‘NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS THIRTY-SECOND MEETING CLOSED SESS ION - ATTENDANCE: - Dr. Herbert B. Pahl, Chairman Mr. Edwin C. Hiroto « Mrs. Audrey M. Mars / Dr. John P. Merrill ’ Mrs. Mariel S. Morgan! Mr. C. Robert Ogden ; Conference Room G Parklawn Building Rockville, Maryland Tuesday, February 12, 1974 2:25 o'clock p.m. Pacite Pees = pl? PROCEEDINGS CHAIRMAN PAHL: If we may come to order again. Would someone please close the door again so that we don't @ have too much noise from the hall. Thank you. Judy, will you please just go ahead and introduce the sequence that you believe best for the afternoon session. MRS. SILSBEE: The council may recall that there were three council site visits that were scheduled after the last council meeting--to Puerto Rico, Intermountain, and on ET rar ee EP STEEP SR MR ERMINE Hawaii. In addition, there was a consultation visit that was recommended for Arizona. So, the action today in this aCe ADIT ATES AR IENAS executive session will revolve primarily around the three @ rn : site visit reports, because in each of those cases council ROTI — SCRE EERE NAINA onanism had recommended action with regard to the applications that were considered in November that required some information gathering by the site visit team and report back to the council before the recommendations could be changed. I think the order today should be Puerto Rico, Intermountain, and Hawaii. The staff involved in the Puerto Rico visit, Mr. George Hinkle, who is the operations officer, Mr. Frank © Nash. The council members were Dr. Merrill and Mrs. Morgan. Dr. Merrill, would you lead off on the discussion, please. HOOVER REPORTING CO.,INC. 320 Massachusetts Avenue, N.E. Wachinatan AM INN? i 3 DR. MERRILL: Yes, I think perhaps it's appropriate that I do present this report, although it was written largely by Dr. Thurman but gone over by all of us. And it © was appropriate because I was the prime reviewer of the Puerto Rican proposal and thought it was very, very poor indeed. And I'm happy to be able to tell you that I and all of my colleagues have certainly modified that opinion. The people who were involved in the visit were Dr. Thurman, who is the Dean of Tulane, Mrs. Morgan and myself, as you know, and Mrs. Maria Flood, who is Program Coordinator for Texas Tech, and she was particularly important because she was born in Mexico and speaks fluent Spanish and this, as we'll hear, is important. We met with all of the people of the program staff, most of the people in the regional advisory group, and a number of others who had been on the staff in the past and are now listed as consultants for obvious reasons. I won't read this report in detail, but I will simply leave you to read it and to give you some vignettes about it and our conclusion. | The grantee organization is the Medical Sciences Campus of the University of Puerto Rico, and we were fortunate @ in having a good deal of the chancellor's time; the chancellor is in essence the dean of the medical school. We met with both the present coordinator and the past coordinator who - HOOVER REPORTING CO, INC. “390 Massachusetts Avenue, NE. | Wachinatan 1 9nane ! 4 ‘now functions as associate coordinator on a fifty percent time allotment, and still, as we found out, had maintained an extremely vivid interest in the program. The problems that they had were of course with staff, which was practically non-existent because of funding difficulties over the past year. The coordinator, the associate coordinator, and the executive officer for the RAG and the administrator, were the only senior personnel present being employed by the program. By the same token, we talked. with a good many of. “the former staff who are. working in ‘other: departments of the university and came back and who had obviously maintained contact and interest with the staff and who were very frank to say that if funds were available for any foreseen period of time, they would be glad to come back. They obviously had been a tremendous help to what staff remained ina consulting capacity, and I would guess that not all of their time as consitltants was paid for. The relationship, as I've mentioned, of the RMP to the Medical Sciences Campus, secondly to the Department of Health, and thirdly with the private sector--and we examined each of these relationships quite carefully; the relationship with the Department of Health and the university seemed obviously to be excellent. There was some question about the relationship with 5 private sector. And although we did talk in detail with one member of the private sector, he perhaps had a little ax to grind. He was very favorably impressed with what RMP had © done. But then he was involved in a new program which he had instituted and which he hoped would be funded. So, Dr. Thurman, who had spent some time in Puerto Rice, spent a lot of time contacting approximately ten other individuals in the private sector, and he informed us that almost without exception they were satiisfied that the programs of RMP had been to the best advantage of the private sector as well as the other sectors of health care delivery. e We talked also with the regional advisory group, and there had been some criticism raised by the fact that the regional advisory group perhaps did not have enough consumer representation. I think all of us came away from this convinced that this was not the case. We talked with a number of people, particularly a Senor Alfredo Rivera, who was head of the Poor Peoples Council and who was a member of the RAG who gave a very exciting, I think, exposition of what it means to be a consumer representative on a Spanish- speaking organization in Puerto Rico. And one of the ladies ©@ who was a housewife gave almost as impressive a discussion. In essence, both of these people, although poorly educated, were eloquent. They were excited about what RMP had HOOVER REPORTING CO, INC. 320: Massachusetts Avenue, NE. Washinstan HC 2000? ! done and what they hoped it would do in the future. And certainly they represented a typical cross-section of the Puerto Rican community, which may be perhaps a little 6 different than communities in Virginia or Oregon. There are a number of other things that were impressive and which did not appear on this grant total. I think here it ought to be pointed out that there is a language difficulty. There is a communications problem, and I think most of us came away from the site visit feeling that in essence this was why the proposal was not favorably received. As an example, the regional advisory group met in February and spent the first part of their meeting discussing the phasing out of RMP. Then then went ahead and reviewed in detail all of the grant proposals which had been submitted to that meeting and their reviews and criticisms were detailed and certainly most true. And I think all of us felt that was extremely impressive. The second thing, I think, thit illustrates the problem of communication was the fact that we felt--or at least I felt--when we first saw their proposal that they hadn't documented any of the things that they had done. And @ that was due to two things. One, they took very literally the instructions that these proposals be very brief indeed. And so they were really totally inadequate. And finally after HOOVER REPORTING CO. INC. 32G Massachusetts Avenue, NE. Mn btw NY -ANnAny | some pressing--and again I think it was a communcations problem--about one of their projects,they pulled out a document which I have here, which documents their past performance and in great detail a very good planning proposal for medical and allied health manpower needs for Puerto Rico to the year 1985. This didn't appear in anything any of us had seen before, but obviously they had given it a lot of thought and. it's an extremely good proposal, as is some of the documenta- tion of some of the things that’ they have done. In addition to this, they have a series of documents written in Spanish which are calculated in a very simple, straight-forward clear way to give individuals the idea of the technique of how to apply for a grant, what the. needs are, what the requirements are, and in essence we found a wealth of documents and information which was totally unavailak to us here and which I thik was very impressive to all of us. There were some weaknesses. Some of the recommenda~ tions for administrative change had not been carried out. We were sure that that was in part due to staff problems and that some had been carried out and others were certainly in the process of being carried out to make sure this would happen. The site visit was unanimous in. its ,opinions that We ia maha ress this ‘program had accomplished a significant amount and is Ate ere tO sae Wo GARR etapa 23 RS tad ¥ deserving of continuing funding. dale ble 8 It is obvious the program has accomplished more than is appreciated at all levels, and it is apparent that they have made a role