NATIONAL ADVISORY COUNCIL

TRANSCRIP

June 13, 1974

 
 

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NATIONAL ADVISORY COUNCIL ON

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REGIONAL MEDICAL PROGRAMS

BOARD MEETING

“ 9:00 A. M.
Conference Room G-H
Parklawn Building
Rockville, Maryland

Thursday
June 13, 1974

 

 

 

 

 

 

 

 
 

WHD-151

 

 

SPEAKER /MOTION
Doctor PAHL
Doctor MARGULIES
Doctor GREENE
Discussion

Mr. RUBEL
Discussion

‘Dr. GOODMAN (Item 6)

Discussion
Mr. -REARDON
Discussion
Doctor PAHL (Report)
Doctor GRAMLICH .

MOTION (Minutes)
MOTION (Mrs. MARS)

ARTHRITIS
-do-
~do-
~do-

CALIFORNIA

GEORGIA

LOUISIANA

‘PUERTO RICO’

MISSISSIPPI
NORTH CAROLINA
SOUTH DAKOTA
INTER-MOUNTAIN

SOUTH CAROLINA
Substitute

CONTENTS

FAILED

 

EEGIN MOTION PASSED
3
5
19
26
29
41
51
55
63
71
75
85
98 98 98
118 119 119
128 130 131
136 136 144
145 148 153
154 155
169 173 174.
175 179 181
182 189 190-
191 196 196
197 ” 209 209
215 221 221
222 223 224
225 243 244
244 246
247 250 258
261 261 273

 

 
 

WD/em

 

 

 

PROCEEDINGS

DR. PAHL: Good morning. I would like to call the

meeting of the National Advisory Council in Regional Medical
Programs to order, and I would first like to welcome to the
council table the new members of the council.

Since we started a few minutes late and there has.
some socializing, I have a suspicion that most of the new .
members at least recognize and have perhaps said Hello to the

current members of the council. Since we will be here for

two days, why, we will make every opportunity to get you

 

acquainted with each other, but we do welcome the new members |

and we are very happy to see the standbys here with us.

In that connection I would like to say that we are
particularly happy to have three members on the council who
represent reappointments. We feel very fortunate in having
Dr. Kamerof, who cannot be with us at this meeting but who
did attend the orientation meeting last month, Mr. Sewell
Milliken and Dr. Ben Watkins are back with us, and we are
very pleased with that.

I would like to comment, for everyone in the room,

that this session of the council meeting is the open session, |

We are delighted to see a number of visitors with us. We
won't take the opportunity to identify you, although we do
know who some of you are; and I would expect that, at the

appropriate time, before we go into our closed session,
 

 

 

 

4

possibly very late morning or early afternoon, we will make
an opportunity for any member here of the public to make
whatever statement or comment he feels to be appropriate.
And if that does occur, I would ask the individual who wishes
to make a statement to please identify himself for the record,
And if he is representing an organization, if he would please
identify that organization or unit.

I would like to introduce to you the people here at-
the head table.

I must say this is a pleasure, We have been known
to use smaller and smaller tables over the past years. So
it's very nice to see a full complement down this end and
also up here,

I think that most of you, or a good many of you
of course, know Dr. Harold Margulies in the center here, who
is’ the Deputy Director of the Health Resources Administration,
and will be making a presentation to you very shortly.
Again, most of you are familiar with the fact that Dr.
Margulies was a director of a program for several years before
moving into this position as Deputy Administrator.

On my immediate left is Dr. John Greene, who is the
Director of the Bureau of Health Resources Development in
which bureau we are located; and Dr. Greene has taken some tim
this morning out of a very busy health manpower legislation

activity that is going on currently to comment, and I think

Ww

 

 

 
 

been coming to you.

 

 

 

 

we will have some comments along those lines that will be
interesting to you,

On Dr. Margulies' left is Mr. Gene Rubel, who not
only is the Acting Director of a comprehensive health
planning program but also has the responsibility for
coordinating internally and in conjunction with what we believ
to be the new legislative directions, the Health Resources
Planning activity of the Bureau, and is Associate Director for
Health Resources Planning in Dr, Greene's Bureau of Health
Resources Development, |

Mr. Chambliss, on the far end of the table here,
I am sure you all have met. I know that, as the Deputy
Director of the Division of Regional Medical Programs. And

Mr. Ken Baum, on my right, through whose good offices , and

 

Mrs. Eva Handel at the entry table, this meeting has been made

possible, for all of the mechanics and materials that have

Now, with those introductions out of the way, I
would just indicate that we have a very heavy schedule for

this particular council meeting, and in order not to unduly

 

delay the other activities that these gentlemen have before |
them today, I will hold off my report to you and first ask if!
Dr. Margulies would give us some perspective from the point

of view of the agency on matters that I know will be of

interest to you.

 

e
 

 

 

 

 

Harold,

DR. MARGULIES: There are two or three general
subjects I would like to raise with you, without taking up
too much of your time, but all I think relevant to the
deliberations of this council, and I think to the general
level of interest which you have in the health affairs of the
nation.

When this council last met, a number of you were
not present, so let me briefly sketch once more the organiza-—
tion of the Health Resources Administration, so you know what
is in it, and what it represents in terms of federal health
activities,

In fact, it's probably useful to those of you who
were here before, because there has been enough reorganization
to be confusing even to those who are very close to it.

The Health Resources Administration was created
with the belief, which I think is basically valid, that there
is a need to address the issues of resources and the use
of those resources in the delivery of health resources ina
rather special and. unified way.

This council and the activities which it supports
are very pertinent to those concepts. It is noticeable,

in fact, as you look at the introduction of major legislation

and particularly as you follow the introduction of legisla-

 

tion national health insurance and the debates on it, that

 

 

 
 

 

 

 

 

 

they tend to divide into two major portions: one of them
representing the processes of reimbursement; and the other |
representing the processes by which reimbursement leads to
effective and acceptable services,

And, in fact, one of the legislative proposals,
the Kennedy~Mills bill, goes far enough as to identify these
as seperate responsibilities, placing the payment mechanisms
in one type or form of structure, and the health resources .
in another,

So that I think the philosophy and the dynamics
are fairly convincing, that if one is to set about paying for
services as a general national responsibility, one must also
set about the business of finding out whether those payments
lead to effective services available to all of a reasonable
quality in a manner which is economical, efficient, and able |:

to contain costs,

That is -~ the latter part is where HRA is.

 

Now, it would he exaggerating things to suggest that!
HRA represents all of the capacity in the country to deal with
health resources. On the -contrary, the capacity for meeting
health needs in this country remains essentially overwhelmingly
a private function of the private delivery system, and there

is every intent that it remain there for whatever period of

 

time is necessary to have the job done, hopefully forever.

There is, however, in HRA, Health Resources Administira-

 

 
 

 

 

 

 

8

tion a collection of activities which is sensitive, critical, |
and, in the course of events, could make most of the ai fterence
between a different and an excellent result as we continue
with our efforts to utilize federal resources for general
benefit,

If you look at the structure, you will find that
the three bureaus contained in any particular order you wish
to take, the resources or the capacities necessary to develop
data statistics or, in a broad sense, the intelligence
required to understand what is going on and what needs to be
done in the health delivery system, and this is largely
in the National Center for Health Statistics. It contains
a significant part of the federal effort and in some ways
the leading edge of health services research which will
assist the country in understanding how better to do what
it is attempting to do in the delivery of medical care.

This includes economic analyses questions, the
quality of medical care, the development of new kinds of
systems, better types of communication and recording, et
cetera,

And in the third bureau, which is represented by the
other people at the table here, those activities which have

to do with the supportive institutions which produce the

health manpower and with other. aspects of effective uses of

 

health manpower.

 

 
 

 

 

 

9 i

Those activities which have to do with the federal
interest in developing health care facilities, hospitals,
nursing homes, and so forth, and the planning elements which
are probably, along with the intelligence elements, the two
key contributions which HRA can make to a better understanding
and a better delivery ‘of health services, now, and even more
so in the future, with national health insurance,

We have been trying to integrate these activities
so they represent a common kind of a function. It is not
difficult for me as an individual having coming from the RMP
to move strongly in the direction of an effective planning
activity and to recognize the relationship between what this
council does and effective planning.

I was pleased not long ago, because this kind of
recognition comes rarely, when someone gave me a certificate
which is based upon the contributions I had made to compre-
hensive health planning. I have been trying to do that
since I came to RMP, .

The first statement I made when I came to Regional
Medical Programs was that this program, RMP, must be dependent
upon an effective planning process which, at that time and at
the present time, is comprehensive health planning.

That confused people initially, but I think in the

course of time most people became dedicated to the concept

that there is an interrelationship between the two; but that

 

 

 

 
 

 

 

 

10
a planless system is an undesirable system, and that therefore
effective planning was critical to effective use of always
limited resources,

So HRA is moving along, but still £acing some real
problems. Its problems are those which are familiar and
which seem agonizing to visitors to Washington, they een
agonizing to those of us who live here as well, when we get
to mid-June and we have no legislation which authorizes us -
to stay in business and no appropriations to pay for us if
we did stay in business.

That's not really too remarkable. It merely has to
do with the pressures of other events in Congress and in the
Administration. And there will be legislation which will
extend those in a variety of ways, and there will be
appropriations which will probably come in varying periods of
time, some of them soon enough, some later than they ought
to.

Of most interest to us hére is what may appear in
the form of new legislation which extends the activities of -
RMP, CHP, Hill-Burton, and so forth -- and I,will comment on
that in just a moment,

We will almost certainly have, without much
difficulty, an extension of the legislation for what was the

National Center for Health Services Research and Development,

now it's the Bureau of Health Service Research. That will,

 

 

 

 
 

 

companion planning activity, to make sense.

 

 

 

1l
I think, pass without much difficulty or delay.

The same thing is true for the National Center for
Health Statistics.

My own personal concern, and I think the concern of
the agency in this particular context is to give very high
priority to the development of an enhanced and growing
capacity in the National Center for Health Statistics, to °
develop an intelligent base, a source of knowledge and
information, and analytical capacity which we do not have in
this country anywhere at any level, and to do it in such a
way that it's useful at the national level, at the State
level, at the urban, the inter-urban level. |

So that when people attempt to get something done,
they know what their base is that they begin from, where

they are going and what needs to be done, This is clearly

top-level priority in this agency, along with an effective

The passage of the legisjiaticn, therefore, for those
two activities is important, but the sense of Congress which
goes into whatever they ee is even more important.
Health manpower legislation is highly uncertain at the present
time. The bills which have been introduced are variable.
The Administration's bill moves in one direction, the House

bill in another, and the Senate bill in a third.

There are points of agreement, and many points of

 

 

 
 

 

 

12
great disagreement. What will happen with what has been
known as the Hill-Burton legislation is also uncertain,
because the Administration. does not propose to extend the
traditional Hill-Burton program. The Senate and the House
have other versions, and that will make a considerable amount —
of difference,

As I am sure you know, a planning bill which is to

extend, as I indicated a moment ago, CHP, Hill-Burton, RMP

wien pe

and some specific activities like area health education
centers, has not yet been reported out; but it has gone far
enough so that one has reason to feel secure in what it will
produce, what kind of a bill we will have. And I think there
is reasonable optimism now about the passage of new legislation
in the fairly near future. |
In any case, Mr. Rubel and his staff and the staffs.
of HRA have been working assiduously and I think rather
remarkably to anticipate the passage of new legislation; |
have actually been looking at multiple possibilities and so
are prepared to move in whatever direction Congress and the.
succeeding regulations require they move. | :
I think the transition will be much less difficult

because of that kind of effort, than it might have been had we

merely waited for the events to catch up with us.

I think what we shall probably see in the new

planning legislation is a combination of the Administration's

 
 

 

 

13

bill and the Rogers bill -- and rather than using those names.,
let me tell you essentially what would be contained in the
activities,

There will be legislation to support within States
a planning activity which is essentially designed around a
combination of public and private interests Which act together,
the planning agents will be private, non-profit in character,
and they will depend heavily upon an interrelationship .
between what needs to be done and the Capacity of the
market and the professional and public leadership to respond
to sensible planning activities.

