l @'34* TRANSCRIPT OF PI-TOCEEDINGS DEPARTI@TENT OF @TALTH PZUChT.@t-0,N AND WELFARE DIVISIOlq OF r-ZE.GIONAL ii@' ICAL PROu'RAYiS AD HOC MM- COIJ41MITTEE PANAL A R.-)ckville, Mciryland MaY 23, 307)-@ ",ages 229 thru HOOVER REPORTING COMPANY, INC. Repoi-tcrs D. C. 546-6666 228A C 0 N T E N T REGION BEGIN MOTION APPROVED 2 IOTIA 231 235 236 3 MEMPHIS 237 251 266 MISSOURI 267 278.' 280 5 NEBRASKA 288 297 297, 6 ITEW MEXICO 299 312 312 7 NORTH CAROLINA 313 321 322 8 NORTH DAKOTA 323 339 341 9 NORTHLANDS 343@ 356 356 10 11 TEXAS 357 401 402 12, OHIO VALLEY 404 421 422 .13 OKLAHO'-4A 423 436 437 14 SOUTH CAROLINTA 440 455 455 15 SOUT14 DAKOTA 4.57 466 475 I(; TENNEESSEE MID/SO. 475 482 485 18 19 20 21 9-2 2.3 2,4 25 HOOVER REPORTING CO, INC. 320 Massachusetts-Avenue, N.[. DEPARTMENT,'OF HEALTH, EDUCATION AND 2 WELFARE 5 6 7 8 AD HOC CONSULTANTS MEETING FOR REVIEW OF 9 RMP.APPLICATIONS 10 12, 13 14 15 16 18 Cofiference Room H Parklawn Building 19 5600'Fishers Lane Rockville, Maryland 20 8:30 A.M. 21 Thursday May 23, 1974 22 2.3 24 25 HOOVER REPORTING CO, INC. 228 5/2 3 am )/em P R 0 C E E D I N b S - - - - - - - - - - - 8.- 40 am 2 MR. CI-IAIIBLISS: I would like to say, first of allo, 3 good morning to the members of this panel. Iindeed commend 4 you again for the diligence and the zeal that you t@ick'led thi3 5 most difficult task we had yesterday. 6 I would like also to welcome to the panel Dr. 7 Scherlis. Good morning, Dr. Scherlis. 8 DR. SCHERLIS: The expression is "the la-:e Dr. Scherlis". 10 MR. CHAMBLISS: And say we are glad to s e you, -11 and we are still.waiting on Mrs. Wyckoff and Dr. Mi ler; 12. but, if the committee so chooses,, I think we can pr ceed. .13 We're halfway through with our task and today i-i-e 14 have fourteen regions yet to be reviewed. The order that I 15 woul d suggest, and certainly this can be changed, would be along the following lines: Iowa, Memphis, Missouri, Nebraska, 17 New Mexico, North Carolina, North Dakota, Northlands,, Ohio 18 Valley, Oklahoma, South Carolina, South Dakota, Tennessee and mid South, and finally Texas, 19 .DR. SLATER: Sir, I have to catch a 5:10 train at 20 the Capital Beltviay, so I have to leave here ab-out 4:15 or 21 maybe a little later,, if it's not raining; and I'm on Texas. 22 I c aft tell you Texas won't take more than five minutes. 23 Jesse Salazar is the primary reviewer, it will take ten 24 minutes. 25 @OOVER REPORTING CO. INC. 20 Massachusetts Averiu3, N.E. 229 em2 MR. CHAMBLISS: It will take ten minutes. 2 DR. SLATER: We should be able to finish. 3 MR. CIIAIIBLIS: I could make the suggestion that 4 we take Texas now. It's too hot in Texas to start wi-.,i Texas. 5 DR. SLATER: We're anxious to talk with each 6 other, because this requires some preliminary review by us 7 to be able to make a sensible presentation.- So if you could 8 do it after lunch, we'd appreciate it. 9 MR. CH2U4BLISS: After lunch? All right, we will @io start out with Texas immediately.afte.r.the-lunch hour. 11 DR. WHITE: Bob, where do we stand in terms of 12 relationship with the other panel? .13 MR* CHAMBLIS: The other panel, as of last night, 14 had completed nine out of 23, and we had completed 14 out of 15 2 8.' 16 DR. WHITE: Some of us'have suggested a target 17 of this afternoon's.joint meeting. Is there some way they 18 can be reinforced in their efforts? 19 MR. VAN WINKLE: We talked with Dr. Pahl just a 20 minutelago and he's over reinforcing that right now. 21 MR. CHAr4BLISS: A suggestion has been made that 22 the first panel that completes its work would go over and 23, join the other and help them speed-up. 24 DR. CARPENTER: I also have to leave about four, and Northlands is therefore a bit of a problem, maybe except 25 IOOVER REPORTING CO, INC. 32 Massachusetts Avenu,, N.E. em3 I if we finish on schedule it won't be. 2 MR. CIIAMBLISS: I think we'll get to N6rthlands 3 about near the lunch hour, just before or just after. 4 DR. CARPENTER: Thank you, sir. 5 MR. CHA14BLIS: Then, shall we begin with Iowa, and 6 welcorie Mrs. Wyckoff. 7 MRS. V7YCXOFF: Sorry to be late; I-couldii't get a 8 cab, 9 10 12. .13 14 17 18 19 20 21 9 -2 2.3 24 25 ioOVER REPORTING CO, INC. 20 Massachusetts AvenL,-, R.E. 231 ern4 1 REGIONAL MEDICAL PROGRAM REVIEW 2 IOWA 3 MR. CHIU4BLISS: In the case cf Iowa, Dr. McP e ran 4 and Mrs. Salazar are the reviewers and Mr. Z-ivlavsky is- the 5 staff support, will provide staff support. 6 DR. McPHEDRAN: . I am recommending that we give 7 Iowa the amount that they are asking for. I think this is a 8 good-Regional Medical Program. 9 And to go through the categories that were suggested 10 on the review sheet, first of all, a little background from 11 me: I site visited Iowa in the past,, it was several years 12 ago, but a lot of the direction of the program that was there 13 at the time is still there, and-I've had occasion to meet 14 with Charles Caldwell on one or two times since then, and he continues to impress,.me as an imaginative coordinator. 15 16 From what is presented'in the application, it sounds as though the Regional Advisory Group, for example, had 17 18 great stength then and continues to be a strength, anticipat- ing the form of the review sheet, 19 To return to thatt the program leadership 1 20 21, classify as at least satisfactory, and the staff-as generally good in the Regional Advisory Group; a good group there. 22 23 The kinds of meetings they have held in t@ past to develop programs and to monitor it as it goes along, seemed ima inative 24, 9 25 and very much to the point. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 23 2 em5 1 Past performance and accomplishments as satisfactory 2 also. Satisfactory in all of the other categories.i 3. I guess that the program staff and the Re ional 4 Advisory Group principally were the factors that make me feel 5 that the over-all assessment of the region i s above average, 6 It is a well-administered staff of gener alists. It's a 7 stated policy,, that is,, that persons on the staff retain 8 some-general competency in various activities that they 9 conduct. 10 There's a good de.al of emphasis on joint lecision 11 making on the staff members. This is gone over in @e 12. current application. I think that they have,, as I say, a good Regional 13 Advisory Group support. 14 The only sour,.note, I guess, for me, was that the 15 16 relationships with Comprehensive Health Planning, which I thought previously were quite good, seemed to be somewhat .17 less than satisfactory, as judged from some letters that I 18 19 think are included in our notebook here, which were not in the original application. 20 But, on the whole, I think that the general program 21- 22 purposes and their past accomplishments simply weren't what 23 they have been asking for. And, according to this master financial sheet, which perhaps I found more helpful than I 24 should, what they are asking for constitutes only 80 percent 25 HOOVER REPORTING CO, INC. ign Mi@tathil-,Ptt@ Avenue- N.C. 233 em6 of what it was thought they could have in targeted available 2 funds. 3 And even if they are expecting to request in July, 4 it would only come to.about 95 percent. .5 I really think with the management and direction of 6 this program it has been good enough in the past that it 7 certainly warrants that kind-of support, without going into 8 further detail. 9 MR. CH2U4BLISS: Thank you,, Dr. McPhedran, lo Mrs. Salazar. 11 MRS. SALAZAR: I subscribe to Dr. McPhedran's 12. views, and this is the impression that I gleaned from the application, 13 14' Hoiieverp there are some concerns which I had an occ asion to discuss with rank briefly about the CIIP involve- 15 ment and some other comments. But the timing seemed to be 16 bad, that they just couldn't get to them. I would like to 17 18 hear from Frank. MR. CHAMBLISS: Mr. zi'vlavskyf would you 19 20 MR .7IVLAVSKY: Iowa,, from the beginning, had a 21@ very close working relationship with CHP. They.have maintained 22 that relationship throughout their program history.' That they have in the application is actually one 23 24 non-official B Agency comment, that there are 15 CIIP agencies in the State, fiv'e of the 15 are actually approved B agencie 25 HOOVER REPORTING CO, INC. qq^ an .... m r 234 em7 The comment you have,here is a comment from one 2 of the non-CHP B agencies. They telephoned them in to 3i Division P14P and requested a three-day delay in their application. This was approved, and they submitted it on 5 the 3rd of May instead of May lst. 6 They just admit it's a breakdown in their machinery 7 for the CIIP to be processed, because they have always taken 8 into account the CIIP comments, have been able to negotiate 9 their differences with CIIP.@ They have submitted five 10 additional letters here, but basically two CHP agencies ave 11 delayed their review. one has favorable comments. one has 12, a recommendation for disapproval. And the last line, I just 13 state that the Iowa CIIP has not yet responded to negative 14' comments or questions due to the short timeframe. We received the , and inserted 15 Pe on the 20th of May .16 these into the books of the reviewers and the coordinator, and we have not had-an official chance to sit down and 18 negotiate on a one-to-one basis with each of the differences. 0 19 of the CHP agencies. And I,usually they have a connent'in 20 there that it's a breakdown in their machinery. The staff is on top of it. 21- 22 I will be watching this closely, and that's really about where it is. 231 MRS. SALAZAR: One of the things that I noted in 24 25 reading the applicati.on is the resiliency of this staff to HOOVER REPORTING Co, INC. A,.@-..- Pi r 235 em8 1 react and turn around and react to all kinds of crises, in 2 a very flexible rqanner. And I think that's very good. 3 MR. CIIAMBLISS: Someone has said that's based on 4 their youth,, because they all are very go-go types, young, aggressive, they move quite fast. I simply throw that in 6 as an observation. 