for themselves in health delivery now © in Puerto Rico. And, therefore, unanimously the site visit Dies teeny team recommended full approval of the amounts recommended , Slgagapenns OSeRn ae Ny ae at eee and you can read these amounts for yourselves om page 12 of the application. This document was sent to all of us by Dr. Thurman as a rough draft. Me all made changes we thought were necessary, additions and deletions, and this represents the final product, which I and Mrs. Morgan have read and which has my wholehearted approval. MRS. SILSBEE: Mrs. Morgan, would you want to add to Dr. Merrill's report? MRS. MORGAN: I agree with Dr. Merrill very much. I think it is probably one of the most impressive site visits I have ever made. Was most impressed with the people's feelings. Here was a group of people that they could discuss medical care with at ease and felt that they really were well represented in discussing this with them. The only question we had, and I think this now, as of today has been done away with, we felt two of their @ projects they would not be able to carry out if everything had to be finished by June 30th, and this was eighteen and nineteen, the two projects would require additional time. But SH ey Sr seg ata SD aves HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NLE. Ulaabinatan PP IANS | 9 it looks like we now have additional time, so I go along — BR i at une wipe aaa ATEN with Dr. Merrill | in 1 recommending the full amount. Baye BS Fa EE ae ER oe ogi yl aRGE seen eons? Fenris oeoee pervs 0 iB a ANG ec ero nepare eens MRS. MARS: As I remember, we felt that some of © their projects really should be controlled or be under state health department supervision rather than being projects of RMP. I think that was one of the criticisms. DR. MERRILL: I think their relationship with the health department is a very good one, and they have made provisions for phasing out some of these things. In fact, one of them was already taken over by the state health department. MRS. MARS: That was part of the council's criticism, they really weren't RMP projects. They were projects which should be under the health department, so to speak, and developed by them rather than being RMP projects. You feel that has been corrected, in other.words? DR. MERRILL: Yes. I was impressed with the number of projects which have been taken over by the health department already. MR. NASH: Two of these that were in this application ought to be taken over by the health department in June. The health department has a little problem in that e their budget is made up and planned a year or two in advance, and it was the original plan that these projects would be taken over by the health department in June. When we sent HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. iMashinntan NP OMANI | 10 them the phase-out notice, it was a little bit impossible for the health department to readjust their budget and pick them up in January. And that's why they appeared in this request. | MRS. MARS: Yes, but with their projects they are |} presenting now for funding, are these still health department projects? This is the thing. Why should we pay for a health department project? | MR. NASH: I don't believe the site visit team felt that the proposals they are seeking funding for beyond June would be inappropriate for RMP funding. | MR. HINKLE: Mrs. Mars, when I was down there recently with Mr. Nash, I brought up the question--because you had asked it at the last council meeting--and the ‘coordinator and the chancellor both in different discussions brought out the fact that the state department provides about two-thirds of the health services; about 80 percent of the people down there are indigent. Through their present health system, the state health department has responsibility of providing health care. They said due to, the scarcity of funds, they do not have sufficient funds to go into these new innovative untried areas for health care delivery. That's the reason they look to RMP to help them come out with these funds to provide these innovations as long as. they're beyond the trial status, the feasibility status. Until they A ll have been proven, then they are committed to take them over. And that's the reason for their good record in having projects picked up by the government. It's sort of © cooperative effort. between the two. MRS. MARS: Say RMP does go on under any form, whatever it may be, do they really have prospects of developing something, projects and programming that will | take care of the health needs of the people? DR. MERRILL: I think we are all impressed with the strength of the organization, which was not at all visible in here. The associate director, who used to be the director, is really one of the most vigorous, eloquent e young men that we met. He's extremely knowledgeable. And in spite of the fact that he is now working half time in another department retains a great loyalty and interest in. RMP today. He certainly would be available. MRS. MARS: What is their full-time staff? What does it consist of? Very few, isn't it? DR.MERRILL: Yes. MRS. MORGAN: At the present time. DR. MERRILL: At the present time--let's see-- MR. HINKLE: As I recall it had about 11 full-time e staff, but only three of those were professionals. Some of them are keypunch people or doing data processing. They have two new ones which they brought on board to help in their HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NLE. lcakinetna Df OND | 12 evaluation of old projects. They have their driver, their secretarial help. MRS. MARS: Are they all native born Puerto Ricans © or are they people who come from the States? DR. MERRILL: I think with one exception. MR. HINKLE: The regional advisor's liaison officer is from the Pittsburg area. She has been down in Puerto Ricco about seven years, and she was associated with the RMP up in the Pittsburgh area also. She is, we think, going to be a big help in their communication problem where Spanish-English has been a problem. MRS. MARS: That is why I asked, because of your talking about the difficulties of communication because of language problems. MRS. SILSBEE: I think, Mrs. Mars, from having talked with both the staff and Mrs. Morgan at lunch, that the communications problems were primarily between us here in Rockville and our inability to translate what we were saying into terms that they could understand, and that their tendency, on the other hand, to take our words literally and not provide the background that we needed to understand. MRS. MORGAN: I think they are excellent people e who are very willing to come aboard RMP and begin working if there is a program going on. Because of the extreme difficulty for these people HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wischineaian BC. AND | 13 obtaining jobs in the Puerto Rico island, that the minute they were afraid this was being phased out, the coordinator found these people jobs within the university so that he could keep them attached to him, shall we say. But where they did have a way of supporting their families. Because for many of these people, it was their sole support, the jobs they had. But if there is a continuation of the program, these people-- certainly in talking to them, RMP was still at their best interest, even though they may be in, another position at this time. . MR. CHAMBLISS: Just to build on what Mrs. Morgan has said, counsel should know that this was one of the truly distressed RMP 's at the time of the phase-out. You will recall that they literally were being carried by the university until that increment of money was put there to support staff right at the beginning of .the phase-out. MRS. SILSBEE: Mrs. Morgan? MRS . MORGAN : I move that we fund Puerto Rico the sete tai tl a PHAN See ord full amount, as was requested, in he original Proposal. eae RM oO i ai PRT ingest“ sehen ee MRS. SILSBEE: In the “application that was received in November? MRS. MORGAN: November. MR. OGDEN: I'll second that motion. ae NAP hte is ua A lo ARE CRD EN ek MRS. SILSBEE: Any discussion? All in favor? [Response] 14 Opposed? [No response] The next visit that was made was to Intermountain. And not only was the language problem different, but the © geography and the money situation, I think. Miss Mary Murphy and Mr. Mike Posta accompanied Mrs. Mars on that site visit. MRS. MARS: I had on the team which I chaired Mrs. Flood again, who went to Puerto Rico with you, Dr. Merrill. And Dr. Girard Craft, who is director of the Albany Regional Medical Program. And Dr. Mitchell Spellman, who was a former review committee member and is currently Dean of the Charles R. Drew Postgraduate Medical School in Los Angeles. And then we also had Dr. Ossorio, who is the Acting Regional Health Administrator, sitting in. And Daniel Webster, who is the Public Health Advisor. As you may recall, probably do recall, the concerns that we expressed at the last meeting of our council which caused us to