There will, in all likelihood, be an associated
agency established at the State level to coordinate, review,
approve those kinds of plans and to make sure that there is
a balance in those kinds of authorities.

There will, in all likelihood, be a separation
. between planning functions and regulatory functions, but they
will be -- certainly the regulatory functions will remain the
State's responsibility, like those that are associated with
Section 1122 of the Social Security Act, which is concerned
with the construction of new facilities, the addition of new
beds, et cetera; the kind of certificate-of-need legislation,

That kind of planning authority would be an
improvement on an extension of comprehensive health planning.

It would contain a modest amount, I suspect, of developmental

 

 

 
 

 

country have not reached the conclusion that it is better to

 

 

{
14 !
|

funds in order to make things happen which might not otherwise

t

i

happen, but primarily as a kind of stimulating or coordinating
i
j
or catalyzing activity, rather than having a large outflow of |

|

funds to do what appears to be desirable at the local level.

If this is done so that the legislation makes good
sense and is manageable, and if it represents, as many of us.
suspect it does, a modification in planning understanding
at a time when people have begun to appreciate more fully
the importance of planning, in fact the essential character
of it, and with the high likelihood that we will have
national health insurance in the fairly near future, we will
have a combination of better legislation, strong federal
support, better State understanding, and a new zeal, I
believe, to put some rationality into the system,

I can imagine no way in which any kind of legisla-

tion will prove effective if the decision makers of the

do it sensibly than by guess and by chance; and I think we
probably have reached that point, although not consistently
throughout the country.

Where it has been inconsistent, I am sure that Mr.
Rubel will help to make it more consistent. That will be an
interesting activity.

This council now, in reference to that kind of

legislation, has a heavy kind of concern, and I would like

 

 

 
 

 

15 |
to make a particular point in reminding you of what this
council is and does and should do. It's a rather remarkable
arrangement,

The National Advisory Council was created by
Congress, saying to the nation and to you members of this
council that you are to be depended upon to carry out the
will of Congress in ways which combine your understanding
of the legislation, your concern of the public welfare, and _
your various kinds of professional skills.

This council is unusual in that it is given more
authority for the approval of grant awards than are councils
generally in this government.

You are told that you will be given some applica
tions which have been carefully reviewed and which have
been put in a form of presentation which you can understand,
and understand quite readily.

And that you will make recommendations to the
Administration, without which grant awards cannot be made,
but which do not necessarily represent the amount of the
award that will be made. In other words, you have a veto
power and you have an approval power. If, however, the

approvals which you provide exceed the funds that are

available, quite clearly there are adjustments which have to

be made,

The forms in which you make your actions, the commen

 

cS

 

 

 
 

16 |
which you make represent the distillation of public interest
representing Congressional action and your final move in the
direction of public welfare.

It is a heavy responsibility, and one which
requires your greatest possible attention. It becomes
especially difficult how, because you are encumbered by a
rather chaotic history of RMP's, certainly in the last eighteen
months,

You enter into.it in what are administratively and
ethically perilous times, so that you need to pay close
attention to what you consider to be right and wrong,

And you are also looking at a set of activities determined by
a court order which at the same time move in the direction,
we are certain, of new legislation before many of these
activities are well launched.

You will therefore have to express some Judgment
about how these activities need best be carried out.

It seems highly likely that before the funds which
you are going to be looking have been provided for RMP's,
and certainly before they have been formally expended, there
will have been new legislation, new considerations, and
new activities facing those organizations which receive these

grant awards. |

AS a consequence, you must keep open the likelihood

that there will be a new set of pressures on instituticns here

 

 

 

 

 
 

 

 

17
and elsewhere throughout the country which may determine the
best possible use of these funds.

I think these ideas need to be set well aside from
your basic concern, from the fact that you are operating
under a congressional Act, which has not been changed, under
court orders which are quite clear, and under a public purpose
which you are the best individuals available to determine. -

Now, finally, let me say in that regard, and as a
special note again, taking advantage of an opportunity to be
personalized, that those of you who have served on the
council before, and many who have not, are fully aware of
the tremendous workload which is involved in bringing to you

grant applications which have been reviewed, given the best

 

possible consideration to be put in form for you to act upon,

In past years this was done by a Large staff, and :
it was hard work. This time it was done by a much smaller
staff over a shorter period of time under extraordinary
difficulties.

It is customary to give thanks to a staff which
has operated in these circumstances. This is no customary
comment. This has been an unbelievable undertaking by those
who are dedicated and who care and who have done what they

have done because they believe it needs to be done.

They have done it in circumstances where their

existence is threatened, where their jobs are unsure, where

 

 

 
 

Harold, thank you very much for those comments. I think we

 

 

|
18 |

their future is unknown, and where they have been given. damn |
little encouragement from any source at any level.

And this goes, certainly, probably several times
over for Dr. Pahl, and down on through the entire organization
It has been remarkable. There is no kind of award, there is
no kind of statement, there is no measure that I know of
that can fully recognize what difficult times these have been.

I remain astonished that people will work that
hard, with that much vigor and that much honesty, in the
circumstances in which they have been placed. And I am very,
very grateful to them, and I am sure you will be before you
are through with this council,

Now, if there are any questions that I can
answer, after what has been about as long as I.expected to
talk, I will be glad to respond,

DR. PAHL: On behalf of the staff and myself,

do indeed appreciate that commendation.

Are there any points -- I believe you can stay a
few minutes longer, but perhaps you had better nab Dr,
Margulies while you have hin.

If you need anything else from that agency point of

view on the tenth floor,

 

s

 

I should add here I am glad Dr. Margulies charged

Mr. Rubel with bringing consistency into government, and we

 

 

 
 

 

 

 

 

L9

will be working toward that end, too.

Well, perhaps we might move on to the next speaker, |

and I am particularly delighted to bring to you Dr. Greene,
to discuss again matters of importance to the council from
the Bureau of Health Resources Development.

RMP has been located now in three agencies since
its history. It started off with the National Institutes of
Health as a home; it was then moved to the Health Services ;
and Mental Health Administration, and when that was organized
last July 1, we moved him to the Health Resources Administra-
tion. Since last July we have been in two bureaus of the
three bureaus of that agency, and I am particularly delighted
to state that we are presently under formal consideration for
inclusion in only one bureau, and it is Dr. Greene's Bureau
of Health Resources Development.

DR. GREENE: Thank you very much, Herb,

I do appreciate the opportunity to meet with the
council. It's my first opportunity to do so.

In looking at the agenda, I have just noticed that
it's a morning filled with remarks, and I guess that's kind
of a remarkable morning _- if you turn it around the other
way. |

I will keep mine very brief, so you can get on with

the rather full agenda that you have.

And I know, since it is scheduled on here, that you

 

 

 

 
 

 

 

 

 

20
might be working on Saturday, I am sure that you are anxious
to keep things short at this end so you can maybe get out of
here, so you don't have to work through the weekend. So
Iwill try to help you in that regard.

It is a pleasure to follow Dr. Margulies, and to
echo some of the comments that he made very briefly about ©
the adverse situation under which the staff has been working
here in relation to the Regional Medical Programs and in
relation to all of Health Resources planning. And the
outstanding dedication and work they have done, as I am
sure you will recognize as you work through this council
session.

But I will let it go at that and add an "amen" to
what Dr. Margulies has said; and I am very grateful to them,
as I am sure you will be, too,

I would also like to congratulate you as the
council and the Regional Medical Programs in general, for
the work that has been done and the-work that you are doing,
and the perseverence of the people who have been dedicated to
Regional Medical Programs through some rather adverse and
difficult times.

The fact that you're continuing to carry out the
purposes that Dr. Margulies outlined on Regional Medical

Programs in the interest of the public and public concern,

and congratulate you for it, and I want to express my

 

 

 
quite busy on the Hill and within the Department, trying to

 

 

21
appreciation to you and to the Regional Medical Progrars in
general for that effort. |

Dr. Pahl mentioned that the Regional Medical Progran
now scheduled to formally move into the Bureau of Health
Resources Development, and there is a formal request to make
that formal, although we have been operating this way since
last February; that there is a request now to make this a .
formal transfer.

We have not a formal, official reply to that, making
it official, but it is expected to come at an early date.

Now, Dr. Margulies indicated that the Bureau of
Health Resources Development, into which Regional Medical
Programs is moving, included the comprehensive health planning
Hill-Burton program, as well as the old Bureau of Health
Manpower Education, which has, as its legislative base, four
pieces of manpower legislation: the Comprehensive Health
Manpower Training Act of 1971; the Nurse Training Act; the
Allied Health Act; and the Act that covers Public Health.

Now, all of these pieces of legislation affecting
manpower expire at the end of this month, and we have been
help fashion a new piece of manpower legislation.

I thought I might just comment on that for a few

minutes, because I know Regional Medical Programs have been

quite busy and active in the manpower area, and I thought vou

 

 

 
 

 

 

22
would be interested a little bit. as to what the current scene
is and what might come out of it; and I will try to make this
brief.

But, as you probably know, the Congress is -- the
Congress and the Department and the general area of manpower
and education are more concerned now about the type and
location and utilization of manpower than the total numbers of
manpower as had occupied the scene most since the Health
Professions Educational Assistance Act started in 1973.

The focus up until this time has been largely on
shortages and trying to increase output, of number of health
professions of all types.

As we move into considering what is needed over the
next three years or the next legislative cycle, the emphasis
has shifted away from a focus on continuing massive increases
in output and has shifted to greater focus on other problems, |
problems more of location of people, geographic location of
people to deliver services; the types of people; the
specialty distribution question; the problem within medicine.

The greater emphasis on trying to increase
productivity of health workers of all types, with great concer
about the continuing qualifications of people after they are
out in the marketplace, and out delivering services.

Now, as to how this all will come out is anyone's

guess at the moment, but let me just run down some of the

 

 
 

 

 

 

23
provisions, some of the kinds of things that are being given
attention, a little more specificity than what I've just
mentioned,

While there is less emphasis on continuing to
stimulate increased output, there is general interest and
concern about the stability of the institutions that do
provide manpower. This interest and concérn is expressed
in different ways, in different pieces of legislation: those
of the Administration,those of Members of Congress, As you
are probably aware, . the Institute of Medicine study which
recommended a certain level of capitatidén.. The Congress
has been quite interested in that study, and the recommenda-
tions made by it, and are likely to latch onto those
recommendations in their committees. That is, in my estima-
tion.

However, the Department is recommending lower
levels of capitation to maintain stability of the institution
‘than was recommended by the Institute of Medicine study.

But in all likelihood there will be continued levels of
Support for the health professions' institutions,

Now, it also -- there also is a lot of interest in
exacting something in return for that front-end money or
basic support. As a minimum it seems that there will come

out of this a requirement that the institutions at least

maintain the current output or current enrollment of numbers

 

 
 

 

24

of people within their school, I think that's a minimum.

Now, it goes on from there in some of the proposals .

in Congress to require such things as having to be

eligible for such capitation Support that all students

within the school would either agree to serve in the National

Health Center service corps or serve in some shortage area
or shortage profession within the country. This is in the
Kennedy bill, and this is an extreme at one end as to the

kinds of requirements that may be placed or could be

placed on capitation support.

It is, I think, unlikely that what will come out of

Congress will be to that extreme. I do think the Congress
will ask for more assurance, that the institutions will be

addressing the problens of geographic distribution and the

problems of specialty distribution than they have in the past.