7 DR. McPIIEDRAII: So I. would move that they be funded 8 in the.amount requested, which, to reiterate, is @l,,061,349. 9 MR. CIIA14BLIS: We have a motion on the floor that 10 Iowa be funded, recommended for fund:ing at a leve of 11 $1,061,349. Is that seconded? 12, DR. MILLER: Well, the yellow sheet says 249; 13 but maybe there's a mistake here. 14 DR. WHITE: IIhat is Mr. Cald@vell's background? 15 MR. CIIAI,,MLISS." I believe his background is either in hospital administration or public administration. DR. WHITE: He's about the third coordinator they 17 have had, isn't he? 18 I!) MR. CII2U.D3LISS: To my knowledge he is the second. 20 DR. McPIIEDRAII: Second. DR. WHITE: Willard Prell was first. 21, MR. VA@l WINI"LE: That is 249. 22 23 DR. I.ICPIIEDRAII: Okay. Amend that. 24' MR. CH MIABLISS: Do you amend the motion? Is there a second to the motion? 25 HOOVER REPORTING CO, INC. ')')A N F 2'>j 6 em9 1 MRS. SALAZAR: I second it* 2 MR. PULLEII: It adds up to 349. 3 MR. CIIAI-IBLISS: It has been properly moved and seconded that Iowa be recommended for the level of 5 $1,061,349. 6 It has been seconded, so we now may have discussion. 7 DR. SCIIERLIS: I note that one of the projects is 8 for emergency medical systems. I thought that was specifi- 9 cally exenLpted unless there were continuing projects. Is. 10 this a continuing project? It's for $74,50.0. 11 MR. CHIV.IBLISS: It is a continuing project. 12, DA. McPHEDRAN: Yes, I think it is a continuing 13 projqct. 14 MR. CHM4BLISS: Continuation of a previously 15 funded project. Is there further discussion? 17 If not, the Chair calls the question. 18 Those in favor? [Chorus of "ayes".] 20 MR. CIIIUIBLISS: Those opposed? [No response. 21' 22 MR. CIlAr4BLISS: The "ayes" have it, and the motion passes, 23 24 25 HOOVER REPORTING CO, INC. m r 237 emlO REGIONAL MEDICAL PROGRAM REVIEW 2 MEMPHIS 3 MR. CHAJ,,IBLISS: So we will now turn our attention 4 to the Memphis Regional Medical Program. 5 The reviews there are Dr. Carnenter and Mrs. 6 Wyckoff, with Mrs. Lorraine Kyttle providing staff support. 7 DR. CARPENTER: This is a region that I I ve had an 8 opportunity to visit. As many of you may know, it is an 9 interesting Regional Medical Program involving part of 10 five States and growing out of an existing health planning 11 body in the Memphis area. That body later became a 12. Comprehensive Health Planning agency for the area and that 13 growth of the regional program made a great series of State 14 and local PI.TP's, naturally, and probably it would have been 15 an impossible situation,without that beginning. But it really has worked well, and given the 17 Memphis Regional Program, I think, a particular characteristic 18 of its own. In some ways it seems to me to behave like a very broad planning agency. The nature of the Comprehensive 20 21 Health Planning agency, as much as it behaves like a Regional Health Program. But I don't think it's all bad. 9-2 23 This is a data analysis that attempts to get into 24' health care problems in the region. It is the latest in a 25 series of publications based on .data that was,demographic HOOVER REPORTING CO, INC. .17n M;mtirhtisetts Avenu i. N@E. 2 3 3 emll data that was available and re-analyzed to meet the region's 2 needs. Also surveys of health in various places in the 3 region. 4 As usual, in the world, it's very difficult to 5 determine that the program has been guided in direct ways by 6 this kind of data analysis, but I believe the ability of the' 7 region to generate that kind of data and to-reinforce and 8 talk about the health care needs of Memphis has provided 9 them with a kind of credibility leverage that has been 10 important in the development of the program. 11 The region has a relatively stable staff. The 12, coordinator has been there, Culbertson, for a long time. 13 And they have d stable -- well, they have had some changes 14 in their varying structure because we had legal questions 15 about the ori inal arrangements. They are now settled down 9 16 into a standard RAG arrangement, and that was not 17 terribly adversely affected by the regional catastrophes. 18 They are not terribly explicit in the way they 40 19 write their application. They list, I guess, four goals- and 20 13 objectives; and, as I tried to analyze them, I come up 21 with what I really think are seven ideas. And these are 22 related nicely to the usual medical goals of the Regional 23 Program, and I don't see any problem there. 24 They discuss priorities as though they were separate from their goals and objectives, which is a little discon- 25 IOOVER REPORTING CO, INC. 120 Massachusetts Avenui. N.E. 23 9 eml2 certing, but by the time one o'clock came around I had 2 solved the fact that they were really paraphrases, and one 3 can in fact group their goals and objectives into some range @4 of priorities. 5 The request is for about $700,000 in core support,,, 6 a million six for 28 continuing applications and a million 7 for nine new applications; $300,000 for developmental awards. 8 The projects from the beginning of this region 9 have not had very specific goals. They have been very 10 general: Let's get together, sometimes plan; let's get 11 together for general action kinds of goals. And they've 12. not been evaluated particularly well. 13 I have great difficulty in this application in 14 understanding in some ways what the@), have accomplished. 1 15 On the other hand, they have brought in an enormous 16 number of dollars from other Sources to the region, or at 17 least have contributed to it, and because of this very close 18 working relationship between Comprehensive Health Planning, 19 experimental health care delivery systems, and Regional Medical Programs in the area, it is very difficult to give 20 21 credit for what happens. l@ich is certainly not-a complaint at all, but it does make evaluation very difficult. 22 I believe that the Regional Program in that area 23 had a significant role in brin@ing something like a half 24 9 25 million dollars to the region in other support in each of the HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. W.iqhinatnn [)C. 20002 2 4 0 eml last three years. 2 They estimate that the have served 200,000 patients' y 3 in the last year, and about 2,000 professionals have been trained. So there are some kinds of program evalu ltion that 4 a 5 are available; but, again# the project evaluation i@ a 6 problem. And one almost gets the feeling that the projects 7 were ancillary to the main issue. 8 Ilhich, again, I think is more an interesting 9 different approach, perhaps; but there are some dif icult 10 I think. 11 There is, for instance, $60,000 invested in a 12. project to improve death certificates. lqhich reall@ turns 13 out to be an experiment by one of the pathologists who does 14 one and a half autopsies a week, and tries to see whether 15 X-rays and gastric analysis would add anything to his 16 ability to perform as a pathologist. 17 That was hard for me to see as a Regional Program. MR. TIIOMPSON: It's interesting, though. 19 DR. CARPENTER: It's very interesting. 20 Of the million dollars, roughly, for the nine new projects, half of it goes for area education centers in ten 21 22 hospitals, and really, this project, lial.f a million dollar project buys an organizer, a librarian, and provides space 23 24 rental to the hospital, provid@s a secretary and some books, 25 journals, and audio-visual material for the area. IOOVER REPORTIttG CO, INC. 120 MassachuseffsAvenui, N.E. Vashington, D.C. 20002 2 4 1 eml4 to be And the outputs of that project are said 2 to list the educational and clinical resources in the area 3 of these ten hospitals, to relate the leadership oflthe 4 clinical and educational resources to determine the need 5 for new educational programs, and to develop an ove -al 6 manpower plan. 7 No;,7, I just believe that that's the work Df the 8 Advisory Conrqittees, not $500, 000 worth of staff. knd I 9 also -- I don't know, at a time when this program i3 going 10 to be phasing out, I wonder what the meaning of a 11 developmental award is. 12. flow, let me stop at that point and see wh my 13 cohort would say. 'MRS. IIYCKOFF: 14 Ilell, I think Memphis has the 15 most beautiful case of euphora about PJIP than any of the I(; P14pls. They have chronic optimism about how this thing 17 is going to go on, and they are just going to conquer all the problems in the world. And it's partly .due to Dr. 18 19 Culbertsonts personality. He carries the thing on his back. 20 pretty well. 21 They also operate as a,very peculiar -animal. They 92 are different from any other RP,IP, because they're like a 23 family. They seem to telephone each other and keep in touch 24 with each other across State lines and across all the terrible amount of paperwork and r ules and regulations that 25 IOOVER REPORTING CO, INC. 20 Massachusetts Avenu-, N,E, Vashington@ D.C. 20002 2 4 2 eml5 exist. They rise above it all and do it in an informal 2 fashion, and they seem to get together after hours and.keep 3 the wheels very well oiled, and do the thinas that ave o 4 be done. 51 It's an incredible.thing, and they cannot believe 6 that they are going to be phased out. They just don't 7 believe it. 8 Instead, as you can see from this report, they 9 make all kinds of alternative plans, so they're goiag to 10 survive no matter what. 11 And I really have a little faith in them.1 I 12. 1 honestly think they may be able to do it. They-havd put it -13 together, they have got this experimental health systems 14 management agency, and of course their Comprehensive Health 15 Planning Groups, and the Y11p, and.they are planning to get ready to jump in any direction when the legislation comes 17 through. They are going to be ready for anything. So I 18 think tjieir development funds will be used to launch l@) whatever needs to be launched at that time. 20 They show more faith in survival, i-i-hen the crunch 21 went on, they went right ahead v7ith their plans, and they 22 are all ready to get their maximum amount of money with new 23 projects and everything wli(mthe funds came through. 