withhold $270,000 until after such a site visit could be made were the need for increased minorities on program and project staff, the large allotment of funds to the planning area option, the need to sponsor projects through outside health agencies, the re-establishment of an active @ inter-regional council to review all activities to be conducted in the overlap areas with written approval to RMP‘s, and the concern regarding the extension of the HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washinetan 1. OANA | 15 poison control project to Boise, Idaho, the question as to who should be funding the health information assistance program to regional legislatures, and the need for further © extension of project activity to rural areas, also the need to clarify for RMPS the mode of operation, program staff, project staff, and the need to include salaries in all applications forwarded to the RMPS review. The first thing that I shall deal with is the restricted funds. We viewed these particular programs, P-1, Q-1l, E-l1, and K-1, that as really to be part of the normal function of program staff and not to be dealt with as e specific projects. We couldn't understand the necessity of requesting funding for these in that category, since they administered individual or clusters of other funded projects. However, we quickly found out that due to the fact that IRMP has a very new coordinator and also other new professional staff, really an error was made in the way these were budgeted. These activities should have gone into wogram staff and should not have been termed projects. This was a grave error. The figures that they presented on their applica- e tion concerning these programs are literally salaries and as such should bring up the total budget for program staff up to $415,000. HOOVER REPORTING CO. (NC. 320 Massachusetts Avenue, N.E. jaa ie beaten AD ANAS | 16 There was also, you probably will recall, the question of the K-1l program, regional program coordination for kidney disease, as to whether or not it complies with the Social Security Administration, DHEW Regulation No. 5, and this was affirmed as being in compliance. As to the activities being conducted in the overlap areas, we had come before our team a Dr. Thomas Nicholas, who is director of the Colorado-Wyoming program, and has just retired as chairman. of the interregional council. He was very communicative and very frank in saying that naturally the way. the area, region, is set up, there are always going to be turf problems. There is no way to avoid them. 'But he did feel that they are being handled by the council as diplomatically and as reasonable under these very difficult circumstances as could be. You have three RMP's involved. You have five states involved. And naturally there is bound to be some friction. However, the programs are being coordinated and there is an overlap of duplication being avoided. Actually this was stated in writing for our benefit. The Interregional Council is active again, and they have been meeting and they have been solving their problems. Dr. Studt, who is now the coordinator of the IRMP 17 will be the next chairman; since it is done on a rotation basis, he will be the current and next chairman of the Interregional Council. © One of the other projects that the council questioned at the last meeting was the poison control center project No. 62. And Dr. Anthony Temple who heads this came before the team. We were very, very impressed with what this program is accomplishing. It's really quite fantastic. Dr. Gerdes of Mountain States,with whom we were concerned as to whether or not he was objecting or felt this was overlapping, is in full agreement, and all the areas feel the real importance and the necessity of this poison control program. I brought back some literature on it which I thought maybe some of the members of the council might like to look at at some point. It has had a considerable impact on lowering health consumer costs, and I know this was one of the things on the site visit previous to this last one that I made when we questioned very much as to whether or not the projects were doing anything towards moderating health costs. And this certainly is an outstanding example. In fact, all the members of the team felt that this was a program that @ the RMPS could look into carefully and perhaps develop elsewhere. It's quite a unique program and the only one in the entire area, except if you go way down into California. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. 2. AA ANAKAS 18 And it's just fantastic what it does. Then regarding the grantee IRMP relationship, this is on a very happy, cooperative footing right now, and I @ think that there benefits being deruved from both sides. We asked again for a letter of assurance from Dr. Dixon, who has the full responsibility for the grantee relationship and the IRMP, and he wrote me a very nice letter. I think there had already been a letter written, but he wrote me another one, and I'll read it to you. "J wish to express my appreciation to you and your team members for the service rendered the IRMP during the recent site visit to Salt Lake City. I have been informed regarding your summary of the visit, and feel that it served a most positive and helpful end. You requested that I provide a statement regarding the grantee IRMP relationship question, which was of concern in the site visit. I am pleased to report to you that all issues have been resolved and that a spirit of complete cooperation between the grantee and the IRMP exists. "As you know, I have direct responsibility as a grantee's representative to the regional medical program by virtue of my position as vice president for health sciences. Yd] In this capacity and also as a member of the regional advisory group, I share your concern in the need for IRMP to devote increasing amounts of its resouces to support HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Yabba AO AANA j 19 health care for the rural communities of the area. "I also want to again affirm the cooperation of President Gardner and his concern for achievement for the IRMP goals for improving health services not only in Utah but for citizens throughout the Intermountain area." So, I think we can rest assured that there are no longer any real problems existing between the grantee organization and the IRMP. And previously certainly this was a great detriment and held back the program considerably. The university has undergone a complete reorganization in its medical department and it has a new president, and it is addressing itself now to the needs of the IRMP. Actually Dr. Dixon was most cooperative, and appeared before us not once but came back a second time. Really it was very difficult for him to do so, because the legislature was meeting in Salt Lake City and he had to appear before them. But he is so enthusiastic about the program and what they are doing, that he really deemed it of great importance to take time away appearing before the legislature to appear before our site visit team. So, I think giving such time certainly can give one assurance that there must be real cooperation between the grantee and the IRMP. It's a very peculiar situation. anyway. when you realize that the university is the only medical center for this large area which is some 800 miles long and 400 miles wide. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Wachinetan NC 200? i 20 So that you can understand too why the university has to sponsor so many of these programs, which has been one of our criticisms, that perhaps there were too many programs originating in the universtiy and under their sponsorship. But I think this is a very important point. The medical department under this reorganization is truly now reaching out into the rural areas. And with the cooperation of the RMP and the university support, I think both are beginning to make a real impact into the periphery of the region. As a team, we strongly recommended that RMP, if it dees continue, should, however, have more appropriate community agencies involved in the development of new operational activities which should be independently based and sponsored by them, particularly outside of Salt Lake City. Naturally everything tends to originate from Salt Lake City and concentrate around Salt Lake City, which again as I say is very understandable. However, they are anticipating setting up sub- regional RMP's, so to speak, and under the direction of Salt Lake City, and it's rather interesting that the man who has been the deputy director, Mr. Anderson, is moving to an area called St. George, which is very much in the desert and very much on the periphery. It's down on the southwest end HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. WWhashinetan OC FINAN? | 21 of Utah. And since we were there, he had intended to completely disassociate himself with IRMP. But now he is going to, along with other things, do a part-time