ae - Transcript of Proceedings. | us DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE | RM2S REVIEW COMMITTEE MEETING at Ty at NN Rockville, Maryland Thursday, 21 September 1972 ACE - FEDERAL REPORTERS, INC. Official Reporters 415 Second Street, N.E. Telephone: Washington, D. C. 20002 (Code 202) 547-6222 NATIONWIDE COVERAGE . 7148 y ‘AIG: paw | 3 @ 1 @ | 12 13 14 15 16 17 18 19 20 @ 99 24 24 e~ Federal Reporters, Inc. 25 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE RMPS REVIEW COMMITTEE MEETING Conference Room Gu Parklawn Building Rockville, Maryland Thursday, 21 September 1972 R 7148 RAIG: paw e~ Federal Reporters, owt . - oO? ~ ° 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 AREA: Maine Rochester Central New York Virginia West Virginia Albany Hawaii £ ONTENTS eee eee PAGE 43 81 134 166 198 218 245 CR 7148 1 #1 Reba l 2 e 3 10 1 e 12 13 14 15 16 17 18 19 20 21 eo # » 23 24 Federal Reporters, Inc. 25 ww PROCEEDINGS DR. SCHMIDT: Good morning. I missed my chance a minute ago, there was a little lull in conversation and ob- viously it was time to begin. But someone said something and I missed that opportunity. I am used to a lot of feedback from my Executive Committee and its groups that I work with, but it usually is not as noisy as the feedback this morning. The room is turned around and there are some new audio equipment in here. We may have a liitie more music than usual. in addition to the new look of the table in the room there is a new look about the table. And first and most importantly we would like to welcome some new members to the Review Committee and I would introduce them to the cher members of the Committee and to the Staff and guests in the room. Immediately to my left, Mrs. Maria E. Flood, no, I am sorry, down there. Hold your hand up so everybody can see Mrs. Flood. Who is from the Texas RMP. She is a staff person, a regional representative from El Paso. And immediately to my left then Dr. Grace James, who is a pediatrician from Louisville, Kentucky. And on Dr. Brindley's left is Dr. Bill Luginbuhl, Dean of the Division cf Health Services, University of Vermont from Burlington. He is on the Northern New England Regional Advisory Committee and is experienced in health care delivery systems #1 Reba 2 2 i ® 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e- Federal Reporters, Inc. 25 and so on. So we welcome the new members to the Committee. I warn other committee members that the three new members have been working hard all yesterday afternoon. They have been briefed and brought on board and made experts and I am a little bit concerned that they may be a little more expert in certain areas right now than the rest of it. Is Henry here? Henry Lemon, our old friend, will be with us for the site visit report to West Virginia. Henry is’on vacation and he kindly agreed to come in for this session. And Dr. Simmons Patson, chairman of the North Carclina RMP, will report on the site visit to Central New York. Dorothy Anderson is ill. Dr. Andrum is ill and won't be with us for this session. Dr. Toomey is coming a little late. Dr. Brindley unfortunately can be with us only today. Another announcement is that Sister Ann Josephine is practically enroute to Rome for a sabbatical year of study. She, this is her last meeting, there+ fore, and I really need not express to the group the loss that this committee will feel when she is no longer sitting there holding down the fort. She has been in Salt Lake City for what did you say, 34 years? And this will really be a sabbatical for her. You are really supposed to get one every seven years, not every 34. But we thought this afternoon that we would celebrate what I think is an exciting and happy event for her, and we will have #1 ] Reba 3 2 1 © 12 13 14 15 16 17 18 19 20 21 e ., 2 23 24 e — Federal Reporters, Inc. 25 coffee and a little celebration this afternoon. Mr. Parks has resigned from the Review Committee, because of other pressing priorities and time commitments and so on, and we will miss Mr. Parks. _ And finally this is the last meeting for Warren Perry, whose term expires in December. I would remind the committee of the confidentiality of the meeting. The confidentiality statement is printed in your material, the discussions of the Advisory Groups are confidential except as disclosure is authorized by the Administrator of the Administration. Dr. Margulies will review the policy regarding review of application meetings. DR. MARGULIES: There has been a new Executive Order which was actually effective during the last meeting of the council but the date coincided with the time the Council was actually in session and it has not yet been made official. It had not been then. It is now. This has to do with public attendance, and it is meetings which are composed of advisory bodies affecting policy which are working with the Federal Government agencies. And it has been further defined since the time of the Executive Order so that there is a reasonable level of clarity now of what it’ means and how it is to be handled. The second, Secretary Richardson, has defined it for our Council as applicable to those parts of Council meetings which are discussions of policy and which lead to advice on poli to government, but has agreed that the review of applications #1 1 Reba 4 2 10 11 © 12 13 14 15 16 17 18 19 20 24 e~— Federal Reporters, Inc. 25 per se will remain closed, and that appears to be acceptable. That means that when the council meets, the agenda will be carefully divided between those portions which deal with policy review which in the case of the Council takes up certainly the majority of their time. And those parts which represent review of applications The Review Committee is not changed in its function. It still remains a closed meeting according to current definitions. The Executive Order applies to all groups which act in an uy advisory capacity and who represent non-governmental group meetings. It also means that there will have to be an appropirat agenda available. It must be announced in the Federal Register at the time of the meeting to be held. It has to be in the Federal Register and there is a mechanism for members of the public not only to attned but to have access to the written materials, to the results of meetings and to the meeting, it- self. | This applies to subcommittees, Executive Committees, and applies for example to groups which we may pull together to advise us on evaluation or on any specific phase of RMP activities. | It applies to all Federal activities and will among other things it seems to me keep a number of people extremely -- people managing all of the data which flows in, has to be e #1 ] Reba 5 2 so ~ Qa 11 @ 12 13 14 15 16 17 18 19 20 21 e » 4 23 24 e~- Federal Reporters, inc. 25 7 reviewed and put out again. It appears very likely that there will be at least some similar kind of requirements placed on grantees. This is likely to take place in the very near future. It will not seriously affect the RMP function, excepting that it appears highly likely that there will be a requirement for the regional medical program when it is preparing or submitting application to give public notice to that effect. The other requirement such as the maintenance of materials, the continuatipn of a library and an available information system for the public, are already in existence in regional medical programs. So also is the maintenance of verbatim records of meetings which we have here, which we have at the Council. But it will change the environment and will create some interesting entries. I expect that some programs will be more directly affected by this than others. DR. SCHMIDT: Fine. Are there any questions or comments for Dr. Margulies? If not, then I would remind the group of the con- flict of interest policy which states that Review Committee Members should not participate in situations in which a violation of the conflict of interest laws and requlations are likely to occur and I am sure that the new committee members know that we do not participate in discussions of applications and affairs of regions in which we reside. #1 Reba 6 2—Federal Reporters, 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 And so on. Also, a reminder of the future meeting dates which are on your agenda, January 17th and 18th, 1973. And May 16th and 17th, 1973. We have a, as usual we have a very full schedule for these two days. We will have to alter the order of review somewhat to allow for Dr. Brindley's de- parture today. And also to conduct a couple of experiments and infor- mation dissemination to the Committee, kind of experiments in easing the review process, and then we have obviously the number of applications to get through, as well as the discus- sions that are on-going about the function of the committee. Probably a good part of the morning will be devoted to report from Dr. Margulies about various things and other staff members. Then moving on to one of the experiments in information dissemination, and in the way that the Review Committee fits into the total picture of the RMP Review process. So that we will begin then with a report from Dr. Margulies about the recent council meeting and other matters that he sees fit. DR. MARGULIES: Thank you. I think it probably would be useful to talk in specific terms about the recent meeting of the Council with the kind of feedback that the Review Com- mittee which I think you will find helpful, and after that and whatever discussion you may want to have on it, I would like to talk with you about appropriations, legislation for 10 i] @ 12 | 13 14 15 16 17 ‘18 19 20 21 e 2» 23 24 e — Federal Reporters, Inc. 25 regional medical programs and other programs, all of which is of particular importance at this time. You have in front of you a manilla folder which has in its a status report to the Review Committee of the. actions taken during the last cycle of the National Advisory Council. This is primarily designed to give you the necessary infor- mation. It looks like this, (indicating), the necessary information regarding the action which the Council took based upon the review and recomnitendalions from this committee. You will find as you go through it that the actions of the Review Committee in terms of funding were held up all the way through. So also were all other actions with two exceptions. One of them had to do with the rather uneasy recommendation on the part of the Review Committee that tri-annual status for Missouri Regional Medical Program be withdrawn. Let me interrupt myself at this moment to say that everyone has been welcomed here excepting the new Chairman, Dr. Schmidt. Welcome, Dr. Schmidt, as Chairman of the Review Committee. What made me think of this was the fact that I was suddenly on Missouri and I realized that T had a new chairman next to me. There was a strong recommendation at the time the Review Committee met that there be a site visit to Missouri, and that this site visit be for very specific purposes. #1 Reba 8 é@ ~ Federal Reporters, VW 12 — gu 15 16 17 18 19 24 Inc. 25 j~ 2 A number of things have occurred since that time in- cluding the Site visit which will be reported on later during this meeting and has just been completed. The other change in the recommendations had to do with some action on.a kidney project which you can find evidence of in Ohio, as I recall. Otherwise the actions, the recommendations, the criticisms of the Review Committee a those that were accepted by the Council and which were an official part of our subse- quent action in dealing with the regional medical programs which were reviewed in that cycle. Now there may be some further questions particularly © abou the Missouri program because this occupied greatly the review committee meetings. I think they would be dealt with better as we get to that recent site visit which I think was completed just this week, wasn't it, Mr. Chambliss? MR. CHAMBLISS: Yes. DR. MARGULIES: Now you may want to spend some. further time going over these figures and over the information SO we can come back if you wish. I will spend, I hope, a rela- tively brief time trying to bring you up to date on such things as appropriations for regional medical programs and new legis- lation. We live so close to it that we sometimes assume that verybody has the same kind of vibrations that we have but bviously that is not true because if I go across the hall I #1 Reba 9 11 12 13 @~ Federal Reporters, 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 Ll find they don't get the same thing I do so let me at least tell you hwere it is from our point of view. I think it is general knowledge that there was an Appropriations bill passed by Congress, vetoed by the President, and the attempt to override the veto failed so that it has been necessary for Congress to go back through the Appropriations process once more. : That is now being done. The recommendation of the President was that the Appropriations remain consistent with the recommendations which had been sent from the Adminis- tration to Congress so that there can be a orderly and accep- table management of the national budget, and since he made that recommendation to Congress there has been action by the House which represents a kind of middle position so far as I can tell between what the Administration had recommended and what was the final action of Congress in the bill that was vetoed. What happened with RMP during that appropriation process was approximately as follows: That the recommendation of the Administration which incidentally was the highest any Administration has made for RMP was around $131 million. That was raised to something like $150 million as I recall by the House. It was raised by the Senate to $184.5 million and then in the Conference Committee it was compromised around a # 1 Reba 10 e ~ Federal Reporters, 10 11 12 13 14 15 16 17 18 19 24 Inc. 25 (12 figure of $164.5. There has been in the action of the House a figure which is approximately as I recall around $149.5 million at the present time. To my knowledge there has not been any Senate action and certainly I have no knowledge about what might happen if that passed and if the rest of the bill is at that level and it again goes to the President. That gets into some speculation which is well beyond me. If the present bill does pass in whatever form it finally emerges there will then be some further delay as there is an analysis of distribution of actual allocation of funds, and it takes a certain amount of time for a program like our own to know exactly what its funding will be. It is very difficult to estimate that time with minor skirmishes like a national election coming up. But it is not likely to be in the immediate future. That always poses a problem. We are rather accustomed to it. It means that in the interim this program like all programs in the Federal Government. operates on the basis of what is known as a continuing Resolution. A continuing Resolution restricts us to levels of activity which are consistent with those that we had during the preceding fiscal year. And it means that we cannot plan on a large increase even though we think one is in the offing, we are free to reduce our funding, but in general we are required Reba 11 2 ~ aul oO 11 ) 12 13 14 15 16 17 18 19 20 21 oe £» 23 24 e-— Federal Reporters, Inc. 25 13 to stay around the same general level. We do not have any figure on the succeeding fiscal year. There will be a budget submission. There will then be another round of reactions between the Administration and Congress, and I think any speculation on FY 1974 is pretty foolish. On the other hand, we have to do a certain amount of speculating because we can't very well make decisions within this program or any other affecting levels of activity for one year and ignore the next year, so we will have the usual kind of calculated guessing games going on as we did in the past. I don't anticipate, but I really can't rule out, another kind of a problem like the one we had during the last Fiscal Year in which we had to deliberately plan around some supplementary grant requests to make sure we could utilize our funds effectively at the end of the year. You will recall that what we had to do was anticipate, well, really at the last minute, the availability of funds during the second week of June, funds which had to be expended effectively and usefully by June 30th. We did that by using a supplementary grant approach. We have no intention of doing that again. We have never desired to do it because it is totally inconsistent with the RMP approach to things. In the current round of appropriations recommendations which have been under discussion to the best #1 1 Reba 12 2 11 @ 12 13 14 15 16 17 18 19 20 @ 22 24 ‘e@ ~ Federal Reporters, Inc. 25 of my knowledge there has been no earmarking of funds by Congress saying that there will be so much for this activity and so much for that activity. There has been an earlier decision which was based on the first appropriation process to take some $15 million for emergency medical systems support. Whether that will be sustained during the present fiscal year, I do not know but I rather think it will be. There is every indication that’ that will be done. That is a budget- ary decision within Health Services and Mental Health Adminis- tration, perfectly acceptable to Congress but not something which was part of their Appropriations Act. Early in discussions on appropriations there were some earmarkings, these were all dropped for one reason or another. But they often reappear or come out in a different form after the Senate takes action, so we simply have to wait to see what will happen. I don't know that I could respond to any question on this subject but if anybody has some later information I would be glad to hear it. Let me switch for a moment to an associated issue, on which I cannot: add any further light, but perhaps contribute to some speculation. We have talked about this during the last meeting of the Review Committee as well. This is the year in which there has to be an extension of legislation for regional medical programs and for a number of others of the key programs #1 1 Reba 13 2 @ 3 10 11 e . 12 13 14 15 16 17 18 19 20 24 2~ Federal Reporters, Inc. 25 15 in HSMHA which are dealing with the delivery of health services, Such joint programs as Comprehensive Health Planning, National Standards for Health Services, R&D, Hi11-Burton and so on. This provides an opportunity for the Administration to try to look at these many forms of legislation which have varied histories in terms of their first passage, first intent, later intent, and so on, and try to pull them together in a kind of pattern of legislative activities which could be admin- istratvely made rational and which could be used to subtend a consistent policy on the part of HEW. The people who are thinking about it in the Department assume quite naturally and I don't say this for political reasons, that they will remain in office for the next four years. That is natural not because of the polls but because there isn't much alternative when you are in the Department except to figure you are going to be in for another four years. However, I think that it is their assumption that they will be in any case. Now if that is true and if their calculations are based on high probabilities, it means that there is a better opportunity now than there has been in many years with the growth and understanding of health problems for aansistent policy to be established, for this to be based on a higher level of grants consolidations, on a higher degree of activities which reflect the concepts of health revenue sharing, on the anticipation of National Health Insuranc Ww #1 1 Reba 14 2 10 1 e@ 12 13 14 15 16 17 18 19 20 2] e 22 23 24 e — Federal Reporters, tnc. 25 16 and some of the other major issues which have been under dis- cussion for the last two or three years, and to design legis- lation so that various kinds of programs relate with one anothey in an effective fashion. That means that for regional medical programs an isolated look at what RMP ought to do would be inacceptable. There has to be an analysis within the Department of what RMP can or should do with some very careful reference to what then this would mean with. comprehensive health planning, with the development of manpower, with the development of insurance systems, quality monitoring and so on, so that I am confident that the basic recommendations which will finally come out and they have not been completed, by the Department for Congres- sional action will depend upon a total analysis of the related legislative programs, and a better elucidation within the Department of what its basic policies and intentions are. There are certain currents which may be confusing; for-example, the development of stronger international heart and lung institutes as a categorical activity, the National Cancer Institute, as a categorical activity, and yet a simul- taneously vigorous statement, restatement, constant statement by the Department that.it wants to avoid categorical activities and to develop greater consolidation of programs. I don't believe that there is the kind of inconsistency in those kinds of comments that one might believe. There is #10] Reba 15 2 3 e id HW @ 12 13 14 15 16 17 18 19 20 21 oe » 23 24 3~ Federal Reporters, inc. 25 17 some level of inconsistency because sometimes actions are taken which are nolitical and which are accepted despite the fact that they may be inconsistent with other kinds of perform- ances but I think that a good illustration of the kind of workin respect which can be established between a categorical approach and what we are attempting to do is expressed by the present plans to develop a national hypertension control program. Now I am not going to go into that in any great detail because it has not been fully developed excepting that the Secretary has permitted the Department ~~.every time I mention the Department I get feedback. The Secretary has committed a group of people for whom he is responsible to a prog of hypertension control. But I think the differences in what is being discussed probably as illustrative as anything that I can find offhand of the ways in which one can deal with categorical disease and not commit the errors of the past. If this were to be a hypertension program as we would have done it four or five years ago it would lead very rapidly to a number of grant requests to which we would have acceded to build hypertension clinics and special investigative units and other kinds of projects which allow people to pursue their hobbies in various ways. And these would be designed around an elaboration of the methods for identifying renal. hypertension, for doing various kinds of assays of blood levels which would associate ran #1 Reba 16 end #2 # 2 fls ¢ ~ Federal Reporters, 10 1 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 18 clinical investigators with a better understanding of the specialized forms of hypertension which they currently don't understand. | What is being talked about in the present Secretarial initiative is not that at all. swl ] so ts, 1 e * 14 1p 16 17 19 20 21 @ 22 23 24 ‘¢ ~ Federal Reporters, Inc. 25 It is an approach to a problem with an epidemioloic basis which argues that one can move from a very miserable level of hypertension diagnosis and management to a much bettey level by using motification withing the existing delivery system rather than setting up separate disjointed units to deal with it in a separate kind of a way. The figures are approximately like this: That there may be 23 million people in the country with hypertenstion; that under the most generous estimates, 7 million of them have a diagnosis and some kind of treatment. To go from 7 million to something approaching 23 million cannot be achieved by setting up a series of highly sophisticated hypertension centers,; It can be done only by simplifying the syste, bye accepting the fact that what you are getting at is essential hypertension, that it is particularly a problem among blacks where the frequency of hypertension is far greater than among non-blacks. That it probably -- although that is not sure -- has an accelerated rate among blacks, particularly among black females. That it is the very major cause of disability and premature death in many population groups including a large number who have no access to reasonable medical care. Under those circumstances, one caould and I hope we will in RMP as a part of this general_project, approach that kind of a problem through the health delivery system and in the process discover something more about how to approach similar sw2 2—~Federal Reporters, oO ie 12 13 14 16 17 18 24 Inc. 25 20 kinds of problems by an elaboration of the system as it consists Quite clearly it will require not only better edu- cation of the public, better education of the profession, but the utilization of the resoruces and particularly of providers of medical care in ways that we currently are not doing but with which we have had some experience. On cannot expect the overlaaded physicians in this country to suddenly jump from the current level of hypertension control to a high level of hypertension control entirely by their own individualized efforts. No one seriously thinks that can be don. So, I think it represents to us an opportunity to dea with major disease entities in a way which is sensible and use- ful and not in the patterns of the past. This will ailow us to work very intimately with the National Heart and Lung Institute and there are plans to work out a long similar lines,a little more difficulty, I believe, with the National Cancer Insitute with some major cancer problems. Back to the legislation. At the present time I think that it is.reasonable to assuem that when the new legislation for regional medical pro- grams is written that the department will have some specific recommendations to give it a higher level of definition than it has had in the past. Now, I can't really go beyond that because there is sw3 1 15 7 17 18 19 20 @ 22 24 ¢ ~ Federal Reporters, Inc. 25 b tee 21 debate going on . here and downtown as to what the definition of RMP purposes should be. I have argued as well as I can and some of my col- leagues on the staff, that we have worked very hard in the last two or two and a half years to develop a series of institutions, regional medical programs, which are capable of functioning effectively but which are currently not guided clearly enought and in exactly what it is they are supposed to do; that they can- not go on effectively doing as many different kinds of things as are being asked of them and survivive; that they must have a cle working relationship: with such major elements in HSMHA research and development, comprehensive health planning, a better defi- nition of relationships with manpower activites in HSMHA and in NIH, but more than anything else an understanding of where they fit in what general HEW policy, a decentralized approach to improvement in health delivery systems and the other kind of legislative programs. I don't believe that it is a matter of life or death for us to have a stronger definition, but I think it would serve everybody's prupose if that were the case. I have personally argued very strongly in favor of keeping as a minimum a.strong emphasis and an expanding concern in regional medical programs for quality assessment. and quality assurance, which is a broad subject, one which must be approache vigorously and one where I think RMP considerssa very useful ax awk — Federal Reporters, Inc. 25 88 . meetings. In fact the primary decision-making group at that time was the planning committee which had 17 members, 13 of whom were university people, three of whom were RAG members and anything the planning committee disapproved was not sent on to the regional advisory group. The planning committee met monthly, the regional group met as necessary and once as necessary was 11 months. In addition, the technical review groups were almost all un- dominated so it was pretty clear who was in charge, the coor- dinates wasn't making decisions, the program staff were inter- ested in their projects, the regional advisory group appeared to be not interested in anything, and decision-making groups were dominated by university people. - This was the first site I was on, may have been the first one ever where there was a feedback session from the site visitors to the program. In fact we were so astounded by what we found in Rochester that Dr. Spellman arranged for two separate feedback sessions so he could be rather frank. lle spoke to the coordinates then spoke separately with the RAG chairman to make sure the RAG chairman would get the message as well and we thought we would be really brutal and we thought maybe RMP would never been able to go back to Rochester. And after all the frank advice we gave them we left i Rochester expected you know, in the next few months something Reba 7 2 1H @ 12 13 14 15 16 17 18 9 20 e 22 24 e~ Federal Reporters, Inc. 25 89 really cataclysmic would happen. It didn't. For a long while you know Rochester went on with business as usual. In the fall of 1970, there was a management assessment visit conducted that was triggered by the concerns of the review committee that confirmed the site visits findings. The management assessment visit found precisely the same thing the site visitors had found, prepared a written formal report that did not mince words, that went back to the coordinates that went back to the grantee, that made precisely the same recommendations that the site visitors had made. Maybe something will happen. Next year in 1971, in the spring of 1971, Rochester submitted atriennium application.| This application showed the same chronic problem areas as | before. So another site visit was scheduled in June of 1971, and Dr. Schmidt was the Chairman of that visit. The only difference we could find in Rochester was that the undominated planning committee had been abolished and an executive committee of the RAG had been formed but aside from that there were the same chronic problems and nothing seemed to have changed, in fact it was almost a re-play of the visit the year before which had had tapes of the feedback ses- sion. Still no. program leadership from any quarters. We could not identify any program direction. In fact the region didn't really know how to come up with program direction ago] Reba 8 2 @ 3 so —? a) 1 ) 12 13 14 15 16 17 18 19 20 21 ® 22 23 24 e — Federal Reporters, Inc. 25 90 they would say things like “You know there is something we could do,. such and such an activity, but the CHPB agency has already done it so we don't know what we should do." It was that sort of atmosphere in Rochester all they could think of was continuing education and central regional services, there still was no program staff that was not project directors. Ana at that time, the site visit team and the review committee really had to sit down and decide, okay, you know what are we going to do now,this has gone on pretty long. I think it was decided that you can't make a revol- ution with silk gloves, and although we thought we had been tough the year before that must have been silk gloves so we put on boxing gloves. And what the review committee finally recommended was that the level of funding for the region should be substantially reduced, that the region should be held to one year approval only, with the warning that we are going to come back next year and see what you have done. Well these time and money limitations apparently produced enough anxiety on the part of the Dean of the Medical School that in September of 1971 Dr. Orbison, the Dean, and Dr. Ernest Saward who is Associate Dean, for Intramural Affairs came down to Rockville to have frank discussions with Dr. Margulies about what was wrong with Rochester. Then they went home. And we thought then maybe we would really see some action. Just a word about Dr. Saward. #8] Reba 9 2 10 1 e 12 13 14 15 16 17 18 19 end 20 dt t 8 21 3 fis 22 23 24 e — Federal Reporters, Inc. 25 91 He was brought to the University of Rochester in the I think it was the fall of 1970. He had been associated with Kaiser-Permanente and the Washington Medical Program and one of his main responsibilities at the University was going to oversee the RMP activities. He has not been very much in evidence and we really had no evidence whether he was interested in RMP or not. I think now we can see in retrospect that he was and he was doing things behind the scenes but we were not aware of that at the time. As I say they went home and things went on as usual, so usual in fact that when Rochester received its substantially reduced award it just stretched the award to fund every single project that had been approved although at a reduced level so at this time you had 17 projects that were going on and I need not tell you what kind they were. Some of them were actually kind of good but they were all continuing education, central services and categorical. Now maybe if we could take a look at this point at what Rochester looked like for its first four years, (Slide 3). CK #9 ty 1 11 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 :e — Federal Reporters, Inc. 25 Very briefly you can see that the allocation of program dollars was pretty constant over the first four years, about 36 percent program administration, which wasn't program administration, about 26 percent in multi or noncategorical and almost all that went for their early disease protection unit which was a multiscreening thing which nobody had been very well impressed with and looked like it might go on to the end of the world and about 35 to 38 percent in categorical activities which encompassed the litany that I have gone over many times, nursing, continuing education, coagulation - laboratories and so forth. In the winter of 1971, though, we did receive word that Dr. Parker had resigned. And then we didn't hear anything more until around February 1972 at the request of the region there was quite a large program staff contingent that went to Rochester to consult with the people. In fact we really laid on everything we had as Dr. Pahl, Mr. Simon from our Management Assessment Branch, Mr. Peterson from Planning. Evaluation and a couple others of us and we thought we were going up there because Rochester really had something to tell us about how they had changed. Well, we got up there and we found that except for Dr. Parker's resignation, nothing had changed. The Executive Committee still was talking about the things that needed to be done but things they had not done. They still weren't ty 2 10 11 ® 12 13 14 15 16 17 ji 18 19 20 21 e@ » 23 24 >~ Federal Reporters, Inc. 25 ¥3 able to determine how they were going to find a role for themselves. So we gave them the same old advice that had been given for the last two years. And came back to Washington wondering, you know, why had we gone to begin with. I think in retrospect we were mistaken or I was mistaken at any rate. There was a lot more bubbling under- neath the surface in Rochester than we could see. I think people like Dr. Saward and others had been arranging their |. pieces on the chess board but before they made that grand swoop they wanted cne final reassurance that this was really the way to go because after we left in February a number of things started happening in very quick succession and I think maybe the best way to explain those is to compare the program that Rochester is proposing this year for its 05 year with the program that they initiated in their 04 year. One of the main areas of the change has been program leadership... As I say Dr. Parker resigned. A new director was brought on board in May of '72. His name is Dr. Peter Mont, And Dr. Brindley when he discusses the site visit will tell you more about Dr. Mont. The RAG has changed. The program has instituted a system for the rotation of RAG members. Now that doesn't sound all that swell until you realize that Rochester didn't have a system like that before and so essentially the RAG that you saw at the end of 1971, the beginning of 1972, ty 3 10 11 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 te ~ Federal Reporters, Inc. 25 94 except for deaths and resignations, was the same one that had been appointed back in 1966. Thirteen new people have been added to the Regional Advisory Group. ‘the minority repre- sehtation has been increased from 2 to 5 of 36 members, and the kind of consumer representation has taken on a different character. Mr. Frank Hamlin who had been RAG chairman since 1966 stepped down, his place was taken by Dr. Peter Warter who is vice president of Research for Xerox in Rochester. As I said before the old Pianning Committee is gone and there is an Executive Committee of the RAG. Another interesting thing to look at is the changed relationship between the university, the grantee, and the Rochester program. When we were on the site visit, Dr. Orbison, the dean of the medical school, assured the site visitors that the university was content to have its input to determination of program limited to that provided by the six university members on the RAG, which seems reasonable. Another interesting thing to look at is space. You know the RMP had thought always it had to be housed with the university, it was part of the university. The university never could spare enough space for the Rechestcr program. Consequently they were scattered in places, so the staff was never put together you know. There would be a few over in this building then you would have to walk across the street and ty 4 19 11 @ 12 13 14 15 16 17 18 19 20 21 oe x 23 24 e~ Federat Reporters, Inc. 25 95 up some stairs to find the rest of the people. Well, now with the support of the dean, the program is moving into a building about a block up the road. It's university off-campus space and you know they will be able to hang out their shingle that says "Rochester RMP" and they will be all in the same place. Finally though this doesn't tell the whole story, I:think-it is kind of interesting to look at project sponsor- ship. (Slide 4.) This is determined by the allocation of dollars by project sponsors. At the beginning of the 04 year every single project, every single of the 17 projects that Rochester: supported was sponsored by the University of Rochester. What the program is proposing for the fifth year, you can see that 44 percent are sponsored by the university but the others are divided, health and education associations, like the education consortium, the Rochester Alliance and Health Association of Rochester, 13 health care facilities, a couple hospitals and a health center. Ten percent are spon- sored by community organizations; the VA is sponsoring one, ancther by the OEC Poverty Agency in the central part of Rochester. I think another thing is program direction. If we can go back to the chart we had before -- ty 5 V1 i3 14 15 16 17 18 19 20 21 © 20 23 24 ‘e ~ Federal Reporters, Inc. 25 71 96. (Slide 3.) Now you can see the fifth year. You can see the allocation of dollars by percentages remain pretty stable for a program administration but this time it really is program . administration. They are going to have a program staff that is more traditional in our terms. It will have program specialists, that sort of thing. They will monitor projects; they will be full time and not project directors. The former program staff, the various members have left to pursue their own interests which apparently were not RMP and Dr. Mont is assembling a new staff. At the bottom, see, only 3 percent of the dollars ar going into categorical activities, that is a regional kidney program. That blue block got pretty big, 61 percent of the money going into multi noncategorical. 