The question of specialty distribution, the major

concern is the growing shortage of persons to deliver

primary-care services, and I think-we can expect out of the

legislation much more emphasis on getting involved and the

whole area of graduate medical education to assure that there

is a turnaround and a drift towards an increased output of

‘persons prepared, specially prepared to deliver primary care.
And, again, the proposals to Congress vary in the

strength of the leverage that they would apply to accomplish

this. Some are quite direct, and others are more indirect,

 

 

 
 

 

 

 

25

I think it's very likely that we would have some-
thing fairly strong in this area, because of the general
concern,

I mention again the question of geographic
distribution and what is likely to come out there,

We have been, I think, essentially unsuccessful
so far in materially affecting the geographic distribution OE
health resources ~- of manpower resources, and because of -
the very general and serious concern over this issue, I think
we may see fairly strong language and fairly strong provisions
in here on this issue. And this becomes an area of particular
concern to you, because you've been trying to do something
about this in the past. It becomes an area of concern to the
whole Health Resources Planning, because this is an area
that must be addressed to the development and distribution
of manpower to serve the country in the future,

There will be greater emphasis on productivity and
greater emphasis on the development of health professionals
who can work together and, in a team concept, utilizing para-
professionals to their meteor to deliver the most quality
services at the least cost,

The committee in the House is now in the process
of marking up a committee bill this week. There will be

Senate hearings, or they are scheduled now to be held on

June 24th. Because hearings have not been held in the House

 

 

 

 
 

 

 

 

26

to this date, it's highly unlikely that we will have anything

to work with, a new bill to work with by the end of this
fiscal year. It will probably be a few months yet, in my
estimation, before we're ready to implement the new manpower,
the new piece of manpower legislation.

One other element in the new legislation is likely |
to be, instead of having the four pieces of authority, we are
likely to end-up with two instead of four. And one would be -
for nursing, preparation of nurses; and the other would cover
all of the other health professions, most likely it will
come out this way.

I will stop here now.

DR. PAHL: Thank you, John.

Perhaps you'd be responsive to questions.

Dr. Haber?

DR. HABER: Dr. Greene, in the move towards
greater provision of primary care it seems to me there are a
couple of options on a national basis, and I wonder if you
could enlighten us as to what congressional thinking, as to
which option seems to be most in their thinking, or are
they equally concerned with all of them?

I am talking now about the move to increase the

Scope and number of allied health professionals, particularly

 

Surrogates for primary care, in the nurse clinicians, physiciah

i

assistants, or are they more likely to try to remake medical

 

 
 

 

 

 

2/
education so that more physicians go into primary care?
Or are all of these options equally significant?

DR. GREENE: The primary attention in the
discussion so far in the Congress has been more towards
redirecting graduate medical education.

However, there is interest on the other option that
you talked about as well, and likely the legislation will
provide authority to pursue both.

And in my opinion both need to be pursued, and I
think there will be legislative authority that will enable
us to do that, |

But most of the discussion has centered around
attempts to shift graduate medical education or primary-care

specialists.

 

DR. PAHL: Are there other questions or comments
by the council?

Dr. Janeway?

DR. JANEWAY: Do you think, Dr. Greene, that two
bills will come out of the House Subcommittee on Health, or
just one?

DR. GREENE: When it first started, I thought

there would be only one. The reason I say it now, and I

had not said it at first, I think there might be two is

 

because the Roy provisions have now been picked up in the

Kennedy bill and will have to be taken seriously now, I think,
 

 

 

 

28

And Mr. Rogers may hold out and not want that in his bill

that he participates in, and other members of the committee
may decide that they want to follow more down the line of
the Roy provision, and may come out with two bills. It's
hard to tell yet, since they are just starting.

They may come out with two instead of one.

DR. PAHL: Dr. Janeway, would you care to give your |;

assessment? -

DR. JANEWAY: No.

DR. GREENE: I'm just reaching out for that one
at the moment. They are going to make -- they are making an
attempt right now, they are in session today to try to
compromise and try to come to one bill.

But I do think the Roy provisions have to be taken
seriously, more so than a lot of people thought earlier, at
the beginning.

DR. PAHL: Are there further comments or
discussions?

If not, I thank you, John, and hope you can stay
as long as possible, or drop in if your schedule permits.

I would like now -- we have not forgotten coffee,
for those of you who didn't find a cafeteria earlier this
morning; but I think we might wait for that until we have

had the remarks by Mr. Rubel, because I really do feel that

this package of presentations will give you a perspective

t
i

 

 
 

 

 

 

29

that's most important to have at this particular time.

And I am very pleased to have Mr. Rubel be able to
come this morning, again it's a very busy schedule, so the
fact that he's here today is somewhat fortunate for us because
Mr. Rubel is intimately involved in the cevelopment of the
Administration's point of view of the new legislation; and,
as Dr. Greene indicated, since about January or February of
this year the RMP program has been working closely with -
Mr. Rubel, who does have responsibilities for coordinating
internally our several activities under CHP, RMP and the
Health Facilities Program.

So, without further comment, Gene, will you take
whatever time you feel you need to bring all the information
to us.

MR. RUBEL: I will try not to be too “remark-able",

First of all, in the context of manpower debate, I
would suggest to you an article appearing in this week's
National Journal Reports on Manpower Legislation. I think
it is remarkably put, the presentation of the problems as
well as the politics, and. there are a lot of politics.

Iwill try to be a little more down to dealing
with the nitty-gritty things,

I met with some of you back in February, and I am

‘

not sure I knew then what I was getting into; but we did

discuss at that time what the Department's plans were for

 

 
 

 

 

30
spending RMP funds. This was almost immediately after the
court had entered its order on February 7, Dr. Pahl, in .
his letter to you aia summarize the situation as it existed :
early last week, It keeps changing. |

You may remember that back in February we discussed
the possibility or, as we saw it, the fact that Section 910
of the Public Health Service Act was in the law and still :
is in the law, and I believe I indicated that the Department :
was very much interested in utilizing some part of the money |
that had been appropriated under Section 910, which is an
authority we can use to do some things outside the scope !
of the individual regional medical programs. :

The Department, through its representatives in the
Justice Department, cid propose an amendment to the court
order, and we have gone through several months of motions and
counter~motions, and all kinds of gyrations, including a lot

. Of time spent answering questions and the like.

We have reached a settlement with the plaintiffs

in the case, the National Association of Regional Medical

Programs, under which we would be able to use up to five

million dollars of Fiscal '73 funds under Section 910. We
have made it clear that those funds will not be used to

Support any kind of State activities in attempting to

plan for future regulatory rules.

Some of you have been very much involved in this, anc

|

|

 
 

 

 

 

31
I won't take a lot of time to go through this,

One thing is very clear, that the Department wants

to put this litigation behind us. We are interested in
administering the laws that we have today as well as
anticipating what is coming in the future, and we don't see —
any great benefit in continuing to litigate here.

As I understand it, the judge signed an order on :
Friday, in which he requested each of several Regicnal -
Medical Programs to comment on the settlement, and each of
the RMP's has, I believe, thirty days to do that, to the
extent that there is no comment, the final order will be
entered; to the extent that there are, he has indicated

that he will deal with them very expeditiously.

So that I would hope sometime in the middle of July

 

this litigation will finally be. concluded. |
In terms of legislation, you have heard a summary :
_ of what's happening. The House Subcommittee did spend Monday,
Tuesday, and yesterday morning debating the questions of
health planning, as they call it. They are kind of
following an unusual pattern, The purpose of those two and
a half days of discussion was to provide guidance to the staff
in order for them to produce a clean bill, a new bill.

The Subcommittee then intends to take that bill

and actually mark it up, go through it page by page and line

by line. But I think, after the two and a half days, the

 

 
 

 

 

32

.

Subcommittee did give pretty much of an idea, understanding
of what it wants; and I don't think the mark-up that is
going to have to come next will take a great deal of time.

It is remarkable that we had so many members of

the Subcommittee spend so much time. It is obvious that they |

are concerned and interested; both sides, from both political
parties, young and old alike.

I would have to say in very general terms that the~
kind of thing you're talking -- we are talking about, is
best embodied in H. R. 13995, which was introduced by most
of the members of the Subcommittee in general, to look at
all the pieces of legislation. They are very similar, and
I don't believe we heard a great deal in those two and a half
days that is different from what was in those bills, with
perhaps one exception.

It appears to me, and I never said it explicitly,
that the Subcommittee is interested in including a large
~~ relatively large -- pot of money at the State level for
the State government to somehow continue on, or with some
kind of variation -- it!s very difficult to know exactly
what -- of the facility construction progran, the Hill-Burton
program. That was not in any of the bills recently proposed
in any case, Exactly what it's going to say and how it's
going to work, I don't know.

It beats me how that staff is going to write some-

 

|

 

 

 

 
 

 

 

 

33
thing; but they always manage.

In general terms, we have what we call a health
systems agency at the local level, non-profit, private
organizations, and the committee was very firm on that, with,
by and large, a larger geographic area or population hase
than we have in CHP agencies today. They came down firmly -
on a minimum figure of 500,000 people, but which coulda be
waived by the Secretary down to 200,000 if he found it to be |
necessary or desirable. |

This agency would be responsible for doing the
planning for its area. It would also have some relatively
small pot of money available for developmental activities.

There would be at the State level a State planning
council whose members would largely come from representatives
of the local health systems agencies, with additional menbers
appointed by the Governor, and it would be that council that
would approve the individual plans proposed by the local
agencies, as well as using State governmental support,
filling in the chunks and making sure that a highway doesn't
stop on this county line and here and start on the next one
two miles away. .

The State would be responsible for whatever kind of
regulatory features are going to be in the bill, and there

was an awful lot of discussion of what anybody means by

regulation. As you may or May not know, there are some

 

 

 
 

 

 

 

34
members of the subcommittee that are very adamantly against
regulation, although everybody agrees that something like
1122's view of capital expenditure, certification of need
is important and desirable,

‘The staff was instructed to draft provisions that
would allow, that would provide federal Support on an optional,
basis with -- for any State that wanted to get into rate
review activities, and that was further than a lot of people
anticipated they would go,

You may know that Mr. Roy is very much in favor of
a mandatory review kind of role, but he was very happy with
an option, which of course is what the Administration proposed
also.

I would be delighted to respond to any questions
either here or privately about features of the bill.

The House Committee has prepared a very, very
exhaustive analysis of the various proposals that are pending,!
Unfortunately, it's either in -- being printed right now or
on its way some place or other, I am trying to get copies for
you, either today or tomorrow. I am not sure that I am going
to be successful.

In any case, if you want copies, you can write to
the Committee on Interstate and Foreign Commerce, and I am

sure that they will supply one for you,

Unfortunately, it does not have a number, except a

 

 

 

 
 

 

 

 

little thing. on the side here, and I don't know what that
means, but, for what it's worth, 32-84, This is an analysis
of all the bills that are currently pending before the
Congress, |

The Senate has not taken any formal action yet,

although it's my understanding that this is a Committee Print,

about to descend from some place.

In terms of a timetable, much like the manpower
legislation, some optimists hope we will have legislation
enacted in August,

Of course, there are a lot of other things going on
on the Hill. There is an election to be run in November.
And we just don't know.

A week ago I was a lot more pessimistic than I am
today. I think the action that the Subcommittee has taken
has moved a very, very long way down the road, and the staff
is talking about working on Saturdays and Sundays; so that's
the kind of pressure they're under from the members. |

Enough about the status of legislation.

Let me turn to problems of transition -- to what,
we know not yet.

We made a decision back in January, that we
talked about in February -- we have three separate divisions
operating here: one for comprehensive health planning; one

for Hill-Burton; and one for RMP, and that is going to

!
'

 

i
t
+
t
 

 

 

 

36

continue until Congress enacts new legislation.

That has caused some problems, but I think, by and
large, we have been able to continue operating as well as
trying to work together anticipating what is coming in the
future.

We have had a series of groups working together,

trying to plan for the future. We have had a group working

on possible organizations and another group trying to plan on-

i
how we go about the area designation process; how do you take »

into account sub State planning districts, PSROareas, current
CHP patterns, standard metropolitan statistical areas and
the like.

We are in the process of producing a series of maps
for every State in the country, and you see lots of lines
intersecting.

How you make some kind of rational health planning
_ areas out of them is a major challenge. I think we have come
a long way. toward understanding how that process might work.

And many other groups, as we anticipate what is coming.