organization of a sub-regional group down there for the IRMP. Another serious concern of the council was the very limited number of minority ethnic representation and women, both in RAG and on professional staff. The minorities actually in the area constitute four and three-tenths percent of the population of the region. The American Indian is the largest of that minority, being two and one- tenth percent. The thing is, however, there are thousands of Mexican-American immigrant workers there who pour into Utah for the cultivation, and it is certainly very vital that their health needs be considered as well as those of the permanent black, Indian, and Chicano population. There has been a very defensive attitude on the part of the IRMP concerning the lack of minority representa- tion. But we were public and I was personally assured that the omissions would be remedied as quickly as possible. We were very impressed with Mr. Knapp, the new RAG chairman, who has strong leadership capabilities. He accepts his resplnsibility very conscientiously, and he assured us, as did Dr. Studt, that he would make a strenuous 22 effort to remedy the sad lack of minority representation. We were also disturbed by the fact that there were no representitives on the RAG of the major voluntary health organizations. And also an adequate number of individuals who could be termed purely consumers. That's one of the reasons I was curious this morning. I asked what really is the definition of a consumer, because one of the individuals who came before us as a-consumer and insisted she was a consumer happened to be one of the leading pharmacists of Salt Lake City. She insisted she was not a health provider, she Was a consumer. So, where do you draw the line, so to speak? But we did feel that there were not enough consumers, and it is rather shocking that the major voluntary health organizations were not represented at all, such as Cancer or Heart. So, this I believe is going to be remedied, and they said there were a number of people who really could be moved off of RAG and who would be resigning so that these people could be inserted. As to the relationship between the CHP "A" and uBe agencies, this is a very strong and constructive tie, an unusual one, I would say, from what I've seen of other RMP's that I have site visited at various times. The four representatives who appeared before us 23 conveyed the impression that RMP jhas been of invaluable assistance in the furtherance of their program, and they simply just praised the IRMP's to the skies. I have never © heard such marvelous, complimentary things said about each other. It was just almost unbelievable. But apparently very t rue. Then as to this salary thing that we asked for, this is why they did not attach any salary, as you may recall. Actually apparently it was attached, and I'm affraid staff did not give it to us; is that correct? MR. POSTA: Right. It was included in the original application but not the other things. MRS. MARS: And so this we cannot blame them for. They certainly made no effort to hide them, and they quickly got out the list and presented it to us, and they could not understand why the council hadn't had them. The salaries are certainly in line and, if anything, they are very much on the low side. Dr. Dixon at the moment is negotiating with the university to try and get a telease so that salaries can be raised and not necessarily kept within a very low salaried rate which the university has as a limit. e Then we discussed the subject of continued project support upon the termination of the RMP funding. And while this certainly does not always appear in the HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. | iMachinatan Tif 9NNN? ! 24 written presentation of the projects, we were assured that the outside sources will more or less be forthcoming for continued support to the majority of the projects that they © have going. The strength and the obvious impact of the program on the region, plus the exceptionally high calibre and capability of staff really in the end far outweighed any criticisms that we had. So, I really recommend that we move for the release of all of the IRMP's funds immediately in order to let them get on with their work. If there are any questions, I'll be glad to answer them. e MR. ODGEN: Since I'm the one who raised the turf yoblem, I'm glad to know that this poison control program is something that Dr. Gerdes has approved. MRS. MARS: He is so anxious to have it continued. MR. OGDEN: I had a call from Dr. Sparkman, who is the chairman of the coordinators group, who said to me that the only comment that he had about Intermountain was that he thought that there still was a turf problem. There was an agreement worked out pretty carefully about a year ago among the coordinators out there. And Dr. Studt has now come into ® the picture as the new director, not having been a party to that original agreement and they're having a little difficulty in getting him to accept the fact that it's there. But I HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Wachinetan MC OAAAD | 25 rhink perhaps your visit has reinforced his need to recognize that he has to work with other members of that tri-council group. And as long as he'll do that, I can't © see that there is any problem. MRS. MARS: And Dr. Nicholas said very frankly, as I stated, that there always will be turf problems. But there is no reason they-- MR. OGDEN: As long as they can work them out. MRS. MARS: Certainly. There is no reason they can't be worked out, and so far there is some clause in that agreement that they can appeal to--what is that clause-- if they can't work it out in council-- MR. POSTA: They do have an appeal mechanism. MRS. MARS: They have an appeal mechanism, but so far they haven't had to use it. MR. POSTA: I think another dimension, from probably about a year or a year and a half ago, when you discussed the turf problem and the particular resolution that was drawn up there, we found at that time that the three coordinators and the three RAG chairmen met together periodically to discuss the intent to develop a particular program where it would be developed and which RMP would be @ responsible for drawing up the further refined projects. Upon visiting the region, this time we felt that that's part of it. The second part is also of the HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Bhabinadan AP ONAN i 26 responsibility of this interagency council, and that is once a project is refined after a particular RMP and goes to the technical review committee in that particular RMP, one of © the three, it would then again come back simultaneously to the interregional council for their endorsement to see that the original idea hadn't been twisted. I think that's a little bit more of a dimension to the whole problem. MR. OGDEN: Then there is an organized structure for handling this. MRS. MARS: Oh, yes. Oh, yes, very much so. MRS. SILSBEE: Mrs. Mars, Would it be your guess that if Dr. Studt is the one that's learning about this process and is now the chairman, that this would make him feel more responsible for it? MRS. MARS: Oh, yes, very much SO. I think it is just probably his newness, that he just didn't realize how serious the problem could be. I think that is part of it. He has never done this sort of thing before. I think--what was he, a neurologist? MRS. MURPHY: He is an orthopedist. MRS. MARS: Orthopedist, that's it, an orthopedist. And while he had served on RAG and so on and so forth, he e had never really been conscious, you see, of these problems, . because the RAG two years ago was not a very good RAG, and there was very little cooperation between--literally very HOCVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Wlaehinetan AP 90NND | 27 little communication between--RAG and the staff. This is what was so extraordinary. And now I think they've got a good RAG, and I think that Dr. Studt now is becoming very conscious of the problems, and he's got a lot to learn, but he is trying very hard, and he certainly is giving whole- hearted effort and gets A for that if nothing else. Since we were out there, the RAG has met, and they are going to submit a rebudgeting, but they did hold it up until after we met, so that they could see whether they were going to get the money or not. So, the RAG meeting waa held and it was agreed to postpone actions on the projects in the surplus funds application until we met. MRS. SILSBEE: By surplus funds, you mean the... ones that we had withheld? MRS. MARS: That's right, yes. There was $139,000 that was surplus. It was carriéd over from their last budget. MR. CHAMBLISS: I think I should provide the council With just a bit more input along the line of the issue raised by Mr. Ogden, in that I was at the western coordinators meeting in Denver just.a few weeks ago, and there was a persistent problem in the minds of the western coordinators that you touched on, about this turf issue. There