wrote to our 2 Board of Directors and our Board of Directors took this up at 3 its next meeting and passed a resolution that the staff should 4 or should not work on the problem. 5 This was the pattern for at least during my stay there 6 and I am sure it was a pattern for all the 24 years of the old 7 council. This meant and still means that a lot of institutions, 8 a lot of agencidi, do what they darn well please because unless 9 they ask us, we have never given our advice. And,, unfortunately, 10 an awful lot of.hospitals haven't asked us. In fact, some of the greatest institutions have never 11 12 asked us about our opinion. And until very recently, none of 13 the proprietary hospitals of which we have about 40 in New FR 14 York City and another 20 outside to make a total of 60 have 15 never asked our opinion, although in the past year this has 16 changed drastically. But this is not because of any action 17 which our Board has taken, bCit the action which Dr. Trussel 18 and Doug Coleman of the Blue Cross have taken. That is, they 19 now ask us to give our advice on these institutions. 20 So we are now advising on the need for proprietary 21 hospitals, but as many people say, it is closing the barn door 22 after the horse has left. We have 60 now. The problem now 23 is to keep those 60 at that number. 24 I say we did studies. Actually, we did three major 25 types of studies over the years. We studied individual AGE-FEDERAL REPORTERS, INC. 61 Co STITUTION AVE N,W 53 I hospitals at their own requests and I would suspect we have 2 done about 100 of those in the past 24 years. Our batting 3 average has been very good, I think, on the individual hospital 4 studies. 5 We have had our failures, but we have had some 6 great successes, particularly in recent years. I' 7 Now, individual hospitals ask us questions. A usual 8 question, of cou-r,se, is: Should we add more beds, inaugurate 9 a new service or new program and so forth. We study those and write a written report which in 10 11 the old Hospital Council was sent to a committee which we called the Master Plan Committee. 12 13 Now, the Master Plan Committee was structured as a FR 14 combined committee of the Board of Directors and a group 15 of outstanding, for want of a better word, technicians. We ha@ 16 about a dozen people on that committee and about half of them 17 Were board men. George Bugbee was the last chairman of the 18 Master Planning Committee. We don't have it any more as such. 19 And we had men such as the Commissioner of Hospitals 20 of New York City. That is the man responsible for the operation 21 of the city's municipal hospital system. We had some knowledgeable 22 physicians who were engaged in research. We had Blue Cross 23 who is on it at this time -- Doug Coleman. Even before he was 24 on the Board, I think. But we had that type of person plus 25 Board people, knowledgeable people, who could give us technic 1 ACE-FEDERAL REPORTERS. INC. 61 CoNSTITUTION AvE N W. 0 C 54 I advice and Board people who could give us the reaction of the 2 community. 3 DR. ROREM: Any voluntary hospital administrators 4 on that? 5 MR. PETERS: Yes we usually had one who came usually 6 as a representative of the Greater New York Hospital Associati,Dn. 7 which is the trade association. In the past few years, it has 8 been Martin Ste:C@berg who, as you can well imagine, brings a 9 much broader approach than that of a hospital administrator. 10 The hospital administrators we have had on it have 11 been selected, not primarily because they were hospital 12 administrators, but because they could give us a broad picture 13 They were not there because they served one hospital or one FR 14 group of hospitals. 15 The Master Plan Committee reviewed the staff's 16 recommendation. The staff would write a report and bring it 17 directly to the Master Planning Committee at which time the Maj;ter 18 Planning Committee would discuss it at great length. And 19 George can tell you what great length means. They would ask 20 all sorts of questions because you had very knowledgeable peop e 21 on this committee who could ask very specific questions and gi-e 22 very specific reactions to the report. 23 In some instances, it was necessary to bring the 24 report back on a second or third occasion until it met the 25 approval of the Master Planning Committee. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE N,W, W@5@"GTON 0. C. 55 I MR. BUGBEE: I never was sure whether it was the 2 function of the council, but I would say they were as detailed 3 and probably better than most consultants would do on a 4 community plan. They might have 100 pages in great detail. 