 

!
I
|
|
|

|
|

i
'

|

Just as soon as legislation is enacted, we intend to

involve in our planning process representatives from all
sorts of organizations, professional organizations at the
national level, representatives from each of the components
that are going to be into this scene.

We don't feel, however, that now is really the time

|

 

 
 

 

 

 

37
to do that, with all the uncertainties as to what may come.

I would like to make one plea. We have had a
fair amount of quibbling, fighting, figuring out whose turf
is whose, over the years. I think that is one of the key
problems that the Congress is attempting to deal with.

We have had a difficult process even during this
review cycle in how CHP agencies relate to RMP's, Frankly,
from my point of view, I am surprised how well things are -
going and how much cooperation and coordination there really
is.

I don't believe it is to anybody's advantage to
continue and perpetuate those kinds of arguments and
discussions at this point. We've tried to get along as best
we can.

It's obvious that if progress were to continue both
programs as they currently exist, I think we would have to
do a lot of work, because I'm not satisfied with the
relationships we have today. “

But I don't believe that Congress is going to
continue the current law, so let's devote our energies to
how we can improve things in the future, rather than arguing
about how poorly they've been done in the past,

In terms of a transition, we have worked very hard

to insure that the agencies, organizations that are funded

now will be funded through some transition period. We don't

 

 
 

 

 

 

 

38
believe it's to anybody's benefit to stop everything now and
then try to start it all over again next year.

Most RMP's will be funded through Fiscal '75. The :
314(b) agencies, the local agencies, will be funded through
April of Fiscal '75. We have a oe real and big problem |
with the State agencies. | |

Mr. Milliken works for one, where, as it was
described in a hearing, "we fall off a cliff on July 1."
I think we can figure out a way to handle that with some
help in the congress, as part of the continuing resolution.

In any case, we have tried very hard to find -- to

insure that there be some kind of orderly transition. I !
think that's something that everybody agrees is very necessary.
The question has come up, and you are going to have to face, )
during these next few days, to what extent there are :
organizations that perhaps should not be continued during that
transition. And that's something you are going to have. to |
deal with on a case-by-case basis.~
I would just like to give you my observation.

That I think you have to decide is something Marginal, you
know, is it doubtful. We've been carrying something along

for a long time in a certain kind of situation, and if that's

the conclusion you come to, my recommendation would be to

let's keep going.

Why co we want to change things now when a year fron
 

 

 

39
now we are going to have a very natural kind of resolution.

On the other hand, to the extent of organizations
that have no capacity, that are not doing things useful in
their communities, I think we have an obligation and you have
an obligation to conclude that federal funds will be wasted
on that kind of situation, and to act accordingly.

Finally, I have tried to make a plea for many months
and that is that we don't want to see major organizational -
changes made at this point in time. I have told -- perhaps
some of you have heard this story, but last October
Congressman Roy spoke before the American Association of
Comprehensive Health Planners and talked about his concept
of a Regional Health Authority, and that evening someone came
over to me and said, "Where do I submit my application?"

And I tried to say, Well, that's just one Congress-
man's idea.

We had people at that point that were prepared to
make all kinds of changes in order to accommodate an idea
that someone had proposed,

Well, if that had happened, they would be in very
‘sad shape today because all of the concepts and ideas that
Congressman Roy advanced have not been accepted, and I think
the same thing is true today. We still don't know how this
is going to work out.

And I don't believe it's in anybody's interest to

 

 
 

 

 

 

40 |;
actually make changes,

On the other hand, all of us are planning and
trying to come up with contingency plans; and that is very
proper.

But let's wait until the Congress acts before we
make any kind of permanent changes, because we may have to
make them all over again.

Finally, I would like to echo pr. Margulies! point,
you are going to have some very difficult decisions to make
here.

I think we have to hit the hard issues hard,

There is no point in trying to gloss over things. I think the

staff has done a very good job, and the review committees
have done a very good job of raising the problems. And
they are going to be difficult to deal with in some cases,

I suggest that we try to make difficult decisions.
‘This is a time that many people are questioning whether
the government can function at all, let alone function
effectively. Let's see if we can demonstrate that as
servants of the people, really, that we can.do the job
effectively.

DR. PAHL: Thank you very much, Mr. Rubel.

Are there questions or comments by the council on

any of the matters touched upon, or just perhaps glossed over,

in view of the vast amount of activity that's going on at

(
t
t

 

 

 
 

 

 

 

41

this time that you would like a little further clarification
or amplifaction?

Dr. Merrill?

DR. MERRILL: I have realized, from what you and
previous speakers have said, that no one has the answer; but
what I would like is perhaps an educated guess, so that I
can respond to people who ask me such questions.

One which I hear most frequently is the following: .
Let's assume the transition period works and all the
contingency plans are fine.

If funding for RMP is continued, in what form, undex
what authority will that be?

MR. RUBEL: I can see about a 99.5 percent

probability that funding for RMP, as such, will not be

f

 

continued. I spent two and a half days before the Subcommittee
and I did not hear a single member even once raise that as an -
option. It is conceivable that it will be done on the Floor
of either House, or yet within the Subcommittee or Committees;
i

but they clearly are looking to set up a new kind of

arrangement, /

Now, on the other hand, it is also very clear that
they intend to build on the structures and the people that we
have working in the CHP agencies and in the RMP agencies,

i can see many RMP's, as we know them today, with or without

changes, becoming very much a part, becoming health systems

 

 

 
 

 

 

42

agencies in many places, and that kind of thing.
I don't know if that answers it.
DR. MARGULIES: . John, can I pick up that five-
tenths percent, because you and I are physicians and understand
about that, | |
There is, up to the present time, no planning bill
which has even reached the House, and we have seen many |
misfalls in legislation, On that five-tenths percent basis, .!

what could happen is a matter of technical process,

It is a continuing resolution and an extension of

legislation in its present form. We will certainly enter the:
next fiscal year in some of our programs on that kind of a
basis, and you realize ~- well, I'm not so sure you realize, |
a lot of people don't seem to realize, even at high levels in:
government -=- that when there is a continuing resolution,
which says that the appropriations will continue into the
next fiscal vear, that also extends the authorizations to
which those appropriations are attached.

So that possibility could exist. That would

immediately be negated with the passage of legislation which

would replace the RMP, CHP, Hill-Burton, et cetera, with a new

kind of planning legislation,

MR. RUBEL: Or by passage of an appropriations

Act.

Now, to be very candid, Dr. Margulies and I were az.

 

 

 

 

 
 

 

 

 

43

an Appropriations Subcommittee hearing not long ago, where
we were told by -= we were asked, the Administration was
asked: You're proposing to eliminate the RMP program --
and then we were told not to hold our breath.

So, you know, there are a lot of things that are

possible, but I can repert to you that in two and a half days.
before, you know, eight of the eleven members of the House
Subcommittee there was not one mention made of continuing .
any of the current programs in their current form.

DR. MERRILL: I think the thing that's been confusing
to many people, including myself, is the kind of thing that
you state, and what I've heard repeatedly, and that is:

Let's keep things going the way they are.

 

And, on the other hand, the statement that there's

99.5 percent chance that things will not be kept going the
way they are.

I realize there's probably no other alternative,
and I certainly don't have one, But -=- I think you have
defined those difficulties.

DR. GREENE: With the council's permission and
because of the importance of the topic, I would like to
recognize Dr. Donald Sparkman in the audience, who is the
chairman of the national steering committee of RMP
Coordinators, who would like to make a statement on this

point.

 

 
 

 

 

44

DR. SPARKMAN: Clearly, Doctor, Mr. Rubel is much
closer to the legislative situation, and Dr. Margulies, than
Iam; but from other sources from which I learn information
about this, it is not quite 99.5 percent sure that there will
be no RMP, |

There is a consideration of this, and I would
remind you that as of a year ago the Administration said
there is going to be no RMP as of June 1973, and the -
Administration officials, Mr. Rubel and others, clearly said
that. And beyond that time RMP probably will not survive,
and the Secretary and others took steps to make it as
difficult as possible to survive.

We are still in business. I think there is at
least a reasonable possibility that some modification of the
existing RMP concept and function will continue, and I find

it difficult to accept his statement.

DR. MARGULIES: John, may I pick up on that,

 

 

because I think your point is an important one.

Partly because it provides us the opportunity to
separate the rather restricted federal view of affairs from
the much more mobile and flexible view at State and local
levels,

Let me go back to what I said earlier to this

council. You are operating under existing legislation, and

there is not much reason for you to speculate about what new

 

 

 
 

 

 

 

45
legislation will do. You are also operating under a court
order, and it's quite clear what Congress intended, and
Congress has not changed its mind,

In fact, this RMP will continue, as does any other
program, unless Congress specifically rescinds Title 9,
which is the basis for the legislation.

But beyond that these comments are, in a sense,
specious or irrelevant, at least; because if there is to be, -
with or without legislation, an effective amalgamation of the
programs we have under discussion, it will be because of the
efforts of people at State and local levels.

The wisest thing that we could do with this
council activity is to encourage and support the RMP's to

function in the most material manner possible, and the

t .

 

wisest thing they could do is to combine with their CHP
colleagues and other appropriate agencies in the State to
talk with one another now about how better to function at the

State level, regardless of what happens.

I dont think there is the slightest doubt about the
need for that to occur, whether the legislation is passed or

whether it stays the same.

In fact, if the States could deal effectively with
the elements within their boundaries, which we are dealing
with at a distance, they could do whatever is proposed in

upcoming legislation without any new legislation being passed.:

 
 

 

 

 

46

The fact that they have found that difficult to
do has encouraged Congress and the Administration to alter
the forms in which they function; but the best thing we
could hope for is for people to act together in a common
interest within the State, knowing more about what's going

on than anyone else does,

And I would add to that, Don, and I know you would

agree, because we talked about this before, that the time has.:

passed for us to concentrate too heavily on two programs
which happen to have been passed about the same time and
have somewhat similar interests. When we are talking about
planning for a State in the field of health that involves a
wide range of institutions and activities in which the CHP
represents the major, and from the federal point of view,
the critical planning force; but it has to deal with
maternal and child health services, mental health services,
hospitals, nursing homes, payment mechanisms, the whole
gamut, not just two programs. And if we can get a little
further toward that understanding, I think, regardless of
the legislation, we are going to be better off.

DR. GREENE: Thank you.

Are there other comments?

, DR. WAMMOCK: I would like to echo that feeling,

because of being involved in that Situation of getting the

States involved, to accept what's going on as a cooperative

 

 

 

 
 

 

 

 

 

~ |
‘ !

4
effort, and I think that some effort has been made in that
direction in some areas to do that very thing. Because you
have got six different roads or detours going off doing
different things,

And I heartily echo that situation, regardless of
what happens to RMP, because there are things in here that
are salvagable and worthwhile to be used in the future.

And if we can combine these with the efforts that the State
level is trying to do, I think we are going to be better off.

MR. MILLIKEN: To this end, I think there is a
need right now. A good demonstration of the need for pulling
this together, to have an effective activity.

I don't know about the rest of the country, but
Region 5 and Region 3, HEW regional offices, are in a kind
of a problem of working with States who are tending to
pull back everything to within their State boundaries.

Now, between Indiana, Kentucky and Ohio, there has
been, for a long time, a very significant cooperative program
where both RMP and CHP are in interstate health trade
regional activities. And there is an urgent meeting called
next week in Louisville to bring regional offices, States
and local areas together to see what can be done to continue
this kind of cooperation.

Now, the HUD program and other kinds of government

planning are not unrelated to this, and it does begin to put

 

 

 

 

 
 

 

 

 

48
us into, you know, if we can't have a strong front here,
in view of the need for keeping these kind of trade area
voluntary coordinated kinds of programs, then I think we
face a very serious problem.