is some concern,. and“I was asked to bring this to the attention of the | ‘council to simply draw their attention to the question that HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Uhaakineian TP INN? | 28 there are still problems in the overlapping areas, and this was brought to me both officially and on a personal basis, that Intermountain still has problems in the surrounding territories of other regions and at least council should begin to think about it in futuro, about constricting the region to its natural geographical boundaries. I don't add ;that to get council off of its discussion on the merits of the matter before it, but at least I did commit myself to western coordinators to make this presentation. MRS. MARS: I think so much of this is influenced, as I repeat, the fact that there is not any other medical center. What happens to these areas if they do go--if you just confine here to say the state of Utah, all the rest of this big area is left, you see, out entirely, with no connection whatsoever to a medical center. fae st t Ag fe ': Being familiar with the area, being MRS. from the area, I think one thing that council needs to be advised about’ is that so much of the hospital care and even the medical care throughout Utah, Idaho, Wyoming, Nevada, is carried on by a church group of hospitals which are throughout all of these states. MRS. MARS: I didn't want to get into the religious angle. Mel Gan MRS. MURBHY It is, I think, a big reason why it HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wachinotan Al IANA? | 29 dees pull into these other states, is the fact that they are operated out of a church group of hospitals. MRS. MARS: Mormons do it all. MRS, raekesaty « Another reason reason why you don't have very many women. MRS. MARS: That's right. Is I say, I carefully-- you brought it out--but I carefully avoided it. MR. OGDEN: There are some things we can change and some things we may have to live with. DR. MERRILL: How big an item of the budget. is it approximately? MR..POSTA: Actually it's two small projects, 67 and 53, both of which were ten thousand each. MRS. MARS: Direct costs were eight thousand, one hundred; and the other one was nine thousand, two hundred and sixty-one. It's a very small amount. MRS. SILSBEE: Mr. Posta? MR. POSTA: I would like to mention just one specific thing. If you look at your red book at tab H, if you recall, one of the big questions about this region for several years is the fact they seem to keep their money close to the university. And the site visit team went into quite a bit of detail to find out just how much money are we talking about or grants, if you will, or contracts, if you will, that had been contracted out of the university. Look 30 through the sums. I hope you can read the last sheet in that group. We did earmark about $817,540 both from last year and this year's award, which was about 25 different activities that had been funded outside of the university. That counts grants, contracts, subcontracts, and what have you. Four of those 25 were in the university. The other 21 were outside of the university. And two of those at the university had terminated. You'll note from looking at the dates of these that quite a bit of this particular earmarking of funds came from last year's budget; and because of the restriction on this particular year's award, they have not entered into any contracts, to our knowledge. MRS, SILSBEE: Do I hear a motion? MRS. MARS: I made the motion. MRS. MORGAN: I second it. MRS. SILSBEE: Any further discussion? MBs. MURPHY: I'd just like to make comment, if I may, and it is in regard to minorities, and I'll just read a paragraph from my report. "An action on the part of IRMP following the site visit is worthy of mention. On January 21st, which was the Monday following that site visit, a Mr. Alvin June, a Navajo Indian from Tucson, Arizona, applied lin person to the IRMP for a position." They don't seem to know who sent him, but he appeared. "Mr. June is a 31 vocational rehab specialist with a Master's Degree in social work. The IRMP employed him immediately, and I have since been informed that he has been a very noteworthy asset.’ © {Laughter} MRS. SILSBEE: The motion has been made and seconded that the restrictions on the funds approved for the IRMP at the last council meeting be removed on the basis of the sit e visitors’ recommendation and report. I: wonder of council would mind if I would add something else in terms of the feedback to the region, and that would be to mention how important you felt this interregional coordination and council was and that you were e pleased that there was action taken and Dr. Studt was now the chairman and you would be following it with a great deal of interest. MRS. MARS: Very good. MRS. SILSBEE: All in favor? [Response] Opposed? [No response] Let's take a five-minute break before we go on to the Hawaii. MR. OGDEN: If you have no objection, Mr. Hiroto and I have a cab to catch at 3:45, which doesn't leave us @ very much time. MRS. SILSBEE: Okay, let's not take a break. There won't be a break. We are going on with the Hawaii report. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wachinatan NM OANND | 32 MR. OGDEN: At the advisory council meeting on November 26-27, the council restricted the expenditure of certain of the funds of this program until a council survey © team had visited the program and could report back to you. The concerns that we had out there I'll go into just ina moment. There $375,901 dollars available for expenditure for the program in Hawaii. $145,249 of it has been restricted by council. Dick Russel just put some figures up here on the board. And $58,665 budgeted for the Waianae Coast comprehensive health center project could not be awarded--we agreed would not be awarded until RMPS had received written assurance that the RAG clearly understood the problems encountered by the Waianae board and assured appropriate use of the funds. There was an additional restriction that was made across the board for the fiscal year '73 monies. And I might say here also that the Pacific Basin portion of the program was not a part of our concern. I might remind you all that the Hawaii Regional Medical Program includes not only Hawaii, American Samoa, Guam, and the Trust Territory of the Pacific Islands. @ The major problem in Hawaii has been the coordinator of the program. This problem has been there for some time. Dr. Hasegawa has been the coordinator since the program HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Wachinefan Af PANN? 33 started. He was unpaid until about two years ago. He has been doing this as a part-time activity. He is a full-time pediatrician. He has been doing this as a part-time ictivity running it nights and weekends ‘and occasionally in the office. We have all had for some period of time concerns that the Management of the program was weak and it was lacking in leadership. The survey team that went out included myself, Ed Hiroto, who is of the same background as Dr. Hasegawa; and Ed has been out there before on site visits; ‘Dr. Hirschboeck, the former coordinator of the Wisconsin program who is now at St. Mary's Hospital in Milwaukee as Director of Medical Services; and Bob Fernandez, a psychiatrist -who is on the staff of Region 9 in San Francisco. And, of course, Dick went out as the Western Operations Branch chief. We agreed in the session, which lasted really all day before we began meeting with their staff and the RAG and the grantee, that we would conduct this not as a site visit nor aS a management survey visit. It was a council survey team. There would not be a feedback session with the RMPH staff. That we would not be led into discussion of the failure of particular projects or the problems concerning the projects that existed out there, particularly the Waianae coast project which I'll talk a little more about in jo HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wachinaotan AM PANN? | 34 a minute, and their emergency medical project; that we would keep an open mind as to whether or not to recommend a change in the staff leadership, and we would attempt to see whether or not our feelings about poor management and lack of leadership were confirmed by observation. And, frankly, we also concluded that this report would be considered confidential-administrative; and I rather fear that if it weren't, if it ever got into the hands of the press in Hawaii, we would see some fur fly. At any event, we met with the RMPH staff. We felt that what we were hearing was a surface glossing over of problems that are still there in internal communication. And indeed staff members told us privately after the presentation done by their deputy director that there was a substantial lack of communication within in the staff, problems of staff morale, lack of unity, lack of leadership, lack of direction. And it all stems from the fact that the coordinator simply is not available on