16 of the 19 activities that were going on in the 04 year have been terminated and | Rochester has been able to initiate new things. Now we can look at that 61 percent maybe in another way. If we can break up -- (Slide. ) ~- the program into four thrusts that Rochester has defined, health care services, education to improved care for underserved, health care systems analysis and, finally, formal education of health professionals. We can compre the fourth year and proposed fifth [0}) ty 6 10 1] @ 12 -13 14 15 16 17 18 19 20 21 @ 2 23 24 2é ~ Federal Reporters, Inc. 25 97 year. You can see where the two big changes have been In the fourth year about 40 percent went into health care services, now about 60 percent is going into health care services. Actually that is more of a change than it looks like on the chart even because the region's definition of what a health care service is has changed. Now what went into making up that 38 percent last year in health care services was things like regional coagulation laboratory, telephone EKG consultation, cancer clearinghouse. The kinds of things being called health care services this year are EMS activities, coordination of home care services in rural counties, rural family medicine practices and that sort of thing. The other big change is the decrease in the amount of money that is being allocated for continuing education activities. The red blocks. And-as I say, even the tenor of continuing education has changed somewhat. That 37 percent last year was physician's and nurse's continuing education programs, many, many activities in the categorical things. That 14 percent represents two activities, one, educational alliance, the other is subsistence level combination of all the formal nursing continuing education programs. The program is designed -- as it is, it will fund through June '73 only, that is to give the school of nursing in Rochester an opportunity to decide do they want to pick this ty 7 3~ Federal Reporters, 11 12 13° 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 98 up in their priorities or do they want it to just go down the drain? Finally, I think another interesting concept, back to the county map -- (Slide.) -- is how in Rochester the programs idea of what regionalizations have changed. Now last year 90-some percent of the activities that the program undertook were designed to cover the entire 10-county area. In fact most of them were things that were emanating from Rochester and going out to do good in the other counties like the continuing education and the laboratory ser- vices. This year about a third of the activities they propose are designed to take care of the 10 counties. But the region apparently has seen a need to design activities that respond to the needs of particular areas of the region. For instance, in the southern tier down there it . is Steuben, ‘Schuyler, and Elmira Counties. There is an effort in emergency medical systems. For instance the five counties there in the center, are the subject and activity trying to coordinate home health care services? Another example is Dansville Hospital down in the bottom part of Livingston County. There is a family practice program coming out of Dansville to serve the rural areas of Steuben and Livingston Counties. ty 8 10 1 @ 12 14 15 16 17 18 19 20 21 @ . 22 23 24 e~ Federal Reporters, Inc. 25 99 There is a training program for bilingual allied health aides to serve the Spanish speaking communi ty of Rochester itself and it is centered in the intercity there. I don't think I need to talk any more about program staff. We know what it is. We are not sure what it is going to be but we think it will be better than what it was. They will be doing things that program staffs ought to do. That is Rochester. You know, I have a feeling you may be saying to yourself you know this is all very interesting but why have you taken up half an hour of our time? Well, I don't know. I think it proves for one thing a program can change, we can document this. We can look at the charts, look at last year, this year and see it is changed. What maybe isn't so obvious is what is the impetus for change? Well, I am not sure but I think what we have seen in Rochester is a disapproval of the old adage that‘: revolutions are not made, they come. I think it is quite clear that if we hadn't made the revolution in Rochester, it wouldn't have come. The program direction, the way it was being adminis-~ tered was satisfactory to everybody in Rochester. It was certainly satisfactory to the university. Satisfactory to the coordinates. It was satisfactory to the program staff as long as their projects kept getting funded and if the RAG ever thought about it it was probably satisfactory to the RAG. 100 ty 9 1 So what it took was dissatisfaction from some 2|| quarter and that was down here. And I think the irritants that e 3|| were provided by the Review Committee in terms of you know, 4] you,got another site visit; we are going to come up and look at 5|| you again and also finally the question in terms of the time 6]/ and money limitations are what brought about the revolution in 7|| Rochester. If the Washington Redskins didn't, you know anyone End #9 8} can. 10 11. e " 43 14 15 16 17 18 19 20 e 22 24 e ~ Federal Reporters, Inc. 25 CR 7148 10 eak 1 10 VW e ° 13 “14 15 16 17 18 19 20 21 @ 22 23 24 ce — Federal Reposters, Inc. 25 101 MS. FAATZ: Dr. Schmidt knows what it is like and Dr. Brindley knows what it is like to have questions. DR. MARGULIES: I think the presentation probably is adequate to prove its point. I think it requires your reflection to determine what it all means in terms of staff function, Review Committee. Eileen is perhaps being modest in not also pointing out the fact that one thing which should be fairly clear from all this is that there is a level of staff dedication involved in such an undertaking without which it just doesn't happen. But the Review Committee can get a sense of what all this means only by occasionally stepping back and seeing what the results have been. | Now, I could not tell you that this all happened because of the Review Committee. I couldn't tell you that it all happened because of what we did here. For example, the appearance of the -- of a remarkable man who first was on the Executive Committee and then Chairman of the regional advisory group in Rochester has a great deal to do with it. You can't say this did it. But it isa combination of activities in which the absence of any one of the elements would have been ruinous, but consistently it was from the time that the Review Committee and RMPS, with it, began to look at it as a total program and the way in which it functioned that it began to make some difference. Now, I was talking with Sister and about what I eak 2 10 i 12 13 14 15 16 17 18 19 20 21 e 29 23 24 ce ~—Federal Reporters, Inc. 25 102 personally believe is the primary merit of regional merit programs and saying to her at the same time that there is no way in which I can sell this to budgeteers, there is no way which I can necessarily prove my point but it appears to me that what we do most effectively when we are effective produces a change in attitude which allows for some change in behavior. That occurred in Rochester. | Now, it could not occur if there were not the potentials for it. It could not occur if there were not needs, if there were not people who cared. But it is a change in social perception. It is a change in the way in which you interpret the manner by which you apply your efforts to what principles you hold. There was nothing unprincipled about the old pattern. There is nothing profoundly different about the principles in the new one but there is a change in the atti- tude toward how one preserves effort and moves to a specific kind of a goal. It also reflects a changing attitude within the Review Committee not the least of which, which I think you all know I strongly support, is a little tougher approach to a program which is doing poorly. I can remember, Mac, that this is one of the several programs in which a suggested remedy was associate coordinators,a deputy coordinator,something of that kind. Well, we went over that jump several times. When eak 3 10 1 . ” 13] 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~ Federal Reporters, Inc. 25 103 a coordinatoris inadequate, the best solution is another coordinator. In fact; it is the only solution. One of the reasons we listed some of the changes which we listed to you earlier during this meeting is to demonstrate that that has occurred in a number of other places and I think the changes are meaningful to a number of members of this committee who have. been onSite visits and who have reported here. Now, I recognize that this has taken a considerable amount of your time. It may not be a characteristic case study. There 1s no characteristic case study but I think it “puts some of the dynamics of a program management in a conten- tion which is worth your time. DR. SCHMIDT: Before you comment, .I' would just like to say that I have watched Harold and some of his staff during the last year and have seen them really kind of be surprised at the vehemence of some of the remarks of the Review | Committee members about the ineffectiveness of the committee or the felt ineffectiveness of the committee in achieving its purpose. And I think that, and Harold ‘and the staff have been surprised by this because as they are looking at the forest they see the great impact that the committee has had and this | case report obviously is an attempt to answer al least soe of the questions that have been posed around this table about the impact of a committee. Through site visits and through what the committee eak 4 10 iN @ 12 13 14 15 16 17 18 9 20 21 e ;z | 23 24 ce~-Federal Reporters, Inc. 25 104 1 says it has recorded by staff, it is carried back to the regions by staff that we kind of don't know about, committe has had voice and a strong one and it has been influential. Our trees have very often been the projects and the details of things as we get into the nitty-gritty, and this was an attempt obviously to retreat back to a point where we could view the forest. Bill? | DR. LUGINBUHL: Under the recent clarification of relationships between the grantee and the RAG, it spells out the way in which the coordinatersare appointed, They are Mominated by the RAG and appointed by the grantee if I am not mistaken. Who has the authority to fire a coordinator? DR. MARGULIES: Grantee. “DR. LUGINBUHL: Thank you. - DR. SCHMIDT: Now, I would like to have any Hiscussion right now before we move on to Dr. Brindley and Further discussion in a more treesy way of the Rochester region. I would like to stay with the forest just for a moment and see if any committee member has any comments about the presentation or interaction of this committee and the Rochester committee or any that has to do with the functioning of this committee in the review process. ' t f Now, it might be that you will need overnight to i think of a come back or something to say, so that we aren't 10 YW © 12 13 14 15 16 17 18 19 24 e~Fedetal Reporters, inc. 25 105 closing down on this issue but I would ask for comments right now if there are any. Well; if not, we will table this until we get through gone of the work of the committee and then we will come back to it. And it is the hope of staff and Harold and so on that we will be able to use this as a kind of a framework to hang comments and discussion on during this two-day period about the Review Committee function. And I would like to compliment Eileen on a beautiful job of reviewing the region.. Having been up there, i can appreciate how clearly she presented the picture. We will turn then to Dr. Brindley and our first really work part of this session then and we will take up an anniversary review procedure to triennium of Rochester. DR. BRINDLEY: Thank you. I also would like to compliment Eileen on a very fine job. I wish she had taken about four more: minutes then I could have just given you a proposal regarding funding. They have made a complete change in almost everything. The goals and objectives have been] changed, they now are much more compatible with national goals. They seem reasonable, possible of attainment. There are three major intermediate goals that they list, are the establishment of methods of restructuring of primary health services in rural areas with particular emphasis on hospital out-patients facilities, emergency rooms. Can you hear me all right? Is this on? eak 6 oO aa © Wy @ 12 13 14! 15 16 17 18 19 20 21 e ; 23 24 se ~ Federal Reporters, Inc. 25 106 The joint assessment of new health care systems in the region and improving the care of the chronicly i111 including those in the rural areas. Right off hand as soon aS we saw those, the question was, well what are you doing about the city. Looks as though practically most of the emphasis was being placed upon the rural areas and perhap they were forgetting that a large part of the people were in the Rochester area and that there were some problems related to the urban poor. We discussed this with them and they had two good answers. | One, that there already is a system of neighborhood centers that were initially proposed by the medical school faculties and by the comprehensive health agencies, and that th thought’ that. these centers would be capable of caring for the urban poor health problems. | One of the proposals as you can see a little bit later is going to be evaluation of systems of health care deliver And it was interesting in our -~- and I will digress there a minute. They have a Monroe plan which is the foundation for medical care, Tennessee Valley Group Health Association, which is the Blue Cross sponsored program, AOEO neighborhood health centers network and family practice program at a Highland hospital... They are proposing that these four programs be evaluated as to effectiveness and that the RMP is going to have its input perhaps into the UT w _ eak 7 1 @ 12 is 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~ Federal Reporters, Inc. 25 107 efficiency of health care delivery by evaluating the systems of health care. An interesting problem came up there. How do you evaluate quality? And who is going to do the evaluation? And we never did receive a very good reply to that. Dr. Berg is Chairman of a committee that will be evaluating quality. And I am sure that is a hard thing to determine, what is quality of care. But they propose that this would be an ongoing assessment and that perhaps the rules and modifications will continue to develop as progress ensues. As we look down to accomplishments and implementation, of course they haven't accomplished very much because this is a whole new ballgame with them. They have proposed 19 projects and of these there were only three that were there before and those three are the Family Counselor Program, the primary care analysis and the kidney program, which already had earmarked funds. They do have a continuing nursing education program which will require some funding until the middle of next year, and they are hopeful that by that time, other sources of funding for the nursing education program will be available. We did feel that there were some deficits in their establishment of intermediate goals and objectives. They had not clearly pointed out how you were going to evaluate progress, what were the milestones going to be that you would look at as you went along with the program. And they also have not established a definite way of determining eak 8 1 @ 12 13 14 15 16 17 18 19 20 2] @ 22 23 24 2—Federal Reporters, inc. 25 108 priorities. They said they had' themselves listed with priorities but there is no clear-cut way of how priorities will be assessed or determined or evaluated. We thought it was very important that they write those out so everyone would know how you are going to determine priorities. That had not been done at the time that we were there. However, the new goals do seem like good ones and they do seem to be consistent with their needs. They showed us a number of studies in which it would imply that actually the rural communities are the ones that need the most action at this time by the Rochester Regional Medical Programs. Some accomplishments have developed. Eileen has | already related to most of these. Of course, they have a new coordinator. He is an impressive young man. He is obviously intelligent. He is charming, has a lot of charisma. I did have two reservations. 4 Dr. .Warter, who is the Chairman of both the RAG and Executive Committee is a very agressive domineering finite individual that is accustomed to really running the show and he is going to. .-- Dr. Mott is going to have to get up early and assess himself pretty clearly to be sure he gets his vote in because Dr. Warter is accustomed to running the whole picture. Otherwise, though Dr. Mott has many attractions, he has a lot of good ideas. He has a nice tactful way of being eak 9 10 1 e 12 13 14 ‘15 16 17 18 19 20 21 @ 22 23 24 se — Federal Reporters, Inc. 25 109 a good liste. er and I think that he will have many possibilities of accomplishing his goals. But he perhaps will need to be a little bit more agressive. The continued support -- oh, they have changed the composition of RAG. They have elected 13 new members and they do seem to be more representative of the committee. They have done a better job of having the minorities represented on the RAG. They are trying to get some more true consumers. That will be represented on the RAG. They have some deficits there. They do not really have allied health professions really represented and need to add more in that area. They have established new goals, terminated old programs. They have a closer relationship with the CHP. They have a superb CHP. In fairness to the regional medical people, the CHP were there earlier and they have the whole ten counties well organized, good committees in each county that have evaluated needs. As I have mentioned, they have already organized the neighborhood health centers. in the city. They have outlined priorities of their programs of development. They are overlapping directorships of RMP and CHP. They seem to get well together and that will be a good person to have on your team. The CHP is strong in the area. Minority interests, well they have some deficits there but they seem to be trying to improve that in all sincerity. This is a new ball club. They eak 10 VW ©} 12 13 14 15 16 17 18 19 20 24 -e — Federal Reporters, Inc. 25 110 have no one on there in the program staff that represents the minority interest buy they say they are trying to obtain those and of the three, they were seeking at the time we were there, one of them was a black person. They are hopeful RAG will be more represented by the minority interest and certainly programe are being related to the minotiry needs over the regional medical programs. Dr. Mott tells a good story to us about how anxious and eager he is to really see that this is fulfilled. Now, in fairness, the executive committee is all male and all white. They are trying to reduce, though, the responsibilities of the executive committee and really have RAG take over more of those responsibilities. If I am leaving out some things about that, do you want to comment more about that, Eileen? MS. FAATZ: No, I don't believe so. DR. BRINDLEY: We did ask them to go to the black committee and ask them if there could be someone there that would be hopeful and they took the pledge and said they would try it. The program staff, they have some nice boxes written down and it looks good on paper and you almost have to vote for them as to what they intend to do. Now, there are some glaring errors on what they presently have because they don't have many. They have got about three batters and then they are out of hitters but they propose to get this new assistant director and I heard you say eak 11 1 10 HW ©} 12 13 14 15 16 17 18 19 20 21 ® 22 23 24 ve ~ Federal Reporters, Inc. 25 lil a while ago, Mr. Chambliss, that they now have one so it will be good to have him. They seriously need to have a person in charge of program development. They have a temporary, we think he is temporary, evaluator, Czechoslovakian. He doesn't seem to be wholly adequate for such a big problem to me and perhaps he will need to have someone else there. Then there | is no one who has been selected for a lot of these other hearings they have on their program. But if they fill all those slots, they will be able to do it very well. They say that these will all be full-time people and they no longer will be directors of projects and that the technical consultant will come from truly people that are experts in their field. They have made a number of feasibility studies ~ and they have cooperated with the CHP in these feasibility studies and actually have put on the board for us areas of responsibility pretty much over the entire region, about what CHP is going to do and what RMP is going to do and how they will relate with each other. Some areas the major response would be RMP and other areas the responsibility would be CHP and how they might dovetail the program. I am a great believer in that so I hope that will he able to work out. The regional advisory group says now that they are going to take on more of the responsibilities. Dr. Warter is a great believer in taking his regiona 112 eak 12 | 1||advisory group and dividing it up into a number of committees, 2\|and these committees would consist of two or three members 3|,0f the regional advisory group and one man from staff. And ® 4|| that these committees would be given responsibilities 5||0f reviewing projects and looking at programs and evaluating 6|| funding and evaluating progress and that they would then relate it back to the entire RAG for consideration and approval. 8 There was some fear that maybe Dr. Warter was 9 dominating this to a degree but he says not. I talked to him 10], about it privately and he doesn't think that that really 1} is a serious problem. Their review process consisted of e . 12|| sending out about 600 letters inviting proposals and then they ot about 45 of those that they thought locked pretty geod... The 134] 9 14|| had a special review committee that would look at each one of 15 these and the CHP reviewed it before. The parent review 16 committee chairman reported it back to the regional advisory 17|| grouP for final approval. The grantee organization, 18 I think, deserves a lot of credit because they were pretty much 19 the whole show up before right now. 20 And their part has been greatly reduced, their 21 proportion of the projects has been largely diminished. They } , 22 will have six representatives now on RAG where they were most 23 of them before. But they seemed very interested. They think 24 this is a good way to go about it. They indicated a Se ae Os desire to help the program. And the people we talked to all wer eak 13 15] 16 17 18 19 e 22 24 e — Federal Reporters, Inc. 25 113 unanimous in their commendation of the University of Rochester and its present approach to the change that had been made. | | Participation, it was good. I talked to the doctors and also talked to a lot of the hospital administrators and they are enthusiastic. One real good thing that they are doing is the medical school is relating to each one of these community hospitals in their training programs, and particularly in their family practice training programs, also, in the allied health training programs. . #11 arl ] 10 11 @ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 7e ~ Federal Reporters, Inc. 25 114 They are sending these boys out, or women, out to the communities to actually serve as primary health care providers under the direction of the staff community hospitals and they are a going so far as to say after you have been out there a while, you find somebody you think will make a good secretary and bring her back to the community hospital and we will train her, too. By doing this, they have been able to get a number of these boys and girls that have stayed in these smaller rural communities and have gone into practice, which was refreshing, and it looked as though they actually were providing a better quality of health care to the region by the sharing of facilities. | Their assessment of need has been done, as I mentioned before, largely through the CHP and their ten-county committee programs which seems to have dne a good job. Really I wouldn't know how effective the new programs are until we have had a little time to see experience, but on paper it looks pretty well. We spent a lot of time on evaluation, and they have kind of an unusual way of evaluating things. Two members of RAG and one member from staff, along with a program director, will evaluate a program or proje¢ and then this project committee will report quarterly through an assistant director to the RAG and then on the recommendation of the project committee the assistant director may change the ar2 10 11 @ 12 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~ Federal Reporters, inc. 25 115 budget up or down up to 20 percent; unless an appeal is made to the project director, and then to the full RAG. And talk to Dr. Warter about that, he says I need to get the RAG involved, I need to have these people know what is going on, they are the ones that ought to have some active interest. I think this should be a management function. Well, you kind of wonder, you know, where does the coordinates come in and assistant director come in, and when does he get to vote so he wked Dr. Mott about this and Dr. Rudolf, was it, and they said, well, now, all of these proposals and recommendations come through them and that they have the right of changing some things or improving them before they actualiy get to the RAG ror full approval. They seem satisfied with this recommendation. We suggested to them that we thought the burden of proof was upon them. If they showed that this system was a good one ad can make it work, why, then, that was fine. If this didn't work, why, maybe they needed to look at another method because it is a little unusual plan that they have proposed, and they have three levels of funding that they suggested to us. One was what they thought was just rock bottom. One was one they thought was -- would do a better job; and three, I sure would be thankful if they gave that to us. We locked those over and we will talk about that ar3 10 in @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 2—Federal Reporters, Inc. 25 116 at the last minute. Dissemination of knowledge, they haven't disseminated yet because they haven't gotten to work yet, but if they do, the things they are saying, it should be very purposeful and I think succeed. | Utilization of manpower and facilities on paper again looks really good. They have made some good suggestions, improvement of care, it should be significant because they are really going to get out with the community, particularly in these rural areas and make a lot of changes that should be helpful. And I have all those projects down, which ones they will be doing, if you want to look at them, but I don't think you need to look at them right now. If you go back to the level of funding, last year, as you remember on the picture up there, they got $858,000. They have a kidney program that is, has been funding out of separate funds for, I believe, $35,000. : We felt it would probably be well to suggest the $900,000 level of funding, plus the $35,000 for kidney, that this would do several things. It would permit them to increase their program staff, to add the men and women they need to have for this; it would show some optimism in the development of their program. And if the program they had last year was worth 800,000, this is sure worth a heck of a lot more. We are ready for questions. ar4 @~ Federal Reporters, 11 12 13 14 15 16 17 18 19 24 Inc. 25 117 Eileen, did I leave out some footnotes? MS. FAATZ: The only thing is I have talked to the region recently. In the box was one of the two main divisions, program development, Shawkadeary is coming in as assistant director for program development. There are four slots for program development specialists under him. You will recall Miss Clark was one of them. They have three new people who have accepted offers for those slots, so that part, they are getting on with bringing on the staff. DR. BRINDLEY: One other thing I didn't mention that is very important, they did not have any bylaws while we were there. We thought it was extremely important for lines of authority not to be taiked about, but to be down on paper. So we asked them about that and so the day that we left, why, they said we just got through writing it last night. But nobody had reviewed it, their RAG had not approved it, so we said we are going to recommend a level of funding contingent upon the bylaws being sent and being read and approved by staff. | But it was very important for them to have some bylaws because everything was just kind of coming off the top of your head. He is responsible. Well, he is. You ought to go this way. But nothing was written down. DR. SCHMIDT: All right, then, your recommendation, would you repeat the recommendation, please? ar5 19 ie 12 o 14 15 16 17 18 19 20 21 © 22 23 24 2 ~ Federal Reporters, Inc. 25 118 DR. BRINDLEY: We are recommending a level of funding of $900,000 exclusive of the 35,000 of the kidney program. This is a one-year level of funding. DR. SCHMIDT: Is it contingent upon acceptance of the bylaws and -- DR. BRINDLEY: Yes. DR. SCHMIDT: One-year funding with then another application due in a year, is that right? DR. BRINDLEY: They said they hoped that after this year of kind of regrouping and getting going that next year Q their program would be mature enough where they could apply for biannual status, but they were not ready to be considered for that now. DR. SCHMIDT: I'd like, before comments, to remind the committee of the RMP review criteria and the score sheets that you are to be filling out. Are there any comments before we go on to the second reviewer, or let's say are there any questions directly to Dr. Brindley? DR. SCHLERIS: I was interested in the emergency service award of $141,000 to Rochester. I was wondering if you were able to get any on-site impression of how they are moving with that in terms of their planning or in terms of how it relates to RMP in that area? DR. BRINDLEY: I asked Eileen a while ago about that so she could tell me how much had been funded out of the 119 ar6é 1 funds you were looking at and that is for which programs, 2|| Eileen? 