DR. MARGULIES: I think one of the reasons that
there was and is a heavy commitment to the private, non-profit
approach to thing is because it does lessen the likelihood
that the artifacts of political boundaries will be too -
constricting,

On the other hand, you' ve been on this council long
enough to know that at the State level that artifact is a
very powerful one. After all, funds flow into States on a
geo-political basis around those boundaries. But I feel
reasonably heartened, as I would think you would, over the
very successes that you pointed to, like that tri~State

arrangement with both RMP and CHP that you've had down there,

 

that people have managed. And I think it's much more likely
from our experience that that could be worked out between the |.
people there than for us to do anything certainly dictatorial
at this end. It just won't come out that way at all well.
MR. RUBEL: I can report to you that the Subcommittee
very firmly stated it is in favor of interstate areas, and
for that reason decided not to allow the Governors to make

the final decisions on area designations.

Certainly the Administration bill would advocate

 

 
 

 

 

 

 

 

49

interstate areas, It's a very. complicated kind of problem,

we tried to get into it, there are some 17 interstate CHP
areas today, but there are 37 interstate Standard Metropolitan
Statistical areas.

Now, some of them we have interstate, some of them
we don't. The political processes are,quite apart from any
kind of knowledge about the medical trade area and what
service patterns are, are very difficult to deal with, .
But it was something that the Subcommitttee did deal with
very explicitly, and you may know that Senator Kennedy's
bill provides for areas wholly within the boundaries of States

So we will see how it comes out.

DR. MILLIKEN: One more quick question.

The new legislation on the relation of PSRO,.
was that left in?

MR. RUBEL: It was brought wm before the Subcommitte
The question was asked: Well, should there be the same
boundaries or not, and I think there was pretty general
feeling that some of the PSRO boundaries don't make much
sense. And the Subcommittee finally decided to tell the
staff to use some vague language about the need to coordinate
with various kinds of things, like PSRO boundaries, sub-

State planning districts, and the like, without any mandate

that you must follow.

DR. PAHL: . Thank you, Gene.

e,

 

 
 

 

 

 

50

Are there any other comments or points to be made
by the council? |

If not, I would like to thank you for the remarks
and say that Mr. Rubel has indicated he will be here for the
better part of the day, and there will be various points, .I”
am sure, you may wish to interact with him as we come to
other topics.

Now, looking at the clock, I would like to ask -
your indulgence for one more thing, because I see that Dr.
Goodman has come into the room, and I know from earlier
conversation that his schedule is very tight today, and
therefore I would like, before we break for coffee, to have
his few remarks to you, because he will have to leave for

another meeting.

I would like to go to Item 6 on our agenda and

 

introduce to you Dr. Alvin I. Goodman, who is the Program

Coordinator for the End Stage Renal Disease Program for the
Bureau of Quality Assurance of our sister agency, the Self
Health Services Administration. They too are located in
the Parklawn Building with us. ‘

We are, as you know, as an RMP program,heavily
involved in a kidney program, and those of you who have been
on the council have witnessed the development and establish~

ment of dialysis and transplantation centers as a result

of the activities of RMP's,

 
 

tion, the End Stage Renal Disease Program has been established,

 

 

 

51

Because of the Social Security amandments of 1972

and the payments that are now possible to patients under

those amendments for treatment with dialvsis and transplanta-~ |
|

|
Dr. Goodman is the director and has asked, ovor recent months |

for the assistance of Regional Medical Programs in helping.

to implement in the initial stages the activities which he i

W

required to establish and administer. >

So I would like to have him address you and stay
for whatever length of time is possible; but I know it will
be brief, because he has, as I say, another meeting.

I think it's important that you hear the message
from Dr. Goodman,

DR. GOODMAN: Thank you, Dr. Pahl,

Members of the council, as most of you, I am sure,
are well aware, in October 1972 as part of Public Law 92-603,
Section 299(i) addressing chronic renal disease as considered
to constitute a disability, was passed by the Congress.

This legislation went into effect as of July Ist,
1973; as part of the mandate of the legislation, there were
various requirements, including a Specific one for medical
review boards. As yet these medical review boards have not

been constituted nor established in the field,

 

During the interim period, an interim policy was

enunciated in June of 1973. Since then, in April of this year’,

 
 

 

 

 

 

. 52}
\ : i

1574, final policies for the End Stage Renal Disease Program | _

of Medicare were announced by the Secretary.
For those who do not have copies of those final

policies, I am leaving some on the desk here,

These final policies reflect the input of many

professional organizations associated with delivery of

End Stage Renal Disease Care, including professional input
from the RMP office. -

The major aspects and issues to address at this

moment is the fact that there will be finally what RMP's
have been working on for years, a development of a network
approach for End Stage Renal Disease Programs, in that the
broad array of professional skills and facilities required
for the treatment of such patients requires such a coordinatio
of effort and that facilities will be organized in regions

on such a network approach,

And perhaps at the apex of the network will rest

 

a medical review board to screen ‘appropriateness of care,to

screen quality of care, and to assist with other organizations
in facility planning. . ;

We are in and in-between phase. This was quite

discerniblewhen I arrived. On the one hand, those local
bodies, RMP's who have had exnertise in these areas and plans |
which, to a lessor or greater degree, were being implemented

~~ often, unfortunately, to a lesser deqree -- their existence

a

 

 

 
 

 

 

x SST

was threatened, as was discussed this morning.

on tho other hand, the PSRO groups were quite, and
still are, in their infancy, so it becam a question of how
does one, as rapidly as possible, establish these netvorks, :
establish these medical review borvrds without going throuch
the long,laborious history that established RMP 's, that are
establishing PSRO's,

In discussions with members of RMP here, it -
became clear that it might be possible, with the willingness
and cooperative approach of various RMP offices across the
country that we can initiate the program and implement the
program through these RMP offices, and see what develops in
terms of what their future history is, and what the PSRO
history is in trying to phase in appropriately this progran
and then phase in eventually, perhaps, with PSRO,

This program will be administered through the
Regional Health Administrator's office. It is readily recogni
that the RHA's andtheir offices neither have the experience
nor the on-board expertise from the professional point of
view and from the planning point of view to, easily implement
this program, yet virtually every community across the country
every region across the country still has an existing RuP
office in which there resides such expertise and much

planning in terms of renal Gisease.

So what is hoped for, in essence, is that various

 

 

28°

 

 

 
 

 

government agencies and authorities in the given regions

will be able to associate themselves together, some lendina

forth the organizational structure, the federal structure,
t

the regional health offices and others Giving their expertise |

ae *

boos

{

in rensd Jis 08. 2 * prev’. = :2-nning toward the rapid
'

t

implementation of the network concept, the affiliation of

institutions in a given region, and a development of local

medical review boards appropriately to work out in the initial

difficult phases this type of planning and this type of
logistical and administrative support.

This is sort of quite compatible with the statement
made within the program of trying to use that type of
programming and expertise still inherent in RMP in facilitatin
new programs and new plans as they come about. We hope that
we are able to develop this cooperative approach,

I still have plenty of time for questions here.

DR. PAHL: Okay, thank you.

I think we are interested in bringing this message
to you at this time, because this is one of the instances in
which the existing organizations known as RMP ' s are finding
themselves to be of great importance to another administra-
tion's program, in fact another agency's program, and we
are delighted to be cooperative and helpful with Dr. Goodman.

And there will be official materials developed and sent out

to all RMP's shortly about this. But there has been a lot of

|

J

 

 

 
 

 

 

 

 

 

un
a

behind-the-scenes vork between these two agencies and two
prograns, in order to try to use our resources to help
establish and initiate a program that ot. trwise would not be :
able to be started for many, many months to come. !

: . 1

I would like to have an, questions or comments that!
you have directed to Dr. Goodman.

Dr. Schreiner? | . i

DR. SCHREINER: Well, we heard about the problems
of integrating trade areas with State boundaries, and this
legislation, when they started out orienting payment out of
the Social Sectrity regions, which are different than the
health regions.

I would like to get your idea, when you're talking
about regional review boards, are you talking about the nine
Social Security Regions? Are you talking about the six
regions of the RMP's? Or are you talking about an entirely
different set of regions?

DR. GOODMAN: At the most local level, at the-
network level, the network level which is completely Flexible,
Since it is contingent upon facilities that bear the care,
One can even see in certain sections of our country, if
you were to talk about the Dakotas, Montana, and so forth,
that you may have a network which is based on a large © |
extensive area that may cover to or three States, in terms

of the most local levels.

 
 

 

 

 

t
{
\
|
. . !
In other areas of the country, the large metropoli- ,
tan centers, you may have several networks or several review j
}
+ os : : : ~,!
boards, similar to the PSRO 5s Stem, within a given metropolitan
é . : I :

area. So that is at that lower level,
At the secondary level, the regional representation

that would stem out of the ten health regions, the ten Health

regional offices, because there must be some way to
administer this from central headquarters, if you will, out -
into the regions. And that would be based on the health regions,

llowever, we are keenly aware of the fact that there

are artificial ‘boundaries in so far as facilities are
concerned, and as far as the patterns of referral of patients,
and that you can have a region -- well, as a classic example,
you might be having a Philadelphia-Camden situation, which

are specifically separate States, specifically Separate health
regions, and yet one health area in terms of planning,
certainly for this particular problem.

And it is certainly an issue which has to be
addressed, and which we are leaving all flexibility to be
addressed, and we hope that perhaps we can even be a little
iconoclastic about such issues,

DR. HABER: Exemplary of possible metamorphises of
relationships between various federal agencies is the VA's
interest in the renal dialysis with which we have been talking!

to Dr. Goodman and others about,

 

 

 

 
 

 

 

57

mh

We estimate that twenty percent of all renal
Gialysis currently performed in this country is performed

+

by the Veterans Administration. We have an effective

arrangement under which a small but growing number of non-
veterans can he dialyzed in our facility through sharing
rrangements.

The rationale for this being that we will dialyze
non=veterans in exchange for comparable services for ~
veterans by whatever hospital or medical school we have such
a sharing agreement with,

this is entirely consonant with our basic mission
of providing care for veterans,

This effective arrangement of limiting unnecessary
duplication of scarce resources is threatened by a legalistic
argument as to whether or not the Social Security Administra-

tion can reimburse third-party payers, who in turn reimburse

the medical schools with which we have these sharing

aad .

arrangements,

Two issues are at stake. One is the legalistic
argument I mentioned, which I hope can be resolved; I feel
fairly confident.it can be,

The other, which I am almost certain can be resolved,
is the question of medical standardization. And we are in

entire sympathy and support with Dr. Goodman's contention

 

that one standard for renal dialvsis should prevail throughout

 

 
 

 

 

 

the country, since most of the people in the VA -- I'm

talking about physician providers now -- who are involved in |
this are people who are emploved on e part-time basis with
the VA and they are also employed at the schools of medicine
and so forth,

So we feel reasonably sure that this will be

consonant with our mission. Sweetness and light will prevail.!
DR. PAHT: ‘Thank you very much, Dr. Haber, -
Dr. Merrill, did you have any questions or comments?
Anyone.on the council?
Mr. Milliken.
MR. MILLIKEN: Well, I think I have spent more
time in the last month on the renal thing, the renal problems

than I have time for, or intended to,

Because of the lack of coordinated concept at the

 

present time, of who is already in the act and who is getting

into it, and what the process, indeed, is.

It's my understanding th our region, for example,

that the Social Security office in Chicago receives
applications for renal programe, They then forward these
applications to the A agencies, who then submits it to the
B agencies for review and comment.

Now, at the present time, in Ohio there was a very

good active program initiated through RMP, which sort of

extended itself into a Statewide renal advisory committec,

 

 

 
 

and there was some unfortunate lack of communications between

“and getting the right people together and finding out who is

 

 

that committce and applicants, and the confusion on what the |,
process is for submitting epnlications ard getting clearance.

We had one case in Columbus where a New Jersev firn

(D
3
hy
Q
uy
og
3
ch

has come in and set up a dialysis rrogram, and at th
time they have been unable to qet back=up arrangement from
the medical center at the university.

So the whole thing is stymied and bogged down -
ricsht now because of the fact that the Social Security
office in Chicago is not able to get the kinds of clearance
from the B agency and the A agency necessary to recommend
and approve that program operating in that city.