a full-time basis. We then met with Dr. Richard Lee, the director of the Research Corporation of the University of Hawaii. It was very blunt. He said that the RAG had protected the staff. The RMPH lacked full-time professional leadership because Hasegawa wasn't there. He termed the RMPH staff weak. The medical professionals in Hawaii would not call on RMPH for assistance. Statements that have never been made to us 35 before, to the best of my knowledge. Instead, he said flatly that he didn't feel that Dr. Hasegawa had done the job and that he would not now © hire him as director of RMPH. Now, the grantee doesn't really hire him. They approve the action of the Regional Advisory Group. We asked him who might be a successor. He mentioned Dr. Satoru Izutsu, who has been the head of the Trust Territories of the Pacific, Samoa and Guam portion of this project. Dr. Izutsu is not an M.D.; he has a Ph.D. in behavioral sciences. And we had some concern about the acceptance of him by the professionals in Hawaii. Dr. Lee @ felt that this would be no problem. We find later that Dr. Izutsu is somewhat of a protege of Dr. Lee's, which may present some problems also. We went on to a meeting of a regional advisory group where really the only critical input came from the head of the CHP agency, Sylvia Levy, with whom we all had a very informative session the following day. She raised some questions about a series of things involving the Waianae board, that even though their regional advisory group proceeded I think with some lack of information, we e did agree that they have recognized the problems that have occurred in this Waianae project. To be very brief about it, and Dick can go into it HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. ~~ NO anans | 36 ‘at much greater length if he chooses, the Waianae project is the outgrowth of an OEO program, an OEO clinic, which when OEO funds were withdrawn scrambled to find money wherever it could. And RMPH put money into it, has tried to keep it going; it has applied for 314(e) funds. The man who was running; whose name is David Palley, had been a truck driver for a Castle & Cook sugar plantation which had closed. Mr. Bryan, who -is the chairman of the RAG, was the man who closed the plantation for Castle & Cook. So, he has a somewhat ingrown relationship with this Waianae project. We found we were treading on eggs wherever we went. And not only that, we were treading on all sorts of political things that we didn't fathom completely. We indeed have a letter today from Dr. Lee, which “I'm sure is merely covering his traces and saying these two men who are resigning--this just came to me from Dr. Lee~- "As you probably heard, Dr. Hasegawa, who has been coordinator and director, has offered his resignation, and so has Mr. Bryan. Because of the timing of these two actions, approximately coincident with your recent visit here, there has been a misinterpretation of the reasons for the resignations, and I believe this misinterpretation reflects unfairly on the individuals concerned and unfavorably upon the activities of RMPH. 1 am particularly concerned, since the two individuals involved have given much time and effort to the program here." Well, he has no choice but to write a letter like 37 that, in spite of what he told us. And he has probably sent a copy of that to the two of them to make sure that they are all still friends. I consider that just a political © letter. I wouldn't pay any attention to it. But, in any event, we met following the RAG meeting and felt that we had to talk a little longer with Mrs. Levy, which we did. We talked then to Mr. Bryan. And I must say that two things occurred in the visit with Mr. Bryan. I asked him why he and the RMPH people thought we were in Hawaii. He said, "Well, it's cold where you come from and it's nice to come out here, isn't it?" which somewhat dismayed us because it simply gave me the impression that they didn't take the visit very seriously. And then the more serious thing was Mr. Bryan's comment that he was surprised when RMPS recommended that the emergency medical services project be taken out of the hands of RMPH and turned over to the Hawaii Medical Association, because he simply hadn't realized that things were that serious, which made us question how closely that RAG and Bryan in particular had been keeping track of the program and how effective the leadership has been. © We had a very frank conversation with Mr. Bryan. He then volunteered to go to Dr. Hasegawa and suggest that Hasegawa resign, and he said the only way Hasegawa will do it HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NLE. Vinabinatan AD OAM HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Wachinetan NC 20002 38 would be for me to go with him and for Bryan to resign along with Hasegawa. The two of them met over lunch, came back to us and said that's what they were going to do. And they wanted to know if that would provide some assurance that the program would be strengthened because of it, and we told them it certainly could, depending upon who the new coordinator would be, what freedome he had to restructure the staff and provide leadership to the program. At any event, Mr. Bryan said that they would need some time to contact members of their executive committee and hold an executive committee meeting. Now, at that point, the time for the site visit team to leave had come. ka left. John Hirschboeck went back. Bob Fernandez went back to San Francisco, Dick Russell and I stayed on. I stayed on hopefully to be on vacation. And it didn't all work that way. I think the rest of the time Dick and I were in conference almost constantly. But at any event, after a few days--and, incident- ally, the letter with respect to the Waianae project came out, and that has come back here, and the money on the Waianae has been released, fifty-eight some thousand dollars. Dr. Izutsu, who has been on leave of absence in Thailand, working for the Agency for International Development, came back © through Hawaii rather fortuitously, 39 Dick Russell met with him. I felt my meeting with him might be misinterpreted until RMPH at least had talked to him. Izutsu indicated that he was interested in taking the job but only if he could make some major staff changes and only if he could apply for it on a competitive basis so that it would not appear that he was being pushed in in place of Hasegawa for political reasons. I can understand Izutsu's situation. Finally on Thursday the 17th, they held a special meeting of the executive committee and resignations were | submitted. Mr. Burkett, the Executive Secretary of the Hospital Association, former RAG chairman, is to become the RAG chairman again. Hasegawa was to see Izutsu and encourage him to accept the directorship. They all agreed out there that an acting director could be appointed until June 30th. Since then they somewhat changed their minds on that point. And as Dick and I left Hawaii, Hasegawa and Bryan were in the process of resigning. No new director or RAG chairman had yet been chosen. No announcement had been made to the staff nor to the press, but it hit the press after we left. And that came from the chairman of their executive committee, who should have known better. But in any event, it's out. All the groundwork for changes in RMPH has been laid. And I think it's going to go ahead in spite of all 40 the political things that may come up out of it. Mr. Bryan will stay on and work with the Waianae project, because he has a personal interest in seeing it be successful. © Dr. Hasegawa will continue to be an advisor to the pediatric pulmonary projects because as a pediatrician he is very much interested in them. And hopefully the way is going to be cleared for a new coordinator to be selected in due course. The final caveat in our report on the last page I don't think is something we need to go into because I don't think it's going to happen. But I will simply leave it there, and you all can read it for what it's worth. It simply says that if they want to appoint the current deputy or Mrs. Rosie Chang, that we on the team would recommend that the further expenditure of funds for the RMPH be restricted permanently. This is the first time that the council has gone out and shook the tree. I don't recommend that we do this very often. “But there may come times when there isn't much choice. And as a consumer sitting on this council, I'm appalled when I see things that should be running well simply not running at all. And I'm also concerned when we see a man e who is a full-time pediatrician making a very substantial income, making $35,000 a year for running this program on nights and weekends. Because it's the kind of thing which HOOVER REPORTING CO, (NC. 320 Massachusetts Avenue, NE. Washinatan AS ONAN? | HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, 0.€. 