3 MS. FAATZ: Well, they have about four separate 4|| AMS components, some two of which I believe were funded 5|| from the special supplemental funds, two of which are funded 6|| from the regular program, Rochester RMP funds. One of the components is for overall planning and g|| development of EMS and two of the people responsible for 9|| that are coming next week to meet with Dr. Rose. We didn't get any on-site experience, no, they had 1 the money for such a short time there wouldn't be much to say. @ 12 DR. BRINDLEY: Leonard, there was one other pretty glaring weakness in it, that was who is going to provide 13 14], the continuity of care. Iaked Dr. Berg that because it is 15 important for the patient to come in the emergency room and 16|| S@Y he had diabetes. Who takes the ball from there? He said 17 that is an interesting problem and we are sure going to work 1g] °F it. 19 DR. LEWIS: I won't take up very much of the 20 committee's time. I won't take up very much of the 21 committee's time because I think that this region ' © 22 has been reviewed by as thoroughly as any other since I have 93 been here. 24 I think in reviewing the site visits, reports ee and present application, one gets the impression that you ar7 2 ~ Federal Reporters, 16 YW 12 13 14 15 16 17 18 19 20 24 inc. 25 120 are reading a psychopathologic conference complete with autopsy. I don't know where we are with this union insofar as not having participated in the site visit, the application is essentially an application for a new region, and in the application it is perfect, I really enjoyed reading it, which was surprising. Dr. Brindley, I think, describes for us exactly what I needed to know. I think that some of the things that are in the grant here that are questionable. For example, they discuss the issue of active recruitment and. redistribution of physicians and the possible role that RMP can play in this which I think would be a rather sensitive area, and I am not sure they are ready for that, but it reads very well. The way in which they are going to distribute their funds certainly appears to be more in concert with what RMPs should be doing. The only questions that I have in reading the application, is with regard to how much the award should be. It is very difficult to know what their budget has actually been because of the -- the figures we get for their previous fiscal period is 9-71 to 12-72 and I suppose that if you assume a constant distribution of expenses over 15 months, then you could just divide it out and get a 12-month figure, but at any rate, the suggestion of $900,000 budget for this coming fiscal period based on the fact that it is a much better program, if the previous programs were $800,000 ar8 10 rT 12 13 14 15 16 17 18 19 20 21 ©} 22 23 24 e~ Federal Reporters, Inc. 25 121 I don't think is irrational judgment because I don't think the previous program was worth $800,000. In fact, $4-1/2 million has been poured into this region in the last four years which I think is a shame. The core budget was $326,000 from September, '71 to 12-72, which might break down to 280,000 for the previous year, and the present core program staff budget would go up to $415,000. I just wondered whether this was not a rather large step up considering -- I share everybody's hope that what is down on paper is going to work out, but the past history of this region has been bad, and I just wonder whether that is not a very significant increase considering the amount of activity that is going on there. So that I would like to hear a little more discus- sion with regard to the amount of step up in the core staff program cost and also what they really need to get started in expanding the program with 13 new projects. I think certainly the money they asked for was far in excess of what they should be getting. I think the $900,000 may be in excess also. DR. SCHMIDT: Dr. Brindley, would you like to comment on the rationale or background of the arrival at the $900,000 figure? DR. BRINDLEY: The core staff expenditures in our ar9 10 | 12 e 14 15 ell 0 17 18 19 20 21 @ 22 23 24 ‘¢ - Federal Reporters, tnc. 25 opinion were important primarily as related to the program staff and program staff development, evaluator, and | perhaps improvement in their financial accounting. They did have a rather large staff before, but it was not a very effective one, and it was accomplishing mostly the administration of projects from the medical school and medical school faculty. Maybe this was an erroneous judgment, but it did seem to us to be one of the major things they needed to do, was to have a good program staff, and that the core was a pretty important part of their program. Frank, do you want to comment on that? MR. NASH: No, = think one of the other reasons the site visit team recommended the 900,000 was to show this region that they have made progress and to reward them for accepting recommendations and making changes that they have. CR7148 #12-ter-1 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~ Federal Reporters, Inc. 25 DR. SCHMIDT: I think that it is certainly the feeling of the site-visitors and staff that substantive changes have, indeed, occurred. The Coordinator and Project Site -- or the Project Directors, not being staffed, the building of the staff and so on. And that the region has done now, for sure, absolutely at least, some of the things that it was told to do. So, then, do you now pat them on the head and Say, "Good boy," and give them some money; or do you then, say, "Bad dog," again? I am trying to train a puppy, so you know, and where does that get you? DR. THURMAN: Gets you a wet rug sometimes. DR. SCHMIDT: Well, Bill, you are bothered. DR. THURMAN: I guess I have had too many wet rugs. I would share Dr. Lewis's concern about adding a hundred thousand more to what amounts to a cesspool. And, too, I doubt seriously that if we think constructively, about what this region can accomplish before they come back in with another year's application, that they are going to be able to meaningfully attract people that they need, particular! in the area of evaluation. to really use this money. I think that Dr. Brindley has brought out some very important points; who is running the program? It has a long history of nobody running the program, now we have either Y ter-2 te ~ Federal Reporters, 10 1] 12 13 14 16 17 18 19 20 21 22 23 24 Inc. 25 124 a RAG Chairmanor Coordinator and we don't know. And, I would just, I think, if Dr. Lewis were making a substitute recommend+ ation for Dr. Brindley's idea of tag along with it because granted anything would be better. The $800 thousand we already spent; let us make - sure the $800 thousand we plan to spend this year are worth at least 800 thousand because last year's 800 thousand was not; so I am a wet rug. DR. SCHMIDT: All right. Dr. Lewis? DR. LEWIS: Well, I don't really feel competent to make a substitute recommendation on the basis of having read the documents but not participating in the site-visit, but I would like Dr. Brindley and the people who participated in the site-visit at this point, to reconsider the possibility of keeping the funding at the previous level, and what its impact would be, because I feel that the recommendation of $900 thousand is in excess, but I don't feel competent to -- DR. SCHMIDT: I mean, what specifically was the previous level? MS. FAATZ: Annualized’ --. it was $800 thousand plus 58 thousand earmarked for kidney. What the recommenda- tion is, is an increase of 900,000. We are talking about an approved level, too, not necessarily a funding level. They sometimes differ. Nine hundred thousand, plus $35 thousand for kidney. ter-3 1] © . 12 13 {A 15 16 17 18 19 20 @ 22 24 ce ~ Federal Reporters, inc. 25 DR. SCHMIDT: Okay, we are not, the Committee in its past, has often spent the most time over the smallest amounts of money. This is, that is proper if principles are involved. So the, what I am hearing now is, do we keep them at the same level as sort of a, you know, okay, we are satisfied, but, you have still got to show us, or do we give them a little more as a pat on the head? Other Committee members have comment? DR. BRINDLEY: In fairness, this is reaily kind of a promissory note, they have not done these things, but they are trying to do all the things we asked them to do; or at least, most of them, and we felt perhaps, it was worth saying, with some encouragement. This, we think this is a good step and we do like to see you try it. Eight hundred would be fine for me. “They haven't proven they can use that 800 well. They have not gone up to bat yet, and have not filled those slots but, I don't want them to say, "We could not fill them because we did not have the green stops. DR. KRALEWSKI: Has this been increasing in the previous years, Brand? DR. BRINDLEY: It has. DR. SCHMIDT: In your loosepleaf books, these illustrations, I think, are included. ter-4 ce ~ Federal Reporters, 1 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 126 MS. FAATZ: There was an increase going into the second operational area and it has decreased steadily, since then. | DR. BRINDLEY: A million, eight. DR. SCHMIDT: I sense that the site-visitors and so on, feel some resistance to dropping this -- (Slide.) -- although then, you kind of say that the 800 thousand would be fine. Let me try to move this along by saying, there is a motion on the floor, it was not seconded, so I will revert to Robert's Rules, by which I hope we will operate. There was a motion on the floor for approval that a one-year level of 900,000 exclusive of “the 35 thousand for kidney, is there a second to that motion? DR. KRALEWSKI: I will second it. DR. SCHMIDT: All right, it is seconded. I will ask Dr. Lewis or Thurmond if they wish to move a substitute motion, or amendment to the motion on the floor? DR. LEWIS: I would move substitute motion that they be approved at the level of funding, exactly as the previous year. DR. SCHMIDT: Okay. ter-5 HM @ 12 13 14 15 16 17 18 19 20 21 @ | 22 23 24 ce ~ Federal Reporters, Inc. 25 Léf That is 858. We will test, then. Send them to the Committee, there is a substitute motion, is there a second? | | ' Luginbuhl?-: ‘DR. LUGINBUHL: Second. DR. SCHMIDT: All right, It is seconded. We will discuss the substitute motion. DR, KRALEWSKI: What you are recommending, then, isa slight increase, it would be 858 and actual need for the kidney project is going to be less this year than last? DR. LEWIS: I think that I, I think that the kidney project should be considered outside of their budget, since in their proposal, they consider it outside of their budget, and I meant for this proposal to be $800 thousand, plus whatever their kidney project is going to be. DR. SCHMIDT: Eight hundred thousand, plus the kidney? I presume your substitute motion includes the other parts of this? DR. LEWIS: Yes. DR. SCHMIDT: Continued on bylaws for one year and so on? DR. HESS: Just like to have us go over the budget sheet, the next to the last sheet, page 23. Seems to me that this pinpoints the difference at least as they see it, between the $800 thousand program and ter-6 11 @ 12 13 14 15 16 17 @ 22 24 ce ~ Federal Reporters, Inc. 25 128 the 900 thousand, is that correct, Doctor? Doctor Brindley? So this would cut back 25 thousand for staff, people on the right hand side, in the lower column. It would not enable them to increase -- or to do as much with the delivery systems evaluation and it would -- it would eliminate the enrichment program and place some limitations on the program. That is what we voted for the substitute motion? DR. BRINDLEY: All right, are there any other comments but Dr. Bridley, or staff? Is there any kind of damage that this substitute motion might possibly -- are there any concerns about the level of 800 thousand? MS. FAATZ: I think one thing we have to consider is that one of the strongest recommendations that came out of the site-visit team was that the region might well want to increase its program staff abaove what they projected in the application, because the site-visit team frankly, did not think that was adequate. They thought that was a bare- bones approach to program staff. So, we, you know, you taight want to think about some words to relate to the region if you are willing to recommend the 800 thousand, and at the same time, recommend they increase the program staff, over what they have projected. DR. SCHMIDT: Thank you. Are there any other comments? MRS. SITSBEE: I weuld like, Betty ~- I would like, ter-7 10 1 @ 12 13 4 15 16 17 {8 19 20 2) @ 22 23 24 ce ~ Federal Reporters, Inc. 25 129 Betty, to consider the site-visit recommendations, and also we have talked about the $800 thousand, not accomplishing anything this year and yet it was, this year that this change was occurring and I am thinking of it from the standpoint of the Division of Operations for Development and not for the individual. region, but when an attempt is made to try to follow the Committee's recommendation of last year, and staff assistance developed; the region responds and they, and the Committee comes back with the same level of funding; I think this is a message that may undermine staff attempts in the future. DR. SCHMIDT: I would think that if the Committee goes with the 800 level, it would be obligated to state why, so there would be a specific message perceived and received, and they would not be left with the idea that what they had done was wrong; which would be one interpretation, or the staff had misled them, or the site-visitors had misled them, which would be another bad message to be received by a cut. I think we would want to be specific as to why the level was chosen. John? DR. KRALEWSKI: I don't want to take too much time, but one guestion, and one comment. Are they going to have a fair amount of surplus ce — Federal Reporters, so wt cD i] 12 14 15 16 17 18 19 24 Inc, 25 130 funds this year? “DR. BRINDLEY: Will they have any? MS. PAATZ: No. I think there -- no I don't think they are expecting surplus funds. DR. KRALEWSKI: they will be able to expend out that eight hundred thousand? MS. FAATZ: Not having to be very much left over. DR, KRALEWSKT: They are then up to expending the eight hundred thousand, and if they have made the changes, you have indicated, I would speak in favor of giving them some increase in funding to recognize those changes and to allow them to progress in their pattern, over the next year. DR. SCHMIDT: I think the Committee is ready to test the motion. I will call the question, unless someone wishes the floor? Dr. Ellis? DR. ELLIS: I would like to see them have some increased funding if they are expending the 800 thousand, because otherwise, they will have absolutely no flexibility for growth. DR. SCHMIDT: Comment from staff? VOICE: Cannot hear. DR. SCHMIDT: We will then vote on the substitute motion. L3L ter-9 1 MS. FAATZ: I think people count here, Dr. Ellis. 2 DR. ELLIS: I thought we were voting on motion, I 3 was just speaking. | | 4 DR. SCHMIDT: Speaking against the substitute 5 motion? 6 DR. ELLIS: Yes, I was speaking against the sub- 7 stitute motion and supporting -- had said and that was that 8 they should -- if they are expending up to 800 thousand dollarg 9 and have no surplus, it would be impossible for them to have io the flexibility for growth, which they need. 1] And, therefore, I would think that some higher @ 12 funding should be made available -- increase in funding, should 13]| be made available to them. 14 SISTER ANN JOSEPHINE: I would like to say one 15 more thing in support of funding by way of encouragement. I 16|| think the report indicated the great mobility of these people 17 and it may well be that in a program of this type, which is 1g} on the -- seems to be going in the right direction, now, 19 shows promise, if there were no increase in funding, they 20 might well lose some of the people who could make the - 21 program go. @ 22 DR. SCHMIDT: Thank you. 23 I think we are ready for the question then, on the 24 substitute: motion. All in favor of the substitute motion, ee eee ae which is voting for the reduced level, please say "aye." ter-10 ie @ 12 13 14 15 16 17 18 19 20 21 e@ 2» 24 e ~ Federal Reporters, Inc. 25 {A show of hands.) 0 wites cer wed t DR. SCHMIDT: You don't follow instructions very well. | DR. SCHMIDT: Opposed, please raise your voice. All right the substitute motion is defeated. The motion then to be considered, is the original motion. All in favor of the original motion, please Say, "aye." Cpposed, "nay." All right, it is not unanimous. "Nays" are recorded. DR. SCHLERIS: I think the illustration. is of value in showing the Rochester program has followed the smoke signals from Washington, as they have interpreted them as far as reduction in categorical areas are concerned. Whether or not the smoke signals will be different in the future, I don't know, but at least, they harkened to the message. DR. SCHMIDT: Bill is going -- DR. LUGINBUHL One more negative comment -- that is going back to what Mr. Scherlis said. The grant shows how well we fertilized their program, and how much we got from them by giving them an increase, we just voted to give them in’the years past. They didn't do anything for that increase of ter-11 ~12/s-~-13 ce ~ Federal Reporters, ‘0 aw oO 1] 12 13 15 16 17 18], 19 20 22 23 24 Inc, 25 tod 200,000. They didn't take a message from a decrease or anothey decrease, so I am not opposed, except for the principle of money. DR. SCHMIDT: I think the staff does have enough from these comments to be able to warn the region that the Committee was aware of the changes, we will be watching very carefully. It is now 12 minutes to one. I think we should take a lunch break at this point, and I believe that 45 minutes will be adequate for lunch. So, we will reconvene in 45 minutes. (Whereupon the meeting was recessed for lunch, at 12:45 p.m., to reconvene at 1:30, p.m., this same day.) 7148 1 aig#13 {21 2 jr l 10 HW @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 @~— Federal Reporters, Inc. 25 134 AFTERNOON SESSION (1:33 p.m.) DR. SCHMIDT: If the Committee could please be seated I think our 45 minutes are up. And we are arranging the sequence this afternoon as follows: We will lead off with Central New York. And follow up then with Virginia, West Virginia, Alabama, Hawaii and Mississippi. And Albany and Hawaii and Mississippi have kind of different sorts cf presentations and I'd like if possible to get through with those today so the maximum number of reviews committee members will be here and will be able to comment on the variations of presentation of material to the review committee. Also like to remind committee members that the scoring sheets can be filled out with any number between 1.0 and 5.0, but the system won't take anything below the unit number 1 or above 5. You can use one decimal place between 1 and 5 if you have problems with just the four categories. I'd like to recognize Henry Lemon and welcome him back to the group. He interrupted his vacation and as I said earlier and came down from the North Country to be with us. So at this point we will begin with Central New York and I believe that we will begin with Dr. Patterson. jx 2 ] 16 1 @ 12 13 14 15 16 17 18 19 20 21 eo -» 23 24 :~ Federal Reporters, Inc. 25 135 DR. PATTERSON: Thank you very much. I believe Dr. Ellis wanted to say a word before I begin. DR. ELLIS: I don't, Mr. Chairman, have anything new to say. I was assigned to review, that is why I looked at you and I was simply going to take the opportunity to say that we had Dr. Simmons Patterson with us who had the good fortune to make two of the review visits and was in a better position perhaps to speak on the more current information than I. DR. SCHMIDT: Let me interrupt right now and say you were primary reviewer and that was understood. My instructions, by somebody who I can't name right now, were that he would lead off then we would turn to you. DR. ELLIS: I see, well fine. DR. SCHMIDT: But however you want to do it. DR. ELLIS: Would this then be all right if he just went on and gave what was seen on the -- okay. DR. PATTERSON: I was fortunate enough to one-year ago attend as a member of the site visit team to Central New York and was pleased to be able to go back the. second time. Regret very much Mrs. Anderson is not able to be here today. Mrs. Anderson was Chairman of the Site Visit Team and was going to make the report which I will make today and she asked me if I would speak on her behalf. I thought probably since you had most of the jr 3 10 iP @ 12 13 14 15 16 17 18 19 20 21 oe » 23 24 >— Federal Reporters, Inc. 25 136 information sent around to you as I understand concerning the comments or different points made by Dr. Brindley con- cerning those priorities so forth, probably I'd give an over- all picture of my impression of this site visit and then could come back to the review sheet and possibly go through it quickly or answer any questions that might arise. In many respects it was hard for me to believe when I went back this year that it was the same regional medical program that I had visited the previous year. The former director, Dr. Lyons, and many of his staff departed this past year, through resignation. It was very obvious from the beginning that the program in recent months since the time of the departure of these individuals, that the program was vastly understaffed. Both John Murray who was elected unanimously by the regional advisory group as coordinator and Mr. Walt Curry who was his more or less deputy, in my opinion, ought to he commended greatly for the heavy load that they have carried in the recent months. In fact when we were present at the site visit Mr. ‘Murray had just recovered from an illness due to over- work, He had just gone beyond the point of human endurance and we quickly made him aware that this was not the right way to go at this job. It's clear that they can't continue in an understaffed manner in the future. jr 4 e~ Federal Reporters, id im 12 13 14 15 16 17 18 19 24 Inc. 25 137 Unquestionably in my opinion and in the opinion of most of the staff of the Site Visit Team, the top priority probably of this program at this time is the recruitment of additional qualified individuals. | At the present time the staff is really in reality so small in number that they cannot adequately handle the duties and responsibility concerning the projects they now have. ._Doing my homework before this meeting I went over the recommendations and -- that we made last year as to what we found they should do. And I believe sincerely that efforts had been made to meet the requests of the previous site team. It was recom- mended at the time that a physician associate director be appointed, a man that had administrative capabilities, that had rapport with the medical profession, and as yet such an individual has not been recruited. They do have a physician by the name of Dr. Carhart who had been recruited to be more or less of a coordinator of what is known as North Ridge. This region is dévided into four areas and they have particular problems in t! northern area because of the isolation due to weather, et cetera. Dr. Carhart.is doing a magnificent job in a liaison capacity in arranging for medical students and so forth to go jr 5 1 10 1 12 14 15 16 17 18 19 20 21 @} 22 23 24 ~ Federal Reporters, Inc. 25 LIS out to the hospitals. But still, Mr. Murray in my opinion needs a physician associate director and we advised him so very emphatically. We have told him that he shouldn't rush into this, that he should be very careful in his selection. Another thing that is most essential is to have an organized staff. From an instructural standpoint. They need people in key positions such as assistant directors of operations and administration, evaluation. One cf tho staff is carrying a dual hat, which is bad. I -- they have several staff members that are -~ they're on the staff,. the program staff, as being in the capacity of project directors, We recommended to them that these people should be made in reality full-time project staff members and not capacity of project directors. This holds true as well to an individual who is coordinating the education. A year ago they had 11 position evaluators. Part-time men. No one knew what they were doing. In no uncertain terms we recommended this be done away with. They heeded our advice and they do have an evaluator now. There is some question as to whether he is the right man for the job because he is attempting to get a Ph D degree and I feel probably he is not able to spend the time with the program that he should. 14 15 16 17 18 19 20 2] @ 22 23 24 2— Federal Reporters, Inc. 25 139 And Mr. Murray is cognizant of this fact. Mr. Murray is a very dedicated man, hard working, has the respect of his entire staff, and it is hard to believe that he is becoming engaged in as many activities as he can. Questions have been asked me as to my opinion as to his ability to administer this program. It is difficult to say. But my feeling at the present is that he can do the job if he learns to delegate authority and if he gets a well-organized structural staff. He must learn to delegate authority. We talked very frankly to him and I think that he got the message and I think that this is the most important aspect in as far as the future of the program is concerned. Last year recommendations were made concerning improving representation on the regional advisory group. This advice has been heeded. Participation by members of this group is excellent. They have a very dedicated physician, Dr. Case, who is the Chairman of the Regional Advisory Group. Dr. Case spends much time with this program. He works closely with Mr. Murray. There is no question of competition, Pr. Case advises and he is not trying to run the program. He is a very clear-thinking individual. He wants to do what is best for the program, and I 10 11 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 @~ Federal Reporters, inc. 25 140 think they're indeed fortunate to have such a man as Chairman of the Regional Advisory Group. I was particularly impressed and gratified by the many and varied health activities that the staff members were participating in. Particularly gratifying was the relationship with the -- "B" agencies. "B" agencies have procured emergency medical service, coordinator is from the areas and regional funding program is funding their salaries. The representation by the regional medical program staff is on all the "B" agencies. The npn agencies have representation of course on the regional advisory group and the relationship between these two bodies is very very commendable. Dr. Scheiner, who I understand is not here today, gave an excellent evaluation of the kidney program. The Kidney Program has been sorely lacking in planning and help from the program staff. They have underestimated the needs of the area and there has got to be more cooperation not only with the program staff but with other groups, agencies and so forth, in this region. Dr. Schneider gave a very excellent report at our session at the end of the site visit and I think ge got his point across very clearly. so -—w La) 1 ) 12 13 14 15 16 17 18 19 20 21 eo =» 23 24 :— Federal Reporters, Inc. 25 141 I got also the impression that possibly the program needs some assistance in their fiscal management but I think this is being taken care of through the State University of New York, upstate medical centers through their business affairs and also through the research foundation of New York who has a branch office in Albany. And I think with help from these two groups that, and Mr. Murray realizes that because of his undermanned staff that he needs this fiscal support and he is taking steps in that direction as an overall picture and inclusion it is my opinion that this program needs help and not dis- couragement. And I emphasize this. And I enjoyed very much hearing Dr. Brindley's presentation previous to this one, and the remarks that several people made. I think that this group really felt like they were, had received a blow last year when they were funded, at quite a low level. They for some reason weren't too satisfied with the site visit. That came out loud and clear this time. We tried to give them the impression and it is an honest impression that. we wanted to help them but I think this program is at the brink now where they, and I am trying not to let emotionaligm take over but I think that this group is honestly trying to do what we recommended last year. jx 9 ] 10 7 ) 12 13 14 15 16 17 18 19 20 eo 3 » 24 e~ Federal Reporters, Inc. 25 142 I think that when Dr. Lyons left it put an added burden on the staff. I think the staff did some things that weren't too wise. | | One was these mini-contracts. Had the opportunity to read about the mini-contracts, they share my opinion. When you think about these mini-contracts it is an effort on the part of program staff to get people in this region involved and they went out and requested projects for up to six months period with a maximum sum of $5,000. And they received requests from over 300 individuals. And in reality, what the program has been doing is dispensing funds for these contracts as if the program had the authority to use developmental component funds. And since this program has not been approved it is not justified in use this way. Furthermore I do not think these mini-contracts related to the overall program goals and objectives. Many manpower hours were required to supervise these feasibility studies and an undermanned staff is incapable of doing this. : It would be much wiser to have coordinators, I mean four individuals that they are thinking of placing one in each region, each area of the region. To have coordinators determine the needs rather than let people come in with varied ideas. jx 10 1 10 1] @ 12 13 14 15 16 17 18 19 20 21 @ 29 23 24 :e ~ Federal Reporters, Inc. 25 143 On this basis money could much more wisely be spent in completing these, carrying out these needs than would be involved in a hit and miss mini-contract idea. Another think 1 think in the program is that there needs to be additional minority members on the program staff. We discussed this thoroughly with Mr. Murray and Dr. Case. They do have one minority member that is working with the Spanish speaking individuals in the area. But the, they need minority members on the program staff, they need minority members on the regional advisory group. We found out there was some, I am just not satisfied with their priority system. We discussed this thoroughly with them. I was not too impressed by their appeal mechanism. I think this should be clarified. I mention all these things not in a negative fashion but just things that I think need to be improved. But the program staff does need help and not discouragement. I emphasize that again. You have a dedicated group, the program staff, although inadequate in number to have done a yeoman's job. All the lines of authority have led to Mr. Murray and he has been as I said before overworked. It is absolutely essential that he fill the vacancies in this new structure with well-qualified capable individuals as soon as possible. Well-qualified staff, adequate number, if it is carefully recruited I feel that jr 1l 1 10 1 12 13 14 15 16 17 18 19 20 2] eo # » 23 24 e@~ Federal Reporters, Inc. 25 144 Central New York Region probably will be ready to submit a Triennial application a year from now. It is important, however, to carefully review the projects submitted in this present application and to approve only a sufficient number that the program staff can adequately develop, supervise and evaluate. To overburden the staff in the next year with too Many new activities would revert the program in my opinion to the same status that has existed in the past six to nine months. It is the feeling of the site visit team that we would recommend $429,000 for staff and, let's see, a total of $889,000, with $429,000 of this to be for the program staff and direct cost to January 1, 1973. We feel this amount would accommodate an adequate staff and would not overburden them with unreasonable program activities. Also, this amount should give them a vote of confi- dence that would improve their morale which is most important and deserving at the present time. Now that I have tried to use as an overall picture. We have comments that we will be glad to make on the review sheet that we have concerning goals, objectives and so forth > and I'd be glad, I know, I think this was sent to you and therefore I hesitate to go through step by step unless you so jr 12 e--Fedeial Reporters, i0 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc, 25 L45 desire. DR. SCHMIDT: I think that it would be probably best in view of all things to hold off just a bit and use that in response to questions that might be, might develop. So if you would remain there I will turn to Dr. Ellis for any comments she might have then I'd like a motion. DR. ELLIS: Thank you Mr. Chairman. He has dis- cussed this very well. I would like to ask one question. How did you find Dr. Patterson, how did you find the neighborhood health center which was one of the problems that we talked about when we were there on the first visit? I notice it has been transferred but -- DR. PATTERSON: I am going to be very honest it didn't come up in our discussions at all, doctor. DR. ELLIS: Well you see the neighborhood health center was one of the things that we talked about because this was a way to provide services to many of the poor people who lived in the community and also the way to use new kinds of personnel in order to get the services to them. But perhaps it was around this discussion and Dr. Lemon was there too, and made the visit to the neighborhood center, that Dr. Lyons had some feeling of insecurity. I don't know. Was this your impression? L460 jr 13 1 DR. PATTERSON: Well at the time Dr. Lyons, frankly, | 2|| didn't know much about what was going on in the neighborhood 3]| health center, that was our impression. 4 And then unfortunately several members of the site 5|| visit team during the visit went and visited the neighborhood 6|| health center and this invoked much criticism from the people ‘7|| that we visited. 8 I feel like I am answering this just from my 9|| thoughts. — It occurred that the region was not involved 10] in the neighborhood health center at all at the time and 11]| because they were so undermanned and so overworked I feel @ 12|| like probably their activities with the neighborhood health i131 center, Dr. Ellis, have been practically nil lately. 14 DR. MARGULIES: I could add a little bit to that, 15|| just purely by coincidence I was in Syracuse in the last two ré|| days. And not particularly, not on a site visit activity 17|| but some other purposes with the RMP. 18 Met with the staff and with the director of the 19 neighborhood health center who was very intimately a part of 20|| the regional medical program. 91 Wherever I went he was. And it was quite obvious @ - 22|| that the working relationship between the two at least as I 23|| observed them casually were very intimate. 