It’s being straightened out, and it will be. Tt's
well on the way, and we're having good cooperation. But

the man-hours lost and running down these leads and problems

doing what is absolutely amazing.

DR. PAHL: Dr. Merrill?”

DR. MERRILL: I might, perhaps, in view of Mr,
Milliken's comment, ask Dr. Gocdman a question,

As I understand it, what Mr. Milliken said is that
there are problems with new facilities. Do you see this.
as more of a major problem that coordination of existing

facilities, or are both equally important?

DR. GOODMAN: Well, there is a very clear mechanisn,.

 

 
 

 

 

There is an allocation of responsibility between the
VESpective ayencies, Social Security agency, and we are at
the stage now, we have the professional input into the
program and implementing professional aspects of the progrean,
The Social Security office for administrative
purposes anc ease of administration receives the application,

CHP, which could not and should nat be ignored, is supposed t

ascertain need on a local basis and on a State basis, to the.

extent that they are capable of doing so and do a good job.
This facilitates the flow of the applications and it
facilitates the movement and their final adjudication,

Dr. Rubel and I are aware of the problem that
c@értain areas have. The CHP's, in some areas they do a
beautiful job, they come out with beautiful plans, as have
RMP's in some areas. And in some areas, as have some RMP's,
they have not, and many more CHP's have not addressed these
issues.

To the extent that they ‘don't, that means the
regional office then receives the application, the health
officer attempts to --+ to the extent that they do not have
the expertise within that office, we do here. We pretend we
do have the expertise, and we make decisions,

Now, we have received about a hundred applications,
we have approved ahout fifty to date, since the program was

on. We have referred others.

a

 

 
 

 

 

 

61
The major problem, indeed, is not so much the

flow, it. is the competition, the competing forces out there

to establish these units, and ascertaining of need,
Quality becomes somewhat easy to ascertain. You can develop
standards easy enough to do that, i

But it is really truly ascertaining need, We are
absolutely in whole segments in the country where we feel
people are not literally dying in the street because of lack-
of our facility. It's kicking them back and forcing the
agency to make determinations, which is a club I think we
can USE.

Certainly the potential providers are warned that
in no way are they starting an operation that binds this
government to pay for it until such tine as they meet the
qualifications, and meet the question of need,

What we are hoping is that by the formal development
of networks, by the development of a medical review board
composed of professionals, delivering the care and allied .
health professionals and health planners -- we may call it a
medical review board, but it has a number of functions beyond
straight-forward medical review -- that it will serve as a
Spearhead and a stimulus to the CHP's and others to develop
appropriate local planners, and to overcome the problems that

you alluded to,

DR, PAHL: Thank you.

 

 
 

}~!

we

nN

B

 

 

 

Any other comments?
if not, FT would just indicate that 1 guess last

month, early last month, Dr. Goodman did meet with a number

of coordinators with the steering committee, and we talked
about the details of how the RMP's could be of practical help

in initiatine this thrust. And, as I Say, Materiais will-be ~

coning forth to the council, our review committee, and also
RMP's in the near future, . -

I would like to call a break at this point, and
thank Dr. Goodman for bringing the comments. And may I
suggest that we ‘reconvene at as close to 11:15 as possible,

Perhaps you would care for some coffee, soft drinks,
and so forth; and the staff and others can guide the new
members to our cafeteria for some refreshment.

[Short recess.]

DR. PAHL: Will the council please come to order,

AS we reconvene, I find myself being bumped to
lower and lower on the agenda, and“about this time I have

decided you won't need a report from me. But I am delighted

to yield to the gentlenan from the Health Services Administra-
tion, who is sitting on my left, who is Mr. John Reardon,

Acting Deputy Director of the Division of Emergency Medical

Services in the Bureau of Medical Services, Nealth Services

 

Administration -- and that long title will be found under

Item 7 on your agenda.

eer een nneper nena so cnet

 
 

 

 

\ | 63

The reason I have asked John to come and speak for
a few minutes with you and again be responsive to questions
and inquiries, is because he is in charge of the Dmergency
medical Services over-all program and is responsible for
coordinating our activities in the EMS area with those of the
Department of Transportation, Health Services, and others.

I have asked him to please give you a perspective
of the total EMS activity, with special emphasis on how
the Regional Medical Program activities fit in, and the
sind of cooperation which we have been experiencing together
over these many months, and particularly this last week
when there was a meeting, which he will summarize for you,
and in which all of the projects from our regions which
will be appearing before you today and tomorrow were
discussed and put into a total framework.

John, would you care to give whatever comments,

-and then be responsive to questions, please.

ed

MR. REARDON: Thank you.

Members of the council:

I think this council has been involved for a number
of years in Emergency Medical Service type problems, and
you have funded a number of activities which, in the past two

or three years, I perscnally have followed with interest,

and many of which I have been out to see, have been

involved in, and am very happy to report that they have

 

 

 
m1 TN san ne an ~ nd it. fF

Can o& accommodated within our new law,
In terms of programs, the bmergency Medical

Service program, which I am involved in, this began about

two years ago when we awarded denonstration contracts, These

are now in their second year of three. We have had successes

and failures, but I think that's part of demonstrations.
I think we have demonstrated that the systems
approach to the delivery of emergency medical services is

not only feasible but is a practical and economic approach

to solving the problem,

We have full Emergency Medical Service systems on
the street, taking care of people on a regional basis, and
these systems are approaching self-support levels.

With that much of introduction and passage, if
you will, of our demonstration activities, as you recall,
last November the Emergency Medical Service System Act of
1973, Public Law 33-154, was passed by the Congress, signed
by the President, and we had funds in the amount of $27
million provided under the First Supplemental to the FY74
budget.

The funds basically are three and a third million

dollars. This year it has gone, been appropriated for research

 

which is being handled by the Bureau of Health Services

Research in Wealth Resources Administration. The training.

 

 

 

 

 
 

 

 

 

\
\

aspect for not only professionals but allied health
professional personnel is six and two-thirds million dollars,
|

That is a decentralized, completely decentralized program )
being handled in the ten federal regions, and the applications
have been received. Those applications are currently under
review.

That program is being administered by the Health
- Resources Administration, Bureau of Health Resources -
Development, Seventeen million dollars is concerned with a
feasibility study, planning, initial operations, implementa-
tion, if you will, and expansion of existing systems of
emergency services,

That is the portion of the budget which I am
particularly involved in, |

Our regulations were developed immediately after
‘the passage of the Act. We went through the clearance
procedure, They were published.on the 29th of March, an
extremely short period of time was provided, essentially
thirty days, to communities to submit applications and have
them back in essentially by May lst, ‘

This was an absurd period of time to put together
a meaningful application for a total system. We recognize
that. However, in order to get rid of the moneys by June

30th, which we were faced with, that was the only way we

could approach it,

 

 
 

 

 

66
We did receive $54 million worth of applications,

and for $17 rm
Sone of those we have not been through. Some of

them were atrocious. We received « few good ones, and those
that were good have a high probability of success. We will

Fund. ,

As part of this; I think it's important that we

‘come back to your interest in the Regional Medical Programs. _

We are concerned with a total system which, in my definition,
contains three major components. The professional services,
of surgical, medical and mental health services. It contains
all the functional components of transportation, communica-
tion, training, consumer education, information type
programs. These are the kinds of things that people
routinely associate with emergency services,

We also have to pay particular attention to how
these services and the components are amalgamated in the
rural and the urban setting. How -you put them together
in the total systems approach is significantly different in

the two types of environmental settings,
We are concerned, though, that we develop total

systems. That is the charter of our law. And the number of

applications we did receive were for categorical requests,

They wanted to buy an ambulance. We turned them down,

because that is not permitted by our law: and other funds are

 

 

 

 
 

 

 

 

 

 

67

4
\

available,

in the repert both from the Nouse and Senate, the
language of the resort very clearly sets forth the intent
of Congress, and this particular Act was to support total
systems, The communities thet seek categorical funds should |
go to other programs for those types of funds.

Now, as far as our working with other programs, I
think we have perhaps set the ground rules way back when ”
we were working with demonstrations. We just finished this
week a national review of the regional recommendations. We
had representatives there from CHP, RMP, the Department of
Transportation.

I understand 11, as you recall, has been very
active in training, communications, transportation.

We brought in Health Service, we brought in other
people like this who were spending money on categorical
components of a total System. We worked very diligently with
these people over the months, to be Sure that we were not :
only concerned about the funds but also that we use their
technical expertise to make it available to ‘the community
in terms of technical assistance outreach programs, so they
can be part of the total system.

We have cross~exchanged financial information in

terms of potential grant award programs, where money is being

Spent, vhere it's being recommended to be spent, to be sure

 

 

 
 

There are others approaching the level of beginning full ~

 

 

68

,
\

\

that there is no duplication of funds, to make sure that our

funds are complementary.
I am also happy to report that within the two or

three regional medical programs that are fairly large,

that you have been involved in. over the last couple of yoars,

those programs have made application and they have progressed.

1

in their development to a point where they are now ready.

system implementation, and we are very receptive to those,

I should mention, if you don't already recognize it;
that within our law there is one part, Section 1207, which
says, in effect, that other funds of the PHS Act, other than
the EMS funds, cannot be used to support full EMS systems;
and that’ is a restriction which the Congress has placed upon
your deliberations,

However, Dr. Pahl, our general counsel and myself
in the EMS program have worked on this, and we have no
problem with the recommendations that will be presented to °-
you in your current meeting.

We feel that these are not in opposition to the
intent of Congress, and that they complement our program and
they do not conflict with our program.

We have also reviewed these against the applications
that we have been reviewing in the past few days, and we

have no problems with this.

 

 

 

 
 

 

 

63
Somebody was talking here this morning about the
Social Security Administration and renal dialysis. I think
one of the things that we are perhaps most aware of in the
topic of emergency medicine is that we are dealing with a
conglomerate of federal acencies, local acencies, State
agencies, This is one reason that we have before the

Congress, and Congress did provide under our law an inter-

agency committee, That committee will be composed of

approximately 22 federal agencies, departments and offices
concerned, and it does involve the Social Security
Administration, SRS, and people like that who are involved
with Medicare and Medicaid.

Because if we are going to develop emeraqency

medical service systems, we have to be sure that the

reimbursement mechanisms covered by those agencies are

‘adequate and are equitable in terms of reimbursement for the

quality of service that's provided.

Our intent is to develop self-sustaining systems
and not systems that depend on continuing federal aid.
We are working on those kinds of problems. , We are starting
now and not looking back, five years from now, and saying
that's a problem that should have been discussed,

We are working with people in the Department of
Agriculture, the Rural Extension Service, in some of our

educational programs.

 

 
 

 

 

70

We are working with the Veterans Administration,

the Departnent of Labor, in terms of inclusion of the
returning veterans in training prograns, getting them
involved in some of the paramedic type activities,

I think we have a verv exciting procram and itis
« 9 : = ?

a program that has in effect been in being for a couple of

years, but has now new legislation, and we are on the
‘threshold,: ~
Next year the Administration has requested a
budget for FY75 of $27 million. Again we look forward to
our '76.plan, we have already prepared the papers requesting
somewhere on the order of the full authorization of 75 million
So we are looking toward building the- program.
‘We will stress funding of quality projects. I will
Say that the one efficient thing we have found in many
applications, and I think it is not due to the applicant's
fault, it's more due to the federal government's fault, this
year is that we had many local conitunities, county, city,
metropolitan community apply, This is fine. It fulfills
the letter of the law. ; ‘
| However, what welre trying to do is to develop
regional comprehensive systems which pull together and make

best use of the investment and resource that tha community

 

has.

I think we will see, through our technical assistance

 

 

 
 

 

 

 

program and through the funds we have spent in the coming

year that there is a growing interest in this regional
approach,

We know it can work,

Iwill be very happy to answer any ques tions that
anyone may have about this pregram, or anything that mignt be
related to your discussions coday. |

DR. PAHL: Thank you. -

Dr. Janeway?