20002 41 can make this entire Regional Medical Program criticized, and it's the kind of thing somebody points to, but it's a freak situation. It doesn't exist anywhere else. And you must remember that he was not paid until about two years ago. I don't know the sequence of how it came to be that he was paid. I think he intended to move out of private practice and do this full time, and that has not occurred. So, he is still in practice. But at any event, Dick, you might follow up on any other comments and then, Ed, if you have anything to say and we'll go catch a cab. MR. RUSSELL: I will defer to Mr. Hiroto here. MR. HIROTO: I would just add you have to understand that although the report has its humorous side, these things were done in deadly earnest. And each decision that was made had to be made based upon the factors that the site visit team saw, and I think that we were extremely fortunate in being able to come out with the results that we were able to come out on a voluntary basis. MRS. MARS: The way it stands now, it just frankly ought to be closed up, shouldn't it? MR. OGDEN: Well, I don't think so. I think Dr. Hasegawa has expressed an intention to resign, and I think he will. I would be in favor of continuing to let them have enough money for that staff to keep their projects going. There are going to have to be changes in 42 the staff. But there are some ‘projects there, and I think the Waianae coast project, this clinic, should be kept going. The South Pacific portion of it is doing well. There are major problems that need to be attacked, including the problem of leprosy, which is coming back into Hawaii through the Samoans moving up there. And I don't think it's an area we want to ignore, and I don't think I would be in favor of closing it down at this point. I think we need to allow time for these changes to occur. And I think they are going to happen. I think they are going to happen. MRS. MARS: What sum of money is required to keep the projects going? MR. OGDEN: Forty-some thousand dollars I think at this point. | MR. RUSSELL: Yes, if I could get into this now, the figure that we are dealing with now really is the $511,352. The top figure was a total award, the fiscal year '73 restriction. That was the across-the-board restriction for all programs receiving the money at a particular time. As a result of council action at this last meeting, $145,249 was restricted, leaving them three sixty-six, plus available, which has been budgeted from January 1 through April 30, leaving the two months loose. What I would like to suggest to this group is that for the seven ongoing projects, their commitment for May and 43 June comes to approximately $41,000. If this group would consider releasing $41,000 of the $145, 000 currently restricted, this would enable the program to meet the 6 commitment to their individual projects. It would not permit them to do anything in the core staff area until the other part of the recommendation is reflected in the report, that that be restricted pending the appointment of a new coordinator and the election of a new RAG chairman. What this would do--I would hope they would get the message. I'm sure they will get the message. I'11 put it that way. That it would say, "Okay, you may tell your projects, the local people, that they may go through RMPH's full commitment to them.” However, the program staff is really limited until they do appoint a new director. And then this wo-ld put the new director in a much better position to control the program. MRS. MARS: Then we can see what happens. MR. RUSSELL: Then we can see what happens. MRS. SILSBEE: Dr. Merrill? DR. MERRILL: Your bomb shell at the end here raises some concern with me, because you knocked off the first three people in a row here, and I gather there is some @ weakness in the rest of the staff too. So, is it only the executive director we need be concerned about? MR. OGDEN: No, it's probably more than that. I HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Unaehinatan Mt INN? | 44 think if Dr. Izutsu takes this on, there are going to be some major changes in the staff. He feels that way. There has been some attrition also. © MR. RUSSELL: Doctor, along these lines, Dr. Izutsu told me that in talking with Dr. Hasegawa--and I've since passed this message on to the other key individuals involved, that whomever takes the job will have to restructure that staff. That is becoming common knowledge in Hawaii. And communications there travel very, very quickly. Too fast. DR. MERRILL: One other brief question. Did anybody in the site visit team get in touch with Dr. John e Lowery? he would welcome a change. MR. OGDEN: Yes, we talked to Dr. Lowery. I think MR. RUSSELL: He was the gentleman quoted by the press. He was deeply involved, yes. MR. OGDEN: I think he would welcome a change. He feels there is a great deal RMPH could do if it had different leadership. MRS. MARS: Are you making a motion then? MR. OGDEN: I will move that--Dick has written this @ out--approximately $41,000 of the $145,249 restricted be — released to RMPH for continuing support of its ongoing projects. The remaining $104,249 continue to be restricted, HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. iMashinatan TED DANN j 45 pending the appointment or a new coordinator and the election of a new RAG chairman. MRS. MARS: I'11l second that. MRS. SILSBEE: The motion has been made and ‘seconded that $41,000 of the $145,000 plus that is presently restricted be released to continue support of the ongoing projects; the remaining $104,249 will continue to be restricted, pending the appointment of a new coordinator and the election of a new RAG chairman. MRS. MORGAN: Then also before that could be released it would have to come before council again? MR. HIROTO: Yes. MRS. MARS: What will happen now on the release of these past funds for '73? CHAIRMAN PAHL: We are not going to be distributing any of the ‘73 funds until the June eouned? meeting, and that would be accordance with specific proposals, and by that time certainly we should have all of these matters resolved. ‘So, that would be contingent upon this. With regard to the question about. whether this would automatically pene back to council, not as this is phrased. I think if you wanted it to come back before it-- | MR. OGDEN: Then let's add that no further funds can be expended without it coming back to council. MRS. SILSBEE: As I read the motion, once they appoint the RAG chairman and the new coordinator, these 46 funds could be released. That's the way I read it. Is that not the way you mean it? CHAIRMAN PAHL: That's the interpretation. © MR. OGDEN: I'11 buy that. I think that would be all right. MR. RUSSELL: We are anticipating and hoping that perhaps Dr. Izutsu will accept this. We're not sure. But we do expect to have a replacement by April lst. If we should run into any snags along this line, we can come back to council at the March 29th meeting. MRS. SILSBEE: That is really keeping the Regional Medical Program in the perils of Pauline. MR. RUSSELL: No, I am not recommending that it come back to council. We're not suggesting that. What I am saying is that as a matter of information, we will have an opportunity to keep council informed. MRS. SILSBEE: Mr. Gardell? MR. GARDELL: I was just wondering if it was clear here, the roles of the grantee and the RAG with respect to the selection and the appointment of the individuals. It wasn't quite coming through to me that Dr. Lee has responsibility for the coordinator; is this so? e MR. RUSSELL: This is quite clear, Jerry. This is the first thing. We would not respond to the bad publicity until we got something from the grantee. So, we HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Waashinatan Po IAAND | 47 were well aware of that. MR. OGDEN: He approves. The grantee has to approve the selection of the coordinators but does not © select them. MR. GARDELL: No. He selects them, according to our policy. That's why I was a little bit concerned about it. He has recommendations from the RAG and then he makes the selection. That's why I was a little bit concerned about it. I wasn't sure that Dr. Lee understood his role. MR. OGDEN: Then I am in error on that. Lee understands this? MR. RUSSELL: Yes, he does. MRS. SILSBEE: I'1l repeat the motion that has been made and seconded. Approximately $41,000 of the $145,249 now restricted be released to the RMPH for continuing support of its ongoing projects. The remaining $104,249 will continue to be restricted pending the appointment of a new coordinator and the election of a new RAG chairman. Any further discussion? All in favor? [Response] Opposed? [No response] The motion is carried. e CHAIRMAN PAHL: I would like to thank both of the council members for carrying cut a most delicate task, and I would like to bring to the attention of everyone in HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Ulcabineatan AP IAA | HOOVER REPORTING CO, INC. 22) Massachusetts Avenue, NE. 48 this room the request made here that this written report and this information