5 MR. PETERS: The average report ran about 30 pages, 3ome 6 went to 100, some reports even went into more than that. 7 When-the Master Plan Committee approved the report, 8 and I might add that they rarely approved the report without 9 putting some sort of word change or something. They always 10 put their hand on the report. It never came out precisely 'as it went in. There was always some change, either a word 11 12 change or policy change or adding a recommendation or taking 13 out a recommendation, although in general, the sense of the FR 14 report always was the same as it went in. I don't know of 15 any time when the staff was completely overruled. 16 When the report was approved by the Master Plan 17 Committee, it went to the Board 'of Directors. The Board of 18 Directors, of course, then did the same thing to it, but with 19 not quite the elaborate discussion that you would get in the 20 Master Plan Committee. And this is the report that was sent 21 to the hospital. 22 Now, the biggest problem we faced then and still 23 face to some extent is how do you assure that the hospital or the group to whic h you are addressing the report will do what 24 25 Youwant them to do. And this was the great problem that ACE-FEDERAL REPORTERS, INC. 6 1 CONSTITUTION AvF N.W o@ C. ii 56 1 plagued the old Hospital Council. 2 We did have one great instrument and one which was 3 very helpful over the years. And that is, we with the Hill- 4 Burton agencies were working with the State of New York on 5 a contractual basis to administer Hill-Burton funds locally,.. 6 So a great deal of our leverage we had during the last @YS 7 of the old Council was based on this Hill-Burton leverage. 8 We could actuall-@ make specific recommendations on where the 9 Hill-Burton money in the five boroughs of New York City should 10 go and this gave us, as I said, a great deal of leverage. And there are many people who believe that many 12 hospitals asked us for studies merely to get on our good side 13 so they could get Hill-Burton money. I suspect this is true. i FR 14 It is certainly not a bad thing. It is certainly better to have a hospital come to us 15 16 for Hill-Burton money after we have made recommendations than 17 have them come to us cold. So we didn't look upon this as 18 such a terrible thing. We used it and I think we used it to good advantage 19 9 20 in many instances. For that, I would say some of our best 21 Hill-Burton grants came out of the fact we did do a study and 22 some of our worst came out of the fact we didn't know too much 23 of the hospital because we haven't had a chance to study them Ln 24 depth. 25 We had our failures, and let me tell you something ACE-FEDERAL REPORTERS, INC. 261 CONSTITUT'ON AVE N W V,, - , , , ,, C, C 57 1 about the failures. You learn a lot by the failures. 2 One of our most persistent group of failures over 3 the recent years has been what do we do with the specialty 4 hospital of New York City. New York City still has a number 5 of specialty institutions. It has, I believe, four or five 6 well-known institutions which provide care for eye, ear, nose., 7 and throat patients. At least two of these are among the 8 greatest institutions of their kind in the world. 9 MR. BUGBEE: With the first physical plant. 10 MR. PETERS: Both of them have old physical plants. 11 'One goes back to the 1890's, the other goes back to the early 12 1900's. Both of these institutions have looked to the HospitaL 13 Council for advice. FR 14 One of them has come to us from, I think, the first 15 study the Council did in 1939. It was the New York Eye and 16 Ear Infirmary. And one of the last studies we did prior to 17 taking on the new Council was New York Eye and Ear Infirmary. 18 We did three studies,, and in all three institutions we urged 19 them to close down their present plant because it was inadequate 20 and to merge with another institution. The hospital still 21 exists independently, so you can-see how successful we have 22 been. 23 Another hospital, Manhattan Eye and Ear, was a little 24 smarter. They never officially asked our opinion, but they 25 constantly worked with Us. They never wrote that all-importart ACE-FEDERAL REPORTERS, INC, 26 1 CONSTITUTION AvE: N W. W..... @,, 0 C 58 1 letter to the Board requesting a survey. But their President 2 has worked very closely with us over the years. And again, 3 it has been a failure even though they have had the best of 4 instructions. They have taken every step possible to merge 5 with institutions, but have never been able to work out a 6 program of mutual satisfaction of both institutions. T 7 And the hospital now with the advice of one of the 8 outstanding coni-iltants in America is planning to rebuild next 9 door to its present location. 10 Those.have been two of our great failures. These 11 have been the knottiest problems because I say we are not 12 dealing here with the kind of hospital which we so frequently 13 deal with in Now York City -- that is, the inferior hospital. FR 14 Here, you are talking about great institutions, institutions oF 15 world leadership. And I don't think I am exaggerating to say 16 these are world leadership institutions. And this has been 17 the.problem. What do you do with the specialty hospital. 18 We have argued about this. We have long lived with this concept that there is no need for a specialty hospital. 191 20 Yet, when you get down to a particular institution, particularly 21 a great institution, you begin to wonder what do you do with 22 them. 23 DR. KLICKA: You succeeded with one, Women's Hospital. 24 MR. PETERS: Yes. 25 Well,, we succeeded, but it is still occupying its ACE-FEDERAL REPORTERS. INC. 261 CONST TUTION AVE N W. 59 1 present plant. Its plan is to merge, but until it actually 2 closes down, we haven't succeeded. 3 MRS. COLEMAN: It is being merged administratively. 4 DR. KLICKA: They are building a new building. .5 MR. PETERS: Yes. 6 We have succeeded with others, New York Orthopedic 7 and one or two others. It hasn't been all failures by any 8 means, but thes@two have been the knottiest ones. 9 MR. SIBLEY: You regard this as a problem because 10 this is criteria you are talking against. You set up a criteria 11 there shouldn't be specialty hospitals. 12 MR. PETERS: Yes, our Board says we shouldn't have 13 specialty hospitals. FR 14 DR. KLICKA: What if you had a children's hospital? 15 Do you think that Board would be against this? 16 MR. PETERS: Yes. 17 MRS. COLEMAN: Not adamantly so. Even though they 18 take a position, they are not married to it to such an extent they want to see good care stopped in order to prove something. 19 20 DR. KLICKA: Wouldn't you consider a children's 21 hospital a specialty hospital, but being a little different 22 really, than an ear, nose, and throat hospital? 23 MR. PETERS: A children's hospital is really nothing 24 more than a general hospital for little people. We are not 25 against all specialty hospitals.' We have certainly not ACE-FEDERAL REPORTERS. INC. 261 CONSTITUTION AVE N@W @ C 60 I resisted the movement of the hospital for special surgery. 2 Of course, they are affiliated with somebody else and 3 are working closely with New York Hospital, New York-Cornell 4 Complex. 5 What we are trying to do with each of the specialty. 6 hospitals is to get them to affiliate with another institution 7 and if and when the time comes to replace their plants to get- 8 some sort of geographical proximity. And here is where your 9 problem comes in Nw York City, Manhattan particularly, where 10 land becomes a very expensive commodity. 11 Well, that's the type of hospital we have had 12 failures with. One of the big problems is everybody hasn't 13 asked our opinion. Unfortunately, some of the greatest institi- FR 14 tions haven't asked our opinion, but these are great institutions, 15 and they have tended pretty much to do what is in the best 16 interests of the community. 17 Now, let's go into the new plarming agency, the 18 Hospital Unit Plarming Council of Southern New York. 19 DR. HALDEMAN: Joe, I hate to interrupt, but one or 20 two people have indicated that a break might be in order. 21 MR. SIBLEY: Jack, I don't think everybody knows 22 Jim Ensign from the Blue Cross Association who has come in. 23 (Whereupon., a recess was taken.) 24 DR. HALDEMAN: I wonder if we can get on with our 25 hog killing. ACE-FEDERAL REPORTERS, INC. 26 t CONSTITUTION AvE N W. 0, C. 61 I MIS3 JENKINS: Jack, that typifies you as coming fro 2 Oklahoma. 3 DR. HALDEMAN: Five years from now I won't say that$ 4 probably, after being exposed to New York. DR. ROREM: You will move up the animal kingdom and )e 6 sacrificed at some other level. 7 DR. HALDEMAN: I might even be seen with an umbrella- 8 Where I came fro-m', a man who walked down'the street with an 9 umbrella would get laughed off the street. 10 MR. BLUBEE: I suppose you will appear at the last 11 meeting with a Hamburg 12 DR. HALDEMAN: O.K., gentlemen. 13 MR. PETERS: Let me run down very briefly the organi,,,,a- FR 14 tion structure of the new Council and then let me give you some 15 background on the criteria that was distributed to you today ilk 16 this material because I think you might find it of some interest 17 in your work. 18 The new Hospital Planning Council of Southern New 19 York is a successor agency to the old Hospital Council. It 20 officially came into being last spring which makes it over a 21 year old now. It covers 14 counties, the five counties or 22 boroughs Of New York City, and the nine Outlying counties whict 23 take it out as far as Montauk Point on Long Island and a little 24 bit north of Poughkeepsie in New York. It is the southern tiez 25 of counties in New York. ACE-FEDERAL REPORTERS, INC. 61 CONSTITUTION AVE . N,W. WASI'A@ION, 0. C, 62 I There were many problems in structuring this, and 2 there is nobody more qualified to tell you about the problems 3 that were faced in this than George Bugbee because he was the 4 chairman of the group that brought this about. For your information, Georgq, there are still some 6 unresolved problems. 7 MR. BUGBEE: I know. 8 MR. PETF.RS: Particularly with relationships of 9 one of the subgroups in the area which is constantly giving 10 indication they.would like to break loose and go out on their 11 own, saying they would like to plan-for the 2 million people 12 in their area which makes a pretty good sized planning area., 13 by the way, 2 million people. But they originally consented FR 14 to join us, and one of the big problems in the immediate future 15 is going to be how can you work with these people, still givin,,r. 16 them some degree of autonomy in their local affairs and still 17 bringing them into the whole regional complexion. 18 This is going to be perhaps one of the most difficult: 19 organizational problems that the Council is going to face in 20 the coming months. But the new Council, as -I said., covers 21 14 counties, and it was structured so we would get representation 22 from the entire region. 23 We have a Board of Directors of 43 people, 36 of whcxi 24 are elected and seven are so-called ex-officio members who 25 represent county commissioners of health, county commissioners ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE N.W, 0 C, 63 1 of welfare, and the various commissioners in New York City. 2 It is much larger than the old Council. 3 The old Council Board, as I recall, was about 30. 4 This is 43. Although it is very encouraging to say that the 5 attendance even though some of these men come from 150 miles 6 away, has been remarkably good. I certainly can't say that th! 7 Board is too,big in terms of attendance., We certainly are 8 getting 30, 31, jeople at.every-meeting, morelthan that. And 9 some of the one,-- who don't ,come are the ones locally. 10 In fact,--the,ones from outl;of thecity have been ii 'very diligent in attending,,,and, .we, certainly have ,no problems 12 in that. 13 As to whether the Board is too big to managed Ao far: FR 14 it,,,has,been no problem, b ut :,it. - is :,r-c)nceive k:th4kt. i5 P:ri* lem,irk .the f tk@ure. W-P- hadAk. master. p@.-lan,; tommittee.,.bef ore 16 whic@hliacted asL sort.@of a,n,@ executive COmmitt,,Oe "in, -t;l'lat it;,;revieiFed 17 all - the- -studies and made recommendations Lprior to giving it -to ,8 the Board.. That.,committee h4A.Officially been abandoned, but 19 in its place, we have-set uP,One:Of,a prpposed,four.committees 20 the Facilities ,plarming Committee whir-hwill represent,one of 21 the maj.or functt@s,,..of the Counci@$,,-.4nd this-,wi.11 be 22 @Ommitt;ee k s xp w:Lt:,h -prob leck -. o-e ans.ion,,,.-. a 23 f f illiation, ancl.,,,so .,f orth.@1% 24 t@ We,, Plan tP., -a et up three,,.other, Llommi-ttects@,,.:and three 25 otheroperat-ing@: n Ss ACE-FEDERAL REPORTERS, INC. 61 CONSTITUTION AVE N W, 64 1 and administrative services. 2 MR. SIBLEY: Would you define each one a little more' 3 MR. PETERS: Sure. 4 Facilities planning will deal with the problems of 5 construction, expansion, location of hospitals in Accordance. 6 with measures the committee needs. They will probably be pretty 7 much in the entire area te old Council stressed. That is, 8 resources, physical resources, how you distribute them and so 9 forth. This is nothing more than an expansion of our old role 10 We are hoping to get into the whole area of medical 11 services. Here we are thinking in terms of the problem that 12 Ann Coleman raised, the problem of quality, quality of medical 13 care, which is a bit of a problem in New York City bec ause in FR 14 New York City, you have,, I won't call it unique, but certainly i5 its-dimensions are greater. You have some of the world's 16 greatest institutions side by side with some hospitals which 17 wouldn't.pass muster in some of your rural areas, even. You 18 have got a lot of small hospitals. 19 Rufus said the smallest hospital was 119 beds.- I 20 wish we could say that in New York City. We can't say that. 21 We have a lot of them 80, 90, 75 beds. A lot of these are 22 proprietary hospitals. Particularly in Brooklyn, there are 23 a good number of small voluntary hospitals. Some of these 24 are good institutions, some of,them are not so good. 25 A large number of the proprietary hospitals have not ACE-FEDERAL REPORTERS, INC. 261 CONSTITUT'ON AVE., N.W. W ...... @,, D@ C. 65 1 even met the standards of the Joint Commission on Accreditaticn 2 of Hospitals. And even though they have passed those standards$ 3 it still leaves much to be desired as far as good hospital 4 care to the community is concerned. 5 We are concerned about this, and we are also concerned 6 about another problem which Rufus doesn't seem to have. And 1 7 that is the problem of medical staff appointments. I wish we- 8 could say that every doctor in New York had the appointment he 9 wanted or has an appointment. 10 DR. ROREM: Not the one he wanted. They have got 11 some. 12 MR. PETERS: Some appointment. 13 We found on the studies