24 They have only seven I think it was out of, 25 was it 18? They had only seven,approved and unfunded request HOOVER REPORTING CO, INC. 320 Massachusetts Avenu 3, N.E. 2 43 eml6 at the end, and I think they had 11 that way, succeeded in 2 putting through at the worst possible moment. 3 So I really think that they may be able to a 4 go of this. 5 I would like to hear a little from staff on what 6 they know aboutthe new plans.they have for this newitrustee-. 7 I ship board. If there is anything in there. 8 DR. IIHITE: I wonder if Mrs. Kyttle might also 9 -comment on this phrase "escro-vi accounts". Is that a 10 substitute for keeping money after the thin g is ove ? 11 DR. CARPEIITER: That's a catalysm. 12. MRS. KYTTLE: Well, you asked about the 0 ganiza- -13 tion that is forming, and you are quite right. It's almost 14 incestuous, because N14CC's spawned MIP, and PI.IP's spawned 15 HSM.' P14P responded to the RFP that R&D issued for experimental I(; health systems, wrote the application, pulled the people 17 together, set it under a corporative kind of stance, 18 because that's what the RFP requires, and Voila, there's 1!) Health Systems I-lanagement, Inc., which is right across the 20 hall from RIIP. 21@ DR. McPIIEDRAN: I'm on the ropes, Mrs.- Kyttle. 22 RFPI R&D sent out a request for contract.proposals across 23 the country. That's a request for.contract proposals, for 24 proposals onexperimental health'dblivery systems. Regional 25 14edical Programs in I-lemphis sat down and wrote one, but did IOOVER REPORTING CO, INC. '20 Massachusetts Avenu i, N.E. Vashinpton. D.C. 20002 eml7 24 4 not send it in under their name, because they were not at 2 that tine a proper applicant, They spawned IISM, R14P and the 3 local B, which is one of the most active B's in the State of 4 Tennessee, not just west Tennessee but in the State of 5 Tennessee, had formed an umbrella trusteeship -- and that's 6 not a catalysm; that'Is tlieirs. They call it an umbrella 7 trusteeship. 8 It proposes the merger of the executive committee 9 of each of these agencies, and it is a straight-forward, 10 unabashed move to present the three of them. This is not an 11 area where one is more interested in surving over the other. 12. The three of them want to survive. 13 They did an intemmting thing. They agreed that each 14 of these.three entities, if their full boards ratified it#, 15 and since this paper was prepared all of the boards have i(i ratified it, the full boards. -The body bringing the largest 17 turf to this umbrella trusteeship, and without doubt that's 18 RMP with parts of five Statest would. bring the turf or I!) cognizance of this new group, should the turf want that. 20 And so there is, then, the possibility that there 21 would be an 30-county five-State Ilealth Service-Agency or 22 whatever might come out of the new legislation. 23 They thought that that would be the experiment, 24 and that's the purpose of that -'Organization you asked about. 25 MRS4 VIYCKOFF: They believe in survival. iOOVER REPORTING CO, INC. @20 Massachusetts Avenu,, N.E. Vashington, D.C. 20002 245 eml8 1 MRS. KYTTLE: The three of tJiem, not just PIIP. 2 MR. THOMPSON: It does-offer complication's? 3 however. We're used to, you know, the one-on-one business, .4 whols on, whols off, between CIIP and @MP. 5 Now, they have substituted a menage a trois kind of 6 thing, to complicate it even more. 7 MRS. KY'@"TLE: I don't know if they look at it as 8 a complication in that frame. The possible complication is 9 that Memphis PIIP has assisted, and that is from beginning to 10 where they are now, all other B's in west ennessee all of 11 them. But the one that is operating in southeast entucky 12. is a Memphis PJIP, funded not any longer, but it was MRS. T-7YCKOFF: And Mississippi. .13 14 MRS. 1'.YTTLE: Northern I-lississippi and the boot- heel'of Missouri and eastern Arkansas. The five operating 15 B's are all B's that have been funded and initiated by 16 17 Memphis RMP. 18 Now, if Memphis RMP comes into this umbrella 19 trusteeship with the greatest territory, it will encompass 20 the territory of those B's,, and they kno.,v7 that,, and they 21 realize that that will be the option. If those- 'local B's and indeed the legislation permits that type of arrangement, 22 they thought that that would be the interesting experiment 23 24 to form a new Health Service Agency for that terrain, wit- 25 subcontracts with existing B's, that they have already funded iOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. n 1, )nnn,) 24 6 eml9 e to give Dr. MRS. WYCKOFF: I guess you hav 2 Cannon a little credit for also holding this organization .3 together. 4 MRS. KYTTLE: Yes,, ma'am. 5 DR. SCHERLIS: IloN,7 much of the funding actually 6 would be directed to,,.,7ard the setting up of such a group? 7 How much of it is seed money? 8 MRS. KYTTLE: They seek no funds for that. T e 9 arrangement they have made is that they are rotating for'the 10 first period of operation, the executive director of HMS 11 serves as the chairman of this new board. The staff is 12. provided by IU4P, and the leg work is done by CIIP. 13 And for the next ninety'days, they first started 14 thinking of a year and they realized that that would be too long a time, the next ninety days the coordinator of PJ4P serves as chairman; the staff of IISM has to fund the money 17 to get the staff work done, and the CI-IP organization does the 18 regional communicating. 19 DR. SCIIERLIS: You'told us about that $400,000 in 20 escrow, 21 DR. WHITE: There's actually 800,000.--There are 22 actually two different escrow accounts. 23 MRS. KYTTLE: This application seeks no money for 24 that organization. 25 DR. SCIIERLIS: Yes. But'where does the money come 40OVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.[. A12thinOnn 1) r. ?()nn? 247 em2 0 f rom? 2 Two things: how is it-labeled, and how can a sum 3 of money be available? .4 MRS. KYTTLE: All right, that's the first question 5 you asked about. The $800,000, when you total the two, it's 6 a combination of five and three. Let's speak to the 500 7 first,, and that is the creation of local consortia to 8 develop health manpower needs and relate them to identified 9 health service needs, and relate them to health manpower 10 resources. 11 MR. CHAMBLISS: Is that to which the funds are 12, going to be used? 13 MRS. KYTTLE: rive hu ndred thousand. 14 DR. CARPENTER: That's for ten hospital 15 librarians, ten secretaries, and ten planners, community 16 organizers. 17 MRS. KYTTLE: You asked if that should not be the 18 work of the local advisory committee, because so many of ii) these groups were formed from such advisory committem; but 20 they have no local advisory committees. These are ptedomin- 21 antly in ares where there are not B's, and this-is ovi Memphis starts B's. 22 23 DR. CARPENTER: No, they.have B agencies now 24 except in -- organized in every area, but not 25 MRS. KYTTLE: They are not funded. HOOVER REPORTING CO, INC. 320 Massachusetts Avenu 2, N.E. Waqhinoinn- D-C- 20002 2 4 3 em2l I DR. CARPENTER: Two of them are not funded. But 2 they are two out of ten at most.. 3 No, these are not B agencies, these are 4 MRS. WV.CKOFF: Health Centers. 5 DR. CARPE14TER: These are hospital libraries. 6 MRS. WYCI',OFF: There's the seed money to start 7 things. 8 MRS. KYTTLE: I said they have no local advisory 9 committee in these areas, save Jackson. Ther6.is one in' 10 Jackson, and there's one ongoing there. 11 DR. CARPENTER: But they showed us a map of the B 12. agencies, right, and they cover the whole area except maybe a few outlying counties. .13 MRS. KYTTLE: These are areas that have no health 14 manpower committees working in them. 15 1(; DR. CARPENTER: Oh, okay. No manpower committees. 17 MRS. KYTTLE: And that's how they have spawned, 18 they have first developed some health manpower committees for B's. These are areas wh@e the B's have formed without 19 20 he.alth manpower committees. DR. CARPENTER: That's the point I'm-making. If 21 they had the manpower committees, they wotldn't have to spend 22 a half a million dollars. 23 I-IRS. KYTTLE: Well,'for some reason, and I have 24 25 tried to research it and I don't understand it, the philosophy, iOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. A12thinotnn 1) P. ?OnO? 2 4 9 em22 I the Memphis-Regional Program thinks local consortia to 2 address health manpower needs should be seated in a 3 hospital. They feel the hospital setting is the setting .4 for an IISEA,, and they have felt that way from the very 5 beginning. And that's where these are, ten sites. 6 MR. CIIATIBLISS: Dr. Scherlis. 7 DR. SCIIERLIS: l@ow welve gotten through the first 8 gear, what happens to the second ten libraries, secretaries, 9 et cetera, for the second year? They are being funded? 10 MRS. KYTTLE: The same thing that will happen for 11 all the others. Some of them will make-application under 12. the new legislation as health service agencies. I mean,, that's going to happen across the country. Most of them 13 14 feel that they are ready to make application. 15 MR. THO!IPSOII:,- Ten libraries are going to be certified as health agencies, as' I understand you? MRS. KYTTLE: One of the first things the local 17 18 area is going to have to do is to create its own manpower committee. The librarian wiri not be -- even she's a part of the system, but she is not the pivot. 