DR. JANEWAY: Mr. Reardon, I can understand your
rationale for this short timeframe perhaps, because I happen
to know of one area that did not submit a request because it
thought it could not develop one of high enough quality.

On the other hand, the EMS research, I find, have a
four times application cycle, and the EMS training, I guess,
will have one,

Is it your guess that with an appropriation for
FY75 that you will have four cycles for applications, or just
one as you had this tine?

MR. REARDON: That's an issue which we are currently
-— currently have our grips on. I doubt very much there |
will ever be four cycles, If we're looking at cycles at all, |
we will he looking,probably, at one or two cycles,

I would like to have a continuous cycle. Tf think”

any time a community has developed a meaningful application

 

 

 
 

and has it ready, it should cone into our consideration so
that we can immediately review it and start to critique it.
i DR. JANEWAY: What. is vour guecs as to the

1

probability of having continuous onplications?

MR. REARDON

re

Ce ne eee bb ey the appropria-

tions cvcle, I think that's thea soverning mechanism in texms

. . - |
iy .
.
of a continuous cycle,

For example, we could be able to receive applications
in July, August or September, but we won't know what our

appropriation is until probably October, November or

December. And it will be very difficult to make the best

investment with those moneys in July or August, although I
think we can review those, and we would hope to work with the

he ek wee

communities to =~ to work with them to approve a good

application, to the point where it should be funded when the

funds becone available,

I think there is a backlash, of course, on the

continuous cycle, and I think cormunities tend to respond
to a stimulation, If we Say it's got to be due by a certain
date, they tend to get things ready, If they are provided
an adequate period of time, sixty to ninety days! notice, | |
we say it's continuous, continuous in our reinforcement that’ |
we are receiving applications, that committees will go. back :

to sleep and they won't submit then. And they lose a good”

Cu

Opportunity. It is a dilemma,

 

 

 

 

 
 

 

73

DR. PAHTs Dr. Watkins.

DR. WATSLNS: Dic I misunderstand you on funding,
when you said you'd avoid Medicaic and Medicare, and
obviously NHI. Are you then going to depend on RMP and one
other source?

I wasn't sure about that.

MR. REARDON: What I said was that as we begin
to develop and implement, the local communities develop and -
implement and put on the street total emergency medical
systens, service systems which are defined in our law, we
are going to have to look for improved coverage and reimburse-~
ment in the area of Medicaid and Medicare to reimburse the
provider of that service at the local community level for
the services that are provided,

Right now, as an example, it's not unusual for
Social Security Administration to be paying ten dollars for
an ambulance call. Well, that's all right if you have -the
vertical or the horizontal taxi, “delivery, that covers the
cost of the transportation and oxygen; but in terms of the
quality service, which is supported with central communication;
well-trained people on board who can do EKG, telemetry,
treat trauma, stabilize trauma, ten dollars is a ridiculous
fee to be paying for this type of service. And we must

obtain an equitable reimbursement,

We are working with SSA and SRS to improve their

 

 
 

 

 

 

 

 

74
coverage and reimbursement mechanisms in this area,
This has ‘to go along with cur national health

insurance proposals and PSRO and HMO and sone of the other

mechanisms that are also being Ceveloped.

|

|

tes!

DR. WAMMOCK s: Are these people going to be classifie

as physician's assistants and EKD's, cr what, if youfre -
talking about on-board assistants and physician's assistants
and so forth? -

MR. REARDON: I can't really answer that because
one of the things we were chartered to do and reported to
the Congress this year is a legal barrier study. There is a
great controversy and in some cases absence of legal
coverage, if you will, were whether it's permissive or
restrictive in the States,

DR. WAMMOCK: I am just asking for information to
clarify it in my own mind,

MR.. REARDON : fi think what we're finding right
now is that a few States do have permissive legislation that
allows these people to perform these services, and I would
say more communities are operating under the remote direction
of the attending physician.

DR. PAH: ts there further discussion on any
of these points, or others that have not been sufficiently

covered?

If not, thank vou very much, John, We appreciate

 

et
u

 

 
 

 

 

that, and we will let you escape,

We will now get to the important part of the
meeting.

The advantage of having so Many speakers precede

you gets it whittled down to where I think it won't take

so very long, which I think is good, because one of the more

important aspects we have coming up this morning is Dr.
Pp p C

- John Gramlich, who will be reporting to you about matters -

which are of importance on the review of arthritis applica-
tions,

So, aS a preliminary to that, I would just like to
make a few comments on a point or two, to make sure that we
try to keep all of you up to date with some of the
activities that have been going on. |

As you know, the council met last on February 12,
Much has transpired, and that has been reviewed pretty well
by the preceding speakers, |

However, we did develop’ a letter to you just last
week which tried to bring you up to date on matters, and I
believe, Ken, that that has been handed out, at the table,
in case you did not receive it in the mail.

If you have been following the Washington Post
stories about the u. Ss. Postal Service, we felt it best to
*erox another copy and give it to you at the table also,

In that report I believe that we have covered most

 

t
1
}
|
{
|

 

 

 
 

 

 

 

 

 

\ :
of ‘the matters. You know that the Secretary did authorize

he £ull stren

= 7 “A
aa ~— o PRPS -~ =
Eh u rath of 2c a

+ “
Soe Ey RL

individuals so that, had all accepted, we would be fully

‘augmented at this point,

There were a couple of non-acceptances, for very

valid reasons, and we regret that: but we are very pleased.
with the fact we have so many new members here,

In order to make this initial experience for the
new members of the council perhaps more meaningful and
rewarding, both to them and to the work that has to be done
here, .we held an orientation meeting for the new members
of the council and any other past members who felt they
would like to attend on May 31, and this was a very busy day.
I will just briefly indicate that we tried to bring this
group of people into full knowledge of something concerning
the history of their program, the major areas of activity
Over the early years, the various earmarked programmatice
activities of 910, kidney, EMS, HMO instruction, arthritis -
activities, and so forth,

We tried to indicate something about the review
mechanism that we had established and followed earlier
concerning the review criteria ratings, the development of

our mission statement, how this had been developed and applied.

We spent some time on the phase-out and extension

of the program and what staff had Gone, what obligations and

 

 

 

 
 

 

 

 

resnonsikbilities had been placed upon local regions, how

these local regions had indeed responded and survived over
: . i

this last year,
And we got into the class action lawsuit and gave

them the current status background, and what seemed to be

the direction we were heading with that, And you have heard
from Mr. Rubel this morning the latest on that item,

We dealt with what we saw to be the transition -
period that we are now in, and went into the current advisory
structure apparatus that we now have with the ad hoc RMP
review committee and the ad hoc arthritis review committee,
what they had done just the week before, and what this
council, at both this meeting and its next meeting in
August, will be called upon to do,

We went into what regions are expected to accomplish;

through their local review processes, our management

assessment visits’ and so forth. We talked about available

”

funds.

We discussed our organizational and staffing
position and posture, what it had been, how it had undergone
changes, and what the current Status is. And we went into
such matters of interest as the Federal Advisory Committee
Act on confidentiality, conflict of interest, open and closed
sessions of the council,

At least from staffts point cf view, I would like

 

 

 
 

 

 

76
to thank those who took this extra time to come to Vashington,.
We found it very rewarding. We know we provided too much
material in too short a time, but we hope that maybe some of

it will make this meeting a little bit more helpful; and

indeed we felt it to be a very worthwhile thing if we would.

have that opportunity Prior to coming together in a large
group.

With respect to our review activities, of course -
the major part of this meeting will deal with the results
of those activities, and Mrs, Silsbee, at an appropriate
point, will discuss some details,

But I would like to Say that we did feel pleased
that the Secretary of HEW did establish, permit to be
established two ad hoc review committees for the work that
we had t carry out, The first of these was the ad hoc RMP
review committee, and I believe you have at your table a
membership listing for both that committee and the ad hoc

arthritis review committee, which was also established under

the Secretary's authority.

 

These two committees each met for three days. |
The one on May 22, 23 and 24 to review the RMP applications !
from all 53 regions, Mr. Petersen and Mr. Chambliss chaired
the individual sessions where the review of the applications
occurred; I chaired the opening session and the closing

|
'

session, where the full committee met, in the latter instance, |

 

 

 
 

“work under the most stringent conditions of personnel, time

 

 

 

 

 

 

 

to review the recommendations cf the two separate panels

a te nyt ee eT BK nw me nent Psi ee
ix. Petersen's and Mr. Chamvliss

oh]

I think I should just tcke one moment and express, |
as the Acting Director of the progvam, my aroreciation to Mrs.
Silsbee for the vast amount of work that she and her total

stafi did prior to this meeting, and again. there is no

point in belaboring it, but it was a tremendous amount of

deadlines, and so forth.

I think that again you will get an impression out
of this when you see the applications on the front table and
note we are down in our staffing to one-third of what we
used to he.

In this connection I would like to also thank br.
Endicott, who is not here, but who did support his commitment
made before this council in February, when he said he would
try to make available to our program the agency's resources |
to help carry out the workload that we had. And in fact we
were able to call upon, I believe it was finally seven

- were
former RMPS staff members who/very experienced with the
€

review process to return from their jobs: in other |
parts of this agency, during the month of May, to- give «
us assistance. And some of them are here, but all of then

are not; I thank both them and their supervisors, because: .

this did help us materially in getting the materials for the

 

 
 

 

 

review committees,
The second review committee, the ad hoc arthritis

- Dr. Gramlich served

ut

conmittee, met on May 23, 24, and 2
as our ex officio liaison council member to that committee
and sat in on the discussions, and shortly will be giving a
report to vou.

Mr. Spear, our staff person for this activity,
has worked long hours and, as with Mrs. Silsbee, deserves a -
special note of commendation for the tremendous amount of

work well done in, again, a short time period from the

inception of this program, when we first brought it to your
attention at the February council, to this point where you
have recommendations on a number of applications.

That committee was chaired by Dr. Roger Mason of
the Nebraska RMP, who didan outstanding job as chairman,
and we had hoped to have him also here to present a report
to you, but a prior commitment made that impossible. But I
do want to note that for the recotd, our appreciation to him.

Turning to another point, our own organization and
staffing, to just merely state that vou have heard fron Dr.
Greene that we still functionally are within the Bureau of
Health Resources Development, and that there has been
submitted to the agency a formal request that we be in that

Bureau organizationally, whereas as of the moment we still

officially are in the Bureau of Health Services Research,

 

 

 
 

 

committed and dedicated to this activity, and have done

 

 

81
Our personnel now number about one~thira of what
we had before. 1 believe you Will see from the work that is

coming to you that there are still many people who ere

excellent work, but, nonetheless, we have lost many cqcod
people; and, nonetheless, I believe we are managing
reasonably well.

Attrition continues of our staff, and this hurts -
particularly in the office of, or Division of Operations that
Mrs. Silsbee heads, and as people depart from that office,
why, we particularly feel the attrition.

We did meet with the national steering committee
of RMP coordinators in May and had a very fruitful day.

Part of that discussion was related to the cooperation
with Dr. Goodman and the End Stage Renal Disease Program.

We also had a presentation from Mrs. Bernice Harper,
who is the Acting Director of the Division of Long-Term
Care, because there are program interests between that
division and this agency and the RMP program, where perhaps
cooperation between the two areas can further enhance the
responsibilities of both.

I would like to make two announcements to the
council. I am both pleased and regret to announce that two
of our senior people will be away for short periods of time.

I regret that announcement because this is our busy season,

 

 

 

 
 

 

i
|

been made about such decentralization, and no determination oni

 

 

 

\
but I am pleased to announce it because I think that the
Opportunities that each will have in the next few weeks will:
be very nice for them, and will certainly make their own

}
growth and cevelopment -~ will advance their growth and

development and also will bring hack to the agencv a broadened

{
!

outlook on matters which are of interest not only to RMP but
to the agenev.

Mr. Roland Petersen will be gone for the next two -
weeks to attend a health executive development program at
corneli, at Ithaca; and I guess will be leaving this weekend.