presented be treated as confidential- administrative. You can see that we cannot be effective in these kinds of matters if this is not adhered to. So, we make special plea that the confidentiality of these meetings be strictly understood and adhered to. MR. OGDEN: Sorry, but we must go, but we have a cab to catch and planes to catch. CHAIRMAN PAHL: Thank you again for a very fine report and fine activity. And we look forward to a successful conclusion. MR. OGDEN: I looked at the material on Arizona, and I think it looks very good, and I would approve going along with the release of funds. MRS. SILSBEE: Thank you very much. {Mr. Ogden and Mr. Hiroto departed from the meeting. ] MRS. SILSBEE: The final item on our agenda today is a report from Mrs. Sadin on the Arizona constiltation visit. There is no action involved. MRS. SADIN: I was wondering, if there is no action involved and you all have that report, do you want to have me present it anyway? MRS. SILSBEE: Yes. 49 I think we all recognize that there is a different flavor sometimes in a verbal report and it gives us an opportunity to ask you some questions. © MRS. SADIN: This does not require any action. It was not a site visit. And the reason we had this consulta- tion visit to begin with was because Arizona has kind of been visited regularly, I think, once a year, because council has continued to have certain concerns, and these concerns have kind of remained the same over a three-year period. I think when they came in for triennial status at the end of '71, they were approved with certain kind of conditions, that they needed to visit again in '72. They were visited in '72 by a site visit team, with representation from review committee and council. And some of the concerns have been addressed, some have not. Specifically those that had not were that they were still continuing to put a lot of money into data collection activities and these were all supported by the RMP, not shared with CHP. And also that the CHP-RMP relationships continued to be a problem. So, that site visit team in '72 recommended that they be visited again in another year. And in the interim we had, as everybody knows, phase-out. And so they were not. ® When they submitted their '74 application, it was looked at by the last council. There was some evidence in the application that some of the issues had been addressed, HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. llachinetan AC FANN | 50 that they had been working with CHP rather well, that they were addressing some of the health service needs, and the council recommended that we have a visit with staff and | © Dr. Cannon who, up until the end of November, was a member of council. And he had been to Arizona, I believe, on the other two visits. So that he knew the region rather well. Unfortunately there was fog over Kansas City, and Dr. Cannon didn't get there until the end of the consultation visit. And so the consultation visit really consisted of yours truly and it was kind of too late to cancel things because I had just gotten the news the night before and we just decided we would go ahead as planned. Mr. Ron Currie was there from Region 9, and myself; Dr. Cannon came about 4:00 o'clock that ifternoon. He did have a chance to meet with the staff, ARMP staff. The RAG members had already left. Ank the CHP people had already left. But he also met the following day with Dr. DuVal, who is a member of their RAG and, you know, was here and has quite a bit of influence in that area. The purpose of our visit was to find out if they had addressed previous concerns, to find out how their plan evolved, and what they were going to plan to do in '74. And @ most of the Arizona RAG members were present at the meeting, and they had many--I think except for two--they had most of the CHP "B" agencies represented there and some other HOGYER REPORTING CO., INC. 320 Massachusetts Avenue, NE. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. i Washington, 0.0. 20002 4 51 organizations. The Arizona RAG had insisted that RMP staff work with CHP. And they had. They really had been around to all of the CHP "B" areas and the "B" people there really attested to the fact that they had been trying to adxdress the needs. The two people missing were the director of the CHP "A" agency, and there are still problems in that area. The director of that agency never did respond to the letter written to him by ARMP, didn't show up at the meeting. The Mericov Accounting, which is the big "B" agency in the area, the director was supposed to be there. He was invited. He said he could come, and he didn't show up for whatever reason. He did, however, respond to the application, made some comments which again were responded to by ARMP staff, by the coordinator. So that we felt that the ARMP-CHP relationships, except for the "A" part, were moving along well. The remaining concerns and the only thing we still have a little bit of reservation about were the composition of the RAG. They still don't have minority representation. They're still largely provider oriented. The excuse we had been given up until this time was that there had been a regulation that the ARMP RAG be part of the Arizona Health Planning Authority, and that's why HOOVER REPORTING CO,, INC. 320 Massachusetts Avenue, NE. 52 it could never be very large. And it had maintained its small size because they thought that was the only way they could manage it. But that restriction had been removed. They still haven't expanded it because--well, they said their enthusism was, you know, kind of dampened because of phase-out. You know, they met regularly. They didn't see the need. Dr. DuVal, who was present when we discussed RAG composition, didn't respond to the issue. And Dr. Cannon, when he met with Dr. DuVal the next day, said that this didn't come up. The staff has expanded. They do have some people that are working out in the areas. Decentralization was another problem that council had before, but now they have six people in Phoenix, and they have people working out with CHP areas in the field. They have field representatives now. But they still don't have any minorities on staff. They said they can't find them. And whoever sent that man to Intermountain, I suggest that he send somebody to Arizona, because they can't seem to find anybody. We think that because of phase-out--I have talked to Dr. Cannon--Dr. Cannon, Ron Currie, and myself feel that since there was a lot of--not disorganization necessarily but dampened enthusiasm and problems because of phase-out, HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 53 that really they are to be commended for doing what they have done in working with CHP. But I still think that they ought to address the minority problem on RAG and staff, and that they ought to expand their RAG because if, as everybody tells us, you know, we're going to move towards having more representation of consumers and third-party payers and government agencies, then I think would behoove ARMP to move in that same direction. MRS. SILSBEE: Any questions? MRS. MARS: How large a staff have they got? MRS. SADIN: They have 14 now. They started out with 30. They reduced to nine during phase-out. And then they have added another five. And these five individuals are--well, some of them are going to be area representatives. But I think the strength will be in working with the CHP "B“ agencies. MRS. MARS: What is the population of their area? MRS. SADIN: A million. They have been working with the Indians on the reservation. And there was a representative of the Navajo Health Authority. MRS. MARS: What did he have to say? MRS. SADIN: He was positive. He said they have been working together and that he had seen some changes. CHAIRMAN PAHL: Thank you for the report, Rebecca. Is there any other business that you feel should 54 be taken up before we adjourn? I believe we've covered everything that was on our agenda. Bob has been working trying to establish what date @ is most appropriate for this national meeting of the coordinators and tying it into the various schedules of those that we certainly would like to have at the meeting, and it's not possible today to do this. So, we'll be in touch with you very shortly as soon as we can establish that, and presumably we will have that rather quickly. So, in the next few days we'll be in touch with you about it. Thank you again. It has been most difficult with a diminshed council, and you suffered through many reports very patiently and helped us considerably on all the site visits and recommendations, and I for one am very pleased to hear the outcomes of these three site visits, which again p roves that it's worthwhile going and talking, not depending on just what comes in the application. MRS. MARS: It's very necessary. CHAIRMAN PAHL: All right, our meeting stands adjourned. Thank you. {The meeting was adjourned at 3:53 o'clock p.m.] HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE.