16@illililloillilliiiiiiiiiiii *!I * c c, @v 22 71. HOOVE@R RI,@PORTING COMPANY, INC. (9.rp,ciat'RepOrteTS Washing,.on, D. C. IS 6 LMc/LMC DIVISION Or REGIONAL MEDICAL PROGRAMS 2 3 4 5 MEETING OF AD HOC CONSULTANTS 6 7 8 9 Conference Room G/Hr Parklawn Building, 10 5600 F3shers Lane, ,Rocltville, Maryland,-20852, 11 Wednesday May 22,-1974. 12 13 - - - 14 15 PRESIDING: DR. HERBERT B. PAliL, Acting Director. 17 18 20 21 22 2:3 24 2;) HOOVER RLPU.4 TING CO, INC@ 320 Massachusetts Avenue, N.E. 2 C 0 N T E N T S 2 3 Opening Remarks, Welcome and Introductions, by Dr. Herbert B.-Pahl, Acting Director, 4 Division of Regional Medical Programs 3 5 Remarks by Mr. Eugene Rubel, Acting Associate Director for Health Resources Planning 17 Recent History and Status Report of Division 7 of Regional Medical Regions by Dr. Herbert B. Pahl 36 9 10 12 13 14 15 17 18 20 21 2;3 24 25 HOOVER RLPUKI ING CO, INC. 320 Massacliusetts Avenue, N,E. @V,@hinaln,i n I'. 9onn9 3 P R 0 C E E D I N G S - - - --- - - - - - - 2 DR. PAHL: Perhaps we can call the meeting to order. 3 As Mrs. Handel distributes the remaining invitations 4 for you ,-o be ap pointed as a member of the Ad Hoc Regional, 5 medical Review Committee, I would like to welcome all of you 6 back to the Parklawn basement for a three-day period and sav 7 that it is ry ve . good to see all of the familiar faces again 8 and to have one or two individuals new to this table meet with 9 us. 10 You will notice that there are around the room most 11 of the familiar faces,- you will also notice that there are a 12 number of faces missing, and we'll have a little bit to say@ 13 about our current status as we go through this morning. 14 First I would like to check whether each person on 15 the committee has in fact signed the letter-and form that were distributed to you this morning because -- it's a technicality 17 but it must occur under our current provisions before we can have you act as a committee. Is there anyone that hasn't received the sheet, Eva, 20 or has not signed it? MRS. HANDEL: Everyone here has it. 21 DR. PAHL: All right. Fine. MRS. HANDEL: A few people are absent. 2:1 -DR. PAHL: Now, although we've been away from this 24 kind of activity for nearly a year and a half, I think I would 25 HOOVER FLPOII I I@tt; CO, INC@ 320 kla@chtise-tt, A@itnue, N.E. 4 like to take the opportunity to introduce some of,our key 2 staff to you, and then, following this, because all of you 3 really have not met together as a group before and worked 4 together-, at least in these special circumstances, perhapswe 5 could go around the table and have you say just a few words 6 about who you are and what your relationship to RMP has been 7 locally or on one of,the review committees so that you can get 8 to better know each other, and I think then we can go on with 9 out business at hand. 10 With respect to the introductions at the head table, 11 I would first like to introduce Mr. Eugene Rubel to my right, 12; who is the Acting Director of the CTIP Program as well as the 13 Acting Associate Director for Health Resources Planning in the 14 Bureau of Health Resources Development,'which is the bureau 1;5 that we are now functionally located in -- and we'll have more to say about that. 17 And because Mr. Rubel has to depart for hearings on 18 the Hill no later than 9:30, we'll rearrange our schedu e a little bit so that he'll have an opportunity to say a few 20 words to you and you can.have a little bit of discussion with him. 21 On Mr. Rubells right, of course, is Mr. Chambliss 22 who has been serving as the Acting Deputy Director of the RMP 2;i program and for a period of two months earlier in this year, ')4 in January and February when I was away, carried the full 25 HOOVER RLPURI lt4C@ CO, INC. @320 411-1@sachusett. Avenue, N.E@ 5 brunt of the office activities, which I very much appreciate, 2 and,, in turn, he will now be away for six weeks from mid-June 3 through July -- '@.turnabout's fair play, so I'm looking forward 4 to taking over his responsibilities. 5 And on my left is Mr. Peterson, of-course, with the office of Planning and'Evaluation. We're doing very little i 7 evaluation; we're still doing one heck of a lot of planning, 8 1 and we're very glad'tolhave Pete with us. 9 Mrs. Silsbedi whom you would expect to see here, has 10 been quite ill this past week. She may be in today or 11 tomorrow -- we certainly hope so. She's been suffering from 12, a combination of the flu,, bronchitis,, and a few other thinas, 13 and I think the pressure of work -- I don't think anvone can 14 quite determine except herself has been very heavy and 15 that undoubtedly has led to A little bit of weakened resist- i(i ance. So we are hopeful to have her back with us before the 17 meeting gets too far along, but perhaps she won't be able to take As full a measure of responsibility in directing the discussions as we had anticipated, but I know you will want to see her and wish her wall if she is back this morning or 20 this afternoon. 21 We have two visitors that 1-know are with us. I'd like to introduce Mr. Don Parkst who is the Deputy Chief on 2,'; the Operations Staff of the Bureau of Health Resources 24 Development and is sitting in for Dr. Green, the Bureau HOOVER HLPUH I trig co, INC, 320t,lassachusett Avepue,N.E. 6 Director. And I know this is Don's first interaction with the 2 committee, and I hope you'll feel free to stay as much of the 3 meeting time as you can, Don. 4 And on the other side of the room we have Dr. 5 Roberts from the National Heart & Lung Institute, and we hope- 6 fu.11v will have his presence during a portion of the meeting, 7 and perhaps there'll be. some discussions you'd like to partici- 8 @pate in as we,go along.,, 9 I don't know@whether I've missed any other visitors 10 or not. If so, you might at this time wish to identify your- 11 self if you are from another agency. 12, If not, I think I would like to ask -- just perhaps 13 starting with Mrs. TAT@7akoff because she brings a breath of 14 spring here in her blue outfit to introduce herself to the 15 committee and just say a word about her relationship to the RMP activities, past or current. And if we could perhaps just go around the table rather quickly, then some of you who 17 18 haven't sat with this group before will have an opportunity to 1!) know who each other is, and then you can get better acquainted at coffee breaks and so forth. 20 So, Florence, would you be good enough to say just 21 9.) a word or two, please? 2:3 MRS. IIYCKOFF: All right. Well, I used to be on the National Council of the Regional liedical Program, and I am now 24 on the Board of the Health Services Education Council, which MOWER RLPUKTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 7 is a baby of RMP, in California in the central five counties 2 with a base in San Jose near my home. 3 I'm also with the National Cancer Institute program 4 Review Committee for Education. 5 DR. IIHITE: I'm Phil lihite and I was on the National 6 Review Committee for what seemed like a couple of decades. I 7 can't remember when it stopped, but I'm glad be back. 8 I'm now a practicing neurologist and 1 haven't had 9 anv opportunity to do paperwork like this for a long time. 10 DR. PAHL: We hope to get you reindoctrinated. 11 Dr. Vaun? 12t DR. VAUN: Bill Vaun, Director of Medical Education, 13 Monmouth Medical Center in Long Branch, New.Jersey; Professor 14 of Medicine at Hahnemann Medical College. 1.5 1 guess I'm here because I've been relating to the New Jersey PAG over a period of years. 17 DR. PAHL: Thank you. Welcome, and we're glad,to have you here. Dr. Hirschboeck? DR. HIRSCHBOECK: I'm the former coordinator of .,,le 20 21 Wisconsin Regional Medical Program and still involved as a RAG member. I am now doing a little mini RMP work in a commu- 22 nity hospital in Milwaukee. 2;3 DR. PAJIL: Dr. Heustis? 24 DR. HEUSTIS: I am a consultant in health programs 25 IIOOVER RLPUXIING GO, INC. 11 @20 Massaci,,Ulletts Avenue, N.E. 8 r mvself. Former- organization on a part-,Lime basis working fo 2 ly I was the coordinator of the Michigan program for three or 3 four years, and before that the'State Health Commissioner of 4 Michigan for twenty-sotne-odd years. 5 DR. PAHL: Tlellt I'm sure you're used to some paper- work, as we are here. 7 Dr. Hess?, 8 DP,. HEc),S: @l,m Joe'Hess. I'm a former Review Com- 9 mittee member. I have'done very little RMP work since we were 10 retired a little over a year ago. 11 DR. PAHL: lqelll rectify that over the next three 12 days. 13 Mr. Barrows? 14 MR. BARROWS: Ken Barrows. My background is the 15 insurance business and I was the original chairman of Idwa's I(; CHP A agency and more recently the chairman for two years of 17 the Iowa RAG. I'm still on both organizations. DR. PAHL: Thank you. We're glad to have you here. Sister Ann Josephine.7 SISTER ANN JOSEPHINE: I'm Sister Ann, and I had 20 originally worked with the Intermountain Regional Program and 21 then for several years on the Review Committee, but since 172, the fall of 172, I haven't had an opportunity to work with 2:3 this group and I'm glad to be back. 24 DR. PAHL: We're glad to have you back, too. 2;-) EFOR@ING co, INC. 320 klassachusetts Aventie, N.E. Washinprton. D.C. 20002 9 Dr. Teschan? 2 DR. TESCHAN: I'm Bill Teschan. I'm a faculty member at Vanderbilt University, a practicing nephr6l@ist, 4 former director of the Tennessee Mid-South MMP, and Chairman of the National Board, 6 DR. PAHL: Welcome. 7 Dr. McCall. 8 DR.'McCALL: @I'm Charlie McCall, formerly Director of the Texas Regional Medical Program. I'm now with the 10 University of Texas Health Science Center, Southwestern p 11 Medical School, Associate Dean of Mddi'cal'Aff'aits-,("honetic)'.- 12 My only current association with the Texas Regional @13 Medical Program or regional medical programs at all has been 14 ber of the (inaudible) Plannin Committee for the as a mem 9 state. DR. PAHL4. Thank you. 17 Mr. de la Puente? MR. DE LA PUENTE: I'm Joe-de la Puente. I used to 18 be deputy to Pete Peterson in Program Planning and Evaluation. Now I am with the Bureau of Health Services Research 20 21 and I'm a permanent friend of RMP. 22 DR. PAHL: Ile need them. Thank you, Dr. Bob Slater. 2:1 DR. SLATER: Well, it's nice to be back. 24 I started off in 166, I guess,, on the first National 2.:j HOOVER RKFOHIING co, INC. 37OMassachusettsAventie,N.E. w.-h;..i@n n r gnnn2 10 Council of RMP when I was in Vermont-and then spent three 2 years on the Review Committee and succeeded George James as 3 the chairman of that in my last year. 4 And then I think I faded out somewhere along the 5 line, about 168 or 169, and I've really lost track of P34P, and 6 I'm happy to be back in again. 7 I've just gone to Philadelphia I'm just moving 8 into Philadelphia with what was the Woments medical College. 9 I'm looking forward to that. It's sort of a social challenge 10 in this next'decade, the emancipation of women. 11 DR. PAHL: I gather you consider that a vast 12. improvement, and I would agree with you. 13 DR. SLATER: It certainly beats working for founda- 14 tions. 15 DR. PAHL: Mrs. Salazar. 1,6 MRS. SALAZAR: I'm Jesse Salazar,, formerly Opera- 17 tions officer and Deputy to Dick Russell in the Western Opera- 38 tions Branch, now retired. DR. PAHL: Well,, we're bringing you out of retire- ment for a short while. 20 Dr.-Win Miller. 21 DR. MILLER: I'm Winston Miller. I was Director of 22 2:@ the Northlands Regional Medical Program in Minnesota for seven 24 years, and I'm now a consultant for medical review in the State Department of Health and I have no direct connection HOOVER KLPOXIIfiG CO, INC. 320 Massachusetts Aveiitiei N.E. with R-f4P. 2 DR..PAHL: Glad to have you back again. Very nice. 3 Dr. McPhedran. 4 DR. McPHEDRAN: I'm Alex McPhedran. I was formerly 5 a member of the National Advisory Council for Regional medical 6 Programs. I'm currently Director of Medical Education at a 7 family practice residency program in Augusta, Maine. 8 DR. PAHL.- Thank you very much 9 DR. CARPENTER-. Last but not least. 10 DR. PAHL: Usually that's the position I get. I'm 11 sorry. 12 Dr. Bob Carpenter 13 DR. CARPENTER: How quickly they forget. .14 DR. PAHL: Bob.charnbliss will take over the meeting 15 now. DR. CARPENTER4. Two years ago I was the Director of 17 the Western Pennsylvania Regional Medical Program and I've retired to academic administration with the University of 18 Michigan. DR. PAHL: I'll try-again. Thank you. 20 21 As you know, we are down-from 56 RMPs to 53 RMPsi but 1 guess Western Pennsylvania is.still with us? and I want 9.) to make that clear for the record. 2:@ Keeping'in mind the time, I would like to make just 24 a few comments before turning the meeting over to Mr. Rubel. 2;y HOOVER REFUNI ING CO, INC. 320 Massachusetts-Avenue, N.E. 12 It has certainly been indeed a long time since a 2 review committee has met. 'It seems to me it was about 3 November of 1972. And I,, for one, hardly know where the time 4 has gone: It has been a very complex, difficult period with much to do with a dwindling staff, and so forth, and I don't 6 intend to try to relate to you all that we've gone through, but I would indicate just a little chronology for you, and 8 again refer you to the materials which Mrs. Silsbee developed 9 and sent out to you which I think are very excellent in giving 10 an over-all perspective of what has hap pened. 11 But since we did last meet, you will recognize that 12 in February of 1973 we informed you and every pne over the 13 country that it was necessary to engage in a phase-out acti- -14 vity. 15 Dr. Margulies at that time, of course, was the Director' of the program and for some five months, February 17 through the remaining part of that fiscal year, the Staff j8 engaged in a rather heroic effort much criticized but none- theless in terms of the volume of activity and the level of 20 professional work,. an heroic effort to have regions phase out 21 in an orderly fashion, and the turmoil both around the country 22 and within RMP was very high.. But on hindsight, for what it's 2:i worth, many of us feel that it was an activity that was well 2-1 accomplished both locally and centrally in view of the circlum- stances that existed at that time. 2;-y HODVER REFUNI ING CO, INC@ 320 Mamchusetts Avenue, N.E. Regions responded against impossible time require- 2 ments, impossible demands to prepare plans-. We, in turn, had 3 to make hundreds of difficult decisions again, I'm sure 4 judgment was in error in many of those but everyone did'do 5 the best possible, and as we approached June we had what was 6 considered to be an orderly phase-out program of a national 7 activity that had been in existence for some seven years. 8 Fortunately, the Congress did see fit to keep the 9 program alive and the President, about mid-June, signed the 10 extension legislation and this has had its ups and downs since 11 then, which, again, I won't relate in detail. They've been 12, highlighted here. 13 But, in general, the net result of that was that 14 instead of having 56 Regional Medical Programs three programs 15 were phased out completely and the remaining 53 programs at 16 that time continue in existence, and we hope will-have a full 17 and vigorous lifetime at least through June 30, 1975, as a 18 result of activities that wp-lll be involved in in these three days and in June, July, and August. 20 The extension of the program did not mean that our own staff was given the same kind of stability and, to, in a 21 9.) very quick fashion we have reduced our own headquarters' 2:1 staff from 247 people to a current figure of 88 or 87 or 85 -- 24 it changes daily, and as people have luncheons and hall cele- brations, why, it's with mixed feelings. T#elre happy to see 25 HO@l'UHIING CO, INC-. 32 usetts Avenue, N.E: WaV ,D.C@ 20002 (202) 54G-6666 14 them gain employment elsewhere; we're very sorry to see them 2 have to leave,the program because of the continued central 3 uncertainties. 4 to lead toward whatever Mr. Rubel may feel he wo@ld 5 wish to discuss with you, I would indicate that not only has 6 the RMP program internally, headquarters-w se, een un ergoing 7 its own set of difficulties, but the agency, as you know, has 8 undergone a massive reorganization and, whereas, we used to 9 be in the Health Services and Mental Health Administration, 10 approximately July 1 last the agency was split into the two 11 sister agencies, the Health Resources Administration, HRA, in 12! which we are located, and the Health Services Administration, 13 in which, of course, the majority of health services-6riented 14 programs are located. Thus, while we were trying to gear up again for an extended year of life, we were also trying to fit into a re- 17 organized agency, and that has had its own convolutions as always and we're still not completely settled down, but for a 3 8 period of approximately six months from last June through this past January, we were in one of the three bureaus into which 20 21 that agency was organized. We were in the Bureau of Health Services Research and Evaluation, which at that time was under 22 Dr. Robert Van Hoek, who subsequently has left, and that has 2:@ undergone a change of leadership. 24 About January or February of this year, when it H R RLPuHyiNG CO, INC@ 320 IIassachusetts Avenue, N.E. Wiishifigton, D.C. 20002 became clear that the Administration and the Congress were 2 both thinking along the same'lines of combining cHp. the Hill- 3 Burton, and RMP programs, it certainly seemed to make good 4 sense administratively'to try to bring these programs together 5 functionally within headquarters, keeping their separate 6 identities, but nonetheless to try to get to work a little-bit 7 more closely together,.and, so, unofficially we have moved 8 ove@ in@part,from the;@one-bureau, Health Services Research as 9 it's now termed, into the Bureau of Health Resources Develop- 10 ment. And the reason for that is because that bureau contains 11 all of the former NIH Bureau of Health manpower activities 12. which obviously are related to our interests and we to their 13 interests. And, secondly it contained the,health facilities 14 utilization Hill-Burton program as well as the Comprehensive 15 Health Planning program. So by bringing P&IP from the one bureau functionally 17 into the Bureau of Health Resources Development, we were able 18 administratively within the agency to bring the three programs closer together, and in fact there has been a much more close-- 20 there has been a closer working relationship and there obvious- ly will be an evolution internally as the external legislation becomes better defined and eventually mandated. 2:3 Now, in order to help coordinate the headquarters' three programs to function more effectively, the appointment 24 of Mr. Rubel was made -- and, Gene, I'm not exactly sure. It 2.-P ISEF,uRtING CO, INC. 320 Massacbu@tts Avenue, N.E. Viashington, D4C. 20002 ign@i 1 strikes me about January -- so manv things have happened 2 but about January, mid-January or so, this year Mr. Gene 3 Rubel was asked to take on a second hat. His first hat, which 4 still continues, is the Director of the Comprehensive Health 5 Planning program, and that's a full-time occupation. 6 The number two and major responsibility which he has 7 been asked to take on is to coordinate internally.@aiid work veii, closelv,@of course, with the agencv and,the department in 9 helping develop the Administratiot's legislative package for 10 health resources planning. 11 So that in a functional sense the Hill-Burton program and ou here ate trying to 12 his oiqn program r program 13 work together under his leadership in terms of getting 14 together and seeing how we can move forward toward healt resources planning before we actually know exactly what the 15 nature of the legislation will be. 17 And because Gene has to be again downtown today 18 because the hearings on health resources planning are going on before Senator Magnuson's Appropriations Committee, rat er I!) than dilute his time, I.would prefer with that kind of back- 20 ground to ask Mr.-Rubel if he would care to comment on anv of 22 these or other matters of organization or direction that he may be going, and then to stay as long as you can and perhaps be responsive to some inquiries from the committee. 24 Gene'.> 25 EFURYINI; CO, INC. 320 Massachusetts Aveniie, N.E. Washington, D.C. 20002 1202) 54fi,fiGG6 17 MR. RUBEL: Thank you, Herb. I am going to have to go, but I will do my best to 3 be back and spend as much time with you today as I can and 4 then on Friday as well, so let's not look upon this as the' only opportunity we have. 6 I think Her]5 has stated the organizational situation 7 quite well. Back in January and February we went through a great deal of debate aLnd looking at alternative$ to figure out 9 what the best way was of taking the monies appropriated in 10 fiscal 174 and those that had been impounded in 173-and con- 11 tinuing pursuant to the federal court order,.as----Iwell as the 12. decisions made in the department, to take approximately $120 million and give it out to the 53 Regional Medical Programs. 13 14 The process that we've come up with is not a 15 terribly satisfactory one, but I think, under the circum- stances, it was the best that we could do. Once we put I together the schedule and the process, we did consult with the 17 steering COMM3'.ttee of the coordinators and they endorsed our 1 8 proposal, and th at's, I guess, why we're here today, and perhap s later on Herb will expand on that -- on that further. 20 We are no doubt at least in my mind in the 21 22 midst ot a transition here, and any transition is difficult. The Congress is presently debating what future kinds of acti- 2:i 24 vities that it wishes to see in the whole arena of planning, regulation, resource developments and that category of 2;-) KLPUKI IRIG CO, INC. 320 Massachusetts Avetiue, N.E. Viashington, D.C. 20002 1 programs. It's doing that in the context of debate on 2 national health insurance,-as we'll as looking at other func- 3 tions that the Federal Government is performing in research 4 and manpower and the like. 5 As you probably all know, virtually all of the 6 legislative authority that we have in our agency expires on 7 June 30th and RMP is among those, as are CHP and Hill-Burton 8 and manpower and research and statistics and everything else 9 that we do. 10 And both committees, Senator Kenn6dyl.%.subcommittee 11 and Congressman Rogers' subconlmittee, have been hard at work 12 trying to decide what thevld like to see in the future. It's 13 in that context that we sit here trying to decide what -- how 14 much funding each of the RmPs should get. 15 It's pretty clear that we're not going to have any new legislation by June 30th at least it is to me but 17 it's equally clear to me that before the summer s over we j8 are going to have new legislation, and 1 don't think it's going to contain in it the continuation of any of the existing 1!) three programs as we know them today, Hill-Burton, RMP or CHP. 20 I think both the Administration as well as the 21 chairmen of both subcommittees have made it pretty clear that 22 they're not satisfied with the structures that we have today 2;1 24 and they would like to make structural changes, and I don t think they're going to take any one of the three that we have 2;) rumllnGco,INC. 320 Massachusetts Avenue, N.E. t'lashington, D.C. 20002 today or continue any of the three for another year -- that's 2 one of the alternatives that many people talk about, "Well, 3 it'll.be just another one-year extension." I don't see that 4 in the cards. 5 The fact of the matter is that there is not a single 6 bill pending before the Congress.-- at least there wasn't 7 yesterday morning I don't know who threw things.in the 8 @hopper yesterday that would continue anv of the three 9 programs as they are currently in the statute and, therefore, 10 I see very little likelihood that the same structures that we 11 have today will exist next year and, therefore, I think -- at 12 least in my mind it's pretty clear that the grant awards that 13 %'Ielre going@to be making next month and finally those in 14 August are going to be the last-grant awards made to RMPs as 15 such. Now, I would extend a note of caution and that's 17 that people said that about RMP and they've been saying it 18 about other programs two years ago, and yet we're still here today, so anything is possible. It's really up to the Congress to make its judgment, 20 )21 to decide what it would like to see. I'm only telling you what I can see as an observer 9.) from afar -- the kind of questions they've asked and the 2:1 legislative proposals that they have submitted. 24 We have had very extensive hearings before both the 2;-) RLI'UH I ING GO, INC, 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 1-@-@ I. I. "I@ Senate Subcommittee -- several months ago now and more recent- 2 ly before the House Subcommittee--- dealing with the subject 3 of what we call health resources Planning, and it's now up to 4 both coi-omittees to produce their proposals if they have any 5 and go through the long legislative process. 6 The Ad-ministration has a bill. In the House it's 7 got a number of S. 3166. It is only one of many proposals. 8 @@S-enator Kennedy@submittedihis@own version; there have been 9 four or five bills presented by members of the House Sub- 10 committee. They're very complicated, very explicit as to 11 what they want to see happen and very explicit about the pro- 12 cedutes to be used 13 Unlike current laws that we have,, certa nly or 14 and RMP today, where there has been a lot of criticism a3out purpose, they now seem to be going in verv much the other direction and laying it out from A to Z three times over. 17 Perhaps one of the reasons for that is their reaction to w at they did back in 166 and I 65, or what their predecessors did. 18 1!) I don't know how much of a holdover in members there really is. 20 Perhaps you know, I don't know how much I should 21 go into the particular pieces'of the legislation. They all 9.) focus one way or another on the three major topics, regula- 2;@ tion, planning, and implementation. To some extent or other, 24 they cover those. 2.:') RLI'UHTING CO, INC. 32OMassachuse,itsAvenue,N.E. Wasliifigton, D@C@ 20002 CAt t-'rfC I think it's fair to say that all recognize that 2 each of these has some role, but dedending'on whose bill you 3 look at, they place more or less emphasis on any or all of 4 those three functions. 5 It's also important to recognize that debate about 6 national health insurance is going on and those functions are 7 also contained in the various and sundry bills that are being 8@@ .-d:Lscussed by -dif-f erent committees on the Hill, ways and Means 9 and Finance Committee., and one of the interesting things here 10 is going to be to what extent they actually manage to work 11 together or somehow work separately. 12 You may know, for example, that Senator Kennedvls and Congressman Mills' health insurance bill has a very large 13 14 resource development fund that three or four years from now 15 would have four or five billion dollars a year in it for the purpose of developing resources, and that's a lot of money. 17 That kind of puts into a little corner everything that the 18 Health Committees havd-done if you add in manpower, and you can even add in biomedical research, and it still looks 20 like a minor fraction. Now, exactly how that kind of apparatus would func- 21 tion, to the extent that it's actually enacted, and how t 22 would fit in with these agencies that we're talking about 2:3 today, is very uncertain. 24 In the meantime, with all this uncertainty we have 2.:-) REPONTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-GG66 RMPs functioning out there; we have CHP agencies functioning; 2 we continue to build health care.facilities, and we have lots 3 of meetings talking about what's going to happen in the future 4 and we have a lot of people bemoaning their fates and sayiAg 5 "Gee, whiz, how can we live with this, all this uncertainty?", 6 Dr. Endicott on manv occasions has talked about the 7 mess that we're living in, and it is indeed a mess. we all 8@. ,re-cognize it. 9 I hope a year from now we can look back on this rtainty there 10 period and say, "Yeah, there was a period of unce 11 but we Ire over it. It 12, It certainly looks very tall and very high to me 13 right now -- but I don't know when weire going to have enact- 14 ment of legislation. I do know-that we have worked very hard to try to structure a transition. We have attempted for all 1.5 of our agencies to build in pretty much a full year of opera- 17 tion so that during that year we can move from what we have 18 today to wherever we're going in the futurei and the awar s 19 that we'll be making before June 30th, certainly for core staffing of RMPS, will allow each of the RMPs to function and 20 function well, I hope,, during fiscal 175, and by the t me, )21 we're finished, I hope we'll be able to more or less do-1--that-@L-1 22 safat"-tfi-ihg@',@f -or'-the@,@oth@.tl'.Orqa'nitAtions. 2*; Fiscal 175 is going.to be, I think, a year of change 24 and it will be in fiscal 176, beginning in 1975, where some 2.7i KTFUXIINGCO,INC. 3 assachusetts Avenue@ N.E. @lashington, D.@ 20002 (202) 546-6666 things are going to be fading away I would predict. 2 Let me just say two words about -- a few words about 3 what you're going to be'doing over the next three days. 4 We have tried to emphasize the need for RMP A-oplica- 5 tions to be reviewed by CHP agencies as part of this process, 6 and I spent a fair amount of time last night going over 7 summaries of the applications that we now have. And, first @8 of 611,@in'the great,ma@j,o:eity of cases it'I's obvious that there 9 is very close working relationship between the RMPs and the 10 various state agencies, as well as the areawide agencies. 11 In many cases I was very happy to note conmen s 12 like, "Formal review was a technicality since we've been work- inq toqether in developing these applications jointly.' 13 14 And that's the situation in the majority of the 15 cages, and it doesn't cause us any problems. on the other hand, we do have some places -- just a handful -- where there is obviously a very basic disagree- 17 ment between what the Regional Advisory Group has proposed and 18 what the CHP agencies feel are the priorities in needs of their communities. 20 21 I would'like you to look at those handful very closely and, based on whatever we have on paper now and what- 9.) ever Staff has been able to decipher, you're going to have to 2;i make some kind of judgment as-to which one of those views to 24 accept, and I think that's the kind of thing that r6al1v must 2;-) ,*RLPU;CllriG CO, INC. 320 Massachusetts Avenue, N.E. 1'4aslii'ngton, D.C. 20002 "III% @Ir ttre .I be presented to the National Council, and they have to make a 2 decision as well. 3 In the papers that you have, it's been highlighted, 4 the extent to which CHP c omments have been received and what 5 they've been, and I would like you to look at those, in par- 6 ticular in the half-dozen or so places where there appears to 7 be a problem. 8- The @se.cond point I would aslc. you to look at is the 9 extent to which RMPs have responded to the challenge of e 10 ing in the planned development process around the country. 11 As part of the application package that we sent out to all 12 the RMPS, I guess earlv in March, late in February -- I also 13 can't remember times very well 14 DR. PAHL: March, I think. 15 MR. RUBEL: we tried to suggest that it would be very useful to try to expedite the planned development process. Congress passed the Comprehensive the Partnership for 17 18 Health amendments, the statute, back in 166, and we know how few areawide agencies and state agencies have actually developed the plan and have really set something down so that 20 21 RMP would have no trouble in deciding,. "This is where we can. put our money.' And we've all heard about the endless struggles, 2;@ "Well, there isn't any plan and, so, we have to do the plan- 24 ning," and the like. 2;-) REFUG I i,NG co, INC. 320 Ma,@sachu Ptts Avenue, N.E. Wasliingtoo, DsC. O,,, (202) 546.666fi We have tried over the last year to focus CHP atten- 2 tion to the planned develop@nt process. We have gone through 3 an extensive development of what we call performance standards 4 and, as some of you mav' know, welvb actually gone out and 5 assessed or are in the process of assessing every single CHP 6 agency in the country to determine how well they meet those 7 standards. ut-it", ar that that planned development process B s c-l@ e 9 is not something thatlb going to happen overn g t, an we sug- 10 gested that it would be very useful -- not necessarily to 11 support CHP, but to s upport the planned development process, 12 and, again, here I think it's fair to say that many, many of 13 the RMPs have responded and have responded very well to that 14 challenge. It's something that I'd like you to look at as you go through the various and sundry appl cat ons. 10 17 Again, I go back and emphasize we Ire in a transition. We have the possibility of organizations, once th s fun ing 18 cycle is over and the funds are spent, facing extinction 20 not just'RMP agencies, but all of these that we've been talk- ing about. 21 The challenge that they have had has had to attract 22 good staff, how to put together good proposals with that kind 2:@ of uncertainty in a very short-timefrwne. 24 We do have another cycle coming here and I think RLPOK I ING co, INC. 320 Massacliusetts Avenuej N.E. Washington, D.C. 20002 @,e met 26 some of the ne,,zer things will probably be in there for most 2 regions. We can't expect a perfect kind of process here. 3 The Administration has stated unequivocally, I think, that it 4 is committed to obligating all of the funds available here'to 5 the extent that there are applications that you, that our 6 Staff, and that the National Council feel should be funded. 7 It's a lot of money by any standards. It can have a significant impac*t,-I-,think,@as@has much of the funding 9 that's already been done over the last six or seven years. 10 Therefore, you've got a big job ahead of you here 11 and you have thirty or fbrtv minutes to talk about each one 12 of these, and I don't envy you. Based on those thirty or forty minutes you've got to make a judgment. 13 14 But like it's been said so many times about our system of government, it's a lousy way to do things, but 15 nobody's come up with a better wav. It's very much the same kind of situation we find ourselves in. 17 !Id be delighted to respond to your questions that you have. DR. PAHL: Dr. White. 20 DR. WHITE: I've heard about the dissolution. What 21 do you feel is the root cause of this? Why? Where does the dissatisfaction arise from? Is it due to quality or political 2:1 situations 24 A VOICE: Can we hear the question, olease? RLPURIINGCO,INC. assachusetts Avenue, N.E. Wast@iiigton, D'C. 20002 I?ng@ ug-FrIty, DR. PAHL: Use the microphone, Dr. white, please. 2 DR. WHITE: I was 'asking for the root cause for the 3 dissolution of these programs, from whence arose the dis- 4 satisfaction and from what did it stem, quality, political, 5 considerations, iihat-hAve-you. 6 MR. RUBEL: I presume you're talking about all three 7 of the programs 8 R. -WI-IITEl: @'yes. 9 MR. RUBEL: @First, Hill-Burton, I think there's a 10 feeling pretty much on the part of ev6rybodv that a program that was very important back in the late 040s, with all the 11 12 problems of nonconstruction of anything during World War II, plus the imbalances between urban and rural Amer ca, t lose 13 14 problems are not with us any more, and structures that we had 15 set up then perhaps were not Appropriate today. One very important point, as part of the Hill- Burton program, we had a planning part you know, that- 17 wonderful magic state plan, and there we set up a nice little 18 bureaucracy to do its thing, and at the same time we had a CHP ag.ency, both statewide and ar6awide, and they were con- 20 )21 flictinq with each other,-and we had GAO presenting very embarrassing reports savina, "They come out with different 22 answers. 2:3 So that I would guess that by the t e we re over 24 here we will have a federal program for construction of some 2,:-) Ktrop I ING co, INC. 3 0 Massachusetts Avenue, N.E. Wash'ington, D.C. 20002 i,)n,)l rar,@rrrr I 1 sort or other, but it's going to be very different from the 2 Hill-Burton as we know it today. 3 RMP suffered, 1 think, from the very beginning with 4 a lack of any clear-cut goal. I think this has been pretty 5 much recognized. 6 I've heard Dr. Detakey talk about his original com- 7 mittee and what they were thinking about and what finally came @8 out df tthe "Concrr-ess and you @@talk to @the . staff people on the 9 Hill -- you can give them a couDle of drinks -- and they'll 10 tell you that they were ordered to write a bill that-said 11 beautiful things but really didn't include anything in it. It 12 was a compromise. They had to come up with something, ut 3.3 they took out all the guts. 14 And I think it's fair to say that RMPS, together with the administration here, were trying to put something 15 into that nice framewor% where there really wasn t anything in the first place. 17 CHP, perhaps more than the others, was enacted before its time. The forces -- our society just wasn't ready 20 for the kinds of activities that were contemplated then. It ,121 was only when Medicare and Medicaid really took a strong hold that it was recognized -- and the federal budget kept going 9.) up and up and up -- that there was more of a recognition that 2:1 perhaps we just can't let the system do whatever it wants, 24 passage of certification-of-need laws in 23 states and all of REVOKIING CO, INC. 370 Massachusetts Avenue, N.E. Washington, D.C. 20002 them using the kind of CHP mechanism, that we had amendments 2 of the Social Security Act, Section 1122. 3 But I think there's a feeling that the structure 4 that was created then perhaps isn't a good enough structure 5 for what we need today', and Congress feels, and the Administra- 6 tion as well, that we've got to make some modifications in the 7 way we do health planning. dealing with both PMP and 9 CHP, that we don't need as many structural units out there as 10 we have created -- 'we.," the Federal Government -- that it's 11 far,better to try to put these together in fewer organizations, 12 and perhaps the reason for that stems from the observation 13 that many of these organizations spend a good deal of their t trying to figure out whose turf is whose. 14 .It gets worse, because we have things called experi- 15 mental health services delivery systems, and exactl how the y y fit in is not entirely clear. We still have remnants of 17 hospital planning councils, some purely voluntary and some 18 fostered by the Hill-Burton program back in the early I Os4 -There are a lot of organizational elements out 20 1 there and I would, in looking at the scene, say that one of 21 22 the purposes here is to tighten things up. Now,, there are some peo le that would respond and 2:; p 24 sayr "That's too simplistic and you really can't; you need different kinds of organizations," and we've heard that kind 25 BEFUNIINGCO,INC. 320 Massachti@etts Avenue, N,E, Washington, D.C. 20002 i,)n,)% c;Ag grrr .5 u testimony over the last several weeks. 2 MR. BARROWS: We've developed a very rich back- c of experience back in the states in trying to make 3 jround 4 these programs do the job that Congress intended. Is that' 5 background going to be called upon in try ing to fashion a new 6 program -- I mean, if the dogs don't like it, do you put out 7 any d food that you want? package of the canne 8'1 'How,ab-out the peol:)le-ithat have@been-trying to ma e 9 these proc k? Have they been heard in this .jrams wor 10 MR. RUBEL: Well, I would say very definitely.- 11 There's very extensive testimony by all kinds of people -- 12. governors, directors of programs, national organizations that 13 represent them -- the record has been made. Now, whether any- 14 body's been listening is a different question, DR. TESCHMI: I'd like to ask whether in the last three or four months your office has issued to CHP B agencies 17 any particular direction As to how they are to request pro- festional and technical assistance from their RMPs in plan- ning development? In other words, what has emanated from your office to stimulate B agencies particularly to utilize the 2 professional capabilities of the WTs in planning.' 21 22 MR. RUBEL: We took the whole application package that we sent to the RMPs and we sent it to all the CHP- 2:3 agencies with a covering memo explaining that this process was 24 going on and we thought it was very desirable for CHP agencies 2;-i REFUR I ING CO, INC, 320 Massachusetts Avenue, ME. Washington, D,C. 20002 1 to work together with RMPS, particularly towards the end of 2 how we expedite the planning development process. That was 3 done in early March, as I 4 DR. TESCHAN: This is to help the development of, 5 those applications weire now seeing, if I understand you c'or- 6 rectly. .7 MR. RUBEL: That's right. @8 TESC@IIAN. 1-@d like to@get o @'DR. ff the present 9 package, if I can, and talk more generally in terms of an on- 10 going CHP planning and need identification and plans to meet 11 those in the various CHP B areas. You see, the development of 12 these applications is a matter unto itself. I'm talking about 13 the ongoing CIIP areawide planning. 14 What direction, if any, comes from your office to B 15 agencies as to how RMPs should be contacted and involved At aIP's initiative, to involve professional and technical expertise on the RMP side in their ongoing plan development? 17 MR. RUBEL: Well, I can't-recall that we've said anything specifically, you know, responding to that directly, although it has certainly been implicit in well, it's been 20 imnlicit for a long time. in some places it works very well 21 22 and other places it works -- i t doesn't work at all. DR. TESaiAN: Well, the thing I'm interested in, for 2:1 example, if you've talked with Herb or are aware of the 24 legislative and administrative history of,CHP-RMP interaction, 2;-) IORLruitfit46 CO, INC. 370@ M3ssachusetts Avenue, N.E. Washington, D.C, 20002 /')n')l CAr CCrg you may be well-aware of not only the mandated -- the legisla- 2 tively mandated clause but also the regulations coming out and 3 the instructions coming out of the RMPS saying how these two 4 shall interact. 5 The mandate so far has been directed, as I under- stand it -- and that's why I brought up the question -- to the 7 r .JJM, as to what initiatives we should be taking the RMP 8 should be taking, That's very-explibit, in a lot of prose 9 and Ken Vaun is one of the authors of that prose in con- 10 siderable detail. 11 I am looking in the current batch and I will be 12 interested in the next several days' discussion as to what 'tiatives I hear that are r ciprocal, and it's the teci- 13 ini e 14 procity that I'd like to in echoing Dr. Barrows' comment 15 that enormous enterprises of five or six or seven years' dura- tion now have assembled a tremendous capability in the regions which in many respects -- in my own experience certainly -- 17 have been largely ignored bv the areas -- at least ignored to 18 the detriment of Dlan development. And so, therefore, it's really in terms of your 20 21 original hat and continuing hat in the CHP agency-ag to whether or not this might not be an excellent time in the 9.) wanin months of needing to have some plan development 2;1 9 (inaudible) for this to occur. 24 I'm looking for it in the applications here as we 2;-) HLPUKIINGCO,INC. 320 Massnhuscits Avenue, N.E. Washington, D,C. 20002 I as 2 MR. RUBEL: 'Elm not sure how to respond. I would 3 agree with you by and large. I don't know how you direct that 4 to happen, and I don't know particularly how you'd direct it 5 to happen when we're on the verge of making some substantial 6 changes in vihat goes on. 7 There is no question that there have been many, many @8@ Prob-l@ems on@,@both.@sides. 9 I would think that in these coming months we've got 10 to focus most of our attention on how to forestall those 11 problems from coming in the future, rather than trying to play 12 with them in these waning months, as you call them. e at 13 DR. PMIL: G ne indic ed that he would be able to be back with us some more both today and Friday? 14 MR. RUBEL: Right. 15 DR. PAHL: Thursday you're out of town. So I think there will be opportunity to discuss 17 18 further with him some of these points because they re very crucial to what both RMP and RMPS and CHP are trying to accomplish. 20 21 Gene, thanks for taking as much time. We look forward to having you bacl,. when the hearings are over. My staff has thoroughly instructed me to deliver any 2:3 number of items of information to vou. At the same t me w at 24 Mr. Rubel told you about thirty to forty minutes per 2;-) RRLi,oKiiNGCO,INC.. 320 Massachusetts Ave@iue, N.E Washington, D@, 20002 1 application is quite true, and we've made all of those calcu- 2 lations here and calculated your time. 3 So I want to assure you before we go on that what 4 we're going to try to do is run through.a number of things, 5 which I think should be of interest and in some cases are 6 important to you to know, and then break at 10:30 for no more 7 than twenty, twenty-five minutes, and you can br ng your @.8 ,coffee .;bacl,,r@,here,--- let's say 2,5 minutes -- and during that 9 interval you will find that these tables are going to be pull- 10 ed apart at the divider line so that we will be able to break 11 at the appropriate time -- we may have to reconvene for a few 12 minutes after coffee as a total group to wind up one or two points if I don't get finished, because we do have to talk 13 .about funding and what it is you're to do and a few other 14 things, but I'll try to just give you highlights, not too many 15 details. But when we come back, the tables will have been 17 separated and there will be a Panel "All and Panel "B,' which 18 you're familiar with. Mr. Chambliss will be in charge of Panel 20 MR. CHAMBLISS: "A." 21 DR. PAHL: -- "A,," and Mr. Peterson in charge of 22 Panel 'IB,," and after this rnorning's discussion, which will end 2;1 either just at 10:30 or shortly after we return, you can get 24 to work on the an li !lowing perhaps a very brief cations fo 25 oe RLFUR [ING CO, INC, 320 Massachusetts Avenue, N.E. Wasliingtoii, D.C. 20002 (2n2i @4fi@6666 review of exactly what the parameters are for running the 2 individual@- panels. 3 Then you're on your own for the rest.of today and 4 tomorrow up until we'd like to target the hour of 11 5 o'clock Friday morning when we would like to reconvene the 6 two panels into a whole again and bring back as a group the 7 findings of your reviews because, handling the applications in :8-, @.@two.@separ-ate--panels,, we want to make cartain@that the same 9 kinds of issues are handled as equitably and consistently as lo we can, and we'd like to have the group as a whole hear any- thing which seems important to know before we take the com- 12 mittee's recommendation on to the Council, which meets in mid- June the 14th and 15th, I believe. 13 14 So I'm urging you, first of all, that the Staff has used these little computers to calculate that you can't get 15 the work done by Thursday night, we urge you to stay until 17 mid-afternoon on Friday -- we reali .ze it's Memorial Dav week- 18 dndo but we also realize that there is a heed to do justice to all the applications whether they happen to be discussed first or last, and to the extent possible we tried to gear our own 20 I Staff work the chairmen are being held responsible for 21 keeping you to about a 40-minute point, and we'll both have 92 some things to say as to how to manage this activity, but in 2:3 fairness to the regions and what they have been through in 24 trying to bring these materials to vou, I'm sure to the extent 25 RLPOKIING CO, INC@ 3chusetts Avenue, N.E. Washington, D.C. 20002 ign9i MR-A;AG possible you will accommodate that final discussion, and if 2 we get together at 10:30 or 11:00 on Friday for a group meet- 3 ing -- perhaps earlv afternoon would suffice, but we have to 4 have a full committee discussions I believe, so the two pafiel 5 chairmen will be able to resolve together with you anv of 6 those matters which t)erhaps.have not been handled eauitablv 7 across regions. 'Now,,-with that apart, let meitrv to take the next 9 period of time and go over with you a few matters which I 10 believe should be of interest -- hitting the highlights,, 11 r Mr. recognizing that we will be here fo a few days Ch@li@5 12, and T are fairlv familiar with all of theIdetails behind all 13 of the points I'm going to mention, and should any of you 14 individually have questions or want further information or clarification, He'll make everv effort to give that to you, 15 but I don't want to bore vou with hours and hours of chrono- 17 logy over the last 17 months, because it really isn't appro- 18 priate. I. would like to a6 back for a moment to our staff- 20 ing because so many of you have been intimately involved with our Staff. I would like to tell you the major changes which 21 have occurred, apart from the numbers. 22 You will recall perhaps that when we used to meet 2;i together we were organized into at least-@two main divisions, 24 a division of operations, which at that time was under 25 320 Massachusetts Avenue, N.[. VYas[iington, D.C. 20002 cAr rtrc 37 Mr. Chambliss' direction and is now under Mrs. Silsbee's 2 direction, and a division of professional and technical 3 development, which at that time was under Dr. Ed Himnan's 4 leadership. 5 We also had an office of plannina and evaluation under Mr. Peterson, an,office of grants management within the division of operations' under Mr. Gardell, and an office of 8 svstems management, our internal computer system for informa- 9 tion gathering and retrieval, under Mr. Frank Ignowski. We 10 also had a public affairs and information office and the usual 11 supporting services. 12, Without detailing who has left because it's too 13 long a list, let me say that as the first casualty of our own 14 internal,phase-out operation of February 173, the division of 6fessional and technical development reduced from approxi- 15 pr 16 mately 70 people, most of whom were professionals with skills 17 in many areas, down to a residue of about eight. That eictht occurred between February and June. 18 We los t the office of systems management head, 20 Mr. ignowski -- we're glad to say he went into the office of 21 the Assistant Secretary of Health, and,I'm sure he's doing a. - fine job there and we're happy to say that his deputV at that -time has been acting in that capacity, Mr. Ott, since then. 2;t That staff has, by and large, remained intact 24 I althoughvtelve suffered a few casualties. 2 HOOVER REI'UKI ING CO, INC. 320 Massachtisetts Aventie, N.E. Washington, D.C. 20002 The office of Public affairs has'been completely 2 eliminated,@so we have no public-information coming out from 3 here and we're dependent upon the Bureauls good offices to 4 providethat service to us. 5 Mr. Peterson's Planning and evaluation group of 6 bright young people who used to number of -- what, seventeen 7 MR. PETERSON: Eighteen. @8 @'DR.'PAIIL: -- seventeen@or eighteen people,, a very 9 sharp group, did a tremendous amount of work, has been reduced i.o to Mr4 Peterson and has been amplified and augmented by Miss 11 Morrill, who was one of the residuals from the division of 12 professional and technical development, and Mr. de la Puente for a while was with Pete -- but basically, from the old 13 office that you used to know, t s Mr. Peterson. 14 The administrative services obviously had the r ups bind downs, but we manage not to have our wastepaper baskets 17 emptied, our Xerox machine generally out of commission, and so forth -- we are doing a fantastically good job for the 18 changes that have occurred. Within the operations division we have been most 20 21 fortunate in that practically everyone stayed for most of the months intervening between the time that we last met. How- 22 ever, over recent months we have lost a number of key people, 2;1 some of whom are represented in this rocm because they have 24 very kindly consented, with a little arm-twisting on our part 25 HOUVERREPOI.tittiSCO INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 and the courtesy of Dr. Endicott, the Agencv Administrator, to 2 return for this month and give us something like eight or nine 3 full davs of their time, at the same time carrying full loads 4 in their new occupations, to help us out with our current 5 applications, and we appreciate this very much. That's the 6 only way that we could even have a sufficient staff to get 7 through this review cycle. 18 -Mrs. Silsbee@has lost about six people with n the 9 Grade 13-14, five to six to seven man-years experience per 10 person, within the last four weeks, five weeks. 11 And, so, you can see that it does remain-difficult 12 to maintain this activitv. 13 @Within the total organization, I am happy to save 14 however,, that vie do have.many of our key people remaining with us and that is a special tribute which I'd like to make, 15 because what you don't know is that for about 18 months we - 17 have been under what in government is known as a RIF situa- tioh, a reduction in force, which is an official threat hang- 1!) 3.ng over the head that there will hot be a job for you, but 20 there is never alcancellation and never an implementation, and- part of my daily joy has been to try to find out whether we're 2 1 going to go ahead with such an activity or not, and the months roll bv and the Staff remain uncertain. 2:3 Some of us know we have jobs; others of us who have 24 less time in government know that we will be out looking if HOOVER RLPUF(I ING CO, INC. 320 Massachusetts Avenue, N.E Washington, D.C. 20002 40 such a thing gets implemented, and that has hung over the 2 heads of most oeople from February of 1973 until about two and 3 a half weeks ago,' which indicates the decision-makina. -4 canabilitv of the department or at least the tenor off the 5 times. 6 der and in addition to that, our Staff has been 7 continues to be under a proposed decentralization of our 8 headquarters' staff to regional offices, which is not puni- 9 -tive,. it is a -- what do l.want to say? an AdministrAti@ori, 10 governmental Policy and it has many fine features tc it. The only point is it either should happen or not happen, and that 12; has been going on for the last two and a half to three months .13 and finally, through some degree of efforts on our part and others, there has been sufficient pressure brought on the 14 Secretarv from the outside that the determination has been 15 made that no decentralization of our staff to regional offices' will occur until after the new legislation is passed, which, 17 of course, can be tomorrow, June 30th, August, September. This means that our Staffi f6rtv of xfhom will have their 'obs handed over into regional offices, will have to 20 3 find other employment, that is, either go to regional offices 21 or find jobs other than in IOLP, and since we have apptoxi- mately eightv-five or eighty-seven people and you take forty, you can see what this does to the morale. 24 Now, the only reason Imention this, and 1 don't 25 HOOVER Rtf'UKTING CO, INC. 320 tAassaChusetts Avenue, N@E@ 41 want to belabor it, is because I believe that what appears 2 before you in terms of what has appeared before you and-what 3 will occur in the way of Staff effort and interaction visible .4 to you his been done under the most low-morale conditions 5 that one could oossibly impose on a staff, and 'I think it's a 6 real credit to their professional integrity and sense of 7 responsibility that they have kept their minds on their jobs 8 while their friends, colleagues, depart, while thev are 9 uncertain about their own futures. 10 And I know this has been recognized by the steering 11 committee, the coordinators; I know it has been recognized by 12 the regions; and many comments favorable to the Staff have 13 come to me and also to individuals on the staff, but I think you should know the circumstances under which they have been' 14 15 and continue to labor, 16 I also want to tell 'you now something about another acti.vitv which w4ill be going on simultaneodslv with yours, and 17 that is, in the current fiscal 174 Appropriation there has 1!) been set aside approximately $4 million for the establishment of a new pilot arthritis center program. this crept into our 20 bailiwick somewhat accidentally. The arthritis group in the 21 22 country had tried to put these funds into .the NIH legi lat on and due to so many quirks that we all know about, it never 2:1 survived and because it was a g6od idea, it found a home in 24 RMP. 2.-) HOOVER RIEFORTING co, INC. 320 Massathusetts Avenue, N.E. Wiehin.fAn n r. )nnng 42 1 So,this year when we finally received our appro- 2 priation in released funds -- which I will mention in a, 3 moment starting in about February, Bob Chambliss well, .4 starting in January, I guess it was, Bob Bob Chambliss and 5 Mr. Matthew Spear, who is 6 Matt, would you just.want to stand up for a moment 7 and be identified for them? 8 Thank you. 9 Bob Chambliss and Matt Spear initiated what is going 10 to culminate starting tomorrow, Fridav, and Saturday, and also 11 at Council time initiated a $4.2 million program in pilot 12@ arthritis centers and we have, therefore, over the recent months been laboring with 53 Regional Medical Program applica- tions, which is a 400 percent 300 percent increase over 14 what we generally have. You will remember that we generally 15 handled about seventeen or eighteen applications because we 17 had three cycles a year. Since we're doing them all at once, we have 53 applications for your consideration and the Councills, and Mr. Spear is t-,he happy recipient of 43 applica- 20 tions-for pilot arthritis centers. We have a group of -- an ad hoe consultant group 21 coming in tomorrow, and that hag been going on simultaneous and all those decisions will be going to the June Council. 2:1 Because of the staffihg situation which I have 24 indicated to you, we have hot onlyih,ad to utilize Mrs. HOOVER REFORIING CO, INC. 320 faassachusetts Avenue, N.E. 43 I Silsbee's full operations division staff for these applica- 2 tions that you're looking at, but,welve had to draw upon 3 perhaps seven or eight employees who used to be in that divi- @4 sion to return, as I just mentioned a moment ago, during this 5 month to help us out. 6 So you all are the beneficiaries of Staff work by 7 -people who've alreadv left the program, but bave donated their time -- and I might say very cooperatively and under- 9 standingly. 10 Mr. Speart on the other hand, has had no staff other 11 than himself and a secretary, and we have had to call on the 12 remaining staff -- and that represents evervbodvo I assure 13 you, within R?-4P.headquarters to first of all learn some- 14 thing about reviewing a pli6ations, what to look for we've pl. had orientation sessionsi.and outside consultants and reading material, and we have drawn in people from all of our offices and units. 17 So people have been doing a very heavy job on two programs. lihat it comes do@ to is about a 400 percent work- load over normal this particular period, March, April, May, 20 21 June, July, and August, with a staff which I've indicated to you and the full understanding and cooperation of those who 22 remain. 2:@ I don't mention it in'order for you t6 do anything 24 because the regions have been laboring under the same kind of HOOVER RLROKIING CO, INC. @320 assachusetisAvenue,N.E. 44 1 nroblem, but to indicate that we have hot been immune from 2 this because we're the ones who issue the edicts. 3 believe Dr. Mason, who will be the chairman of -4 that arthritis committee, will probably be meeting here with 5 us sometime over the three-day period, and that grouD will be G meeting with us in the room s here in the Parklawn Building 7 startina tomorrow, so I will not be with you-at least in the 8 early part of tomorrow as a result of getting that group 9 oriented-. And, as vou knout, with a brand new program there 10 are many issues and policy matters to be discussed. 11 Now I'd like to turn from those matters to a little 12; bit of a history, again a quick rundown to give you a perspec- tive or a framework of understanding, and I'm primarily refer- 13 ring to material now which -Mrs. Silsbee sent to you in a 14 15 memorandum of may 7th and she included -- and you don't need this in front of you -- an Attachment A which was termed 17 "Historical Sketch." I thought it was verv well done -- I was depressed when I read it; I didftlt realize I had been through so much; I was sorry she had done it -- but it' s so well one I call it to your attention because I'd like to run down and 20 just perhaps amplify on one or two points, hitting the high- 21 lights for vou. This historical sketch starts June 1973 with the 2:3 extension legislation. one of my favorite memories in recent 24 years is June 18th, 1973, which I believe was a Monday, 2,:-) HOOVER REPORTING CO, INC. 320massachusettsAvenue@ N@E. 45 because that-preceding Friday Dr. Margulies very graciously 2 turned over the reins of the nr@ ram to me -- I forget who our 3 Administrator was at the time; we've had six or seven in that 4 period --,and my appointment was effective Monday mor-ning, 5 June 18th, and it turns out that the President-signed the 6 -extension legislation on that day, and Dr. Margulies conqratu- 7 lated me as having achieved something which he had not been 8 ablt to do in the preceding months. 9 What he didn't tell me was what it was qbincr to-be (sic) 10 like havina followed that extension of the legislation. 11 Nonetheless, starting at that time we engaged in a 12@ series of convolutions with the regions which can perhaps best be described as reaction to crises and hectic. You will 13 14 recall that at that time we had 56 Regional Medical Programs 15 and they were all on a presumably orderly phas6-out plan. With the signing of that Zeqislation and with the expectationI 17 now, of funds, fiscal 174 funds becoming available to us since the President signed the legislation, we all tried to reverse 18 ourselves and see just what wos needed to get through the summer months and get back into viable programs. 20 21 Three programs in fact were phased out; two in Ohio, Northeast Ohio and Ohio Regional medical Program, and the 22 Delaware Valley -- the Delaware program which was in the plan- 2;3 ning phase, 24 The expected funding for fiscal 174 did not dome 25 1400YER RLROKI ING CO, INC. ,?O Massachusetts Avenue, N.E. Y@ashingtoti, D.C@ 20002 46 1 about immediately as is customary and there were difficult 2 times over the s . er, and as @4-rs.. Silsbee indicated we-had 3 to give emf-,rciencv funds to certain Programs just to trv to .4 keep some people on a salary basis from week to week., I would 5 indicate that those were difficult times because we. were work- 6 inc verv closely with Dr. Edwards' office and there were 7 Periods of areat uncertainty.' At times it was indicated that 8 perhaps it would be best'to fund regional medical proarams on 9 a monthlv basis until thev could decide what to do with the 10 procrrarft, and you can imagine some of the turmoil.i Then vie graduated from th at propqsal, not made bv 11 12 us, to a quarterly funding to see how the PMPs were doing an that brought its own set of complications and somehow we .13 survived over the summer. There were manv long distance 14 telephone calls; Mr. Cardell's offi ce of grants management 15 was ctuietlv going crazy with the numbers and the dollars; 16 the.communications between downtown and Parklawn BuIld3na were 17 1113 frequent and at variance with the Preceding conversations, so that we. never quite knew whe@- we stood. But at the end of fiscal 173,, in June of 173 just 20 before the start of fiscal 174, there was a balance in our 21 program of nearlv '7 millions of dollars which, according to i the directions of Dr. Edwards, we did finally distribute to 2:3 i , so that about midnight! of June 30th, in good govern- regions 24 ment fashion, we distributed to all regions or to most of thei 2,r) HOOVER RLPUNIING CO, INC. '@20 assacbusettsavetue, N.E. 47 regions, I'm-sorry, all excent four or five, an allocation of nearlv '7 millions of dollars. 3 Unfortunately at that time we had been given @4 instructions that this allocation could not be used 'by the' 5 regions, just hand it to them,-and after the dbt)artment 6 decided what the program should.be, we would then let the regions spend this money. So we found ourselves in the 8 months of July, August, and September in the peculiar position 9 of having given monev to the regions but thev couldn't use-. the jo money and they were in certain cases borrowing and tryina to 11 keep staffs together, and this seemed to-be a paradox, but .12@ that's what continued on not only through the summer months 13'1 but all through the fall. But bv that time the wheels of government moved, 14 and as Mrs. Silsbee indicated, eventually through a lot of negotiations the department g,ave-us '17 millions of dollars for the first quarter funding it came rather late for a 17 first quarter funding, but we were verv happ .y to receive it and distributed those funds t@ regions which tort of kept them alive up to December 31. 20 Then later in the fall we- were successful in vrving 21 loose twentv-four additional millions of dollars And that 22 monev was desianed to keen regions alive from Jahuarv of 173 2:1 until last june. 4 You'll recall that there was a government-wide FOOVER RLFORTING CO, INC. z2L! ItassactiuseitsAiepae, l@@E. i r,,, #,-i n C, C ' f,,2 48 crisis with impoundment of funds, and obviously we were 2 caught very heavily in that, and, so, we had a bank reserve, 3 if you will, of about $89 millions of fiscal 173 funIds and 4 something in the neighborhood of I keep getting these 5 figures mixed uD, but perhaps Jerry, fourteen? 0 How much did we hav e released, $19 millio 7 M-R. GARDELL: Actually, it was about twenty-five. .8 ])R. PAHL: I've never seen so manv budget documents 1.9 in my life, but, anywayi we had fiscal '74 funds in the order 10 of $25 -million which were not available to u-,.and fiscal 173 11 impounded funds of approximately $89 million, and we had this little $7 million kitty distrib uted around which no v could 12. seem to release, and we were oft emergency funding, and that 13 is the set of circumstances under which the regions were oper- 14 ating and, so, when I tell you our problems, I do want to indicate that the regionsvwere having their own. 17 -Then things became a little bit clearer and this was because of an activity which the Regional Medical Programs 3 8 initiated. There was the development of the National Associa- 20 tion of Regional Medical Programs. They became incorporated and thev introduced a class action suit against the government 21 to force the government to release the impounded funds. The 22 lawsuit was filed in SeDtember and it has been a most interest- 2;1 ing period since September -- I've never had legal training, 24 but I feel like a half-baked lawier; I've certainly een 21) floOVER PLPUITTING CO, INC. 3,.O Mamchusetts Averue, N.E.I tnn f)C 2CjOa2 49 1 involved in the process. 2 s cited in this There were a number of defendant 3 lawsuit. That included Secretarv Weinberger -- it included 4 the Honorable Secretarv TTeinberger and the Honorab e-..George 5 Schultz and the Honorable Roy Ashe and Herb Pahl, and I was 6 about to file a Grievance action, but I didn't. 7 The lawsuit was entered in September and due process 8 occurred so that we anticipated an action on this by the 9 first week of December. T a was something-@ihich I found,. 10 doesn't occur. It's sort of like the present litigation that the country is in. It seems to go on forever, and, actually, 11 12 today is mav 22 and I still don't have the final Answer, 13 although the court finally decided on February the 7th to accede to the plaintiff's request to release all funds. 14 15 So, actually, on February the 7th, a Federal 1. District Court Judae did @ssue an order which required the release of all impounded funds# $89 million from fiscal '73 17 18 as well as the- rest of the fiscal 174 funds. So all of the 1() funds from 1973 and 1974 theoretically became available to us. That order also required the Administration to 20 21 remove the various kinds .of restrictions which we had place on local MTs from the preceding February so we had t 22 opportunity to learn how to draft rescinding notices and semi-. 2:1 legalistic documents which basically out the program back 24 into its prephase-out set of circumstances without a number 25 HOOVER RTFUN I !NG CO,INC. 320 Massachusetts Avenue, N.E. n r. @Inn9 50 I of restrictions that the department had placed upon the 2 programs relative to the funding or how the funds could be 3 used, and so forth. 4 Since February the 7th there has been an interesting 5 series of events which I couldn't possibly go through t e 6 chronology without looking at files, b ut merelv to say that 7 the government felt that the amount of monev that had been 8 :released en toto which would be'available for support of RMPs .9 was too much.to be used effectivelv-by -@s and there have io been a number of activities, one of #hich was filing an appeal to the court order by-the Government and requesting that funds be permitted to be used for some other purposes. 12. This has resulted in a series of negotiations across 13 the table which have not quite been completed and the initial 14 request, which was to use as much as uD to $30 million, has 15 now been whittled down toferhaps $5 million, and hourly I 17 hope to know how much money you all nav be talking about, but I can give you a figure within $5 million of how much we may have -- the onlv thing I know is that bv June 30th I will have the answer because we have an obligation to distribute some 20 funds. 21 I do want to indicate to vou that it has been a 22 very, verv complex period through the class action suit. Whati. 2:@ that suit basically does, though,, is it did release the funds. 21 I The actual amount available to -RM@Ps I will give vou in a 110OVER REFURTING co, [Vic. '420 Ma@ huse sac ttsAvenue.N@E. Y@ashirigton. D@c. 20002 minute -- is-known within 5 millions of dollars at this point and that's pretty good compared to where we started from. 3 The court 'order also did remove the various kinds of -4 restrictions and it says that RMPs may engage in those kinds 5 of activities in the current set of applications and the-forth 6 coming set of applications to be submitted iulv 1 which are in 7 accordance, obviously, with the enablihg legislation of 8 Regional Medical Programs, Title IX, as well as the Mission 9 Statement that you're all familiar with, as well as whatever 10 Council volicy has been, but it does not put restrictions or requirements on the regions to do one thing or another. 11 12@ Therefore, your applications will show ci wide spectrum'of activities. Some of them will not be as .13 14 "balanced" as perhaps you might like to see, but there are not requirements on the regions that they engage in emergency 15 medical services or that they have a kidney activity or that 16 they engage in this or that. And this is important because Mr. Chambliss and I have been trying to operate uader what has been not only our 0 interpretation, but with the General Counsell.s Office here 21 and we've formed many close and enduring friendships with a few individuals in that office -- what has been the intdrpre- tation of the court order. 2:1 I think that's all I'll say about the litigation. I lie hove to have an answer shortly, but basically it won't 2fi HOOVER RLRURI IN(; CO. INC. 320 Massachusetts Aie nue, li.E. ni' ')! @'@7 52 affect your decisions right now because I can give you a 2 rather close figure. 3 And I would like now, therefore, to turn to what 4 out and give you a picture kind of funding we are talking ab 5 of that. 6 And, Bob, why don't Pet6, would vou wan 0 7 what I would like to do is have vou look just briefly at the 8 table which we're distributing and which came out of our 9 office of systems management -- that s to show you that it.'s. 10 a viable office and this has a good deal of information 11 and i,don't want you to get too absorbed in the details 12: because there will be an opportunity for you laterlto refer to this as you go through individual anplications. 13 14 What we have tried to do here is to give you an over-all Dicture of the dollar amounts request ed b-,r regions and the dollar amounts available. 17 The first column gives the name of the region, just alphabetically. 18 The next column is what their current annualized 20 level is, which represents the six-month funding level of support which was provided in the current award starting 21 9.) January 1, 174, and which we have projected over a twelve- i month period. Basicallv that is their operating level if 2:; thev had received a full yearlw award most recently, which 24 they did not. We gave them all six-month awards up through 2;-) l@IODVER REFURTING CO, INC. 320 Massal.husetts Aventie, N.E. 53 I this June 30th, and all this does basically is show -vou what 2 their yearly operating level is. 3 The second column is targeted available funds and @4 at the bottom of that column are the totals, and you will see 5 that there is a figure of $114 million. That is the figure 6 which we believe will be available for support of programs totally from the released impounded funds together th the available remaining 174 funds. In other words, we have that much monev to support the nroqrams from their current an lica- @9 10 tions together with the applications that they will be send ng in July 1 and that you'll be looking at in July. Th@s is our 121 total amount of money left to support RMP programs a@d'this monev will be used to support activities through June 30i 175, 13 to support RMPs through June 30, 175. 14 That figure is soft by perhaps $5 million because the litigation is not yet ended and, if anything, the $5 17 million will be reduced from that, so you might say we have $109 to $114 or $115 million. Exact figures are not known. But that's pretty close; that's the best I can do for you right now. 20 Let me come back well, no. Let me discuss the- 21 targeted available funds right now. That column opposite the individual regions reflects 2:1 the total fiscal 1973 and fiscal 1974 funds which we believe 24 will be available for distribution to the RMPs and was 25 140OVER REPORI INC, Go, INC. 54 used in 1 derived by using the same Percentage factor as was 2 distributing fiscal 174 funds provided in the current bu get 3 period. 4 Now, that sentence doesn't mean much to you. except 5 to sav that when we finally had fiscal 174 funds become avail- 6 -able to us over last fall as I indicated to you in those separate allotments, we had, you will.recallr no review com- 8 mittee. We had to make a decision as to how to distribute 9 those first and second quarter dollars to regions. 10 What we did was try to find out how much in the pre- 11 phase-out period of the total amount during the fiscal 173 12z ptephage-out period each region had received on alpercentage .13 basis. go if Region x had received 6.2 percent or .12.1 per- Cent of the total ptephase-out immediately prephase-out 14 took that same Percentage and ap dollars, then we Plied it to 15 the fiscal 174 funds thathad just become Available to us and made that calculation and distributed those dollars to the 17 is region. That was the onlv fair way we could because we ha no review committee, we had no applications all we ha J!) received was dollars from the Bureau of the Budget and an 20 21 immediate ord6tl like, "Why didn't you do it yesterday?" to -get the dollars distributed. 22 So we had to do a formula and we, therefore, kept 2:)' i the relative merit of the regions intact by using the same 24 Percentage allocation for the fiscal 174 dollars as we had 2.-) MIDOVER REPOKIING CO, INC. ti.E. 55 1 found resulted from th orough reviews in fiscal '73 prior to 2 the phase-out. 3 1 hope that makes sense. able used a formula which we 4 felt was fair. This was also checked out with th steering 5 committee of coordinators who felt that it certainly was 6 fair; the Administration felt it was fair; and that's what we- 7 did. So those available targeted figures that you see in 8 9 this column now represent that same percentage for' each 10 region applied to what we believe will be the total funds available for distribution, namely,, the $109 or the $114 million. In other words, we are perpetuating in that column, 12 merelv as a reference -point -- we're perpetuating the relative 13- order'of regions that was in effect irmediatelv prior to 14 phase-out. Now, that's sor@'of a complicated historv and if 16 there's a question on that, I'll try to respond to you. If 17 not, let me go on. 18 The next column -- I:he next three columns are the May l.reauests and the total figure for Alabama requested is .)o seen there in the current application; the next column, the 21 difference, is the difference between the May 1 request bv 22 each region and Column C, the targeted available funds, and 2:1 then that shows the percentage difference. So, for example, 24 Alabama has@come in with a request,which is 136 percent above HOOVER xLfUHTING CO, INC. 320 M@sacliusetts Avenue, N.E. W.chinat"r, n c 2onn? 56 basis of 1 the available funds targete@i for that region on the 2 the calculation which I've indicated. 3 Now, I want to ci7-..ne back and make sure yo do under- .4 stand about targeted available funds when we finish because I 5 don't want any misunderstanding on how that's to co fine in 6 anv way or restrict in anv Tgav vour discussions or evaluation 7 of applications -- but we've been working in the transition 8 period ahd-iielv6 had to have some reference points4 9 Then as vie go across the page you will see columns 10 which are headed May 1 plus July 1, and you'll see the iulv 11 estimate. we have asked each region to provide to us what 12@ they believe will be their requested amount in thei July 1 bmit July 1 .13 application if, in fact, they intend to su a 14 application. And as you run down that d.olumn, I think you 15 will-find six or seven regions where there are zeros which indicates that thev onlv intend-to use the current application and.do not intend to submit a July 1 application. 17 The next dolumn would be the total of the May 1 and the Julv 1 application to show what their total Program woul be -- what their total requested program is through next year. 20 Then the same difference between that total request 21 and Column C. that is, the available funds, and the percentage 22 of that that that difference represents. 2:; And then the last column oh the right you don't 24 have to do anvthing with, but we thought you might be 25 HOOVER RLPUKI ING CO, INC. 320 Massachus!tts Avenue, N.E. 57 thritis interested in that these are the figures for the ar 2 applications requested from those.regions. These applications 3! in arthritis are not coming to this committee, unless there's .4 some reason that the two committees should confer on-soriething 5 Those funds have been earmarked and they are above and beyond 6 1-that $114 million. So we have 43 applications which will be competing 8 for approximately $4.2 million and that $442 million is above 9 and b6vond that $114 million or the $109 million which I've 10 indicated to you is available for support of the