20 DR. WIIITE: I'm suffering from an inability to 21 recall Webster's definition of "escrow". But it seems to me 22 it has to do with putting money aside for future use, 23 MRS. KYTTLT: They w"ant to impound their own 24 money. They want to put $500,000 Aside now so that they feel 25 HOOVER REPORT114G CO, INC. 320 Massachusetts Avenu,, N.E. n f, I)nnnl) em23 250 by July they will have gotten these things ready to go to 2 contracts, or in the writing stage now of when, I think one 3 is in Kentucky and the other is in Crittenden County in 4 Arkansas. Rather than coming in in July with thl3 proposal 5 of ten sites all worked up, they want to escrow the money 6 out of the total package now, so that it can begin in July 7 rather than make application to us in July. 8 MR. THOMPSON: So, in other words, they wa t to use 9 the escrow business as a substitute for a specific proposal. 10 MRS. XYTTLE: Yes, and they want to tell you now 11 what they want to put it aside,for. 12. MR. THOMPSON: Has this proposal been matched up 13 through the whole internal review process as a proposal? 14 MRS. KYTTLE: As a concept. 15 DR. CARPENTER. I think there are a series of 16 small proposals. Isn't that the way it got through the RAG 17 as small proposals? But it did in part, in $25,000 hunks 18 it went through RAG. MR. THOMPSON:- $25,000 hunks up to $500,000? 20 That's a nice piece of business. 21 DR. IIIIITE: They have got $800,000 there. 22 MRS. KYTTLE: And it all went through at once. 23 DR. CARPENTER: They didn't hide any of it. e 24 MRS. KYTTLE: It did not bleed through,, it went through as a concept, and $25,000 apiece for ten sites. 25 iOOVER REPORTING CO, INC. @20 Massactiusetts Avenui, N.E. 2 5 1 em2 4 DR. CARPENTER: Can I. at this point, break into 2 the conversation and make a funding recommendation? 3 MR. CIIAIIBLISS: You may, indeed, Dr. Carpenter., -4 DR. CARPENTER: I would, just to get the discussion 5 going, move a certain funding level. Their annualized rate 6 now is a million and a half. Their targeted rate is about 7 two million three, and they request three million four now 8 and predict that they will ask for a million two later, 9 and that will get them at two times target. 10 I think that the region is pretty good, but not 11 in a position to go from a million And a half to four million 12 seven at the time of phase-down. I would suggest a funding .13 level a little above the target level, of $2,,600,,000. 14 MR. CHAIIBLISS: Will you place that in the form of 15 a motion? 1(; DR. CARPENTER: Yes,, I do. 17 MRS. WYCKOFF: I'll second that. 18 MR. CIIAt4BLISS: It has been moved and seconded 19 that the level be established for be recommended for.- Memphis at $2,600,000. 20 Is there discussion? 21, DR. WIIITE: I would like to pursue this further, 22 23 and I an, going to. We've talked about the 5OOtOOO. There's another 300,000 in escrow dollars, which I interpret as this, 24 25 Mrs. Kyttle, as underwriting the survival of these three in HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.[. 25 2 em25 I whatever form they're going to take. 2 It says that, I think. 3 MRS. KYTTLE: It says that high priority out of 4 this developmental will be given to those agencies, 'You know, 51, in the total region. That's the RTIP region that I'm. 6 pursuing, the logical kinds of things that the new legisla- tion proposes. 8 There again that falls within the umbrella purview, 9 but the umbrella -- the organization that is the umbrella is 10 not seeking funds, but it seeks to fortify its philosophy 11 that it's a good umbrella, it hopes that the legislation .12. will speak to a State, you know, whichever one comes out first, 13 and it wants to have agencies funded within it, that it can 14 contract with. 15 That's what the high priority is for those agencies. 16 DR. IIHITE: Now, is that $300,000 the same as the developmental fund? 17 18 MRS. I'\,YTTLE: Some of those are B's. Yes, that's out of that. 19 20 MR. TH014PSON: I think what we see here is probably 21 the bald statement of the problem that you are finding more or less in the same degree in all of these, most of the 22 proposals, and this is an attempt to second-guess what the 23 i 2,4 legislation is going .to be as f'ar as, you know, whether this is regional health authority or State health authority, 25 ,OOVER REPORTING CO, INC. 20 Mamchusetts Avenui, N.E. t'ashin@n- D-C@ 20002 253 em2 6 and it's floating around in all these crazy bills. 2 Now, I think we have a'policy problem here, 3 whether our RI-4P funds should be used to relate an agency,'a 4 proposed agency for nonexistent legislation. And I think 5 that's true here, I think that's true in a subsequent thing 6 that I'll review to you. 7 In other words, when you, from PI.IPS sent the 8 message down: Fellows, get on the ball with your CHP and 9 no kidding this time. We've seen a lot of getting into bed 10 with CIIP, and it's -- in fact it now looks like a plot by 11 the two of them to survive, whatever happens. 12. Now,, I don't know what's going to happen if this '13 legislation setting up this envisioned Regional Health 14 Authority is delayed by two years. You know, all this 15 money that we're pouri@nej @n here to build these various elaborate umbrella agencies, the consortia -- they have about 17 six names for it --.it's going right down the old,tube. 18 MR. VAN WINKLE: I would like to.point out that 19 they have been encouraged to start various programs with'CHP. 20 MR. THO@IPSON: That's what I'd like to know: who 21 has the crystal-ball authority that they can tell me- that 22 the Regional Health Authority is going to be established 23 by the end of P14P's life, and take'over RMP's staff or skills 24 and start in business. Who the hell has got that information. I don't have it, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. 254 em2 7 MRS. KYTTLE: Mr. Thompson, you know it would be 2 beautiful if that were the case,-but no region has,had that 3 word, and they are all trying to take the most logical and 4 flexible stance that they can, trying to provide for the 5 1 possibility of State structure as well as providing'for the 6 local structures, until they see what the legislation is* 7 MR. TflOf4PSON: When you cover all the bets' on a 8 racehorse -it costs a lot of money, and that's what @ese 9 people are doing. They Ire putting two bucks on eve horse lo in the race, hoping that somebody will come in and ey will 11 be on it! As long as it's not their money, that's okay. 12. MR. CHAIIBLISS: This is one of the poli@ questiois 13 that we alluded to earlier on when the committee was convened., 14 and this is one of the issues that will be dealt with as the 15 review goes forward. 16 I would like to acknowledge the presence of Dr. 17 Margolis here, our former Director. And since this is a 18 policy issue, I'm wondering if he would say a few words-on l@) this point. 20 DR. SCHERLIS: I was just going to make one suggestion. I think that Memphis really shows some good 21 judgment with the idea of an escrow account for $800,000 and 22 23 I would think that some of the wisest judgment that this 24 Review Committee could make is to have an escrow account of 25 a hundred, a hundred and twenty to 'forty thousand dollars, HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Wa%hinpton. D.C. 20002 em2 8 that we would have available, and say, let's save that for 2 some decent health planning as of July lst, 1975. 3 @ihile 'I wasn't here yesterday, which is a .4 calendar error that I apologize for, I spent, really, as all 5 of you did, a very difficult time reviewing these, because 6 we're doing it on promise and hope and faith and, frankly, 7 charity. 8 And all the old judgments that we have used have had to go down the drain completely in reviewing these; and 10 I think that if Memphis gets approved for an escrow account, 11 that my next suggestion will be that we vote an escrow 12, account of a hundred or eighty million dollars for July lst, 13 to be used if there will be health planning then. 14 I don't think that putting this into some thirty, 15 forty, fifty little different projects, that we're begged 1(; for and scrounged for by going out and saying, Come on in, 17 we have this last chance to get it. A lot of them read that 18 way. That that is really the equitable way for us to use government funds. 19 20 I have the serious questions that all of you have had, and we're operating within a very difficult framework, 21@ to reach equitable decisions. 22 I am all for escrow accounts, particularly of most 23 24 of that one hundred and twenty or hundred.and forty million 25 dollars. 40OVER REPORTING CO, INC. )20 Massachusetts Avenu,, N.E. Nashington, D.C. 20002 256 em29 I didn't mean to pre-.empt you,, but I wanted that 2 stated somewhere along the line. 3 DR. tiARGOLIS: Well, my most positive word is that 4 I an delighted to see my good friends here again. 5 I am delighted to see that you are tearing at things as usual. 7 I don't understand.your concern, John, in not 8 knowing how to spend money on nonexistent legislation, 9 ioney was appropriated, impounded in 173 to be, After all, r 10 spent in.176; when the authorization would expire by June 11 30th, anyway., 12. So itis a perfectly clearcut situation! 13 I would like to address this question, because I 14 think the points you raise are important, and rather than 15 matters of policy, althpugh.they certainly involve policy, 1(; there are also senses of timing in judgment, which will have 17 to replace, as they often have in this program, some kind 18 of policy base. In all of the discussions on planning, 19 legislation, developed both some kind of unified health 20 planning proposal, there has been more dissatisfaction -- and not very well hidden -- than satisfaction with everybody's 21 22 proposal, as you implied. 23 The administration is not wildly enthusiastic about what it has proposed. The Rogers Committee feels about 24 the same about its own proposals..'Theke is fjreat uneasiness 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.E. em3O 257 about what would occur. Time is running out. And some 2 of the basic problems remain. 3 The problem which everyone has looked at, usually 4 defined so poorly, that it is looked at plainly, is the 5 meaning of planning,, the relationship between planning and 6 implementation; and the relationships between planning and' 7 management. 8 Traditional questions which have been up for 9 consideration time and time again. The difficulty involved 10 in all the pieces of legislation and in the debates which 11 really don't get around to this is that'no one is ready to 12. say what that relationship ought to be. Nobody is willing ..13 to come down hard, although there are indications that a 14 position has been developed.. 15 For example, it is now felt that whatever these I(; health service agencies will bet or whatever name they come 17 out under,, they will be private, nonprofit structures within 18 the State. There will be an uncertain kind of support for I!) State structures. The planni"ng process will be kept from 20 State implementation, however, there will be some small 21 amount of money for implementation, a larger amount of 22 money for implementation based on whose bill you're looking 23 at. 24 What is missing in the process is something which 25 can produce, in the health delivery system, a cooperative HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. w.@hinafnn n r. green? 25 8 em3l 1 structure which allows people to operate in the private and 2 in the nonprivate systems in such a way that they are able 3 to do together more effectively those things which they wish 4 to do than they can do them separately. Which is an early 5 description of Regional Medical Programs. 6 It creates a real problem. And in many ways what 7 our reviews are attempting to do is being approached under 8 other names, with different kinds of understanding, and with 9 a variety of methods. 10 But the debate has not been joined. I don't think it will be joined. And when you' re through with this 12. session and we're through with the review session which is 13 coming up after that, there is still going to be great 14 difficulty in making a judgment about what is IUIP going to 15 do in relationship to CIIP, what will the planning function actually be, what will the relationships be between pl anning 17 and implementations and, furthermore, what is going to be 18 the role of the State government in this? Because, in general, the role of State goverment 19 has been downgradedalmost lost sight of 20 there have been 21 serious objections to it from outside and from within. And we're going to be entering the fall season whether using an 22 escrow account or not, with no more certainty about what 23 that relationship is than exis@s at the present time. 24 25 What we have been saying,is a'consequence, and it's HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washinzton, D.C. 20002 em32 2 5 -0, about the only way out,, maybe not too bad a one, is that the 2 most proved factor beyond a Regional Medical Program, and 3 it's now my job in addressing all these programs, it applies 4 to others as well, certainly the CIIP; but beyond the CIIP, 5 the other kinds of federal programs which are in the 6 States v7hich have sort of opted out of this activity, 7 the most judicious thing for.thera to do is to get together 8 with one another as rapidly and as fully and as enthusiastic- 9 ally as possible, and decide what they're going to do together, 10 regardless of what the legislation is going to look like. 11 And betv@7een the passage or nonpassage, which is a 12. good likelihood,,of the legislation, its approval, its 13 appropriation, its regulations -and its administration, 14 so many'things will occur that if the people who are out 15 there quit trying to decide who is going to be in charge and 16 decide how they are going to run the thing together, they 17 are going to move rapidly ahead. 18 Now, sometimes this is interpretative on the part 1!) of PI,4P people, if I'm talking to them, as some of the RMP's 20 are, is that they should quickly move to take over. 21 Now, that v7ouldn't work. CHP takes the same 22 response when they are listening to their own partisans; 23 it's for you to take over. 24 And if they will get just a little smarter,, they 25 will move together; but they are going to have to move with HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. Washini,ton, D.C. 20002 26 0 em33 other programs. Maternal and Child Ifealth Service, Community 2 I-lental Ilealth Service, which, for' some reason, along with 3 others, have never been considered a part of the general 4 concept of comprehensive planning. 5 Migrant programs, all of then have each been looked 6 at separately, and all the conversations have been PFP and 7 CHP as if those were the only actors in the game; when, in fact, they are some of the actors, and in many instances rather minor actors. 10 Nov7, I think the additional.thing which isi going 11 to make a difference, about the time we get started,@ith it, 12. is the gro.iqing concern with the regulatory function @within .13 the State which will produce an entirely different enviroh- 14 ment for the total relationship between planning and. 15 implementation. Because,.the regulatory function will throw 16 in a new responsibility which must be a State responsibility,, 17 almost by definition. 18 That regulatory function already applies to 1$) institutional development. It's going to, in all likelihood, 20 involve cost control, becaiiselwe get national health insurance, 21 and there is freer and freer conversation nov7 about a 22 complement to certificate-of-need legislation for construction, 23 and that will be some kind of certificate-of-need for man- 24 power. Noi.i, wien these kinds of things occur, people who 25 IOOVER REPORTING CO, INC. ;20 Massachusetts Avenui, N.[. 'iashington. D.C. 20002 2 6 1 em34 have been vying for responsibility may find themselves vying 2 for getting out of sight,- because it's going to be no 3 child's game. .4 And yet by looking at the total structure, as it 5 will be much faster than many of us have expected, the 6 relationships between the planning, the implementation, the 7 operational and the regulato ry functions can become clearer, 8 and the responsibilities for the various parts will begin 9 to fall into place. 10 But to try to assume full management or full 11 authority for any one of them is injudicious,, it won't work, 12. and I don't think anyone would really want it when they get .13 all through with it. 14 The real struggle, in all sincerity, will be on 15 the part of those who are determined that the regulatory 16 function, particularly control of rates and fees, be placed 17 anywhere but where I am. Nobody is going to want that. 18 And yet it is going to be the part of the system which is 11) going to have the greatest power, and from which most of. 20 the strength is going to flow within the States. I think it will go in the States gradually. 21 The other big debate is whether the National Ifealth Insurance 22 2tl is to be more federal or State directed; but that's a very fundamental issue. 24 Now, I know that's not a policy thing,, but at least 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. w.@hi..f.n n r. )nfin,) 262 em35 it's a statement ofsome kind of dynamics which will work 2 well some places and not others. 'The concept of escrow,, I 3 would certainly agree with you, is certainly -- if '(OU re 4 going to consider the setting aside of funds for an,uncertain 5 but realizable goal in the immediate future, that should be 6 a programmatic kind of action across the board, rat@er 7 I than,.limited to any one program, to come up with that kind 8 of an idea 9 And even then, it is a risky kind of thin to do, 10 because you don't know what the situation w ill be w en those 11 funds are released. 12. I don't know if that helps or not. 13 MR. CHPIIBLISS: T,,Iell, thank you, Dr. Margolis. 14 There may be some questions that the panel would like to 15 raise, in addition to --,. Dr. Vaun? 16 DR. VATA4: Getting back to this, not with regard 17 to Dr. Margolis' comments,, the only thina that concerns me 18 about the escrow is that, does this place any of the I!) other P14P's that have seen fit to core back in July,, at a 20 disadvantage? 21 In other words, are these people gambling that all 22 money is going to be doled out on the first round, and,, reall@, 23 whatlpulve been saying is not so there won't be any money 24 left for the second round, so they're putting their little nest-egg in escrow. 25 iDOVER REPORTING CO, INC. @20 Massachusetts Avenu,, N.E. nr,)nnn,) 26 3 /2 64 em3 6 Has that thought occurred to anybody? Is this 2 v7hat they are tr-,,,ing to do? 3 MR. CIIAT-IBLISS: There will be a sum of moneys .4 remaining for the second round. 5 DR. VAUN: So as you envisage it, this would be 6 not placing anybody at a disadvantage? The other PIIP'S. 7 MR. CHA14BLISS: Well, the total-amount is limited, 8 so therefore what is ultimately awarded to Memphis comes out 9 of the entire amount available. 10 DR. MILLER: Isn't it true that previously, 11 except for developmental fund awards, which has not been 12. mentioned in the current directions, no region was allowed to just apply for escrow funds, by lump of escrow money. 14 You got it another way. But,you couldn't apply for escrow funds. And now you do not have an authorization or 17 direction for regions to apply for a development award, 18 either; do you? 19 MR. CIIAIIBLIS3: We cfo not. 20 DR.MILLER: well, isn't it appropriate that this 21 review committee specifically record in the record that we do not recommend funding for that activity or that kind of 22 23 an award, that part? MR. CII7UIBLISS: That would be a problem and we 24 are looking to this committee for its judgment on that. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.E. Nnthinorfnn 1) r. 9nnO9 em37 265 1 DR. IIILLER: Do you want that in the form of a motioa? 21 MR. CI-IAIIBLISS: A motion is not in order at the 3 present time. There is a motion on the floor, and that 4 motion is-that the level of funding for Memphis be recommends 5i at $2,684,000. 6 MRS. WYCKOFF: Well, v7hy don't we do it? 7 MR. CIIPIIBLISS: You may so indicate that, and the 8 staff eople will take due notice of it. p 9 MRS. WYCKOFF: Should we amend the motion that the 10 escrow funds be taken out of this? DR. T@NIITE: All of the escrow 'funds are on the 12 yellow slieet, they are not on the application. The awards. l@Inat you see on the application@is a developmental award and 14 a project, and I believe we are not supposed to get so deeply 15 into the region's management as to reject a specific 16 project. 17 I guess I have the feeling that if we reduce the 18 requested funds by an appropriate amount, the region will 19 probably behave fairly @,iell..'And I would be satisfied just 20 to reduce the funding amount and then proceed. 21 Does that make sense to anybody. 22 DR. llcPIIEDRAN: Then hov7 about, as a separate pieCE 23 of business that does not have anything to do with this particular consideration of this program, that we could have 24 25 this motion that Dr. Miller suggests. Could we do that? 40OVER REPORTING CO. INC. L?O MassachusettsAvenL,@, N.E. flr 9i!ar,7 em38 266 Just as a general part of the proceedings of this 2 committee. If we could do it that way. 3 MR. VA14 WINKLE: But the staff can also express 4 your concern about these two items. 5 MR. CIlIU4BLISS: Then I call the question, 6 Those in favor please indicate by the usual sign 7 in voting. [Chorus of "ayes".) 9 'MR. CHAIABLISS: Those opposed? 10 [.No response.] MR..CHIU4BLIS: The motion is carried. At two 12. million six, with the concerns of this panel being conveyed 13 to the region in the advice letter and by staff, 14 I must say that the privilege that we've had of 15 having Dr. Margolis, the Deputy Administrator of the i(i Health Resources Administration, come in just at this key 17 moment, when we were discussing a very critical issue having 18 to do with Memphis, was most timely. I would endeavor to ask the staff to set the 20 whole question in some type of framework, and then we would like to have Dr. Margolis comment on those issues be 21 22 conveyed to the staff and to perhaps some of the regions. I think this is very timely, what he has done. 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. 26 7 em39 REGIOIIAL MEDICAL PROGPUL REVIEW 2 MISSOURI 3 MR. CHA14BLISS: We shall now then turn our 4 attention to a review of the application from the Missouri 5 Regional Medical Program. The reviewers here will be Dr. 6 McPhedran and Dr. Ililler, and staff support will be provided, 7 by mrs.,Resnik. 8 Thank you, Dr. Margolis. 9 DR. McPHEDIWI: Yesterday Dr. Miller and I got 10 some additional material on the Missouri application, and 11 I cite this now not to beg off, because I have read it, in 12. fact, but it was interesting because it was. a staff visit 13 to Missouri and it was suggested to me that maybe I ought 14 to chan'e my views to some extent, In fact, the value 9 15 of this program and the,.merit of the application, specifically. it; But I must say I think it hasn't changed my views 17 a whole lot, and, while I've got more to say about it than is I did, it really remains about the same. 19 To go through the review sheet: program leadership, 20 I was unable to classify one of the categories, and have checked "satisfactory to poor" because I think that it is 21 variable, without mentioning particular persons. I think 22 that it really is uneven, and I'm basing tJiis on the fact 23 that the leadership seems to me very much the same as I recall 24 it from at least two because I've been there twice 25 IOOVER REPORTING CO, INC. 20 Massachusetts Aveou @, N.E. 26 8 em4O two previous site visits, and a lot of discussion at various 2 National Advisory Council.mectings. 3 I really think that what has happened in Lis. 4 application reflects this leadership to a considerable 5 extent. 6 I have no criticism to make of the program staff, 7 and never did, except that I'tliink it used to be ve large, and the proposal suggests enlargement. I can't _- pnless 9 the marking of that enlargement, it ii 10 currently 30 with a proposed addition of 45 staff. 11 The program staff in the past we used to Friticize, 12, maybe this should have been more a criticism of th elleadershid, 13 for its lack of initiative in helping people in the region 14 to develop parts of the program, develop projects and 15 develop other component parts of the program. 1(; According to the.most'recent visit, that is not a 17 problem now, but it certainly used to be. 18 I am persuaded by the recent visit, I have said l@) that at least it's satisfactory, but I really wonder whether, 20 if it's satisfactory now, it is justified to consider all the additional staff to such an enormously large-staff that 21 22 is proposed. 23 The Regional Advisory Group which, until a couple 24 of years ago, numered only twel've, has been increase4, I thin-,, 25 by two stages to a total of 55 members, and it appears that IOOVER REPORTING CO, INC. @20 Massachusetts Avenu @, N.E. Vashington, D.C. 20002 em4l 2 69 it is satisfactorily supervising the activities of the 2 program. In the fourteen montlas-before this application 3 there were four Regional Advisory Group meetings, I think 4 eight of the Executive Committee, and several of the various 5 technical and standing committees, 6 So the committee structure has continued to functio@ 7 and the Regional Advisory Group also said that there is a 8 fifty percent attendance rate at these several RAG meetings. 9 Past performance and accomplishments, 1 think ate 10 mediocre for the most part. I found it difficult to either 11 say satisfactory or poor or inadequate 12, Considering the amount of money that this program has gotten in the past, it is difficult for me to be more 13 14 generous in my assessment of this. 15 In the past there was a very large investment made in a lot of computer centered activities, and I guess that 17 this still remains with me, although it's all gone from the present application. 18 We thought, those of us who visited it,, that there 19 20 was bad judgment and even, perhaps, appropriate for the State of Missouri 21 mulishness about following the direction and guidance that we attempted to give. 22 The objectives and priorities seemed to be satis- 23 factorily stated. 24 I think that the proposed activities, and I can 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 2 70 em42 summarize briefly the categories are satisfactory but not 2 e feasibility, that is, the likelihood that imaginative. Th 3 the activities proposed can be accomplished in the ime that 4 they anticipate the program will continue is, by th i 5 own statement, likely in some and unlikely that the 6 manage in others. 7 For example, they -state that all the EMS activiti s 8 that they-have proposed, and I will come back to thIis, there 9 is a question pertinent to the one Dr. Scherlis raised 10 earlier, whether or not these are new EMS activiti s; but 11 they say that they feel these activities can be up q, raded 12, in the next year. I really ,7onder whether that is Is 0. 13 The cooperation with CHP seems to be quite 14 satisfactory. 15 l@ over-all assessment of the region is that it is only average. 17 I am afraid I have more comments and remarks to 18 make. 19 In this Regional Medical Program there appears to 20 be no serious problem in the relationship of the grantee, which is the University of Missouri, and there-never has beer, 21 and that continues to be,-i gather, a satisfactory relation- 92 ship. 23 MR. TIIOI.IPSON: You'don't shoot Santa Claus., 24 25 DR. McPIIEDRAN: No, not intentially. HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em43 2 7 1 The major thrust that they have stated for then- 2 selves are five: emergency medical systems; health; 3 manpower; education, and under that category especially 4 training people to deal with the problem of high blood 5 1 1 pressure, and training seminars to be conducted for many 6 categories of hospital personnel. Third is listed as integrated health care delivery systems, with especially heavy emphasis, as I see i,:, on 9 -supporting hospitals in developing JCAII type criteria, and 10 also a problem of oriented records for local practi ioners. 11 Ambulatory care systems, particularly con@erned 12@ about availability and of care. 13 The purposes, the major thrusts are as general 14 I'm quoting from the application there; just general, as I'm 15 stating them to be -- systems for-end-State -@- kidney manage- 16 ment. 17 Their fiscal year 175 suggests that their EMS 18 role will be completed, and the local communities will be I!) able to take the developed programs and projects and handle 20 them on their own, although I don't think that my reading of 21@ the application particularly supports that. 22 Then I went through the request for funding, 23 including changes in core staff. I. spent less time, I 24 must say, on the continuing pro ects, but a good deal of 25 time on the new projects, and tried to dig out for my own iODVER REPORTING CO, INC. @20 Massachusetts Avenui, N.[. Vashington, D.C. 20002 7fVi FAfit" em4A 272 I purposes what I thought was a necessary expansion of core 2 staff. And what I questioned might be new EMS projects, and 3 I realize the staff might have gone through this and may want .4 to, perhaps, dispute my judgment. The excisions that I performed enabled me to cut 6 their proposal from $3,010,113 down to $2,295,113. I felt 7 that there was $713,000 that could and in my view should be 8 removed from the proposal; and it happens to coincide with 9 what staff, in the person of t@irs. Resnik# has recommended,- 10 and I guess it also coincides to some extent with the 11 targeted amount. 12, But I think it is worthwhile to suggest what specific things there were. 13 14 There were, for example, requests for what amounted 15 I think, to increases iki core staff. They have six district i(i consultants, and the recent staff site visit suggests that 17 they should be continued. I have no quarrewl with that. 18 But there is a suggested sum of $31,000 by sub region to 19 increase staff support for tl7e distrist liaison to $186,000; 20 and I will quote from the application xqh.at the ultimate justification is. 21 22 It is said that the specific outputs would be a 23 plan and method of implementing the plan to operate under 24 the new legislative athority. If no legislative authority is forthcoming by fiscal year 176,'this year-Is effort will 25 HOOVERREFORTINGCO,INC. 32OMassachusettsAvenui,N.E. Washir,t@n, D.C.20002 273 em45 have been one of which the Missouri Regional Medical Program 2 can well be proud. We will have'brought toge-ther at the 3 working level members of principal federal and State health 4 agencies, to work toward a common cause of improving the Statewide health care system, and I think that I would really 6 have felt that even in a rorm 15 something more specific than 7 that could have been given me as a peroration to convince 8 me that that money ought to have been spent. 9 There are other things in there that I feel are 10 similarly if not worthier of support. I won't bother you with the details, but I do want to mention that I thought that 12. there were about around twelve, as I see it, new projects, 13 no EMS, twelve, roughly, totaling around $245tOOO, that I 14 just don't think are in the guidelines, are they? 15 MRS. RESNIK: We're treating them as sub-components i(i of already existing and ongoing EMS projects, which is 17 essentially what they are. They are dealing with training, 18 but in different locations. And they tell us that they 19 understand that that is within their authority under the. 20 present guidelines. 21@ They are applying to the EMS bureau, but they 22 don't foresee any grants. 23 DR. McPHEDRAN: This looks to me like new EMS, 24 and so that's 245,000, and then going thro'tgli some other 25 projects, I noticed this, but I did it an@iay,, I thought there HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 k74 em46 I were several things,, like there's a quality criteria 2 project in a hospital in Jefferson City, and it looks to me 3 as if that really is PSR activity, and I wonder if that 4 similarly should be excluded. And several other things that also seem to me un- suitable. 7 So that, in summary, what I did was I felt that 8 at least $715,000 could come out of it, and I came.out with 9 a recommendation, as I say, of $2,1295,113, which is obviously 10 unreasonably precise, but it is approximately where the 11 targeted sun is. I would have no quarrel if we said the I 12! targeted sum would be satisfactory; and I would like to know 13 what Dr. Miller thought about it. 14 MR. ClIP14BLISS: Dr. Miller. 15 MR. MILLER: .This is an interesting experience we 16 all go through. I pursued a rather different and more 17 devious route of arriving at the same conclusion. 18 I have known the Missouri Regional Medical Program I!) for a long time and many of the staff people on it, an 20 perhaps it is worthwhile to mention a little@ of the background 21 on this. 22 @lhen R14P got started, Missouri was really ready, 23 because Missouri was more regionalized in the medical 24 establishment than most any State in the'union, having their 25 medical school in Columbia, which 'is a small, a relatively HOOVERREFORTI CO,INC. 32OMassachusettsAvenvi,N.E. Washin-Kton, D.C. 20002 em47 275 1 small city, and therefore, having had to farm out clinical 2 medicine for a long time into other communities, which is 3 almost never done in most of the other medical centers in 4 the United States, and which was extremely repugnant to them, 5 as you may all remember. 6 So Missouri was, its time had come, and the mule 7 characteristics recognized this, and they proceeded with 8 vigor. 9 They also had some people in the leadership posi'tio-i 10 who have,considerabl.e skill in recognizing political 11 expediency,, and when it is popular at the national level 12, to spend money onlelectronic computer equipment and remote 13 control things, they were in there for millions and got @em. 14 When it is politically expedient to turn th4m. off, they 15 turn them off like it w4s a water faucet. Tqhich they have now done, because something else is politically exp edient. 17 I have four applications that are mine that are 18 coming up today, all of them are somewhat similar. And 19 Dr. Schleris' comments previously have botlired me, yesterday 20 and today and last night, and even lose.a little sleep over 21 it. 22 Because the principles formally ascribed to 2.3 Regional Medical Programs of quality programs, well evaluated 24 demonstrations that are woth the,money, seem to be all gone, and I suppose it seems a matter of political expedience, but 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.[. Washington, D.C. 20002 em48 2 76 1 it looks like weire stuck anyway. But it is bothersome. 2 And in these four programs that are corung up, they all have 3 applications, they are going gung ho for election, it's -4 politically expedient to get the money and they're out to 5 get it. And by whatever most clever mechanisms they felt 6 could be used to get it, regardless of whether it is cost 7 effective or will be continued really, or what the ultimate 8 goal is. 9 Noxi,, Missouri has done it to a.ratlier great degree. 10 It has it doesn't have an escrow item in here,'a develop- 11 mental fund item, but its method will give it a nice big one. 12. There are separately described staff component 13 projects,, 26 of them in this application, either with a dollar amount, none of which is excessive by itself; but 14 15 together is nice. There are six district liaison systems with a total 16 17 budget of $186,oob. They went all out on EMS without having a general State EMS plan, which is forbidden, so there is are five continuations and el@-ven new EMS projects, for a 19 total of $518,000. 20 21 It would be some little job to keep them coordinated. Maybe they will need those district guys to keep all those 9-2 different outfits working in any kind of a rational coordinatin g 23 way . 24 I could ao on in more details, but I think I will 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenv@, N.E. Washington. D,C. 20DO2 em49 277 1 say,, first, hoviever, that a little bit in contrast to Dr. 2 McPhedran's view, I feel that the basic questions that we're 3 supposed to answer on this review sheet, most of them 4 relative to other RTIP'S, you'd have to grade Missouri as 5 good to excellent. 6 The program leadership, you may not like them, but, 7 they've done a good job in Missouri. The program staff is 8 equally so. 9 The Regional Advisory Group, they get along with 10 very well. It's a little funny, but it works. Their past performance and accomplishments,, they 12. have been a leader in Missouri without any question. They 13 have lead regionalization in Missouri to a phenomenal 14 degree, and they have more general acceptance than many 15 other regions. Their objectives and priorities I would interpret 17 As political expediency, and they have done it extremely 18 well. 19 The feasibility, of course, is.very low, because we are theoretically supposed to grade these things on whether 20 they can do this in one year, and they obv'lousl@-can't 21 possibly do what they've got in this application. 22 They get along fine withCIIP,, they,support them in 23 f many ways. So they will get -go'od'acceptan6e .by them. 24 The total picture, 26 staff component projects and 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em5G 278 27 continuation projects and 19 new projects. 2 Much of this is overambitious for one-year concept,, 3 and it looks like it cannot be accomplished. -4 MI, conclusion: I recommend funding, however, at 5 the targeted level, which I think it is a way out of the 6 dilemma of coming up with adollar figure. 7 MRS. RE.SIIII,',: They are coming in with a $500 request 8 July 1, they indicate. 9 DR. MILLER: We will address that t-i,7o mo ths from 10 now. 11 MR. CIW93LISS: All right, each of the reviewers 12. has cone up with a different amount here. -13 DR. McPHEDRAIT: Well, T really didn't make that'in 14 the form of a motion. I have no quarrel with 15 f4ILLER:----,Ohl I wbil-ldn't@mind if he 'd DR wante -t6- figure out how you can justify c-'oming out with $2,295,113. 17 I'll go along with it. 18 DR. McPHEDRAII: I will move the target amount, I!) which is $2,364,333. 20 MR. Cl,'Al4BLISS:. Is there a second? 21 DR. MILLER: Iwill second. 22 MR. CIIMIBLISS:. It is moved and seconded that a 23 recommendation for Missouri be the-targeted amount of $2,341,490. 24 DR. IIcPIIED@@: I ]-,now you were probably semi- 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. W.ithincrtnn DC-20002 em5l 2 79 facetious, Dr. Miller, in saying that tlle changing in the 2 computer or the electronic program direction which had 3 developed so many electronic aids to care that was turned- 4 off like a water faucet. In fact, that really wasn't so. 5 It was damn hard to turn them off. I mean it really was 6 hard. It took a great deal of effort and persuasion, and 7 determination, and repeated visits, and Bob-Toomey 8 DR. SCHERLIS: It has not been turned off, the 9 output has been changed. 10 DR. MILLER: Excuse me, I should make a comment. I have been through this with several other JU@IP's, some of 12. which I made site visits on also as a coordinator. ..13 I agree with you. The electronic fanaticism in 14 our society is extremely difficult to turn off. lqe had it 15 in T@iany others. Georgia was a good example, when I was down 16 there. 17 But it has been turned off now in almost all is PL,IP S. 19 I-IR. ClIM4BLISS: May I restate the recommended- 20 amount for Missouri as.being @2,364,333.. 21 Is there further discussion? 22 I call the question. 23 Those in favor of the motion, please indicate by 24 the usual sign of voting. 25 [Chorus of "ayes".] HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. VVashin on,D,C.20002 2 80 em5 2 MR. CIIA@IBLISS: Those opposed? 2 [No response.) 3 MR. CIIMIBLISS: The motion is carried. 4 DR. SClil@RLIS: I ask one question now that you've 5 voted on it. 6 This relates to the fact you said they had a great 7 many different types of EMS activities, and you questioned 8 coordination. Is that correct? 9 DR. MILLER: Very difficult to do' this with this 10 many separate components. DR. SCIIERLIS: You mean they are making no .12 effort to coordinate it? Is there any umbrella EMS for the 13 region? 14 DR. MILLER: No, no. They would hope to get one. 15 But in the meantime they are going to have all of these 16 various sub-components v7eldh are 'allowable. 17 MR. THO@IPSON: Mr. Chairman, would you transmit our 18 unease about the EMS situation in Missouri to the EMS people? 19 MR. CII@"4BLISS: We 4,iill, indeed. We are much 20 aware of the discussion here, and we will be.in touch with the EMS people, 21 DR. SCHERLIS: I would almost suggest that we give 22 no EIIS funds if they are to be used in disparate programs, 23 24 In the State of Maryland we have had examples of what is. now a large State support of some $2.4 million throu(rh. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. Washington, D.C. 20002 (2021546@ em5 3 2 81 the Covernor. In the face of what are already small EMS 2 activities and some not so small', and you will spend endless 3 dollars trying to coordinate what are programs that begin- 4 with noncompatible equipment, noncornpatible standards, 5 noncompatible operations. 6 And I would think that if we perpetuate such 7 support, that we will be causing an excessive amount of funds 8 to have to be spent later on. 9 Some training programs will differ, criteria for 10 State certification will differ because you will be training 11 at a different level. 12, I think part of the insistence tha'L. we should have 13 would indeed be that these be coordinated,, regardless of 14 what the ground rules are. Otherwise, we should not support 15 any EMS activity whatsoever. 30 I feel very strongly about that, having spent a 17 good part of my energies in Maryland, because of the very 18 reasons that we have had different types of funding, I!) different community structures and different involvements. 20 We would be undoing a great deal of what has been done in the 21 past. MR. CIIAMBLISS: The EMS people are moving towards 22 State plans and State systems, Statewide systems, 23 DR. SCHERLIS: But if you give money to that group, 24 they will do their thing. The hist ory of our society is 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Waihington. D.C. 20002 2 82 em5 4 that everyone does his thing if he has the wherewithal to 2 do it,, and I would assume that by making separate structures 3 administratively, with our own means of support,, they will 4 do their own thing. I hope this won't be true of Missouri. 6 MR. VAN WIIIKLE: Vie did that in I-,idney, you know, 7 Len. If that did meet with within the State plan itself, 8 nothing was approved here. 9 DR. SCIIERLIS: But we have this leverage over- 10 these programs,, I gather from some of the feeling that we don't. 12 MR. THODIPSON: You see, the problem is that many 13 of the States do not have State management. 14 MR. CIIAIA-BLISS: A good amount of our previous 15 funding for El-IS has resulted in the,development of State plans. I can assure you of that.. 17 DR. IIILLER: Can I make some comments? I have 18 been connected with this at the local level. Although I 1!) don't pretend to know it all-, I know quite a bit. 20 EMS systems started out with an office of Transportation funding, which is very large and many have 21 them -- there are many of them in the United States. We 22 happen to have a very large onein Minnesota. And they're 23 24 buying ambulances. They are h6aded by ambulance drivers,, 25 by and large; they're buying ambulances and training ambulan(e. HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 i-)n,),k @Ar rcra em55 283 attendants, and setting up standards for their performance, 2 and that funding is precluded from doing anything with.the 3 patient except delivering him to the door of the nearest 4 hospital. It cannot go any further. lihen EIIS incentives started with M,!P here a couple 6 of years ago, why, the focus was to try to get comprehensive 7 planning for comprehensive care of emergency caseslland to face the issue about what happened to the patient after they 'got inside the hospital.door. And so many IVIP's un( r oo 10 to do this, And many of us supported planning for c riprehensire 11 emergency system development in the States. 12. Then E.',,IS bill came through, and it seeme.d@like la that this was going to take over, the over-all coordination; 14 but this,, as usual, has not happened. 15 And the leadership there doesn't seem to have the 16 capacity yet for attacking the whole problem. 17 So at the local level the possibilities of local 18 B agencies or regions or districts within the State of 1!) getting funding through the new EMS bill was really quite 20 remote and they came back to RMP in most of the local levels to do this. 21 22 So there are three separate fragmented kind of 23 programs for EMS in this country right now, and they're not coordinated at the national lev'el, and the attempt of RIIP's 24 is to try to get coordination at the local level, which we 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em56 284 have always been challenged to do in the IUT management 2 system. 3 MRS. I-IYCI',OFF: But if you offer them money and .4 say, If you will make a State plan and you have thi,[ money, 5 would this create a climate? 6 DR. MILLER: That's exactly what we did two years 7 ago. Many of us did it two years ago. .8 -1-le paid for the deve lopment of some kind of a State 9 plan. 10 DR. SCIIERLIS: Not necessarily. Iwas c irman 11 of the EMS Committee nationally that reviewed all e 12. pro3ects that came in, and these weren't, except in rare 13 instances, State plans. And I'd say if you look at the whole 14 United States now, there are very few States that have any 1.5 semblance of a State plan. Maybe two or three. 1(; DR. MILLER: Now, there's a good difference between 17' a good State plan and a State plan, so I'm not saying they're 18 good; I'm just saying 1!) DR. SCI-IERLIS: My only concern here is that I hope 20 in whatever letter goes out indicating funding that one 21 proviso of that letter states that each of tliese-areas have 22 set up compatible systems, that there has to be a plan utilizing all their forces. I don't think that this state 23 24 is large enough to have individual areas designated as they 25 have, unless there is some over-all State compatible plan of HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. Washington, D.C. 20002 285 em5 7 communications and eve rybing else that goes into it. 2 I would think that unless we put that into whatever 3 support letter we send out, this will be something that will 4 have to be dismantled later on and will have to be 5 fragmented. That's the only point of my observation. 6 MR. CIIAIIBLISS: We do appreciate these observations 7 that the panel has made. We have at the table Mr. Mike Posta, who coordinated 9 the EMS activities for the P14.Pls, and he indicates to me that 10 of the 23 site visits that were made by staff over the last year, that the majority of them had, as an effect of the 12! 11 i support, the development of State plans. And we will keep in mind your admonitions for 14 lessening fragmentation and more coordination between the i5 three federal agencies that are supporting EMS activities. I want to assure you that P24P has already been in 17 contact with the Emergency Medi.cal Service Program here, and agreements have been reached as to what we probably might 19 0 fund and what their area of responsibility is. And I assure 20 you those discussions will continue before these funds are 21 awarded. 22 I would call to your attention 231 MRS. RESNIK: May I add one word about the Missouii 24 El@ program and the thrust in this application? 251 It was stimulated, by and large, by the passage of HOOVERREPORTINGCO,INC. 32OMassachusettsAverw@,N.E. Washington, D.C. 20C,02 2 86 em5 8 State Law 57, which set forth standards and requirements for 2 equipment on ambulances at various training levels,: to the 3 extent that these programs involve program with 1 ttle 4 training, and that is the majority of the new acti ities, 5 it is not new in the sense that they are treating new 6 as ect of EL@IS. They are training at various level to p 7 conform, or their existing training to conform to e 8 state requirements as described in the law. 9 And that is why,it looks fragmented, but it is part 10 of eventually a total training system. 11 I raised the question with them about equipment 12, a4d various items of that sort, and there was still! a 13 considerable number of dollars that has to be looked into. 14 But there was a major point in establishing these as separate 15 activities to conform to the State law. I(; MR. CYIPIIDLISS: I think we have already had a vote 17 on Missouri, and the discussions we have been having is an 18 add-on. I would simply suggest to the committee that it 20 mall wish to take a coffee break at this time; and, if so, 21 maybe we could return at 10:30, 10:33 with our -coffee and 22 resume. 23 [Short recess.] 24 MR. CliAt.4J3LISS: May I call the panel to order again please, and indicate to you'that I gather that the 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E@ Viashington, D.C. 20002 em59 287 other panel is moving quite well -- and so are we -- and 2 suggest that we might take a look at the application from 3 Nebraska Regional lledical Program. 4 Yes, Dr. Thompson? 5 6 7 9