24 Of course, Murray was in that kind of an activity 2 - Federal Reporters, Inc. : 25\| very deeply before he became the current director of the jr 14 } 17 18 19 20 21 eo » 23 24 2—Federal Reporters, Inc. 25 147 program up there so it's becoming .a natural part of their interest. DR. SCHMIDT: Miss Kerr? MISS KERR: My response is strictly from the written word not having been there as a site visitor and I do have as a result of my reading and study some major questions, some of which I think Dr. Patterson has answered quite well. I still have some questions in mind. And I will express them and if he or one of the review people will help me, I will appreciate this. I think there is no question but what Mr. Murray as a new coordinator has improved working relationships with agencies throughout the region. My question about the leadership of the coordinator is not one of public relations and not one of motivation necessarily. All through the report it seemed to come to me that there was an indication that he was a person apparently unable to delegate responsibilities. And that in several instances said he feels he must do everything himself, and I am wondering, and basic to the weaknesses which have potential for strengthening, if with the enlargement of staff, and this permeates the whole report, the need to enlarge staff and expertise and competency needed to carry out the vision they have, but if the staff is enlarged to the point needed, is the coordinator going to be able to jx 15 1 16 ia 13 14 15 16 17 18 19 20 eo 2x 24 e — Federal Reporters, Inc. 25 LO develop the ability to delegate responsibilities and the authority that goes with it? This is a major concern that I have. Secondly, the region has been advised about the addition of minority representation on the RAG and while there has been some it seems to me it is in the nature of tokenism and I think we need to stress this again. There are many other areas. More specifically there are two proposed projects here having to do with nursing homes, improvement of personnel in nursing homes in the areas of medication administration and, something of this effect. I am wondering how aware leadership is in this region as to the vast amount of funds now available through other sources for nursing home personnel. And I question the amount of money that they are requesting in those two particular projects for this reason. DR. PATTERSON: I will try to answer the first question. Maybe Dr. Margulies knows more about this than I do. Of course the only two times I have seen Mr. Murray are the times on the two site visits and it is impossible for me to answer some of the questions you asked. Prom a personal any better off than John Murray as far as ability for desire I thought I had to do everything and to delegate authority. I soon learned that that was an utter falsehood. 11 @ . 12 13 14 15 16 17 18 19 20 @ 22 24 2— Federal Reporters, Inc. 25 hk DS We had a very very frank talk with him about this. And I don't think it was too frank but very forthright and just told him what happened to him from a, from physical exhaustion was a good example. And I told him that of my experiences and so forth. And all I can say is I think he got the message. He is the type that will carry these things out, I don't know but I think so. That is a personal impression. Dr. Margulies, maybe you could answer that. I just can't go any further than that. If I had to say yes or no I'd say yes I think he can do it. Second question you asked about concerning allied health. When we first had our first site visit great emphasis in this region was on nursing, There are health services, education activities and so forth involved in nursing more than anything else. The site visit team a year ago recommended involvement of more than just nurses and did not recommend the funds they wanted. Whether this led to the resignation of the nurse coordinator, I forget her name, Miss Soebia, I don't know. T know she is trying to get her doctorate degree now. Whether this led her to resign, I don't know whether she was upset about the decision or the recommendation of the site team, decision of the review committee I don't know. jx 17 ] 1 @ 12 13 14 15 16 17 18 19 20 21 ® 22 23 24 2~ Federal Reporters, Inc. 25 150 But I think when she left they lost a very excellent person in the field of nursing and allied health. I think that condition still exists. I think they have to make strides forward in involve ment of allied health. People not only in their proposals, their programs, but also in their regional advisory group and so forth. Here again we had very very heart-to-heart talks about this matter. It sounded like this was the sole site visit business but it in reality was one and I think they were satisfied and took our recommendations very well. Now concerning these two proposals I am going to ask Gary. MR. STOLOV: This was done as a core staff activity and there is no requested project directed. It was -- they were working fairly close with the New York State Department of Health in reference to the nursing home business. DR. PATTERSON: Do you think they realize they have DR. SCHMIDT: You all are giving the reporter fits here. Speak within about an inch of the mike, would you please MISS KERR: In summary now that my questions have been responded to I would support Dr. Patterson's recommenda- tion that this region be given encouragement rather than discouragement through the funding level. jx 18 @—~-Federal Reporters, VW 12 13 14 15 16 17 18 19 20 2] 23 24 Inc. 25 Lol DR. SCHMIDT: Would you make that in the form of a motion then to support the recommendations as outlined by Dr. Patterson? MISS KERR: I would so do, yes. DR. ELLIS: I will second that. DR. SCHMIDT: Oh, good doctor. Our primary reviewer then goes along with that. As a second. So we do have a motion on the floor. Remind you it is for a one year approval at the rate of $889,000 with $429,000 for support of staff. MR. STOLOV: Dr. Roberts reminded me to say that the site visitors included in the $889,000 is $16,000 to continue their home hemodialysis program one more year so I was unclear as to whether the $889,000 included kidney but I wanted to make that for the record that this includes a $16,000 earmark. DR. SCHMIDT: The record will show it does include kidney then. | DR. SCHLERIS: The present core budget is -- DR. SCHMIDT: Should be on that big long sheet you have there. DR. SCHLERIS: Looking at the core personnel. MR. STOLOV: Could you repeat the question please. DR. SCHLERIS: Yes, the question I asked was wisest is the present support of core personnel as of 6-30-72. jx 19 1 oO at > 11 @ 12 13 14 15 16 17 18 19 20 e 29 24 2 Federal Reporters, Inc. 25 LOL I read that as being 309,000 and if I’ add correctly there are 18 vacancies on that, that leaves 29. DR. SCHMIDT: The correct figure given down here is $341,745. According to the yellow sheets, the fourth, back of the fourth yellow sheet. DR. SCHLERIS: I pulled this out of the original grant requests and there was an insert in it that was apparently an update from the old one. Am I correct on that? I guess the question, what? MR. STOLOYV: Yes. DR. SCHLERIS: In other words they have 18 vacancies now and you are increasing their core by a significant amount of money. They already have i8 to fiil. Is this part of the source of their mini-contract funds, unexpended course. DR. PATTERSON: That's right, from resignations of last year, that is where they got their assessed money, from mini-contracts. But some of these people are being paid as project directors and we are recommending that these people that are project directors be brought on the staff and paid as full staff. DR. SCHLERIS: The question I have really has to be answered by your judgment. Do you think that they can fill not only some of these positions but additional positions as recommended because that seems to be a healthy increment “T jx 20 ] 1] @ 12 13 14 15 16 17 18 19 20 e 22 24 ce —Fedetal Reporters, Inc. 25 153 to existing core not to a planned core. DR. PATTERSON: I personally do. MR. STOLOV: However, grants fenagenent officer asked me to call to the review committee's attention that there is a large unexpended balance that was made available to us. And we have as a site visit team recommended a manage- ment survey go over this but we feel this is quite significant, this unexplained balance. DR. SCHLERIS: I would think so with the number of 18 vacancies in 29. DR. PATTERSON: I am sorry I neglected to mention we have recommended very emphatically that the management assessment team visit inthe early part of this coming year. DR. LUGINBUHL: As a new member I'd like to ask, when we approve this level, that is a maximum level that we are recommending is that not correct? And that the actual level of funding will be deter- mined by decision of Dr. Margulies and staff, that our recom- mendation is a ceiling, is that correct? DR. SCHMIDT: Yes, our recommendation goes to Council who then approves a figure that is in fact generally accepted as a ceiling, then depending on monies availabie, principally, staff can award money or Dr. Margulies, or surgeon- general or now the secretary or President Nixon can award actual amounts. jr 21 ~— 11 12 @ 14 onl q@ 15 16 17 18 19 20 21 © 09 23 24 >— Federal Reporters, Inc. 25 LOs Based on dollars available and so on. Generally, staff does not unilaterally make a decision more or less arbitrarily on the basis of disagreeing with the review com- mittee or Council and give them less than we recommend. If they do give less it is usually because funds aren't available or budget cut. DR. SCHLERIS: I think the reassurance is if they get the money theywill spend it. The mini-contracts bother me because they shouldn't have been core expenditure. DR. MARGULIES: Again by coincidence I discussed this with them when I was there yesterday, indicated to’ them that the use of funds this way either in the endeavor to spend it because you have it or to initiate contracts because you think you have a chance to do it is not looked on very favorably. If they came back to us and said we miscalculated and we have not spent as much money as we thought we would that that would get a much more favorable hearing. In answer to you question, Bill, what we would normally do if this committee takes action and Council confirms it, would be to make the grant available to them based on of course our available funds, but also on an assessment following a management survey and the state of progress in that program so if it looked indeed like the point being raised is an important one, that they cannot utilize the funds jr 22 e — Federal Reporters, 14 15 16 17 i 18 19 20 24 Inc. 25 . adjusted around the facts. through RMP funds, is that correct? boo as they had anticipated then the grant award would actually he It is so difficult to be sure of these things at the time of review. MR. TOOMEY: I believe you said RMP funds a number of CHP was that correct? DR. PATTERSON: No, sir, what I said, and Jerry, I'd like for you to correct me if I am wrong but -it was my under- standing that a coordinator for emergency services was re- exruited for each area by the CHP agency and then was paid MR. STOLOV: Dr. Rose just had a technical consul- tation and before I answer I just wondered if he discussed that Mr. Murray is using the CHPS as a recruiting arm and then these personnel now become part of RMP personnel and may be housed at the CHP office. DR. JAMES: As a point of information I would like to know in circumstances where the region may have quite a few problems, has it been a policy of the review committee to make a recomendation for the total years allocation based upon possibly the fact that many of the problems be resolved within a period of months, for instance; contingent upon three months improvement, then one may be assured as to the steps that the program is going to take. Or is it usually the policy that the total year jr 23 1 10 11 @. 12 13 14 15 16 17 18 19 20 2) oe » 23 24 :~ Federal Reporters, Inc. 25 156 award be made and then go back again a year later perhaps and find that the program has either stood still as we heard this morning, or has even regressed, I wonder has there ever been consideration in giving three months, six months approval. DR. SCHMIDT: That is sort of tough because regions have to plan, recruit and so on and breaking the year down has not generally been done. But what has been done is that awards have been made contingent on something that could happen fairly quickly, such as the set of bylaws being approved and so on. But you have just about got to make an award and let people go ahead and perform or not perform. What we do do is send back very strongly worded messages that you must do this and this and this. And you know the year goes by very quickly and in this particular instance they will be back in a year. But everybody from the OMB on down has to plan their budget and So on more or less on the basis of the year. We have not made three monthly awards or six monthly awards. DR. MARGULIZS : Can I just add to that for. a moment? DR. JAMES: Yes, because I think you missed my point a little bit. What I really was saying, that the total year allocation would be available. jr 24 1 i ) 12 13 14 16 17 18 19 20 @ | 22 24 e~ Federal Reporters, Inc. 25 Los However, the approval of the project or the region would be based upon a three-month period of time dependent upon -- this is not to dissipate their funds or to piecemeal funds going into the region. In other words the total allocation of money would be there. However, at the end of six months or whatever arbitrary period of time depending upon how quickly they came together with improving the deficiencies, the money would be totally awarded for the whole year. I don't know whether that clears it or muddles it. But I am aware of some agencies, not necessarily in this particular group, however, being on a three-month watchdog’ basis. And if they haven't come up to standards, then their annual budget is cut and withdrawn. DR. MARGULIES: The closest I could come to a response to that is to tell you that when programs receive a grant award and the funds are made available to them, we do follow the rate of development and rate of expenditure, if they get, well say $800,000 and it appears that those funds are not going to be utilized during the course of the year those funds do not remain available to them. There was a practice in past years of letting them carry over funds from one year to the next. That's not the case. Unexpended funds are a part of RMPS general funds and are then placed somewhere else. el jx/ 8 sO ad Q ie @ 12 13 14 15 16 17 18 19 Le 24 >-—- Federal Reporters, Inc. 25 158 If it's apparent that they may expend it at a rate of half what they anticipated then we make an adjustment in our budgets according to the rate of expenditure. DR. SCHMIDT: That still doesn't get to I think what you are looking for. If I understand what you are looking for we haven't done that. In the past. And particularly with an established region with the sorts of activities that are going on here, cooperative arrangements and these sorts of things, three months, and recruiting and so on, three or six months, an awfully short time. A year is a block of time for RMP that might be equivalent to three months with some action program with more discreet and finite objectsives. DR. JAMES: The comment I would like there was based upon the experience we had this morning and the review of the, first program I believe, Rochester, in terms of three or four or five, six years going on with a total expenditure of money which does in the long run amount to a great deal. . And I had understood that strong worded messages had been sent back but they did not result in change. And I wonder would the review committee want to consider going on and on and on for a number of additional years without some assurances that important changes in program would not be forthcoming and not having to wait anot her year for the changes to come back. jr 2 1 1 12}. @ a 14 15 16 17 18 19 20 21 © 22 23 24 >— Federal Reporters, tnc. 25 Loe DR. MARGULIES: There is one exception to what we have said to you. The only time that we have felt that a pro- gram was in such desperate straights that it needed to have shorter-term funding, we have acted that way. I think we might have done it in the past in the program that was presented this morning. But I think those who were on review committee before recall that we in fact in the State of Ohio put three programs simultaneously on six month funding, at the end of which time they had to show evidence of progress toward what we had outlined for them, went on from there. It did have a good result. But when there is a good potential within a program and it is moving, it is a terrible hindrance to tell them you can't be sure of this money unless you meet such and such a mark, and it is a kind of character role with the regional medical programs that we have tried to avoid as much as possible. DR. LUGINBUHL: I think the concern we have is that there are vacant positions and if they indeed were funded at this higher level we might end up with either those funds used for other purposes as they were in the past or that they would simply be carried over and I feel I have gotten the assurance that it is possible through administrative control to make sure that doesn't happen. So I feel that it is perfectly acceptable from my jx 3 1 © 12 13 14 15 16 17 18 19 20 oe » 24 3—~ Federal Reporters, Inc. 25 160 point of view to approve this level with the understanding that it can be managed through the administrative role. DR. Derriey I think that and I think once again the record will show the committee's concern that the staff be built up and the monies provided for the core staff be utilized for such. John? DR. KRALEWSKI: One final comment in that regard. To read through this the recommendation was that you higher a deputy coordinator with talents and public relations indicating you feel they need something to reach out and balanc¢ of administration which means you know you think you need some administrative talent within which really doesn't leave much left for the coordinator and doesn't leave me with a great deal you know leave me very comfortable with him. Then coupling that with the fact we have got 18 vacancies and we are giving them another $150,000 on top of those, for core, you know it just doesn't seem to follow in terms of recommendations. I wonder if the -- if this whole surplus bit really did come up during the site visit or maybe that is a new piece of information for your group and would perhaps influence your recommendations and amounts of money? DR. PATTERSON: Maybe I misrepresented my feelings about the position of the site visitors impression about this. 10 11 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ¢ ~ Federal Reporters, Inc. 25 161 I think that what I should have said they need a man that does have some administrative ability. I think that anybody in the position of associate director or deputy director does have some administrative ability but I think they need someone that can become more closely associated with the county medical society, the state medical society, so if you have got a man, administrator who is not in the position I think that is a moot point whether it's wise or not. But accept the fact that this administrator is in that position. I think it’s wise to have a physician in this position, if something should happen to Mr. Murray from illness or if he is away this man would be the one who would be in charge of the program and therefore I think he should have some administrative ability. That is my concern, it's hard to find a person like that but I think they need closer relationship throughout the region with other groups, allied health, physicians, and so forth that such a man could give them. | DR. SCHMIDT: Seems part of your answer to the question would be that management visit was strongly recom- mended and if the committee would wish the motion could include something to the effect that pending the results of the manage~ ment assessment visit, somebody, staff or Dr. Margulies, could reduce the award by some amount of funds that they obviously weren't going to be able to spend or some such. LO2 jr 5 1 We are lacking some information I feel. I feel it ig 2|| necessary to answer some of the questions about the surplus 3|| and what they will be able to spend and so on. 4 Presumably that is the reason for the management 5|| visit. Like to be sure that all the issues are clear. b We are spending a little bit too much time on the 7|| same issue here that I think is before the committee. Are g|| there other issues to be brought up. 9 DR. ELLIS: -- 10 DR. HESS: One of the things that's concerned me 1] || is the combination of staff and expanding project activity. @ 12 13] be given to building program staff before project activities, And the question as to whether or not some priority ought to 14] is in a better position to manage it. 15 And a related question is about the quality of 14|| Some of the new projects, if in your opinion they were good 17 quality projects. And then the second question is, what are the decision-making mechanisms and guidelines which they will 18 19) use in deciding which of those they have to select from will 20 in fact be funded if they get reduced funding. om} How they go about picking the ones they think will © 22 give the most mileage given their resources. 23 DR. PATTERSON: Well in reality we are recommending 24 just that, sir, this they do not undertake hardly any new eee ere os activities. Continue what they are. jr 6 1 14 15 16 17 18 19 20 21 eo # -» 23 24 :- Federal Reporters, inc. 25 LOS They have gotten into the field of emergency medical services which is going to take quite a great deal of time, What we want them to do is try to continue what they are presently doing with only a few additions which would keep them from being overburdened. I think you are absolutely exactly right. That is the word that was passed along. | MR. STOLOV: They have ranked each one of their projects on a basis. And the site visit team felt that the -- because of the ranking situation we felt that no new activities should be carried on through this period but built on the PMS and also education until activity is that do demand a lot of staff time. | DR. HESS: If I am reading these figures right, I am looking at -- at, on the yellow summary. And the new projects appear to the right of this double standard dividing line sort of comes down through the middle of the page. Those new projects come to substantially more than $200,000, and that's the difference. If you turn to Page 4, about $200,000, current level of operation projects, you are recommending 460, so it's about 260,$270,000 difference and it seems to me that there is more new ones there on the, on Page 5 than can be accounted for here so it looks to me as though they are getting into some new things. MR. STOLOV: The region has merged some projects jx 7 e— Federal Reporters, VW 12 om GQ) 14 15 16 17 18 19 20 24 Inc. 25 Lo4 that were originally started and put a new number on it. So that accounts for project 44 and project 46. And projects 23 to 31 have been merged into health systems Northwest 45. Because we got no report of phasing this out this is the way it turned out to read. DR. SCHMIDT: Dr. Ellis, did you have a comment? DR. ELLIS: Thank you, Mr. Chairman, I just wanted to say that Ihad the opportunity to see Mr. Murray once and I was extremely impressed with his administrative capability. I felt he really related to all aspects of the community and had the, -- he could work very well with all - of the disciplines within’ the framework of mutual respect. I could not see anything wrong with having a person who is a non-medical person in an administrative position. I felt he had a much better understanding. I thought it would be interesting to know that he did not have the opportunity to make final decision on many of the things when he was not in the director's role. | DR. SCHMIDT: We have a motion on the floor and the points brought out by discussion. I think we must come to a decision point. If we continue at this rate we will be here until nine o'clock tonight before we get done with what we ought to today. Are there any issues that haven't come up that anyone wants to discuss before we do test the matter. jr 8 11 12 ee Ww 13 14 15 16 17 18 19 20 21 e 22 23 24 a-- Federal Reporters, Inc. 25 LOO We have a second motion for the one year approval at the level of $889,000. We had a management assessment visit coming up which would provide staff with some information We have the obvious sentiment of the committee that building staff is there first priority. Warn them against utilizing their energies in other areas until they have staff competencies built up. Are you ready for a vote on the motion? All right, all in favor, please say aye. Opposed, no. I ask for a show of hands, ali in favor, piease raise your hand. Seven is. And opposed? Five No's. So the motion is carried. Thank you very much, Dr. Patterson. 10 MXXXXX 11 © 12 13 14 15 1é 17 18 19 20 e . 24 e-~ Federal Reporters, Inc. 25 166 DR. SCHMIDT: We will move on to Virginia. Again, I remind everyone to fill out your sheets, using number 1 through 5, nothing lower than 1, nothing higher than 5. You can use decimal points between 1 and 5. The order we want to get through this afternoon is Central New York, Virginia, West Virginia, Albany, Hawaii, and Mississippi. So we are on number 2, Virginia. There was a site visit. Sister. Ann Josephine. SISTER JOSEPHINE: Thank you. The site visit was made to the Virginia Regional Medical Program on August 3rd and 4th of this year, and I had the opportunity to chair the program and Dr. Benjamin Watkins was a member, as were Dr. Morton C. Creditor and Dr. Vaun. We had hoped they could be here to also review the program with me, but it wasn't possible for them to arrange their schedule in this way. The members of the staff were Mr. Frank Nash, Clyde Couchman, George Hinkle, Marjorie L. Morrill, and Joan Ensor, and they were most helpful to the Staff. I had an opportunity to visit the program last year as a site visit team. At this time it was apparent that there were a number of problems related to magnitude as well as a number of problems related to the program itself. dor 2 11 @ 12 13 14 15 16 17 18 19 20 24 sé — Federal Reporters, Inc. 25 16/ There was little opportunity for us to make any significant changes in the arrangement of the schedule planned for the site visit. We asked for : number of changes, hoping it would give us an opportunity to evaluate the program a little more effectively. However, it became very apparent that members of the program were defensive and were somewhat hostile. Doctor, that is true. I had to check on this because is changed and I don't want you to do to me what you wanted to do to Albany. You know, I keep being afraid of time because, as I look at Dr. Schmidt, I see somewhat my own Bishop who recently stood up and said the prayer in the middle of a sentence I was making, so I want to hurry up. (Discussion off the record.) SISTER JOSEPHONE:’ The program when we reviewed it in 1971 had categorical thrust to the program and I say these things because it is kind of interesting in mind of what was said about Albany and in mind of our own experience and probably experiences other programs are going to have. I think some programs .° have coordinators who have attracted staff, who have more quickly moved along and felt comfortable in programs that do change its smoke signals frequently. Also, I think some programs have probably been dor 3 10 1 12 14 15 , 16 17 18 19 20 21 Yd) 22 23 24 e —Federal Reporters, Inc. 25 168 able to attract to them staff, people who have developed expertise in grantsmanship and I think all this does make a difference in the climate of the programs and I think this has to be taken into consideration and this program is a slow learner. These kinds of things did not exist a year ago, but. during -- also, this program is unusual in that there is a minimum amount of domination from the two existing medical colleges. In fact, there was very little interest in this program. Also, the RAG was very weak because all the decision making process really existed in the Board of the corporation that was the grantee agency. This year it became apparent that a number of things had changed. Bet wen the time of the site visit in '7l and our site visit in August of 1972, staff has worked very hard with the members of the core staff and with the coordinator. And they simply are to be complimented on the success of their efforts. Their efforts, however, were successful because core staff and coordinators responded to their efforts, and | I think all this exists in Virginia Regional Medical Progre: at the present time. dor 4 11 @ 12 | 13 14 15 16 17 18 19 e 29 24 ce ~ Federal Reporters, Inc. 25 169 The goals and objectives which this program has developed during the past year reflect the goals and objectives of the program nationally and reflect a much better under- standing of the latest mission statement of the Regional Medical Programs, It was our impression that they reflect regional needs and problems, although the site visit team felt that the core staff need -- the core staff under::the.direction of the coordinator, need to develop ways and means to better identify the local needs. This, however, the difficulty of identifying local needs,however, is bound up with the fact that they have at the present time a rather inadequate data base in Virginia, and so they don't have this type of information to draw on. But on the Regional Medical Program, it is going to participate in the accumulation of this type of data and will have it available as time goes on.. The triannual application which they presented, we felt, was not as well written as we had hoped. In fact, there is so much duplication in it and repetition, and it is presented in a way that might be confusing to the reader. It is interesting in the first evening we met for discussion, I think all of us felt that the program had not made the advances that we had anticipated: they would! in response to the directives and help given from staff. dor 5 10 im @ 12 13 14 15 16 17 18 19 20 2] @ 22 23 24 ¢ ~ Federal Reporters, Inc. 25 170 But as time went on, we realized that the triennium application was probably written by someone who did not have the expertise that may exist in other programs where better applications are written. However, as we took time to sit down and talk with the people involved, we found that their program was a much better program than was reflected in the written document. | The region has endeavored to prioritize the goals and objectives as well as prceposed activities. And this has not been to their advantage. So the site visitors felt that they would do better not to try to prioritize objectives as well as programs, but rather to show how the programs were related to objectives. The evaluation process as it exists in the Virginia program has many things to be desired. The young man who is in charge of the evaluation has some of the limitations that were indicated existed in the Albany program. And in discussion with members of the sitevisit team and hearing ir reviewed here today, that my recommendation and the recommendation of the group was that if at all possible, the Regional Medical Program Services be given to -- through their staff capabilities, be given to develop (XX 5 10 11 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 —Federal Reporters, Inc. 25 171 evaluation criteria and evaluation programs that can be turned over to the different regional medical programs, maybe even as a canned program or as a model, that they could use for evaluation to ~~ for their own process, and they could modify it in their own process. It was our impression, it continues to be my impression, that we have too much energy that is being put into developing techniques and skills almost in a competitive atmosphere that should be shared between the programs and probably we could move further ahead, and T think that Virginia R etional Medical Program, the young man who is doing the evaluation could profit by this kind of help. Evidence of significant program staff activities was manifested by involvement toward imporved care for stroke patients in underserved areas, development of skills in utili zing medical audit as an educational instrument to improve quality of patient care, and activities related to rehabilitation consulting teams for nursing homes, educational programs in sickle cell anemia were beginning to be pahsed out of Virginia Regional Medical Program into Public Health. In the past, one of the problems that existed in the relationship between the Department of Public Health and the Virginia Regional Medical Program was that the head of the Department of Health was also chairman of the RAG, of Regional Medical Program. dor 7 11 12 13 14 15 e—~Federal Reportess, 16 17 18 19 20 21 22 23 24 Inc. 25 172 And I think that with his resignation from that position, I think a better relationship, more effective working relationship will be developed with the Department of Public Health. The program staff activities have stimulated or directly resulted in greater involvement of dentists, pharmacists, and allied health personnel. There is a measure of accomplishment in the building of relationships in five subregional districts staffed by community liaison officers and eventually they hope there will be representatives from Regional Medical Program in each of these subregional offices. And this is envisioned by the coordinator as one of the functions of liaison officers in coordinating activities in the state. In some areas the activities of comprehensive health planning and activities of the Regional Medical Program are all intertwined but as I listened to them talking, as I thought about them, the things that were said later at this point in time, this may not be all bad. There is one thing that is very evident in this program and it may exist in other programs, but may not be so evident, and I would like to comment on this and that is that as we sat and listened to their explanation of the program, we sensed that there might be some hidden agenda that wasn't on the table. dor 8 10 1 © 12 13 14 15 16 17 18 19 20 21 eo =: 23 24 — Federal Reporters, Inc. 25 173 And as we continued to pursue with questioning, we found that there really wasn't a hidden agenday in the sense that they didn't want to share it but the planning that they were doing was long-range planning, and while they were describing the projects they had at the present time, they already had their plans laid for the future, but weren't sure that you disclose this. And I think that it was not in an effort to be secretive in any way. And then I thought also about the climate in this particular state. I think this is a very conservative culture in this state and I was reminded of the time when I was working with kittens as experimental animals. The pharmacist said to me, "If you keep moving the hand so fast to get at the kittens, you are going to be clawed to death," and I think this is the same here, and I think Dr. Perez is very sensitive to the people in the area, he moves slowly and he moves consciously and as a result, he is able to plan ahead and then when he sees it is the right time, he implements his plans. I would not have realized all these things had I not returned for a site visit within a year and saw what had happened, and he felt much more comfortable with me, it was much easier to begin to see this. This may be true in other programs and if it is dor 9 10 11 @ 12 13 14 15 16 17 18 19 20 2) e 22 23 24 ce — Federal Reporters, Inc. 25 174 just a one-shot deal, maybe I get the wrong impression. I don't know. They have currently ten projects ongoing. They are still in the initial year of support and there is no positive indication of future sources of funding. And one of the criticisms that could be made of this program in the past is that as they have developed projects, they have not built into the project design possibilities for phase out funding. However, this will be true in the new projects, the 15 new projects, that they are recommending. Like the Albany program, the 15 projects for the most part show -- indicate an anticipated activity rather than ongoing activity. And in support of these projects, I would say that the change in attitude, the change in climate, the change in attitude, the new members of the core staff who have been brought on board, indicated to us on the site visit they were capable, they were knowledgeable about what was going on in the area, and their willingness and under- standing, the new direction in which the Federal government anticipates that we shall make the programs go, as well as their success in identifying phase-out funding, will probably be supportive of the 15 projects they are suggesting although there is no evidence of past success, dor 10 10 1 @ 12 13 14 15 16 17 18 19 20 oe 24 e~ Federal Reporters, Inc. 25 175 there is no, little evidence of past success in all of the areas. We talked to Dr. Perez about the need for a deputy coordinator. We used that term because this had been suggested on several previous visits and it became apparent aS we were talking that probably we were really saying, it is necessary that you delegate more authority and -- or I suppose you delegate responsibility and give people authority to carry it out. I think the concern we were expressing is that if anything happened to Dr. Perez, there is really no one to take over the rein, and this is a program that has come as far as it has because of the leadership and strong control that he has exerted over the program. He was a little resistant, initially, to the idea of a deputy coordinator, but was receptive to the idea of another member on the staff who would, to whom he would delegate responsibility. It is -- I think maybe in the past semantics were the kind of thing that stood in his way, but I think this is very important in this program because if anything were to happen to him, it just isn't going to move without him. And this recommendation came through again from the site visit team. dor 12 10 11 @ 12 13 14 15 16 17, 18 19 20 21 @ 22 23 24 se — Federal Reporters, inc. 25 177 for better communication with the chairmen, the chairman of the RAG who, in turn, will be able to do a better job with RAG, but I feel he may well be one of the very good chairmen that we have of the “Regional Medical Program RAGS. The Virginia »Regional Medical Program is an incorporated entity governed by a 12-member board of direcors and since their incorporation, three of the wiginal board of directors have once again accepted membership on RAG ‘and this has been good because it is assured knowledge and understanding of the separate functions of each of the two groups. And it may be as time goes on that one or two others will rotate onto RAG. However, in discussing this with Dr. Perez, the site visit team pointed out that too heavy a concentration of this group on RAG would destroy the benefits of a more diversified representation. The Virginia Regional Medical Program has established closer interrelationships with the major health oriented organizations within the state and Mr. Hinkle will comment on some of the meetings that have taken place since we were there on the site visit, which would indicate that they are pursuing closer relationships with different agencies, so that they can be more effective in providing their, or in functioning in their role of catalysts. I think they do not have the problem of seeing dor 13 10 1] e ~ 12 13 14 15 16 17 18 19 20 eo » 24 e~— Federal Reporters, Inc. 25 178 themselves as broker although they have been sensitive to areas in which they can provide seed money for some of the projects that would be supported by Comprehensive Health Blanning: It would appear that the region's political and economic power complex is actively involved with the participation of all three medical schools, CHP (a) and (b) agencies, the State and Local Health Departments, both the Medical Society of Virginia and the Old Dominion Medical Society, Virginia Academy of General Practice, and others, were present each of the two days of the site visit an it was possible for Dr. Watkins to become aware of how he could possibly provide better services for the Black people in Virginia than he was providing at the present time. | The doctors who are working with this group of people in Virginia are overworked and are unable to do all that they really want to do, but in the past, they have not seen other organizations as providing the capacilities for them to expand their services. They have simply concentrated on doing it themselves. This is one of the things that came out of the meeting and it might be interesting next time the program is evaluated to see how successful they have been in this area. The Region has established mechanisms for obtaining comprehensive health planning and review and dor 14 °) wl oO ‘qd © 12 13 14 15 16 17 18 19 20 21 eo » 23 24 s¢ ~ Federal Reporters, Inc. 25 179 comment but as is true in many other programs, the projects are sent through on too short notice and the Comprehensive Health Planning doesn't really have an opportunity to review the programs adequately. At the present time there is no systematic, continuing method of identifying needs, problems, and resources, and as I indicated earlier, this may be related in some way to the fact that there is a very important data base available in Virginia. And this is one area where the program needs help, and needs to continually be monitored. The Management blueprint followed by the Virginia Retional Medical Program appears to be conceptually adequate. | The fiscal management review that was made in ‘71 found the program adequate in this area and we called earlier today and found out that at the present time that there are, I think it was May or June reporting, the program is $10,000 "in excess of its budget, which isn't all that bad. It was the consensus of the team that the workload and responsibilities of the review and evaluation committee should be delegated to a larger base of people who had more technical expertise and maybe some of their money should be invested in consultation. Since the last site visit, Virginia Regional dor 15 i e 12 13 14 15 16 17 18 19 20 2] @. 22 23 24 e ~ Federal Reporters, Inc. 25 180 Medical Program has established a RAG program committee whose responsibility is to review and update goals, objectives, strategies and concepts for the Virginia Regional Medical Program, along with providing guidance to the executive director for program activity and project development. And they are beginning to move along in this direction. I think that there is quite a gap that exists betw een the knowledge of core staf f£ and coordinator and knowledge of RAG. But this gap will, if they continue going in the direction they are going, should gradually be decreased. They are utilizing their manpower and facilities in an efficient manner so far as we could see and their programs by the testimony of some of the people who came have led to a better utilization of personnel, to better disseminiation of knowledge, better quality of patient care and in some instances, a containment of costs. They are moving along with regionalization, and are beginning to develop better cooperative agreements in various regions and they are also beginning to be able to identify funds that can be used as matching funds for Regional Medical Program funds. Before I comment on the recommendation of the site visit team for funding, probably the second reviewer dor 16 10 1 ® 12 13 14 15 16 17 18 19 e 22 24 é~ Federal Reporters, Inc. 25 181 would have some comments to make. DR. BRINDLEY: I have not had the opportunity of having a site. visit. I know the area, know many of the people there, and Sister, perhaps I read the wrong things while you were speaking, but it sounds as though you made many apologies for the program as you were going through it and indicated some hopes for improvement in a lot of areas. My only point of difference really was in your funding level in which I just wondered and I want to ask some questions about that when we get to this. If I may, I have nothing else pertinent or that would be helpful to the discussion but it seems to me that there are many areas that are weak and we hope will get getter and in the program that you have indicated are probably going to be improved but have not yet. DR. SCHMIDT: All right, let's go on then, to the recommendations of the team. | SISTER JOSEPHINE: The site visit team spent some time in discussing the funding level and I think that had we made the decision on the first day, our decision would have been somewhat different than it was after we had an opportunity to visit it with the group the second day and to find out that there were more things that were going on *' than were really reflected effectively in their application. dor 17 1 @ 12 13 14 15 16 17 18 19 20 21 ® 22 23 24 -e ~ Federal Reporters, Inc. 25 182 “That is a very poorly written application. Accordingly, the site visit team recommends that the Virginia Regional Medical Program be approved for triennium status at $1,800,000 direct cost level for each of the three years, and the developmental component, which was requested at $80,000 level to be funded within this total $1.8 million. DR. BRINDLEY: May I ask questions about that? DR. SCHMIDT: You put this in the form of a motion, I presume? . SISTER JOSEPHINE: Yes, the site visit team recommends that the Virginia Region Medical Program be approved for triennium status at $1,800,000 direct cost level for each of three years;,and approval for a developmental component in the requested amount, which was $80,000, to be funded within the total $1.8 million level. DR. SCHMIDT: Is there a second for this motion? DR. SCHLERIS: Second. DR. BRINDLEY: About core personnel and in their budget, I know the current year has listed $501,000, in their request for the first year, it is a.million sixteen. I can't see where that million sixteen is coming from but maybe I don't have all the information. Here is core personnel over on form 6 where they presently have budgeted $351,000 and they have 12 more people that they hope to employ and if they include their salaries, or 19 16 2 @ 12 13 14 15 16 17 18 19 20 21 eo 2 23 24 :~ Federal Reporters, Inc. 25 184 about two hours. Then finally we ended up ten’ of us in about three or four different groups and we came up ~- we tried going through project by project and we couldn't get anywhere on that basis, because th ge asked for almost three million dollars and we knew they were only around a million now, and I guess that made it not feasible to take that approach, so we got into our separate groups and first of all, I personally came up with about 1.6, someone came up about 2.2, and we thought we would have to work some more and we did, and then finally, someone else came up with 1.6 and the first evening, after about two hours, that was the support level we thought we would recommend. Now, this is after the first day. The second day, we met with the program staff and then following the session after that, but during the program,staff, as the site visitors, consultants, primarily, had opportunity to quiz the program staff, what they were doing, what they were planning on doing, how they were going to do things, things that weren't in the application or at least, we couldn't derive it from the application. As soon as we got through, about an hour and a half session with them, one of the consultants again, as soon as we broke, said that one point six isn't enough, let's make it one point eight, so that is how we arrived at it. dor 20 10 11 @ 12 13 14 15 16 17 18 19 20 21 ® 22 23 24 ce ~ Federal Reporters, Inc. 25 LBD ’ 4 DR. LUGINBUHL: I am sorry, but I am lost. ‘I don't have the application. What I have got is the yellow sheet. Well, the yellow sheet shows $500,000 for program staff in the current year. $536 for operational projects. A total of about a million dollars. And then in the request for the triennium, their request is almost $3 million for the first year. That is three times as much and they are doubling the amount for program staff and they are increasing fourfold the amount for operational projects. SISTER JOSEPHINE: Actually, their current funding now is $1,037,000. They are asking for $2,989,000 and we are recommending $1,800,000. | Unfortunately, the recommended amount isn't in here for the first, second and third year, but this is their request, which on this seet, oh, yes, is for $2,989, $80,000 developmental. We are recommending one eight. DR. BRINDLEY: Can you see one eight, you think they can use one eight effectively? SISTER JOSEPHINE: Yes, we felt they could. There is a certain element of risk, but we felt they did it. dor 21 1 i. @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 se ~ Federal Reporters, inc. 25 L3o DR. SCHMIDT: Let's give it back to Bill and let him finish because he isn't done yet, I can tell. DR. LUGINBUHL: My problem is they are going to double their core staff between this year and next year, and they are going to increase then their operational -coprojects also. They are going to double those. That seems to be a very rapid buildup in a program in which there seemed to be some reservations and without looking at the projects, I obviously have no way of knowing how this money is going to be spent but it just seems to be an awfully rapid increase in a program budget. SISTER JOSEPHINE: As we go to those i5 projects, there are a number of them which could well be incorporated and they could probably be stronger projects, so that I think the 15 is a larger number than they will finally come up with. Insofar as the cor e staff goes, I think that they realize that it will not be possible to fill all of those vacancies but they have as an alternative.the possibility of purchasing services with some of these funds in the absence of being able to fill these positions which would be an alternative way to go. DR. SCHMIDT: First Joe, then John, then -- DR. HESS: I had a question related to the dor 22 e~ Federal Reporters, 10 11 12 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 187 previous one asked. That is, does the site visit team have any recommendations as to how that one point eight might be split between two program staff and operational projects? Togehter the contracts are all contracts for core staff support services of one sort or another. SISTER JOSEPHINE: Yes. DR. HESS: Some of what he said sounded like developmental component, feasibility studies, that kind of thing. I just wonder if they are getting the two mixed up. SISTER JOSEPHINE: No, I don't believe so. DR. HINKLE: br. Hess, the contract, 379,000, I did a little analysis on that and what they are asking for, 342 thousand of it I could identify, that is for central type regional services which they want to continue. One of them happens to be their stroke project for rural stroke rehabilitation, which was a project. They don't want to review the project. They think they should continue a little vig. Another consumer project, at a reduced amount into their core until they can get the state health department to take it over, they think they have a firm commitment. Feasibility study done in the prior year, the year they are in now, they anticipate two of those will be completed, two dor 23 14 15 16 17 18 19 20 21 @ 22 23 24 e~ Federal Reporters, Inc. 25 LOS of them are, have evolved in program proposals, and six of those are ongoing now, again, moved over into the central regional activity. | I have a list of them. It is staff library health data, survey of continuing education needs, career en- hancement for allied health. One of the. big one is ~~ well, I punched a hole right where it is, but it is health care and -- the last three of them. And another one, they have a physician and residents activity which they claim to put six thousand in that, to their core, those are big items plus a few that run two thousand, twenty-five hundred, and up to about 342 thousand. We feel that the funding level or the site team aid recommend that they will have to cut back on some of these. If some of these are marginal since they have prior year experience on them, they may just decide not to continue them at all but we don't feel they can come anywhere hear a million dollars into their core based on a million eight hundred thousand funding recommendation. DR. HESS: Well, I would just like to comment on what this kind of think suggests to me or at least, the question ir raises, that has to do with their readiness for dor 24 11 @ 12 13 14 end 14 15 16 17 18 19 20 21 ® 22 23 24 ce — Federal Reporters, Inc. 25 189 triennium status. It seems to me if we accept the sit e visit team's judgment as a kind of measuring stick, objective measuring stick, it is very disparaging judgment between the region judgment and site team judgment as to what capa- bilities in the region are. I just wonder perhaps the funding level is all right, but I am not wondering about their assurety in terms of managing capacility, whether or not they are eligible SISTER JOSEPHINE: Did I hear you say that the site visit team feel they are but the region doesn't, is that. the impression I have. DR. HESS: No, you recommended triennium status. SISTER JOSEPHINE: Yes, sir. wt FLY # 14-A kar 1 18 11 ) 12 13 14 15 16 17 18 19 20 21 @ | 22 23 24 e~- Federal Reporters, Inc. 25 LYU _DR. HESS: Obviously, the region believes they are ready. But I am questioning the readiness in view of the rather substantial disparity between your estimate of what they are ready to do and their estimate of what they are ready to do Seems to me there is a very substantial weakness there in terms of if we accept your judgment as correct, what they are really able to do and I just wonder if there isn't some more maturation desirable before they go triennial status..~. So I am questioning that particular part of your recommendation SISTER ANN JOSEPHINE: Well, you know, it just may be that I didn't -- I am really very sorry that Dr. Creditor or Dr. Vaun, one or the other, aren't here because it may well be that I just didn't reflect this very well. I think what I -- I sm sure that they, you know, do need more maturation. I think the question is not whether they made more maturation, but are they at a point where over the next three years they Cal handle triennial status. And I think that is somewhat different And I would say that that is true, That they do, they have indicated at this point. You see, they have within the course of a year really changed from a totally categorical focus to a service focus within the framework of the categorica I think, realistically, they have done as much as anyone can. do, but the way they have done it and the way they talked about it as we were there, indicated to the site visit team, and I am usre I am reflecting accurately when I say this, the site -—s ve . kar 2 1 15 16 17 18 19 20 21 @ 22 23 24 @ ~ Federal Reporters, Inc. 25 191 visit team felt that they would develop considerable maturity during the coming years, but that they had attained a maturity of judgment and a demonstration of competency in the way they had moved this far and in the way they anticipated they were going to move with their programs, that they could handle triennial status at this point in time. DR. SCHMIDT: I would like to move us along because Dr. Lemon is going to have to leave about four. And that means that we will have to have our little party and give Dr. Lemon time. | \, So that I will ask John to be brief,-and Mrs. Flood}. but we will want to cover the points. DR, KRALEWSKI; i will indeed.. It is still not cleay what kind of increases we are offering, I wonder if we might go back to Joe's question again, that budget, how much are we offering them for staff, how much for core-staff activities, and how much for projects. And that will give us an idea of what the increases are, Maybe they are not as substantial as maybe they Look on the surface, DR. SCHMIDT: George, can't you do that quickly? MR. HINKLE: Yes, sir, we anticipated that type of question, but unfortunately at the time we were there, we would say well, suppose you get a million and a half or two million, how would you allocate it? That is the only way we could get kar 3 1 10 12 14 15 16 17 18 19 20 2) @ 22 23 24 2 ~ Federal Reporters, Inc. 25 192 a feel of whether they would take a cut in program staff or whether in their projects, DR. KRALEWSKI: Where did you think they should take it? MR. HINKLE: I think a little out of both. They just about doubled both. We asked them what procedure they had set up, you know, what plans they had made and they said they were waiting. Now, at that time, they said they were waiting to get their funding level, then they would have to meet and almost start and retrench again, That. is the reason we mention our concern about prior advertising their projects and their goals with no indication how they were going to use them, but I was on the pnone with them the other day and they indicated to me that they are ready, since we were down there, and I think this indicates their receptiveness, They have come up with four alternative plans for funding. A, B, C, and D.is the way they identified them, And whichever funding level they hit is the way they intend to go, and I didn't have the nerve to ask them what range they were looking for. I thought about it, but I was afraid to ask, but they are working on it. DR. SCHMIDT: I think in this particular area, it would be safe to say that the information you are after we reall couldn't get until after they know how much they are going to get, then they will make a decision so that way we are back to Y 193 kar 4 Joe's question. It is a matter of.our judgment as to their 2 judgment and it is clear that the site visit team did feel that @ 3 they had the porcess for making the wisest. judgment, given 4 Virginia and so on, but I don't think we will know how they will 5 spend the money because they don't know how much money they will 6]| have to spend, and their decisions will, obviously, be made in 7 part depending on how much money they get. 8 Mrs, Flood? 9 MRS, FLOOD: Well, I appreciate the opportunity to 10) address the point that I was going to make, put it has been wel] 11} covered now because it was the same question, the same concern ©} 12), for recommendations from the survey team as to which level 13] for what. Thank you, 14 DR. SCHMIDT: Are there -- 15 DR. LUGINBUHL: I see in their first year request 16]| that there is $376,000 which is labeled as post-contract money 17!| which is an alternative with expenditure as core staff. Would 18] it be possible since we don't have a very clear understanding 19], of how they would react to a cut in budget to make that item in 20] some way a contingency item? 21 DR, SCHMIDT: To make the contract money a contingency @ 22|) item? 23 DR. LUGINBUHL: On clarification on how they would ~ 24|| spend that money or built to spend it at core staff, getting 6 -~ Federal Reporters, inc. 25|| back to the flexibility that seems to exist for staff decision kar 5 |! iP @ 12 13 14 15 16 18 19 20 21 @ 22 23 24 2— Federal Reporters, inc. 25 17 LY4 after we have approved an upper level funding, DR. SCHMIDT: It is my understanding that area was fairly well blocked out, that the contractual money was to be used for fairly definite and specified feasibility studies and so on, George? MR. HINKLE: Within the application, those funds are explained even with the narrative, a little porposal narrative of what they area going to do on form number 12 in the applica- tion, There is 11,000 on the form 11 at the feasibility study, but they are both covered under central regional activities under form 12, I have the complete list and balance if you would like to run down -- DR. SCHLERIS: I think we can discuss any applicatiog before this review committee on an item-by-item basis, I think a great deal of the decisions that go on really relate to the advantage of a site visit group having spent a considerable amount of time getting to what really amounts to certain levels of confidence and how well a region can really handle the funds which it requests, I don't think it is a reflection of immaturity for a region to ask for three million and you say sorry, we are only giving you one point eight. That is the name of the game. So I don't question the fact that there is disparity in the judgment of the site visit group as opposed to the amount > L. kar 61} Oo nat © 1 @ 12 13 14 15 16 17 18 19 20 eo » 24 ce ~ Federal Reporters, inc. 25 the opinion there. 195 requested. I think all of us on the site visit find that before we, when we read the document before meeting the group, we come up with conclusions that prove to be totally fallicious after you have met with the group and had an opportunity to sample I suggest we have a vote, I have serious questions, but I think most of those have been resolved by the nature of the responses that have been given and they really result in the fact that after you have visited with a group, you have confidence if they have answered the questions that have been raised, | DR. SCHMIDT: All right. The vote has been called for then, We will do so, unless someone urgently requires the floor, If not, then the motion is for approval, again, at the level of 1.8 direct cost for three years with the developmental component to be founded within this. All!in favor please say I. And opposed, no, And the motion carries with dissent, It is 3:23 or 3:24. And we will, within this room right now, have a little celebration in tribute to Sister Josephine who is leaving for Rome, The occasion is dedicated to her. Coffee is dedicated to Warren Perry. This is his line we wrote on the cake and tried to write on the surface of the coffee and the sugar stuff melted, so there is no message on the kar 7 1 10 1 © 12 13 14 15 16 17 18 19 20 21 eo 23 24 e~ Federal Reposters, inc. 25 196 coffee, But we won't have any speeches or anything, but over in the far corner of the table is our coffee and cake and before we do get up, Dr, Margulies will say a-word, Before I relinguish the microphone, in order for Henry to make his plane, we will reconvene in ten minutes after we stand up. Harold? DR, HARGULIES: I actually had prepared a very long speech about Sister Ann, but sitting next to Mack, I can't do it. I would like to say just a couple of things. one of them is that this decision for her to go to Rome was at no time cleared through us, I was a little startled by that. I suppose the Vatican recognizes itself as a higher authority than this one, but we haven't always felt that way about it, | Sister Ann, for those of you who are unacquainted with our experience with her, has always, for some reason, inherited some of the toughest programs to review that anybody ever has to take on. She has a great capacity to cut through the mirk, She looks extremely gentle, but the main reaction of the staff which told them that she was going to Rome was, well, is Rome ready for her? I don't Know What she is going to do there, I do know that she requested that the review criteria be translated into Latin. And so we expect to see some kind of reasonable change by the time she returns. 13 E # 14-A 14 15 16 17 18 19 20 21 @ 22 23 24 e- Federal Reporters, inc. 25 197 We also had a popularity vote on her as a member of the review committee, And we did a control study, she turned. out to be one of the most popular members of the review committe we ever had, and we took this for nonsecretarian purposes as a vote both on and after Yom Kipper, and it came out. the same, You can't say better than that, And so I do want to wish you God's speed, but before I do so, I would like to attempt that if anybody attempts to hijack your plane, he is in trouble, SISVER ANN JOSEPHINE: Well, you know, to respond to your question about, well, wondering why I am going there, when I heard about this, I said to myself, you know, life is not a series of problems to be solved, but mysteries to be lived. (Break.) e CR 7148 Tape #15 jean 1 11 12 13 14 15 16 17 18 19 20 21 22 23 24 :¢ — Federal Reporters, Inc. 25 198 (Recess. ) DR. SCHMIDT: Can we bring the coffee to the table and reconvene, please? DR. SCHMIDT: Move on now to the West Virginia area, DR. LEMON: Thank you. Now that everybody's relaxed over coffee, this should go very quickly, I hope. I till try to be very brief; otherwise, I will miss my plane. I wish to spend a little bit of time on the background which I think is quite vertinent, since this particular area has been somewhat neglected by being under site visited; nevertheless, it has, in the opinion of the site visitors, done very well with very limited resources. The problems in this area are geography = We might have the first siide (slide); it is 61 percent rural. Tnere's been a massive exodus of physicians from the area. They have lost 30 percent of their physicians in the last decade} The economy is in rough shape, between '40 to 50 percent of the patients in the rural counties are no pay indigent. The medical resources have only recently been organized and the medical center which is peripherally located at the top of the geograph- ical mao away from the major centers of patient care. Further- more, the graduates that are now coming into practice in the state, 65 percent of them are FMG's, and they have over 400 non-licensed MDs practicing in some of their coal mining clinics} That is 400 out of a total, in addition to a total licensed population of somewhere around 1,000 or 1,200, I forget the jean 2 S wt oc u oe. ” 13 14 15 16 17 18 19 @ 2 24 e — Federal Reporters, Inc. 25 199 exact figure. The area assets, however, are considerable. These people are quite independent. They like to work out their own problems and there's been a very excellent working relationship established between the state medical association leadershin and the medical center, the medical center which has been a tremendous asset to RMP. This is centered on Dr. Andrews, who's been sort of the moving force, and much of this has gone without detailed organizational lines or committees, done on a first name basis, and this is one of the things that we were initially mystified by; how so many things got done with so few people and we were soon informed. Next slide will show (slide) well along in sub-regionalization. This slide snows comprehensive health planning regions that have been developed. Some eleven of them in the state and the RMP has now gotten I think five or six. Next slide shows the RMP sub- regional offices which are congruent for the most part with the CHP offices and throughout CHP the "B" activities have been flushed out and firmly established through the very excellent neripheral regional activities of RMP. Furthermore, they have local foundations, the HYGEIA Foundation, Ephraim McDowell Foundation, that have come across with matching funds to supply their health delivery programs which have been initiated under FHP, and this is on an eight to one matching basis, in other words, RMP has invested over $12,000 and they have over $1 milli returned, On jean 3 10 V1 12 eo 14 15 16 17 18 19 20 21 oe 4» 23 24 e- Federal Reporters, Inc. 25 Now, the high priority basic medical needs here are develoy ment of residency training programs. They have none outside of the medical centers at Morgantown, which is way at the top of the map. These are in the works and the state legislature has appropriated $300,000 to hely develope these in Huntington, Morgantown and Parkersburg, located in this area and down there, They have done little, however, in getting their unlicensed MDs. This is one of the criticisms we would lay before you on the program thus far. Next slide please (slide). This just reviews the state- wide programs that are underway. You can't possibly read all those, but there are quite a wide ranging number. For the most part, these involve the development of better health care delivery services in specific areas in cooperation with local lay people and professional people.. Next slide (slide). This shows the proposed projects and how they are centered around it, some of the major regions and you see these are all peripheral for Morgantown, so we have here a very concrete demonstration, this was the thing I thought would be very helpful to the committee, to see that indeed this medical program is not the creature of the medical centers but it has gone out. It's acutely aware of the medical needs, their priorities are well established in terms -- their object- ives I mean -- and they have gone out and done a very capable, thorough job of sub-regionalization. jean 4 16 1] @ 12 13 14 15 16 17 18 19 20 21 e 02 a 23 24 ce ~ Federal Reporters, Inc. 25 201 Is that the last slide? (new slide). This shows the, this is emergency medical services, Two subregions, this is one of their three major priorities. These are two of the projects in emergency medical services. (Slide) The next one shows another group of their projects. I can't read that from here. It shows different distribution. I'11l point out that they do’ not try to do much at the present time in the very southernmost tip of the state, which has the majority of their non-white population, because this already is covered by very large Appalacian programs, with which there has been some, I won't say conflict but they have been rather slow in getting involved down there, because this is part of another regional srogram, i think that is the last slide, is it not ? Thank you very much, Lights please. We interviewed a total of some 41 people, and it was amply demostrated that they have -~- that the objectives are quite congruent with service objectives of RMP, and they revolve around health care delivery, emergency medical service, and health manpower. Every one of their proposed new programs,: of which they have a considerable number, relates specifically to these objectives. Now, when the area had the disastrous combination of circumstances of losing its initial original coordinator by death then getting a site visit, I guess from the last site visit three years ago, the -- they chose Mr. Holland as the jean 5 . @ " 13 14 15 16 17 18 19 20 21 @ 22 23 24 se — Federal Reporters, Inc. 25 202 acting coordinator and they have been very effectively led by Mr. Holland, whom we rated very high for his administrative ability, his energy. He had been the assistant coordinator prior to that, and he has gotten in a good group of assistants. It's a rather simplified organizational structure which he has developed, but he has been able to develop the six subregional offices staffed by regional liaison officers who report directly to him, and they coordinate their activities very closely with the "B" agencies and the university county extension programs. The state university has its own county extension program in various areas. You have not only the "B" level programs, but the other programs of the state university. We felt that the decision making objectives, decision making and review processes,were quite adequate for tri-annual support, and we felt that they had performed really quite ex- ceptionally in their planning process and in the flexibility with which they continued to redefine their objectives and goals The institutions, as I said, are the backbone of this and . this was readily apparent from testimony of the dean of the medical school and Dr. Andrews who is now provost of the uni- versity, which is sort of a flexible Mr. fixit job. And he continues to keep a very close eye on RMP, so that Mr. Holland has quite adequate high level professional assistance in the political power area from the president of the state medical association, Dr. Week, and from the dean of the medical school, jean 6 1 @ " 13 14 15 16 17 18 19 20 21 oOo » 23 24 se ~ Federal Reporters, Inc. 25 203 and the provost of the university. The program staff activities, with a rather small budget, has been very effective, since there is a 30 year background really in the development of community efforts to increase and retain position coverage for some of the small towns, and since there has been this background of community action in terms of medical care, RMP has been able to move in, I think, more rapidly in this area in sub-regionalization of medical care access than in many other parts of the country and they have done very well, and this is where the major emphasis of the approximate five-fold expansion in non-core staff funds. They are not asking for expansion of their core staff funds, but they ere asking for more funds to initiate the development of many more local group practicing centers. In addition to the United Mine Workers initiated group practice activities from which they're basing their present model for extension of medical care, the individual solo practic of medicine by the members of the medical society is due for a change. There is a large group practice now being organized in Charles Town, and I would like to have you remember that the conventional medical practitioners in this area have never been sympathetic with the UMW clinics, but these two are going to come together, we hope, and we think RMP in the next three years will have a tremendous opportunity not only to improve medical access and general medical care in the outlying rural areas, but iw jean 7 7e — Federal Reporters, 11 12 — Ww 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 204 to develop liaison and backup with specialized high quality medical care from the major medical centers of Charleston, Huntington, and Parkersburg through the development of residency programs. Now, if they know they only retain 40 percent of the physicians they train at the medical school who largely go out of state for internship, if they can get them into residencies in the state, and there are none outside of the medical centers, about 79 nercent of them will elect to stay in the state. They have done very well in getting continued support. I think this is one area that they have demonstrated very well that they get continued support for RMP initiated programs. Some of the criticisnis that relate to this regional advisory group, they have not really been able to answer the earlier criticisms of previous site visitors that the regional advisory group was not sufficiently made up of minority groups. In their area they think the most urgent problem is with the medically indigent. They don't have adequate representation of the medically indigent consumer on their regional advisory group but with 50 percent of their population either without or unable to nay for medical care this is a problem that they're very much concerned about. This is not adequately represented on regional advisory group. The coordinator has done all he could. We went into this in considerable detail to recruit minotiry employees for the program staff, but there was only one minority = jean 3 ‘e ~ Federal Reporters, Se) ae © 1 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 205 representative on the core staff, so we felt that this should be certainly something that should be remedied in the future, As I said, we rated the coordinator very high. He knows how to delegate responsibility, and we felt also that somewhat he was in a rather advantageous position being a non-physician, because he could relate equally diplomatically to the university and to the leadership of the state medical association. He works well with both of these major resources. Program staff was all high quality, well trained. We did feel that they needed more input from physicians, physicians time on the staff and a nursing physician, particu- larly in terms of evaluation. This is one area where we don't have any problems in evaluation. You can actually count the additional number of people who will have access to physicians where there weren't physicians before. ‘I mean this is an area which one should be able to evaluate what they are doing very well. We felt that the Regional Advisory Group bylaws were restrictive, they they shouldn't -~- again the previous site visitors had come into this were very health prior oriented and this should be opened un. It is,not that the people on the Regional Advisory Group are not cognizant of what they should do. For instance, HYGEIA, a foundation, is putting many hundreds of thousands of dollars in supporting these programs, but there isn't a representation of the HYGEIA foundation on their regional advisory group. jean 9 so = vm e " 13 14 15 16 17 18 19 20 @ 22 24 ce ~ Federal Reporters, Inc. 25 206 This is a matter of ordinary diplomacy. You would think they would get representatives from the major foundations who are helping their work, the grantee organization. There's been some problems with this. There's been assessment recently, and these problems are probably pretty well worked out. There is a long delay between the presentation of vouchers for payment and payment, as long as there months. This is because it's a state university, it's the grantee agent,and this has to go through all the checks and balances and delays of'a state uni- versity system. Again, this has been an educational business both ways. The university has become educated and the RMP in what it can do and through the checks and balances there is little chance for any real mismanagement of the funds by this organization. Our power structure of the state, political and medical, is well represented. The nurses, however, are not represented. There's been a 30 percent increase in nurses in the state in the last tei years, and, of course, in areas where they can't put physicians in, pediatric nurse practitioners, that type of program is in the works, and they should have much more nurse representation, both in their core staff and on the Regional Advisory Group. We feel that they have not recognized the problems adequately, as yet,of the 400 foreign trained physicians or U.S. trained physicians who have been unable to get licenses, but they made the decision very early in the course of RMP that they had to jean 10 10 it ® 12 13 14 15 16 17 18 19 20 2] eo » 23 24 se ~ Federal Reporters, Inc. 25 207. concentrate on first things first, and they were going to leave continuing education to the medical centers, and they did not make it a part of their regional medical program, Managenent was well done; we felt that the office of program and research and evaluation, this is staffed by a single program evaluator, data analysis and a research assistant. Now this is in the process of change. We felt that their quarterly progress reports and recording were quite adequate, but we didn't think that the feedback was getting back to the regional advisory group, was getting back to the coordinatoy and his staff, but it's not getting back to the regional advisory group in terms of the regional advisory group really being kept thoroughly informed as to the relationship between proposed programs and how well they are meeting their objectives The executive committee of the regional advisory group, for instance, meets on a monthly basis. That just shows how much responsibility the coordinator and the staff have been given in terms of running this program. We had no real question as to the programs which they had carried out. There was one rather extensive program which is producing few nhysicians, but this program was probably very important in the early stages of this medical program in educating the physicians in what RMP was all about. If they want some money to continue this, this is one of the things we felt could be cut in the future, not put another hundred thousan jean 11 iv 11 e 13 14 15 16 7 18 19 20 21 @ 22 23 24 ce ~ Federal Reporters, Inc. 25 208 dollars in it, and we have information that that can probably be funded by others, from other sources in the future. Finally, on page 17 our recommendations, I think I have covered most of the lesser points. On the funding level the one big item, most of the new projects represent just sort of seed money for the organization for new clinic activities or feasibility studies or health planning activities which are well tied into CIP. They did ask for $250,000 for the first year for total staffing of the new clinic, Camden on Galle. we felt that was a littie bit high. Maybe RMP should only buy 50 percent of that, and since that was a precedent, all the other things that they'd be able to start, they'd started with a much lesser proportional funding. So that if we knock out half of the Camden on Galle support which they requested and we did not allocate another $100,000 for the physician and mecical self audit program which is now in its fourth year, that knocked out about $175,000, then with the usual startup problems in new programs we felt that a reasonable figure for their operational year would be one-and a~half million dollars, then one-sixth for the fifth operational year and 1.7 for the sixth operational year. We had no real concern in view of the, of their 46 national increase, there are practically no physicians in the rural communities any more and people don't have really the transportation to get to a physician. We had really no feeling that they would not be able to do great things with theig jean 12 10 11 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 se — Federal Reportess, Inc. 25 209 developmental component. We did hope they would put part of this into development of their residency programs, that this would be within RUMP guidelines, and also do some kind of pilot study to see how they could bring their unlicensed physicians into the medical community. DR. SCHMIDT: We have a most excellent and strong secondary reviewer which relieves some of the pressures we are under, and I'd like to ask Leonard first if he has any questions of Henry, because he is going to have to phase out in about ten minutes, So, the most important thiny is to be sure that the secondary reviewer gets what information he needs. v DR. SCHLERIS: I want to ask one or two questions. fn looking at the approximately 15 or 16 projects that are to be supported, do you feel that they have the necessary strength in West Virginia and the core to make sure that these are productive ventures? In looking at numbers, oh, 21 on down? Not just that one but all 16 projects listed. Do you think they can adequately evaluate those? DR. LEMON: Well, we did, the second afternoon we went out to look at one of the clinics that's been developed by the community, without any benefit of RMP assistance. These people have the know how to develop entire political, comprehensiv Nealth programs covering the whole community, including everybody in the community,and if they can to this in the town of Fairmont, Jest Virginia, including a bus system for the patients so they © jean 13 7 NO ant “<> 1] @ 12 14 15 16 17 18 19 20 21 @ 20 23 24 ce — Federal Reporters, Inc. 25 Z£1U can get to the clinic, as I say, you have to know them, and I have a professional associate who's from West Virginia and one of the reasons they half a deficit of physicians, these -people are great do-it-yourselfers, if you give them half a chance, We felt very sure that they would be able to do these things and this is backed up by the people at the medical center and the state medical association. They're not without the best help they can get in the state. DR. SCHLERIS: Are they going to do anything about the core itself? I note that essentially $577,000 for core the current year, asking only for $584,000, DR. LEMON: They did not ask for -- we felt the core ehould he -~- needed some strengthening in particularly the eval- uation. We felt that what they were doing was so valuable there and there are some other activities like these other organized clinic activities that now have such a large amount of expertise and exnerience that we were hoping they could beef up their evaluation and get more of this out in the printed word in the form of reports that would filter to other areas and be helpful to other areas. DR. SCHLERIS: Are you suggesting any strenghtening of core? DR. LEMON: We felt the core program was slightly under staffed, but not inordinately under staffed, and they do have help from the medical centers, West Virginia medical centerg G2 jean 14 sO amet CQ 11 @ 12 13 14 15 16 17 18 19 20 21 @ | 22 23 24 2e ~ Federal Reporters, Inc. 25 ‘a secondary reviewer. 211 and university. DR. SCHLERIS: How strong are your recommendations for reorganizing West Virginia -- | DR. LEMON: I think here you have to walk the path of diplomacy. They have done a very good job. I would like to put it in strong language, but I would not make the award con- tingent on that. DR. SCHMIDT: All right. DR. LEMON: I put this in the form of the motion. DR. SCHLERIS: Dr. Schleris: Second. DR. SCHMIDT: Dr. Schleris puts it in the form of a motion, SiSTER JOSEPHINE: Second. DR. SCHMIDT: Dr. Schleris, we will turn to you as DR. SCHLERIS: I have gone through the document. It's very brief. The anectodal part of it is extremely brief and the site report is more lengthy than the. anecdotal comments, so the review is very important in this instance. The individua projects aren't described. This is why I asked whether or not you felt this could be self running. You have a great deal of confidence that this is indeed so. DR. LEMON: I think their performance is extremely good in that out of $120,000 RMP has put into development they n generate a million dollars of support from HYGEIA. How much DV jean 15 n @ 12 13 7 15 16 17 18 19 20 21 @ 22 23 24 ‘e~ Federal Reporters, Inc. 25 212 longer the Galle foundation can add to the support is -- DR. SCHLERIS: I have: indicated my concern about core remaining the same in the face of 15 or 16 new projects scattered throughout the state, many of which will have to recruit additional physicians and personnel who, as I read it, may not be available. So, I think it's probably wise in terms of startup, there will be undoubtedly delay in many of these organizational and staffing problems. DR. LEMON: We went into rather thoroughly how flexible they were and they have been rather quick to phase out programs they felt were unproductive or where they couldn't get adequate assistance in the local area, but there is in most of these areas, as far as we could determine they'‘d;: see their sub-regionalization with these subregional directors, they're out in the boon docks 80 percent of their time. This is where their time is going, making sure these resources are there. DR. SCHMIDT: Are there questions or comments from committee members? MR. HILTON: Two questions. You mention the southern most portion of West Virginia and some problems there. Is thera interface? DR. LEMON: There is a $5,000,000 Appalachia. health project that includes McDowell County, which is 25 percent black. The rest of West Virginia is only about 4 percent, but jean 16 10 i °° 13 14 15 16 7 18 19 20 eo 3 »« 24 ve ~ Federal Reporters, Inc. 25 213 that one county, which is one of the most depressed and re- tarted counties, is included in another $5 million Appalachia program, DR. LEMON: Wo, this is under Appalachian Regional Commission, MR. HILTON Are you satisfied, are there opportun- ities for cooperation or not? DR. LEMON: I think they are hust now beginning to develop their contacts there. I think the other projects had some problem in persuading the health providers of that region to get involved and so fourth so that we were told that they -- there is a good liaison now, but this is only a recent develop- ment, DR. MARGULIES: If I can comment on-this, we are currently exploring the relationship between regional medical programs through all the 13 states on the Appalachian commission and the commission. It's an extremely complex kind of thing with traditional politics involved. It varies tremendously from State to state. The commission is designed around governor, gubernatorial control with a chairman set up by the governors and a federal co-chairman appointed by the president. Then, the funding goes through local political processes and becomes unendurably complex. I have asked we explore it only if it looks like it's worth exploring, because it may be the kind of thing on which you can expend an extroardinary amount of time and jean 17 se ~ Federal Reporters, 14 15 16 17 18 19 24 Inc. 25 ho od OE come out with a trickle on the other end. In West Virginia it's particularly troublesome, I think we have had something like five million a year for nine years or something like that and, in that area. And, its pretty well controlled by the group that's down there and it's probably just as well they don't try to compete with them, MR. HILTON: one other comment, the question was raised about representation of poor consumers from the West Virginia area, and while we were all, I think, suitably impresse with the accomplishments of this particular program in other areas, I think it's important not to under estimate the role of great developnent on the part of poor folks in West Virginia with the program. I think we are prepared to, I get the feeling we might be prepared to let that kind of slide, because other aspects appear to be quite good. Statement was, question was raised earlier as to whether or not our feelings about this particular matter were strong enough to make reform a contingency on funding. Indicated it would be, should have a very strongly worded suggestion. I would like to raise the possibility that we do in fact make a contingency. DR. MARGULIES: I'd like to comment for a moment on that and pickup on something Henry was already identifying. The people who work in the subregions around the state work also with the extension service, and their involvement with total community is,in mv knowledge and. RMP's,unique. ivhen jean 18 10 iF e 12 13 14 15 16 17 18 19 20 21 e 22 23 24 ce ~- Federal Reporters, inc. 25 215 they go in some place everybody knows them; they deal at every level and they function in a different way. That doesn't deny the importance of presence on the regional advisory group, but it would be a dis-service to the West Virginia Regional Medical Program to suggest that they are not dealing directly as they are with the poor in the state, But, they are doing it through a different kind of a process. Nevertheless, I think your point is well taken. If they are not represented on the regional advisory group it certainly isn't because that is in the concern of that RMP; it is its first concern, MR. HILTON: What you are saying is it really should be easy for the recruitment. DR. SCHLERIS: I was going to second that. There are five members of the public, one of whom is a professor in civil engineering, one an extension agent, one an executive director of the planning commission, a state director of United Transportation, and a housewife. I would think they could be urged to have a more broad representation. | DR. LEMON: They have some very dedicated people with long experience in the health field, and the consumer end of this, but they have had troubles really in identifying these people. We got that testimony from some of their comunity health veople. People in that area, you know they don't go beyond their front yards. They're very,.very insular in their jean 19 ce ~ Federal Reporters, 1 12 13 15 16 17 18 19 20 24 Inc. 25 216 approach, It's very hard to get people out of their front yard, DR. SCILIIDT: All right. Are there other questions or comments? If not, are you ready for the question? Seeing heads nod I think I will call the question. All in faver of the motion then for approval of the rates designated please say aye. Opposed, no. I hear no dissent, Henry, thank you very much, Been fun having you back. I think you will make your plane. While the cast of characters is changing and there are still this number of committee members here, I would like to call attention to a document that you have; it is entitled "Chapter 4, Application and Review." Paragraph 4, three review groum structure functions and authority. This pertains to, again, the functions of the review committee, Council and Staff Anniversarv Review Panel, and again it's something that was developed in good part in response to the previous discussio by the review conmittee on its function and what it's doing and what it is for. And without attempt: being made at overkill, this again is something else that is prepared in large measure for the committee, and I would hope that committee members would look at this toniaht and he prepared to comment on it either tomorrow or by letter or by phone call in regard to any response that the document evokes. It will be part of the, of sort of “OT jean 20 217 || the official litany or liturgy, whichever is the right word, 2 of RMP. 3 SISTER ANN JOSEPHINE: Ritual, maybe, 4 DR. SCHMIDT: Ritual. 5 Moving on then to Albany, if I am counting correctly. Right. end #15 10 1 @ 12 13 14 15 16 17 18 19 20 21 eo 8 -» 23 24 se ~ Federal Reporters, inc. 25 CR 7148 1 2 16 2 6 1 3 XX¥X 8 10 | @ . 12 13 14 15 16 17 18 19 20 2] @ 22 23 24 @-—- Federal Reporters, Inc. 25 218 DR. KRALEWSKI: This consists of 24 counties made up of 21 counties cf northeastern New York, two counties in Vermont, one in Massachusetts. We have a slide here that shows that block of counties. It interfaces with four other regional medical programs, northern New England, Tri~States, metropolitan New York and the central New York that we reviewed, today. | They have a committee put together that attempts to iron out the interface problems between these different programs and in general it seems they do not have a lot of difficulties in relating the programs to their needs. Now this group of counties in the Albany REgional Medical Program is made up of rural and urban centers. The compilation is generally pretty much split. It is about 53 percent urban, 46 percent rural. In the rural areas we have generally the problems of rural health care across the nation. We have a number of small towns. Some of them have lost their physicians and have not been able to attract new physicians. Some of them have physicians but they are aging > and’ they are overworked and they have not been able to bring a lot of additional talent. That is the headquarters of the program is located in Albany. The program is one of the older ones formed under PMP guidelines. It was formed by the Medical College back in 1966. ais kt fou Peba 2 2 10 1 @ 12 13 14 15 16 17 18 19 20 2) @ 22 23 ¢ 24 e~ Federal Reporters, Inc. 25 213 They had an initial grant for planning in 1966, and in 1967 got an operational grant. And at that time the Dean of the Medical School at Albany became the Chairman of the Regional Advisory Group, and it was largely through his initiative and the Chairman of the continuing education program or department at the university, a fellow by the name of Woolsey, that the program got off the ground and Dr. Woolsey then became the coordinator of the program (Slide). That essentially is the background of the program. | It covers a population area of about two million people and it has about a six or a seven percent of minority groups. And the population area. Now the history of the program is mixed, As I mentioned it was started in 1966. rt was spawned by the Medical School, had a strong orientation toward con- tinuing education, and as a result a great deal of their initial effort and our money went into education continuation programs dominated by the university. This was of great concern to several site team — reviews through the history of the program. And they gave of course advice to the program to broaden their program input. Many times it did not result in any substantial. changes. Now this past year in 1971 we site visited the program. Then at that time they were applying for triennium. Again we looked at their projects, the very narrow program they had, some other points we looked at in the program, and we £16 } Reba 3 10 "1 e 12 13 14 15 16 17 18 19 20 21 ® 22 23 24 e~—Federal Reporters, Inc. 25 229 Ged at that time we probably should fund them for one more fee Cec year and then they should come in for triennium after they have attempted to implement some of the changes we believed were necessary and that they said they wanted implemented in order to strengthen their program. These included phasing out of some of their very narrow projects, particularly a two-way radio communications program they had for continuing education that they had not phased out, was just an on-going project funded by RMP. We thought they should fund that out before we looked at the triennium application. We thought they needed to straight: out their rapport with the medical school because the program was quite dominated by the medical school. The Dean of the Medical School is Chairman Brag. They had a weak regional advisory group, a weak executive committee, they met only once or twice a year. Attendance was fairly low at those meetings and it clearly was a question as to who was running the program. We thought they needed strengthening on their program staff. They lacked a Deputy Director, the Administration was mixed to say it in its kindest way, and the program staff generally were acting on their own volition, taking other kinds of tasks they wanted to do with very little overall direction. There was question over the location of staff. They were located in several different buildings so they never were #16 ] Peba 4 2 10 Ny @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e- Federal Reporters, Inc. 25 221 able to be pulled together, there was question over some of the talent on the staff. They regionalized their area into six different regions in order to be able to reach out to the population a little better and they developed a program where they would have people on their staff who most of them, who were formerly drug salesmen, detail men, that would act in the capacity to handle these regions and interface RMP with the different agencies in those regions. Always there will be some question as to the effectiveness of that program and the relationship of the people they had in that capacity to the individuals assigned to program management and program projects. Again that was a question we raised a year ago, one we thought they had to face. They had 28 people on their staff. They had many capable individuals we thought, they would pull them together. They had a great deal of potential the way it looked. They had support from the Medical School and it seemed to us that Dean Witgers was willing to consider substantial changes in order to make the program viable. Yet this was all on the paper as proposed changes and we as I mentioned thought we would be best to give them a substantial amount of advice in writing regarding the kinds of things I just mentioned, to carry on another site visit this year, and then to decide on triennium application form at this time. #16 1 Reba 5 2 3 e 10 1] @ 12 13 14 15 16 17 18 9 20 21 e : 23 24 te ~ Federal Reporters, Inc. 25 ponents $90,000 a year and asking for staff support of nearly 222 As a result we gave them essentially level funding last year, a small increase so that they could undertake some new activities and reorganization and then when more money be- came available this past year RMPS gave them a little more money to implement some of the projects that they had in mind. All right. So in front of us then we have an appli- cation that resulted from that ~-- those deliberations and this year's application then asks for money to fund new projects essentially. 23 projects. Seven of those projects were imple~- mented with funds RMPS gave them in the middle part of the year as excesses occurred and the rest of them are new projects, They phased out all their old projects; the ones we were concerned about. They are asking for developmental com- $800,000, per year. And so asking for about 2.3.per year support for the triennium. So this is the application then that is in front of us. Well, we carried out the site visit this past summer then, and some of the site teams members were the same people who were there the year before so we had an opportunity to look at their progress and see how they were doing. Now when ° we read their application it seemed to us that they had made substantial progress. Yet we were skeptical for a couple of reasons. One, we were really wondering how much they could turn an #16 Reba 6 2 iw 10 1 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e~ Federal Reporters, Inc. 25 223 organization around in that length of time, and number two, you know, whether now that the same site team members were coming back, whether they knew the right words to use and could therefore give us a little better presentation. In part I think that probably did occur. On the other hand, we were fairly pleased,. quite pleased as a matter of fact, with the progress that they had made. All right. Our finding, on an I might mention we did not as far as the recommendations, recommend that we go back next year. I was quite pleased to find that because on the trip in 1971 coming out of Chicago we lost an engine and the trip this past summer we were coming out of Philadelphia and we lost an engine; So I am not about to try a third one under any circumstances. All right. Well, their findings then, number 1, they have tried to restructure their corporation. They have taken a look at their relationships with the university and tired to develop a different corporate structure that would give them more autonomy and would strengthen the RAG. They have expanded the RAG to include different members on it and give different orientation away from univer- sity control. "(Slide). This shows you the transformation that has taken place. From the domination, fair amount of people on the RAG from the Medical School, you can see going from the blue to the red, 1970 to 1972, that they have decreased, the providers have decreased,consumers have increased, and you can £16 1 Reba 7 2 10 11 ) 12 13 14 15 16 17 18 19 20 21 e 22 23 24 e~ Federal Reporters, Inc. 25 224 see they have decreased the members of RAG that came from the Albany area and increased it from the outlying areas. So they have really done a remarkable job in being able to re- structure their regional advisory group. Part of their ability to do this resulted from the fact that they expanded it from 27 to 37 members. That gave ther running room and gave them a chance to add some different people. In terms of minority representation they are still light. They have a couple of members from minority groups. They recognize that they have not been as successful as they hoped, in that area, but they really, in terms of the projects they hope now to carry out, we feel that they need to make some more progress in terms of minority representation on their regional advisory group. Secondly, after revising ‘the group, itself, they, Dean Wiggers from the Medical School stepped down as Chairman and they then recruited a new chairman for the group, a man formerly who was administrator, also an MD, a very capable gy, he devotes one full day a week to the program and comes in and works on their bylaws and things such as that. He is devoting a lot of effort and it is largely because of his efforts they have been able to restructure the program as much as they have during the past year. They have restructured their executive committee and working executive # 16 ] Reha 8 2 10 i @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 2~— Federal Reporters, Inc. 25 Qas— 226 committee. They are meeting monthly. Their regional advisory group, they are trying to get together as much as nine times a year. I don't think they will ever really put it off, but they think they need that much input. They are breaking them into working subcommittees so when they come together they work as subgroups on different problem areas and it is really an active, involved group and we are really impressed with it. The executive committee knows what is going on, they look at themselves as policy makers in terms of the program and. they are obviously enjoying the role. Medical school as far as we can determine are quite pleased to see all this happen. ww They don't appear to he feeling at least that they hav lost anything over the whole shift and it seems to be working out fairly well. They have been able as I mentioned to get more community involvement through regional advisory groups and of course that has helped them restructure their program again. As a result then of reorganizing the RAG, they have been able to reorganize their bylaws and then reorganize their goals and objectives so again we have seen restructuring in both of those areas. We feel the bylaws are still a little weak in that they do not explicitly state who has the hiring and firing power for the coordinator and they leave some areas Sllent in terms of relationship with the university. And we feel they should spell out some working document 10 1 @ 12 13 14 15 16 17 18 19 20 21 eo » 23 24 7e — Federal Reporters, inc. 25 227 with the university that deals with some of these fringe issues and they are now attempting to do that. As they went through the reorganization of the corporation, the regional advisory group et cetera, they then added a deputy director to their core staff, aman by the name of Dr. Kraft. He has a great D ' deal of experience in group practice. And he is well versed in organizational matters and we feel he is really a strong Ouy. He added a great deal to the program in terms of the administrative ability and he started reorganizing their staff, he started phasing out some of the regional coordinates, the drug detail men they had on their staff. He phased out two of them and now is reconsidering you know, whether he should keep the other two or reallocate their talents in some other way. We has also streamlined many of the other relationshiy in their corporation internally, because they had at one time as high as ten or twelve people reporting to one person. He is now you know restructuring. that so they can handle the dif- ferent staff members, he has been a real strength to their staff. As a result of that, of course, the staff has built into a unit and are now pursuing tasks the program wants them to pursue rather than what interest them that comes across their desk and we believe their administrative hierarchy still Ss Reba 10 2~ Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 228 has a way to go, and while we believe they probably need to outline some of their directives a little more in terms of operating policies, we nonetheless feel that they have gone a long way in the last year and that that staff is really cap- able now of handling a mature program. They have, still, many vacancies on their staff and they are attempting to recruit for those although they are not anxious to fill them until they decide exactly what they want to do in terms of reorganizing the talent they have on board now. That seems like an honest approach to us and one that made a lot of sense. We did note, however, that since they were embarking on a number of new programs it would be well for them perhaps to add some new staff members, particularly tose with monitoring talents, and with fiscal talents, and to be able to monitor those projects as they develop. Otherwise they will get out of hand. AS a result of these changes I have mentioned they hav been able to turn the program around, they have phased out their projects and to their credit they have been able to find other agencies to come up with the funds to carry almost all of those projects so they have not terminated. New projects, they have submitted to us, they were able to obtain nearly 1-3rd of the money for those projects so the money from PMP is essentially the two-thirds of it. #16 01 Reba 11 2 10 1 @ 12 13 14 15 16 17 18 19 20 - 24 e 22 23 24 2— Federal Reporters, Inc. 25 229 They have been able to take it out of university Gomination and spread it more judiciously throughout the region. We have a slide here that represents the results of those attempts, (Slide), and you can see the first diagram to the left essentially is our visit in 1971 and the one to the right is our visit this past sunvner. You can see how the projects have changed to a broaden representative group in terms of sponsoring agencies. In other words, reorganization of RAG, bringing in more community representation they have really been able to reach out and to bring that large number of sponsoring agencies to put in project proposals. Through this process they glean some 45 new projects and then through their review mechanisms they brought these down to 23. We feel that review mechanism still needs refinemen and there is an assessment to be carried out later, it was going to be carried out after our review but after’ we got through with our review they were ready for a rest, and had decided to delay it a bit. But that will. be carried out a bit later. We feel however, that they have the basic mechanism pretty well outlined They have the mechanisms to review projects in terms of their priority. They have the technical review process outlined and we feel they are capable of handling projects,. and to realign Ichem into the program as they go along. We have one more slide #160} Reba 12 2 @ 3 10 1 ) 12 13 14 15 16 17 18 19 20 2 @ 22 23 24 e@~ Federal Reporters, Inc. 25 230 here that Burt will put on that deseribes a little more their regionalization of the projects (Slide). DR. SCHMIDT: While he is doing that let me inter- ject here that this is one of the kinds of test presentations to the committee. And we will ask specifically your opinion of these visuals, this method: of principles’ presentation by the review committee member. The other two presentations were a combination of staff and review committee, also with light and sound. But I will ask specifically about the visual so I woul like you to be thinking about how helpful they are or not help~ ful, because they are work that we don't want to put people to unless they are helpful. DR. KRALEWSKI: I am afraid -- okay, fine. This represents, A, the little triangles there, the main, some of the main projects they are submitting for funds, this represents where they would be based and represents the fact that they will be you know, out, some of them at least out of the Albany area based in some of these other areas. Burt ,maybe you would like to explain that. MR. KLINE: Yes, possibly, these are the headquarters sites for activities which are city-wide in neture. The next overlay will show the activities which are county-wide in nature and the triangles represent the geographical locations of the project site headquart ers. The next overlay shows the multi- oh county activities of -- and the triangles again represent 2416 Reba 13 2 10 1] @ 12 13 14. 15 16 17 18 19 20 2) @ 22 23 24 ‘e ~ Federal Reporters, tnc. 25 231 again the project site headquarters. The fourth (slide) is the region-wide activities and the project site headquarters. Mentally adding the triangles you get the feel, I hope, at least for the regionalization or the outreach of the Aibany regional medical program during the past year. DR. KRALEWSKI: Not only the outreach but the fact thay they have been able to bring logical groups together in the counties for regionalized kinds of efforts which we thought were quite useful, helping put together grant applications for W0, feasibility studies. They have been working very hard to initiate health programs, working with hospitals, working with universities, working with -- well, there are no doctors in towns in the rural areas, trying to develop programs for them. And develop projects that would train nurses for these roles after they get the program set. This is essentially what we found. We believe this. We think we have seen a program here really turn around in the past year and we feel we should give them support. They are asking for a lot of money. We felt we could not give them quite as much as they are asking. We felt, however, we should give them some additional advice in terf of the strength and weaknesses of their program. We note that everyone of the pieces of advice we had furnished to them last year they have accomplished. They had aS 10 im @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e— Federal Reporters, Inc. 25 addressed the question. They brought in an cutside consultant from another regional program and asked him to study their organization and give them recommendations of how they should reorganize their relationship with the university. They addressed everyone of the suggestions we aave them last year and have made progress in correcting every one of the deficits. At our feedback session this year they asked us to comment on several of the areas where they were strong or weak and we did and we have a letter from them already indicating the progress they have made on some of the areas we thought they were weak in. So it is really a heads up organization that is attempting to strengthen the things they are doing and that impressed us. In some though we feel they -- they get these projects together rapidly and as a result there are a group of projects but they don't probably represent a programjust yet, also some projects in there that don't fall within the RMP guidlines and we had to recommend those projects be deleted. We noted perhaps as mentioned before then that the core staff needed some strengthening in terms of being able to handle these many projects and therefore we would recommend they ada some additional talents and fiscal management. The letter they wrote us said they already had been able to attract aman of that caliber and so they are taking that position to strengthen core staff. #16 Reba 15 2 10 11 @ 12 13 14 15 16 17 18 19 20 @ 22 23 24 e~ Federal Reporters, Inc. 25 bo ae eo fo continue to refine their core staff and to reallocate some of the talents and we feel Dr. Kraft will do just that because he is a good guy. He has some real adminis- trative ability. No question about that and I think he has the willingness to make the hard decision we have to make. In terms of hiring and firing to be able to re- allocate those talents, so we feel he will do it and has done some of it already. We feel that they have to clarify a few more issues with the university. Many of their staff members have faculty appointments and there really is some question about how much time they should spend teaching or how much time at the university, et cetera. We feel they should outline that ina working documen4 with the university so they spell out those factors, let their faculty know about it so they can operate within those guideling We feel they should go back to these projects and put them in ay take a package and put it into a program and we feel they have the mechanisms to do that and we feel the regional advisory group will be anxious to assume that responsibility to do it. They should also bring their staff together, as I mentioned, they were housed in different spots. Again all we have from Dr. Woolsey indicated they have already done that. We recommend to them also the university provide space instead of it being in our budget because they are charging 52 percent overhead, the university has responded to that by giving Ss. #16 Reba 16 — end # 16 2 ARf1s 9 10 11 12 13 14 15 16 17 18 19 20 2t @ 22 23 24 2 ~ Federal Reporters, Inc. 25 them since our visit and to bring their staff toge These are indic are. but Iw perhaps. so the university is picking up the space In view of that revi 234 tal for they have furnished enough space ther since our visit. ations to us of how responsive they ew IT have some suggestions for funding 411 I will offer those after our secondary reviewer Loa arl } 10 7 13 14 15 16 17 18 19 20 21 e 22 23 24 e ~ Federal Reporters, Inc. 25 235 MR. TOOMEY: Not having had the opportunity to visit the Albany program, but knowing some of the people who were involved in it, I frankly was more interested in the people, the organizational structure and their achievements over the past year rather than in specifically looking at their projects. | I am impressed with the fact that they have a practically new leadership both in their organization and in their RAG. I knew Dr. Woolsey from years past, and his interest in continuing education, and frankly I am not surprised that this two-way radio system was their primary thrust for the first period of years with the organization. “I also know that he is a very, very smart, very capable and very fine person, very dedicated to this whole — idea of dissemination of knowledge for the benefit of the people who will receive that knowledge and use it for the benefit of patients. Iam a little bit surprised that there is so much emphasis on his deputy or assistant coordinator because I would have felt that once Dr. Woolsey was off on his particular kick that he would have been able to accomplish this pretty much with his own capabilities. I am also impressed that you were able to get Dr. Bordley, and I am not at all surprised, I know him most by reputation and what he's done with the Mary Imogene Baptist 10 1 ) 12 13 14 15 16 17 18 19 20 2] e » 23 24 7 ~ Federal Reporters, Inc. 25 236 Hospital in Krugerstown which is perhaps a model for hospitals in this country in terms of the relationships with general practitioners, the relationship of private practicing physicians and yet with a full-time staff in a hospital and a great educational program in that institution. So that I was, in. reading the material, quite impressed with these changes because from these changes, of course, can flow all of the other good things that have happened to the Albany program. I think that Dr. Bordley's leadership in the meeting times and turn around in the RAG, the numbers of times that they met, the use of task forces, the preparation of proposals, seemed to me was a —~ I was guite impressed with it. I think perhaps unlike you, Dr. Kralewski, I . felt that their establishment of goals and objectives was quite adequate, quite appropriate. I similarly felt that the establishment of priorities in terms of the projects that they were to under- take were quite sensible. | For instance, they had seven projects that they rated as very high priority and using almost 50 percent of the funds for the allocation to those very high priority projects. Another 35 percent of the funds allocated to those that there listed as high priority. And this represents some- where in the neighborhood of 80 percent of their money going ar3 10 in @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e~ Federal Reporters, Inc. 25 into projects for which they themselves in terms of their goals and objectives had established the highest kind of priority. | I think that they also should be commended for the regionalization. It was -~ it was, and as far as RMPS history is concerned, understandable that an organiza- tion in RMP would be captured, if you will, by the university in the initial categorical kind of structure of the regional medical program. And I think it is a tribute to the leadership in Albany, including the Albany medical college, that when the thrust of the regional medical program changed, that they were capable, once it was called to their attention, that it actually was something that seriously needed change, that . they were able to make the turn around in as short a time as they did. And with the same, I think, effectiveness. All in all, I was quite impressed with what they had done. And I know Dr. Kralewski is going to recommend the financing for this, and I will turn it back to him. DR. SCHMIDT: I think I would agree with most of the comments, but just add that once Frank Woolsey's attention was captured, some things happened rather quickly, so on. But it took a long time to get his attention. John? DR. KRALWESKI: It is somewhere to it, couldn't 10 1 @ 12 13 14 15 16 17 18 » 19 20 21 eo 2 23 24 e — Federal Reporters, Inc. 25 238 quite get the mule to work and promised if he bought the mule from him, he wouid always be kind to him, so he called the original owner over. He said, “What should I be doing?" He said, "You hit him over the head with a two by four." He said, "I thought you said be kind." He said, "Yes, but you have to get his attention." I have outlined some of the funding of the program since I started. We are going up here, doing pretty well, and we cut them in here, and during this period, and then this got to be a 15-month figure, so really it came down to 300,000 total. Part of this 900,000 was money that was given by RMPs to the program in the midpart of the year after they had shown they really were turning the place around. So we came into last year with them for funding, was like $700,000. They were really going straight down and they were very concerned over it, then, of course, they really decided they should do something. | All right, so totally, then, during this last year they had, after the RMPS supplementary funding, $900,000 broken out as 631,000 for staff, 269,000 for projects, and no developmental funds. What they are requesting now is this, triennium, but for the next budget year, they're requesting 768,000 for 10 11 @ 12 13 14 15 16 17 18 19 20 2) @ 22 23 24 ce —Federa! Reporters, fnc. 25 staff, million five for projects, 90,000 for developmental, tune of 2.4. Overall for the trienniun their request would be $8 million. that is what they would like to have. After reviewing this whole thing along the lines I just mentioned, and breaking this down to some categories to see if we have come to grips with what we think they could handle, we are recommending they go in with a staff of 638,000 which gives them a 5 percent salary increase from last year. They have got staff vacancies in there, so they can add one or two people within that figure and that will force them, we believe, to reshuffle some of their talent which they have really got to do, and fire a couple people. Craft knows that, and he is willing to do it. And that will give him a couple openings to hire some people. So coming in at 680,000 -- we are recommending this million five they are asking for projects be reduced to 950,000 dollars. We think that first of all, there was about three projects in there that did not fall within RMP guidelines, so we told them about that, and the projects got thrown out and reduced the budget. Then we went through the rest of the projects to see exactly what they were doing and where we might cut money, and came up with this kind of figure for them. We believe ar6 7e ~ Federal Reporters, 10 2 12 13 14 15 16 17 18 19 20 21 22 23 24 inc. 25 240 they are capable of handling a triennium application and capable of handling developmental funds, but we think $90,000 would be hefty, so we are recommending $30,000 for the first year in developmental. The remaining years we are recommending the staff goes up by one position is all, then the remainder is increases for cost of Living. We recommend these projects essentially increase by the percentage proportion that they had originally asked for based on ae base. So they would go up to the third year to a million one. We recommend that the developmental funding from the 30,000 we are recommending for the first year, to 45 for the next year, 60,000 for the final year for their developmental component. So totally, then, we are recommending a $5 million budget for them for three years as opposed to their $8 million request, developed along the lines right here of those three figures added up to make up that 5 million with this figure right in here (indicating) being the figure we are recommending for the first year of the million six as opposed to their 2.4.that they were asking for. DR. SCHMIDT: We will accept this, then, as a motion on the floor and seconded by Mr. Toomey. So the floor is now open for discussion. Mrs. Clark Flood? a 5 ~~ 10 VW @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 7¢ ~ Federal Reporters, Inc. 25 fo sn a) MRS. FLOOD: Do you really feel in light of their new thrust in regionalization with the operational base of these projects being shifted from a strong university center with all the skills and management, that reducing the potential for hiring the skills they need in their personnel is fair to them, to ask them then to adjust to a regional concept with small institutions, small educational institu- tions, health delivery people, assuming the responsibilities for project information without being able to buy the in-house skills for supervision, project management, evaluation? DR. KRALEWSKI: That is a good question. First, their shift from the university does not mean they lose any of the university support services. They maintain all of those. They need no additional people. What they have really done is gotten it taken out of the picture in terms of running RAG and a new guide in and new corporate structure. The university is still the grantee organization. Still furnishes them financial back-up, does their auditing. | In terms of monitoring the projects, you are right, they need the staff to do that, but we believe that they should just take a hard look at that staff and reorganize it and they will have spots. Plus the fact they did have two vacancies, two, was it, Burt? I believe two vacancies, so they have those two positions they can fill, and we think ars 10 1 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e¢ - Federal Reporters, tnc. 25 242 they can do it within that context. Plus, of course, as I mentioned, the second year we are giving them then an additional man. DR. SCHMIDT: Burt, do you have any comments? MR. KLINE: Only if I understand your question, Mrs. Flood. They have a monstrous task, I think, facing them in terms of surveillance and fiscal management. In light of this, what they have done as reported in this recent letter is they have hired a fiscal man which they did not have before because they are very aware of this problem. Secondly, I believe if I am not mistaken, and I could stand corrected on this, but they had two 50 percent men from the medical college assigned to work with the financial aspects of the Albany regional medical program. What they have done is they have traded those two 50 percent men in and gotten one 100 percent. This gives them a firmer grip on financial aspects as they relate to the college system. DR. SCHMIDT: Other comments or questions? DR. “THURMAN:: Burt said they had 21 professional people on their staff and this represents even for a large region, I think, a sufficient number of people. I think they are worried about it. This is the picture I got, is that they are worried about the fact they have so much area to cover, but they also, I think, are willing to do with it. With 21 professional people, I think they have a pretty good 10 i e 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e~ Federal Reporters, Inc. 25 chance. DR. LUGINBUHL: On the yellow sheet it lists $75,000 in the current year for operational projects. And your recommendation is increasing that to 950,000 dollars. That is not in accord with the figures up there. There is some discrepancy, and on your figures, the projects are 269,000 in the current year, going to $950,000 next year, which is a threefold increase, but nevertheless not of the magnitude suggested by the yellow sheet. DR. KRALEWSKI: Right. The $75,000 represents the old projects that they had and they have phased them all out. The difference between the 75 and 269 is the additional money that kMPS gave them in the middie of the year, and they started seven new projects with it. Projects with it. So that is what they are going into this year with. Since they did restructure your whole program and you are exactly right, that is a big jump in projects, but since they really phased out essentially everything they had and started those seven, we felt that, you know, that they had now an opportunity to add the ones around that made sense and that they could handle, you know, that amount of money to do it. DR. LUGINBUHL: I also get the impression there's been a reshaping of the core staff which will give them the capability for handling increased project commitments, 244 arl0 ] management projects, evaluations. 2 DR. KRALEWSKI: Right. A beginning, at least. @ 3|| And we feel that it will continue. 4 . DR. SCHMIDT: All right, are there any other 5 questions? 6 If not, then we will vote on the motion for approval 7 of the amounts on the board. 8 All in favor, please say aye. 9 Opposed, no. | 10 I hear no dissent. nN We have done five. There are eight together. @ 12 We could move on, or work hard tomorrow. I will ask you if 13 there is any strong sentiment. 14 Do you want to take one more? 15 DR. LUGINBUHL: One more, at least. 16 DR. SCHMIDT: Okay, let's move on to -~ we ~~ we 17 thought we would go on to Hawaii next. So, Leonard, you are 18 on. L6-a 19 20 21 e 22 23 24 e~ Federal Reporters, Inc. 25 CK $17 ty 1 AAXX ] 10 rr e 12 13 14 15 16 17 18 19 20 21 ® 22 23 24 e — Federal Reporters, Inc. 25 245 MR. RUSSELL: First of all, I would like to call to your attention at the request of the staff and representativ¢ that we are reviewing the Regional Medical Program of Hawaii, American Samoa, Guam, and the Trust Territory of the Pacific Islands. In doing this, we will look at the two programs, the State of Hawaii and that of the Pacific Basin separately. They are closely related but they are ina way separate programs. This is what we refer to as a Pacific Basin, however, American Samoa is not shown on this map. These numbers in the circles are not pertinent to this presentation. The Basin covers a geographical area of over 3 million square miles. It is populated by 220,000 people who live on 105 islands. Ten different languages are spoken. And the islands, here is Guam with about a hundred thousand population, American Samoa somewhere off of the screen, around 28,900, which gives us approximately a hundred thousand people spread out over 103 islands. The Regional Medical Program in Hawaii has moved into the Trust Territory, into the Basin. They have two pro- jects based in Guam. They have another one based down here in the Palau Truk and another one in the Truk district, Guam; American Samoa and Guam are different. More than 50 percent of the population have no ready access to health care. So to 3 o> ty 2 10 7 oe ” 13 14 15 16 17 18 19° 20 21 @ 22 23 24 6 ~ Federal Reporters, Inc. 25 give you an idea of where this is located, Saipan, which sits here, is 3900 miles from Honolulu. So that is really regionalization when you reach out thet far. Then if we could have the next slide. (Slide.) Now we are Looking at the map of the State of Hawaii. The total population here is around 750,000. By counties you can see the County of Honolulu has the largest population of 623,000. The next largest is Hawaii County, 62,000 population. Then we move to Maui County with approximately 38,000. Then Kauai with approximately 28,000. By air, Honolulu is approximately 5000 miles from Washington, D. C. It is 2400 miles from the Mainland. The chain of islands, if you draw a straight line from this island on down to the other side of Hawaii Island, would be approximately 400 miles. From Maui to Hawaii, here, is approximately -~ I am sorry, Maui to Hawaii is about 40 miles I believe. Hawaii to Oahu is 170 miles. . Oahu to this island is 80 miles. And then Oahu to. Molokai is approximately 30 miles, Of course the main means of transportation here is by air. The headquarters is located here in Honolulu. This, of course, is a large blowup of the main island Oahu, not to be confused with the largest island in the state, the- Island of Hawaii. 10 1] 13 14 15 16 17 18 19 20 @ 22 23 24 e — Federal Reporters, Inc. 25 247 There are no CHP "B" agencies. However, the CHP "A" agency does have committees on all but two of these islands. The location of RMPH activity, as reflected in the review you will be doing, covers most of the state. There. are 18 projects in the application. Four of those we have already mentioned are in the Pacific Basin. Fourteen of the projects are within the State of Hawaii. There is one here on the Islard of Hawaii, the bedside nursing care project. There is one on the Island of Molokai, which is a home health service There are eight projects which are statewide in nature, cancer, chemotherapy, physiological data monitoring, Manpower utilization and hospital cost, medical care utilization project, renal program, continuing education for nurse practitioners. Medical library and continuing education project for nurse practitioners also reaches out into the Pacific Basin. So there are actually six projects which do have an impact on the Basin. In addition to what you have in your application there, there is an emergency medical service project which has already been funded and does also cover the entire state. There are four projects that have the operational base in Oahu. There is a patient origin study. There is a dietary counseling project which serves a rural area of Koolauloa which is on this side of the island. Also there is a health screen for ..the elderly project which covers two urban areas and the Honolulu ty 4 10 11 @ 12 13 14 15 16 iB 19 20 2) e® » 23 24 ‘¢ ~ Federal Reporters, Inc. 25 248 area. And then two rural areas. One of them is in -~ rt can't pronounce it but it is over here and the other is ~- Frank, could we have the Waianae overlay? This is known as the Waianae Coast, up the coast from Pearl Harbor, about two-hour trip by bus to Honolulu. This communi ty here has the lowest health profile within the State of Hawaii and this is a particular matter of interest because this is where the Regional Medical Program of Hawaii is putting one of their proper priorities: and has had an impact. With that as a background, I will turn it over to Dr. Schleris now. DR. SCHLERIS: Are there any questions on the geography of the area? I think it might be of interest to know that the Territory, Samoa, Guam, so on, many of the people find it more convenient if they are going to one of thos¢ islands to another to fly back to Honolulu and then go back down. So the transportation problems are immense. We went to Hawaii. The visiting participants, I want to list some of these because it really was a group with which all of us enjoyed working. Mr. Hiroto, a member of the National Advisory Council. Kenneth Barrows, Banker Life Company. Dr. Holcomb, Eugene, Oregon. Mr. Russell, Mr. Sullivan, Mx. Currie, and Dr. Hinman. It was a valuable visit. I had opportunity to trave over with Dick Russell. On that flight we had opportunity to an ty 10 1 e 42 13 14 15 16 17 18 19 20 2) @ 22 23 24 2~ Federal Reporters, Inc. 25 249 review every document that has ever passed between Hawaii end RMPs. We met informally the evening we got there, trying to outline what we viewed as areas we particularly wanted to explore. And I think this is a particularly useful device, to try to underline what areas appear to be most important. Several things I learned in Hawaii. You don't tell people in Honolulu what it is like in the United States. You can tell them what it is like in the Mainland, but not in the United States because you will quickly get reminded that they are also part of the Union. Secondly, the background of many of the people on Hawaii are totally different from that of the Mainland and these sensitivies have to be part, I think, of the reaction of the group. We had been particularly forewarned as far as Hasegawa was concerned and documents related to him as far as the coordinator of the Hawaii Regional Medical Program. So we were alerted to. some potentially important areas. First of all, as far as the history of the area goes, their grant was divided very nicely into three aifferent approaches; where they had been, where they are now, where they would like to go, which is a very logical approach. And they had originally started back in 1966 with the organization being University of Hawaii. ty 6 10 VW @ 12 13 141) 15 17 18 1911 20 21 @ 22 23 24 e— Federal Reporters, Inc. 25 1611 At the present time the University of Hawaii is a two-year school but its present freshman class went through four years, so they have made that decision in the legislature. Actively as far as getting faculty and gearing up for this, and I would think that both the RMPs and medical school benefit from this. Although. I didn't see anything of Hawaii on this trip, I had had the opportunity to be there a year ago, had gotten to five major islands and had been to most of the major island hospitals at that time. So I had some background to apply. After they had planned for about 26 months, they put into -- requested three operational grants received in 1968. And part of the original problem of Hawaii stems from the fact that they do include American Samoa, Guam and the Trust Territory. This is not exactly a homogeneous type of request from one small geographical area. Albany thinks it has problem in geography. It only has to think of coordinating the varied activities in this area with its varied wings. To cover first 1971 they received a one year grant which they used to go from their transition from what had been a purely categorical approach to assist the improvement of health care delivery system. They have nicely summarized in their brochure exactly what they presented the public at the present time.as being what they have accomplished in their transition. 10 11 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e ~ Federal Reporters, Inc. 25 £ will come back to that in a moment. This one year grant was extended to December 31, 1972 and at the present time they are applying for a second triennual, beginning January 1, 1973, with the request also for developmental component. I think the site visit group f shared made a rather than usual recommendation as far as when to start developmental component, roughly one year after we left the island but I think you will see why we did that. They define Regional Medical Program of Hawaii as folllows which is the present statement, as a consortium of providers in linkage with consumers which assists in the advancement of health care delivery system of Hawaii by improving equity and access, maintaining quality and influencing moderation in the cost of health care. They have a Regional Advisory Group chaired by one of the -- I was going to say better. I would have to say one of the best chairmen whom 1 have had the opportunity of meeting. He is Mr. Bryan, serves as chairman of their group. He devotes a good deal of his’ time to the effort. He has some physical disability which not only doesn't immobilize him but I think is part of his contribution to the program. He is a strong individual. He is.well aware of the program, of the area, of the directions it has had in the past, where it is going. I think he is one of the strongest people as far as ty 8 10 1 © 12 14 15 16 18 19 20 21 oe =»; 23 24 e~ Federal Reporters, inc. 25 252 the program is concerned. Members of his RAG when we met are capable people very much involved with the programs. And I refer, will, a little later, to various documents of the past t Hawaii indicating specific problems in their area and how they think they have met each one of these, because they have really tried specifically to meet each and every one of the problems. Functions are described, RAG functions, in the usual way, additional functions on various committees. They have an Executive Committee. They have a committee which they call PIE which is for planning, implementation, and evaluation. This committee poses some problems if you attempt to look at the structure of the group because in reality so many things pass through PIE that it gets to be a group which in many ways presents overlapping and conflicting routes as far as administration is concerned. They have some categorical committees but actually these are now, the advisory committee, continuing education, allied health committee, Pacific Basin Council. So this is show they define the categorical committees. Not in terms of heart disease, cancer or stroke but in terms of their actual delivering quality of health care. I mentioned they include the Basin. The program staff has been added to in the past few years. Many of the people who have been at it are indeed very strong. Perhaps I ty 2 10 1 @ 42 13 14 15 16 17 18 19 201 21 @ 22 23 24 e ~ Federal Reporters, Inc. 25 ‘He indicated he was busy with some other problems at the time could spend a moment discussing Dr.. Hasegawa, a great deal of our evaluation in that area is dependent upon views of Dr.. Hasegawa, his potential strengths and-weaknesses. He is still a partially practicing pediatrician in Honolulu, and sometimes, I guess a little later for meetings. He was about 10 or 15 ininutes late for our meeting. As chairman, stimulated by members of the group, I decided to start without him which I think he could pardon. Having come so far we thought it might be nice if he had been there at the scheduled time. We waited 10 or 15 minutes, then decided to proceed. I don't think we phased him. and this was an impression. which ‘my sensitivity is such that it took a little time for it to wear off. But I think the rest of the group took it in stride. And as time went on I gather that Dr. Hasegawa -- he posed problems to me in evaluation and it is a problem that as I read in one of Mrs. Silsbee's letters in 1970, it went on page after page. Also presented problems in your group of evaluating, both in performance, personality and so on. It became apparent as the days went on, he operates very much in the total community. He belongs I think to every committee of any importance on Oahu. He is:respected by all of the organized groups in thg island. He has been a tremendous impetus. to the acceptance of we ty 10 10 1 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 2~— Federal Reporters, Inc. 25 group, recognizing the fact that he has been reluctant to give RMP at every level we can discern as far as consumers, provider And maybe it is his many faceted personality that permits this. And 1 would say that in terms of what he has done for the up many of the powers of director that he has now managed to get the deputy director, Mr. Omar Tunks, who is functioning very effectively with one problem, that is that the controller would prefer to communicate everything to°Dr. Hasegawa, would rather not discuss much of the economic aspects of the group with Mr. Tunks, but that too seems to hope fully be on the road to being modified somewhat. But Dr. Hasegawa functions very effectively I guess as Mr. Outside, and spends a good deal of his time as I have indicated getting RMP accepted. It is one of the more important committees of the local medical society and acceptance of RMP into the medical society, Dr. Hasegawa is bei accepted by the medical society. So I would say however a complex individual he is, a complexity is only minimally hit by my discussion, apparently has been part of what has been viewed as being good leadership. And: this is something that we will try to get out in many ways, whereever we looked” at it this became apparent. After being essentially categorical for a period of three years and its categorical emphasis was on rehabilitation, catastrophic diseases, education to nurses, home care progran, { ty Ll 10 11 @ ‘12 14 15 16 17 18 19 20 2] @ 22 23 24 ve ~ Federal Reporters, Inc. 25 255 some of the hospitals and so on. Then entered a period of transition. The program osmosis I was familiar with was the CPR program, what impressed me was how all the islands related beautifully with RMP, Honolulu, that program. That has been phased out, is being partially supported and apparentl at a fairly adequate level by the Heart Association. This was good to see that it was ongoing. They then entered a period of transition where they stated the goal was to improve the total health care delivery system to the region while not restrictin with the categorical disease field. In reality they did restrict that. They entered into priorities I gave, better health services, trying to develop health manpower, better utilization of health facilities and so on. One of the first things they became involved with was attacked as a catalyst is. where the Waianae Coast: Comprehensive Health Center which is in an area of real need. And we met staff-who had been involved with this from the point of view more of time than funds and this had proved to be a very important contribution. We met people who had been involved with this from that area. They spoke of the contribution RMPH made of this venture. What they are requesting is a much greater movement toward their goals as they see it now in terms of projects so they are interested in a greater contribution. They are interested in taking over and modifying somewhat EMCRO. . a K vy ty 12 tO 10 11 @ 12 13 14 15 16 17 18 19 20 21 @ 22 “35 24 e~ Federal Reporters, Inc. 25 which is the Hawaii Experimental Mental Care Review Organization under Dr. Anderson. This is now being supported through the Hawaii Medical Association but apparently throughout side developmental funds, and through Dr. Anderson's involvement with this they are looking with care at peer system review and other methods for evaluation, delivery heaith services. Dick, you correct me if I am wrong.. I think some 54 percent of all the physicians in Honolulu are involved with this, isn't this true, as far as their EMCRO is concerned at this time? MR. RUSSELL: I don't remember the exact figure but a substantial number are. DR. SCHLERIS: Yes, and their feeling is thatthey would like to support this through the Hawaii Regional Medical Program for many reasons, first of all it gets them into quality health care services, also into physician practiceg in the area and there is wide support for this. And they have listed certain strategies for improving health care and have indicated how they will approach it. First strategy is to improve your system of care. MR. RUSSELL: Just since we have been back I talked to Omar Tunks, the deputy. And I said, "Did the Hawaii Medical Association get the message?" And he said, "Dick, I don't think they heard a word that was said." So ty 13 10 11 12 13 14 15] 16 17 18 19 20 21 ©} 22 # 23 24 e— Federal Reporters, Inc. 25 257 they are still working that problem out. DR: SCHLERIS: I guess they got the message but don't know how to interpret it. The second major priority is designing system measure providing health care services. ‘iThis is part of what I referred to under the heading of EMCRO with Dr. Anderson. The third priority is better health manpower develop ment. This involves upgrading and trianing of many of the nurses on the Island of Hawaii. Better utilization of health facilities and again this involves training in the allied health field. Emergency medical services I have referred to. Let me discuss some of the unique problems presented by the Basin area. As you can imagine there are very few physicians there. We met the individual of their staff who was assigned to that area and he was one of the more impressive individuals of their staff. He spends a good third of his time out of the main island on the coast of Guam and Sam and the other areas. Projects for which he has asked for support, and I will refer to thosein a little more detail later on, really referred to the need for something like physician's assistance or health assistance. They aren't talking about the very sophisticated training that is being given in many areas of the Mainland. They are talking in many instances of taking natives who now function at the minimum level, upgrading ty 14 10 1 @ 12 13 14 16 17 18 19 20 21 ® 22 23 24 ce ~Federal Reporters, inc. 25 their training by using very basic audio-visual techniques so that. they can either treat some of the more simple illnesses they found or be able to communicate by radio with physicians on some of the islands. They have very basic problems there in terms of needs. Youngsters have hearing loss, they want to screen these for help. There are problems as far as some of the more basic health needs in that area and some of the funds requested for specific basin are specifically earmarke for a specific basin. That means in terms of our figures we will be specifically suggesting that "X" funds, be specifically for core or for specific programs in a certain basin area. I know this has been done somewhat previously and we feel this should be done at the present time as well. With reference to the specific site visit report, you all have that. Perhaps you have been scanning it as I have been presenting the report. Perhaps I can mention some of our concerns and then some of the assets of the program We were concerned about some of the key projects. This was related to the feedback.sessions with Dr. Hasegawa. Emergency medical systems troubles us because it should be a trouble system which it doesn't appear to be. I mentioned to Dr. Sloane since they do not refer very much to corenary needs or other emergency problems I asked Dr. Hasegawa whether they had utilized the ICHD reports in arriving at any of their PG ty l 10 7 @ 12 13 V4 15 16 17 18 19 20 21 @ 22 23 24 ce ~ Federal Reporters, Inc. 25 259 recommendations fo: the emergency medical system and there was ¢ pause which ran for 30 seconds while I deliberately waited to see 1f there was a response and I had still been waiting because I have a feeling that ICHD is not known to the RMP group in Hawaii. In fact afterwards it was apparent they had not utilized these reports, not only haven't utlized them but haven't been aware of them. To this extent, many of their staff. And.I would..suggest that. some effort be made to make sure that various RMP programs indicate at least an inaudible. Dr. Anderson's position in core is not yet fully understood.either by us or. by him. Very often questions were asked which could have been answered by him. They more often were answered by Dr. Hasegawa and he is aware of this as well. Waianae has a great deal of promise but yet there is also a considerable area of risk. If they promise certain services and they don't work out in that area I would be concerned about potential reaction. Pacific Basin area, this is a group of individuals who obviously have chauvinism, possibly to their own island, their own area. As far as it was away we have three or four individuals who were there and were extremely interested and involved and know what is. going on in Samoa and Guam and the Trust Territory. This is an area that bears watching, I know there are Little pressures which are of extreme importance in ty 16 10 1] @ 12 13) 14 15 16 17 18 19 20 2] e 7 23 24 \ce ~ Federal Reporters, Inc. 25 260 that area. And I think a word should go to Dr. Izutsu, who is the associate director for American Samoa, Guam and Trust Territory on behalf of the Hawaii staff. He is excellent and I think one of the strongest people they have. TI think if he were to leave that whole project would fail abysmally but he is obviously married to it in many ways. Mentioned problem providing continuity by early planning for other sources of funding rather than at the last minute looking for alternate fundings. We are very concerned about their evaluation system. they do have PIE. But when we try to get a clear understanding or. evaluation the man in charge of the evaluation gave it one way, Dr. Hasegawa tried to give it another way. I think he used the term that heads will fall because there was confusion on this point. Request had been made about RMPs, can't give developmental component without bylaws and at the moment it requires revision. One can't have developmental component without having more formal bylaws than they do now although agai as I said they are giving this a very, very high priority. We were-concerned about the relationship of PIE to the Executive Committee, to RAG, seemed to be a duplication of the way documents would move. They never really stop anything once it enters the system. They do invite the person who submitted | the project to be available and to come to each one of the review mechanisms so you can be a categorical one then a RAG n ty 17 10 1] 12 @ : 13 14 15] 16 17 18 19] 20 ° 2) @ 22 || 231 24 .ce ~ Federal Reporters, Inc. 25|/ t 261 then executive then PIE and it can go on and on so this was discussed and-they didn't think duplication was the problem but obviously PIE is somewhat in concept with them. We thought communication within the organization shout be improved because again as I have said Mr. Tunks should. have great access to the comptroller and funding. It is hard to run a show without knowing where the money is. We were concerned they should have more: ‘allied health representation. This was conveyed to them. We were favorably impressed with the leadership as far as the head of RAG.. I told you the complexity of Dr. Hasegawa and it is apparent that now that he has appointed Mr. Tunks as deputy director that there are changes and the changes are real. Mr. Tunks at the site visit took a very, very active role and obviously knows what is going on and those like Russell who knows the problems of Hawaii this is a very refresh ing change. He has a good staff, a lot of bright*young people aboard and they are interested, they are dedicated, and I think a good group to move with. There are little problems that take place. The head of CHP agency, use to be the secretary to Dr. Hasegawa. So this gets to be a little difficult in terms of having your former secretary head of another large agency but apparent this hopefully will work out. A lot of the projects are very innovative. Had to be impressed with the tremendous change in t ty 18 se ~ Federal Reporters, an 10 li 12 13 14 15 16 17 18 19 20 2) 22 23 24 Inc. 25 direction. We are impressed with the Pacific Basin Council. They have set up a separate council to help review the problems of that area and the other thing was we asked them suppose they only got half the money they asked for, what would they do in terms of which projects they would support and they had a list there already of priorities for each and every one of their items which demonstrates a certain level of responsibility. The university has a research corporation which serves as a fiscal agent and very fank discussions, this has worked out extremely well. They have had no problems with this}. It has been a good source of support, fiscal-wise to RMP. It should also be mentioned that the funds of-Hawaii RMP represent the greatest source of funds for that research corporation, so the university is obviously very interested in this, dean of the medical school was there and gave very, very strong support of RMP. He obviously knows what they are doing but like Hasegawa, really runs a separate show. I will go thorugh the details as far as the rest of our meeting was concerned: We obviously had questions in terms of their bylaws, in terms of evaluation. It is thorough but confusing. This is really what it amounts to. And what I would like to do at this poin t is to have the secondary reviewer comment. Then give our recommended levels for funding MR. HILTON: I promise to be very quick, not only out of altruism to fellow committee members but at this point ty 19 10 11 @ 12 13 14 15 16) 17 18 19 20 2] @ 22 23 24 ce ~ Federal Reporters, Inc. 25 263 the call of nature is very emphatic on my part. I appreciate the comments with regard to Pacific Basin. Some concern and some questions about that. ~ do need some direction here with regard to the yellow sheet. I see the figure of about -- is that currently available for a two-year period? That threw. me off a little bit, maybe we ought to discuss that when we talk about projects but I didn't quite know what that meant. You. find it on the -- on the very bottom, No. 2. MR. RUSSELL: The money there that is shown there, the $1.4 million, has has been awarded for the emergency medical services project. actually that is two years' worth of money. However, it has been awarded for fiscal purposes in a one year period. They will be able to use it for two years. MR. HILTON: I was concerned.about the Hawaii Community Clinic. Am I under the impression that "the ‘state and model cities will pick that up or is the ~- apparently they are going to phase :it.out and a number of other projects as well at the end of next year I believe. Are these'things being picked up for continued support or what is happening to them? DR. SCHLERIS: Well, they are very actively involved] in Waianae groups in getting all the support they can. So far the Hawaii RMP Has acted as really one of the ty 20 MN 10 1} @ 12 14| 15 16 17 18 19 20 21] 22 23 24 ce ~ Federal Reporters, Inc. 25 best friends they have had towards being accepted in respectable society as a group that could come in for funding and their acceptance now by the medical society, even though it is whole- hearted, enthusiastic one, whatever has been achieved has been through RMP. They are looking at all other sources of support and right now most of their support is from outside RMP. Remember I mentioned that some of the strengths are potential weaknesses If Waianae doesn't get support after RMP this could really react unfavorably for RMP. They appeared to be very aware of this and are doing everything they can to assure support. Do you want to comment further on that? MR. RUSSELL: Just to point out that Mr. David Pollick, the gentleman we heard from at the site visit, is a key man. Mr. Pollick: is really one of the leaders in the minorities of Hawaii. The minorities there being the Hawaiians, Puerto Ricans, Portuguese who were brought over as ~~ in the plantation days. Mr. Pollick is extremely active politically and if there is anyone in Hawaii who can shake loose state dollars which he has been effectively doing I think we can have a ring of confidence that there will be social support coming as long as IPH is there to guide Hawaiian representatives MR. HILTON: I am concerned with that. I am glad to hear there is another possibility of support. Actually, well, maybe -- will your recommendation include some kind of ty 21 10 1 © 12 13 4 15 16 17 18 19 20 21, @ 22 23 24 ce ~ Federal Reporters, Inc. 25 265 contingency? DR. SCHLERIS: Yes. MR. HILTON: Also, you are recommending a figure that is a hundred thousand dollars higher than they are requesting and I was interested in that. You are recommending 1.8 and they are requesting 1.7. DR. SCHLERIS: I will come to that. MR. HILTON: Well, that concludes mine. DR. SCHLERIS: Mr. Chairman, do you want me to comment and make our recommendations at this point? ~. Bach of you has been given a comparison and these are listed at the top part of the page in terms of Pacific: Basin, I am Sorry, the top part combines them both and the bottom is the Pacific Basin. Perhaps I can go to the Pacific Basin area first which is the last series of blocks on the page. The Pacific Basin only, the program staff now is $50,000. They requested $107,000 and we, column four, are recommending they be granted that amount. The reason is the staff now is very limited. The are to be covered is large and in terms of what we think are programs that will go, they appear to have projects in those programs which are indeed viable. They now have $142,000 for projects in the Pacific Basin. They requested $192,000. We have recommended this amount be granted and what we would a ty 22 10 1] @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce — Federal Reporters, Inc. 25 like to have in our final recommendation would be that these be specifically stated as being for the Pacific Basin. I have no doubt these funds will be utilized. As I mentioned, Dr. Izutsu operates alone in this entire area and the cost of transportation alone as you can appreciate is tremendous just going back and forth between these areas. This is one reason why many of the members of these islands don't come too often to RAG or as I said they were there for the RAG, as I said they were there at the time. This is one recommendation as far as the staff of Hawaii only <-> if these names are confusing while we were there the suggestion was made by one of their legislators and I forwarded «this note to RMPs, that a name be changed because now it is RMP Hawaii, American Samoa, Guam, Trust Territory of Pacific. It comes out as Hawaii RMP. They suggested we just call it Regional Medical Program, period. But it was pointed out this conflicted with all the other regional rpogram in the United States. They are currently being funded at $467,000 and had requested $584,000. And we didn't specifically make a recommendation as far as staff is concerned. But in terms of their total projects, they have requested, they now have 395,000, .had requested 1.092 million. | Now if you refer to the upper blocks across in terms of combining these, program staff and projects, currently ty 23 267 | $1,079,000. Requested $2,254,000, which for them would be 2 an increase of 109 percent. We recommended $1,820,000, @ 3] which in terms of what they are getting now is a 68 percent 4 incerease which reflects a high degree of confidence in their 5 change in direction and in the leadership and staff of core, 6 and in the specific projects that we reviewed. 7 - It is obvious that we are cutting out several. We 8 are not recommending developmental. We think they could handle 9 it if they only had bylaws which were accepted and if they 10 only had, I think, a few days work.going over the evaluation 1] procedures. But what we suggested instead was that they be @ 12 considered for developmental components the second year of the 13 triennium, and that there be not a formal site visit but almost 14 can be a staff site visit to assure us that they indeed have 15 evaluation procedure and bylaws. 16 I think they can handle it. I think that the 17 combination of Dr. Hasegawa and Mr. Bryan, the deputy director, 18 the staff that he has, and their ability to get involved with 19 programs that are starting, to me, is a good indication that 20 they are all moving in the right direction, and are mature 21 enough to handle it. @ 22 They try to answer every specific, oh -- in the past 23 they have had many letters back and forth indicating weaknesses. 24 They have tried to answer every one of these and they have 2~ Federal Reporters, Inc. 25 very effectively accepted the ones I have outlined. eo ty 24 10 11 @ 12 13 14 15 16 17 18 19 20 21 22 23 24 ce - Federal Reporters, Inc. 25 268 I recommend what we have here. DR. JAMES: I am not sure I understood the reference in your material relating to the inability of some members to get information "from the comptroller." Could you speak to that point? - DR. SCHLERIS: Dr. Hasegawa has always run the Hawaii Regional Medical Program very tightly. He has been the source of all information and I guess one way of doing this is to have the comptroller respond only to him. One very strong recommendation was made that the deputy director, who now has, who has taken over a great deal of the internal control but as far as the comptroller is concerned that. has concerned us, anything that goes out, you, 34 you have a deputy director he should know what is going on. Do you want to comment on that? MR. RUSSELL: Yes. I would like to point out that inthe past Dr. Hasegawa has been very reluctant to confide in any of his staff members except the comptroller. In fact for a long time it was very difficult to tell what was actually the deputy. As a result of site visit recommendations in the past, about a year ago I believe it was, Dr. Hasegawa did appoint Mr. Tunks deputy. However, up until this past site visit, after a few traumatics to Hawaii, only -- was Mr. Tunks allowed in fact to operate as a deputy. He is, as we saw it, tremendous change was being looked to as deputy ty 25 269 1 but all of the staff except the comptroller. 2 Now, I know for a fact there is a personality clash 3\| between the comptroller and the aputy . This may not, however, 4}, be the primary problem. 5 We know the withholding of fiscal information 6] policies of the RMPH not only to the comptroller but to the 7\| association. They had a great deal of difficulty -- g|| (inaudible) --:this may well be and this is condoned by Dr. 9|| Hasegawa. This may well be Dr. Hasegawa's way of controlling 101) which information he wants to go to whom and when. 1lj| However, we do plan as a result of the review process to @ 12|| hit very hard to this issue of making the deputy a real 13} deputy. 14 And we think that when the word goes back to the 15]| RAG, which now is definitely taking over control which in 16], the past belonged to the coordinator and to the Executive 17 Committee, I feel confident that the RAG will be given more 18|| direction to Dr. Hasegawa and aS a result, we will see some 19} changes. 20 Does this help? 2] DR. JAMES: Yes, the way that it was written in the @ 22|| report here, gave me some concern. If in fact no one else 23|| was sharing fiscal except the director and the comptroller, the) 24|| how could the RAG or others be apprised or know what was going ice — Federal Reporters, Inc. . , 25|| on in the development of the program? Just seemed kind of odd ty 26 10 11 @ 12 13 14 15 16 17 18 19 20 2) ® 29 23 24 wce ~ Federal Reporters, Inc. 25 270 er strange that those -~ that was a tremendous amount of responsibility for one or two people. I don't know. I didn't understand in the narrative as to who was the, monitoring the fiscal -- MR. RUSSELL: It indeed has been strange in the past I think it is on the way out. I think a year from now we may well have a case history as we did on Rochester. We are now getting down to, if you will pardon, the real gut issue which have been ferreted out and now we can deal with them from the advice of this Committee. DR. SCHMIDT: As far as fiscal sresponsibilities go there is no question about the handling of the money or anything like that. It is more a personality and power issue than it is anything having to do with counting. MR. RUSSELL: Last night I received a call from Hawaii and they wanted me to be sure and report to the Committee that their bylaws they say are finalized. They have gone through five drafts since we have been there. I asked them if they had incorporated the recent - REMPS policy on the grantee+RAG relationships and they said "Oh, yes, we have modified it substantially.” So I said, “We will have to see that. Right away." So to go on with what Dr. Schleris has been saying, they have not had an opportunity to test the review process and their bylaws. The review process by the way they tell me has ty 27 10 1 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ice ~ Federal Reporters, Inc. 25 271 been rewritten since we have been there and it is complete but here again hasn't been tested. — DR. KRALEWSKI: Two questions: One, did they call collect? The second one, as I recall the last time we reviewed this program we attempted to earmark some money for the Pacific Basin project. Did that work out? Did they use the money for that? And so your similar recommendation here you feel will be -- DR. SCHMIDT: I think it is safe to say that the coordinateor feels very greatly the responsibility, this vast territory. And I think he used to be certainly anxious to put money into it. DR. SCHLERIS: There is no question I think as far as RAG is concerned. They have a great deal of sensitivity about that area and are willing and anxious to do everything they can. They support the Pacific Basin Council. They support Dr. Izutsu. I am sure they will accept this recommendation. If any of you appear confounded by our statements about Dr. Hasegawa and his relationship to the comptroller and deputy you share that, we were there for a few days and I am sure that RMPS has shared that for many years; is that a fair statement? MR. CHAMBLISS: Doctor, I don't intend to respond to your question. I wanted to add additional information if ty 28 10 7 © 12 13 14 15 16 7 18 19 20 e 21 22 23 24 ice ~ Federal Reporters, Inc. 25 272 I may. It was out of the concerns of this Committee that the earmarking was done for'the Trust Territory. Just last week.the HSMHA raised questions as to the kinds of commitments that RMP was making into the Trust Territory and it is out of your actions that we were able to make what we considere to be a very substantive response to show that there is definite commitment from RMPS, and that things are happening with our dollars in that area. I thought you would like to know. MR. RUSSELL: In answer to Dr. Kralewski's question, yes, that earmarking was extremely effective. As the people on the Basin said we are damn tired of planning. Now RMPS is one of the first organization that has come in and funded operation in the projects and they are very, very successful. DR. SCHMIDT: Never forget the first time I met the coordinator he came in my office and I had a lot of stuff on my desk and he was trying to make a point of how big the Territory was and in describing he swept everything off my desk. Now we have a motion on the floor but no second. DR. KRALEWSKI: I will second it. DR. SCHMIDT: Are there further comments or question directed to the reviewers? Or just to me? tG UY ty 29 10 1 @ 12 13 14 Time is XxX15 6 p.m. when this 16 portion was. taken. 17 18 20 21 e 22 23 24 ce — Federal Reporters, Inc. 25] 19 273 If not, is the motion understood? DR. JAMES: I would like to make a comment. If I do understand, that this is a fairly new area for the RMPS- to engage in and because obviously it is primarily an area that will be considered minority I would certainly want to say that it is tremendous and if the man wants to keep his mouth shut about his money I don't blame him because it may be part of growing pains and it may be a good thing that the comp- troller and director share such information for any new program as valuable as this. I am sure there must be some distrust somewhere lurking, either in the Mainland or on the Islands. | DR. SCHLERIS: I will make a comment but after the vote if I may in response to that statement. DR. SCHMIDT: Anyone else? MR. RUSSELL: We have another kidney problem, Mr. Hilton. In terms of the project and the application, maybe Dr. Miller, would you like to comment on that, please? DR. MILLER: Actually there are probably two problems related to the kidney proposal with Hawaii. The first one, the main one is the fact that there is a competing hospital on the main island and that is Kuwakini Hospital. And the grant was originally set up so that St. Francis Hospital would be the primary tertiary center for the ty 30 10 1 @ 12 13 14 16 17 18 19 20 21 eo =. 23 04 ‘¢~Federa! Reporters, Inc. 25 274 islands of Hawaii. It is my understanding that there has been no resolution of the problem of competition between these two hospitals, and it would seem rather foolish to put one's money in one bag and have competition in the same area. It would defeat the purpose of the kidney idea of establishing just one tertiary center in one area to serve the population. DR. SCHMIDT: Dr. Hinman? DR. HINMAN: I attended the site visit and discussed this issue with the RAG chairman and staff there. Part of the problem revolves around the issue that one of the hospitals is predominantly oriented toward the Chinese population so there are some ethnic background issues that have to be addressed involving this problem. RAG has taken the position -- according to the verbal statement given to me -- that they will support St. Francis Hospital activity and that will be the only place they will put their money because this is where the primary | competency is. It is anticipated that the Kuwakini Hospital will either eventually begin to share with or work with the St. Francis group or it may be difficult for lack of support. “DR. SCHMIDT: Leonard, you were going to make your comment. DR. SCHLERIS: No, that was what I was going to say. ty 31 10 1 @ | 12 13 14 16 7 18 19 20 21 e 10 23 24 ice ~ Federal Reporters, Inc. 25 DR. SCHMIDT: I am not sure I should pursue this. Is there any need to pursue this further? DR. SCHLERIS: I don't believe so. Dr. Hinman who attended our sit visit as you know is charged with the responsiblity in this area and I am sure that the funds would not be expended until such time as there is a coordinated effort. It has been our assumption and our goal that there only be one program and that dupli- cation be avoided and I think Dr. Hinman will find duplication in his own way in this or his group would. DR. HINMAN: Of course the problem is that we could never tell when we were to stop providing care of any type. The only controls we have is to not fund their activity or not support them. I believe the Comprehensive Healt Planning Agency is aware of some of the problems here. There are several other things that lie somewhat behind this in the number of different ethnic groups in Hawaii that have to participate and work eogether. They have some unresolved problems here. It is a very complex thing. fT think they are working toward what is the best possible solution for the patients in the area. DR. SCHMIDT: Thank you. Any other comments or questions? DR. MILLER: One other point I wanted to make. That was in the proposal there was an item of equipment called ty 32 10 1 @ : 12 13 14 15 16 at os: O07 19 20 21 @ 22 23 24 ice ~ Federal Reporters, Inc. 25 276 a liguid scintillation spectrometcr which deals with testing compatible kidneys. You mostly really in retrospect and mostly really dealing with related donor population. The proposal does suggest that they purchase this machine which I assume from reading this, they don't state it but it is about another $15,000, in the actual monies, and according to the technical reviewers of the project, two of the technical reviewers felt that this item of equipment was not necessary. The RAG, itself, did not address itself to this problem and I think that something should be mentioned about this. Again I am going to refer to Dr. Hinman on this who represented the renal group:as well as the staff. | Do you want to comment? MR. RUSSELL: What we need here, I don't think the lack of a Regional Advisory Group, not to consider this, I don't think it was deliberate... I just don't think it was clear to them that they were supposed to decide between the two. I am serious. You have to have been out there to understd it. DR. SCHMIDT: Strikes me as being a rather technical decision and I am not sure it is one the advisory group should make. MR. RUSSELL: Well, they have the recommendations of what it boils down to, three people. Tow of them say no, one of them say yes. I think what we at staff need is say bhi ty 33 ce ~ Federal Reporters, } 10 i 12 13 14 15 17 18 20} 21 22 23 24 inc. 25 16] 277 will you make that decision for them since they failed to do it or will you delegate this responsibility to Dr. Hinman's staff? DR. SCHMIDT: Once again concern is registered and you are aware of this. I thank you. | Other comments or questions? If not, we will call the question. DR. KRALEWSKI: Just quickly, are we voting on some money for that kidney project now then, or are we not? DR. SCHMIDT: Yes, it includes the kidney project. DR. SCHLERIS: I think it should be a matter of record that Dr. Hinman's group will have the final word on that. We have not looked to them in detail. We have always looked to the renal.group. | DR. HESS: Does it meet that criteria of the region having developed a regional plan when there is another hospital developing activities? DR. HINMAN: The region has a plan and the plan is to support the St. Francis Hospital activity. | DR. HESS: For that activity? DR. HINMAN: Yes, sir. DR. SCHMIDT: I don't think Dave can be faulted because there may be a dissenting group that wants to go on their own. That would be asking I think too much. DR. HINMAN: I think the same phone call last night ty 34 10 " ©} 12 13 14 15 16 17 18 19 20 21 e 2 23 24 ce—Federal Reporters, Inc. 25 278 Mr. Russell received there was another approach that they are trying to work out in that area which may involve that actually some of the surgery is done at Kuwakini Hospital by a team at St. Francis which is a possible solution which would get aound some of the considerations’ so they are actively working on the issue. I think that it is complex enough looking at the entire history of Hawaii and the socioeconomic conditions that I think for us to recommend anything more stringent than what we have already done would be a little unfair to the region. DR. JAMES: Right, I agree. Would that not constitute an internal affair of the region which possibly would not be, well, could be resolved at that level? DR. HINMAN: That is what we have asked them to do. DR. SCHMIDT: Questions? If no one wishes the floor, that is really not in order. We can vote. We can't call the question. That is really not a legal parliamentary procedure. We will call the question then. All in favor, please say aye. Opposed, no? Once again I hear no dissent. Leonard? ty 35 10 in @ 12 13 14] 15 16 17 18 19 20 21 @ 22 | 23 24 cb ~ Federal Reporters, Inc. 25 -o¢ And if you break up all the groups there all minorities, you the tremendous limitations. He is a tremendous asset to the ‘region provider to the presentation by the Committee member. 279 DR. SCHLERIS: The comment I wanted to make was that the whites on Hawaii are.39 percent, nonwhites are 61 percent. know, no one has the total majority there. So it is hard to define minorities. Dr. Hasegawa represents a different issue in a way because he was one of the unfortunate Japanese who lived in apparently California at the time of Pearl Harbor, was one of those who was confined in a concentration camp at the time. And a great deal I am sure of*-- of his reactions and operations are rightfully based on that experience and I. assume that part of the problems might relate to that experiences | “Hadn't brought that up before but I think it is pertinent in his being coordinated. He has not only been accepted but has done an exemplary job as coordinator, despite regional. organization of Hawaii. DR. SCHMIDT: Before we break up, I would remind the Committee of several things. First, now we have had the Rochester presentation by Eileen this morning, then we had the presentation by John with the aid of some visuals and in th last presentation we had a short overview by Dick of the Now these are all variations on the theme. There wi be one more in the morning after which we will stop and discuss ty 36 16 17 18 End. #17 19 @ 22 23 24 de ~ Federal Reporters, Inc. 25 20" 21 280 for 15 or 20 minutes various forns of presentation and see thether the visuals which are included in your review book by the way are helpful in this sort of setting the region in place, and is valuable enough to continue. I would remind you the document is Chapter 4 that we would like you to look over tonight. We will discuss it a little more. The function of the Review Committee, it is your reading assignment and we will have an oral quiz‘on this at 8:30 in the morning when we start. | Your rating sheets you may keep but they should be kept more or less confidential. Do you want to pick these up today? . All right, keep them but put them away and continue to use the same sheet then tomorrow. With thanks to the group for their good work today, we will adjourn and reconvene at 8:30 in the morning. (Whereupon, at 6:10 p.m., the meeting was adjourned, to reconvene at 8:30 a.m., Friday, 22 September 1972.)