The other item is that Mr. Chambliss will be gone
for Six weeks attending a program for health sys tems
management at Harvard University .Graduate School of Business
Administration, and will be returning the end of July.

I think we will certainly be looking forward to the
return of both he and Bob,

We have been operating, back to our general staff
picture, under a postulated decentralization of Regional .
Medical Progran functions to HEW regional offices. I am
happy to say that after a reasonable amount, of discussion
internally that that decentralization plan has not been
implemented as of now, and in fact I think, through the
offices of Mr. Rubel and others, it has become possible for the

Under Secretary of HEW to state that no determination has

 

 
 

 

 

 

83
this point will be made at least until after legislation
is passed,

Nonetheless, having szié that, you will appreciate
the comment that Dr. Margulies made earlier, that job

uncertainty continues to face our staff, hence the attrition;

yet we are happy when we can place our employees in perhaps

more viable jobs, although we are Sorry to see them depart
the program, paxticularly when they have had several years ~-
of experience,

I think, for the most part, they still enjoy what
they are attempting to accomplish,

Our current funding situation I think will become
clear as we go through it today, but in general it's some~
thing on the order of 110 to 115 million dollars to provide
support for the Regional Medical Programs out of both this
council and the August council.

During our closed session, you will be reviewing
the’ recommendations of individual” applications, and I am
certain that by the time the council meets in August we
will have an exact figure. fox You, as a result of the time-
table, with the conclusion of this much extended litigation.
But at this time, the best I can do is to give you a $5 millioh
range under which we'tre operating, and I think that's pretty

good, from the point that watve been at some time in recent

months,

 

 
 

will have a report by Dr. Gramlich, which I believe is of ©

‘activity. And we have the other items shown on the agenda. -

 

 

 

 

84

Mr. Rubel and others have gone over in some detail

4.5 ~,

7 om he -
CLuUM, tue sit

1
bt ia

4

alus of that, and I feel that £ donit

a
ad

a te
bis LO

wo

want to comment further and take your time on that,

With respect to the over-all program for the

council today and tomorrow, I would like to say that we

general interest to the open session, about the arthritis

And one or two items of business, which will come up
both at the time when the public comments are in order and
under Other Business.

Then we will go into a closed session of the
council, at which time we will treat in detail the review of
the applications, and staff will be present to add comments ,
and there are a number of people from the regional offices
and other federal agencies, and they are invited to attend.
Members of the public may not attend.

The closed portion of the meeting is under the
restrictions of confidentiality and conflict of interest, and
I believe we brought that to your attention routinely in
certainly the orientation meeting and I believe the statements;
in the package of materials given to you,

During this open session of the meeting, however,

the information is open to everyone, and I therefore caution

speakers or others not to gct into Specifics of applications, |

 

 
 

 

 

 

,

\ 86

technical review cormittee approach when it met on the 23re to
the 25th of May.
All the members were present,
The funding there was, as Io am sure you know, in
the neighberhood Of $4,275,099 available for which the
committee had the problem of properly approaching on an... a

over-all view something over $15 million in Grant requests,
There were 43 epplications involved.in these qrant requests.

Interestingly, ten regions had not submitted
requests for a variety of reasons.

It was immediately apparent that this was a unique
RMP function, on a pilot basis, one-time-only, and some of
the aspects of the uniqueness of thia particularproblem were
well exposed by Dr. Pahl and by others, in that these were
funds that would be Supervised by individual RMP's, that

there were no specific legislative constraints,

This funding oOperationg in toto had been somewhat

. :

interesting in its inception, but at the same time this was
a truly pilot type program, the development of which, and the
Philosophy, might well have profound influehce on programmatic:
thrusts and such even more remote aspects as the effects on
future legislative ‘action.

One of the committee members promptly pointed out

that the RMP had frequently led the way in such critical

bs

matters, and used the e

ample of the kidney dialysis and

 

 

 

 

 
 

 

 

\ 87

transplant program with pilot studies and establishing

‘policy and networks leading to the ultimate adequate
legislative funding, and he hoped that such a situation might ;
well develop with arthritis; and it might.

“Ane to quote this particular committee member, he
said that this arthritis program may be a unicue oppertunity
to make a major impact,

Now, the committee had the benefit of staff review,
and although Dr. Margulies and Dr. Pahl have very properly
lauded Mr. Spear and members of his supporting team, I think
the highest compliment that I could pay them as an observer
at this committee meeting was that the staff work was good,

The requests were noted te have several conmon
characteristics:in the patient care area, there were many
elements aimed at the development or enhancement of inpatient
or other central facility care, leading in turn to satellite

Clinics for arthritis.care,

4

Qu

Many of the requests ha etrong patient education
components and public education components, and here an
interesting dinkage with -the arthritis foundation developed,
Which was that the Arthritis Foundation was involved in many
other grant requests,

There were some Specialized programs to develop, for

instance, juvenile arthritis programs, arthritis care

Programs, gout was in a lot of the grant requests, and there

 

 

 
 

 

 

 

&&
were program elements that were quite common to most of the
requests also, such as major equipment acquisition,
purchase of vans, development of svnecialized laboratories,
enhancement Of existing equipment, audio-visual. Some
grant reduests had considerable funds hoped for in terms of

research, including epidemiology and tonography as well

as patient care and basic research,

 

[

|
{
}

some grant requests were looking towards specialized

units in hospitals, arthritis and rheumatism units somewhat
similar to intensive_care or coronary care. units.

after the assessment of the over-all view of the
many requests, Dr. Pahl very kindly discussed some of the
committee's policy charges; and this was an enormous asset
to the committee in its functioning and future thinking.

He first noted that it was important that this
was to be a national program, not a series of small isolated

projects, but that its impact would be Significant if the

fa-

committee succeeded in putting t all together, and that
this aspect should be seriously kept in mind during its
deliberations. - ‘

The essential elenents cof the one-year program
were outlined and in this regard there was some effort made
to devise the appropriate direction of appropriations or of

activities in the areas of the more sophisticated arthritis

units already in existence, or in those with minimal or

 

 

 
 

 

 

 

\

widely spread capabilities,

The pilot aspect was emphasized as was the
necessity for some measurement of the one-year outcones
‘for the benefit of the ongoing legislation program,

The appropriate role of a local arthritis chapter
was discussed at some length, as vas the feasibility of
proposals that cane through the arthritis chapters,

There was considerable direction toward the ~
desirability of giving additional weight to program elements
such as outreach in response to special population needs.

Patiént-focuing rather than general public-focusing
prograns, and the basis for the continuing deliberations
of the committee was clearly established.

After the summary of the staff review, the public
comments were called for, and then the committee went into
full session, .

Now, this signaled the beginning of a full day's
deliberation in closed session as’ to the guidelines, the
appropriate guidelines for assessing equally and in-depth and’
impartially all of the grant applications. . And the committee
did give a great deal of thought and effort to establishing
the appropriate guides by which the evaluation and recommenda-
tions for funding could be made for each individual applica-

tion that was being processed,

The first plan that was worked out is a brief

 

 

 
 

 

 

 

 

\ | | |

summary which discussed about nine or ten areas of policy
Significance. The comprehensive health care for patient
groups, that is the elements of coordinated care, was
discussed at some length. The matter of professional
education of people ,providing. care, including the cutreach
area, the concept of “train the team" and including
techniques of reaching or training the patient, was a najor
consideration, :

Quedstions as to what might be the best module
for delivering care, the kinds of provider roles, the
different kinds of patients, coordination of communication
took the attention of the committee for a considerable
period of time,

The matter of the delivery team, how best it could
be managed, facilitated, what the range of its functions
might be was considered as an element important in the
assessment, Research and evaluation was an obvious need

which was considered by the committee, as were the problems

of needs, assessment and quality control,

 

Then the matter of funding ongoing existing programs
‘ |

as opposed to new start-ups, was considered at length by the

committee, and finally the matter of needs for future funding

after the expiration of the one-year RMP grant was a major

concern,

These were just broad guidelines that were then

 

g

 

 
 

 

91

 

distilled into the resolutions and guides which you have in

front of you in the minutes, and which I won't need to
detail particularly.

I would emphasize that throughout all its

 

deliberations the comnittee kept in mind the need For a

degree of. cohesiveness on a national basis, and at the same

time maintaining an objectivity in the assessment of cach
of the individual grants.

The guidelines that you have in front of you
emphasize the importance of outreach, and this was a major
consideration as the main thrust of the programs to be
approved and funded in the opinion of the technical review
committee,

There were some negative aspects, and the committee
felt strongly that data banks and registries, per se, should
not be funded, At the same time it felt that these were
not appropriate funds to spend on expensive hardware,

= -

particularly complex audio-visual, televis £

i

es
este
im makin

rt
sy

a

Aan
Sweep

ventures that would have. very short-term, if any, payoff,

 

The cormittee did feel, however, 'that if there were |

demonstrated needs and usefulness for audio-visual materials,

|
|
using video tapes as an example, there were certain areas in |
|
i
the country of expertise where , on a loan basis, widespread |

distribution might be obtained of materials on a somewhat

more centralized basis than if each unit went about establishing

 

 

 

 

 

 
 

 

 

 

its own,

In the matter of public education, the problem cane
up several times of public programs aimed at fund raising,
‘and of course it was immediately apparent that this is
prohihited by federal requlations,

Vehicles were mentioned several times in particular
grant requests, and it was felt again in general by the
review committee that it was important that large amounts of
funds not be spent individually on equipment that might have
very little long-range use, and might be unsupportable by
future funding.

So that there was definite concern about large
amounts of funding for hardware.

The final negative guideline was in relationship
to professional training, since a number of applications had
requests for funding residency prograns and degree granting
directions for personnel,

The RMP policy was such that the residency programs
in general could not be approved,

Now, this sounds a little negative. It is not,
actually, because you will find when you start going through
the applications that the matter of positive effect in terms
of outreach, and the various principles involved in the
solution to the problens of the pilot program were carefully

dealt with and the discussion went on in depth and was not

 

 

 
 

 

 

pressured at all, :

In

- sane

the ova

luation of the applications, each
application was reviewed in depth by the entire committce
and the over-all national viewpoint was kept strongly in

mind in the assessment of east canr bigest tan)

The individual application was assessed, It was:

sometimes modified. It was given a ranking score. And after
‘this the committee discussed program coordination and outcome,
And this, I think, merits a quote. The notion
that communication and evaluation of this program pervaded
the entire technical review committee's deliberation,
The committee felt Strongly that the development
of experiences and innovative activities ~~ and I am quoting
now <= “conducted under the pilot arthritis program should
be widely publicized, that a periodic newsletter or similar
communication about deve lopment of supportive programs
should be supported by BHRD, to increase Shared experiences
and to avoid duplication of effort,"
The committee suggested, if possible programs should
make quarterly reports, and that there should be enough
action on the part of the individual recipients that staf
be well underway at the end of three months and that personnal
and organization he completed and in operation at the end of

six nonths,

In terms of evaluation, the committee requested, if

 

 

 
 

 

 

 

 

 

— - SO 94
possible, that there should be conference in six months, cr :
Some reasonable period, at which time they would see -+-
they or the committee would see what was going on in the
funding program, to maintain contiscuity,.

It was recoracuc o- >. dino s*. dL owas respectfully
requested by the technical review committee that the actions

’

of this council, the advisory council, be made reasonably

“available then, so they could appreciate and evaluate the ~
benefits of their work. .

This committee was a distinguished committee, as
Dr. Pahl has méntioned it was chaired by Dr. Mason from
Nebraska, and I will briefly tell you who was on the
committee ~~ not for subjective reasons, but because it
will perhaps help in future deliberations this afternoon
on the grants themselves, about the membership of the committee
which included a Mrs. Annette from California, a nurse;
Dr. Baily, an arthrologist from Georgia; Dr. Donaldson, an
orthopedist from Pittsburgh; Dr. Engleman, a rheumatologist
from San Francisco: Dr, Pfeiffer, an orthopedist from Washing-
ton, D. Cy; Dr, lastings, a podiatrist from. Washington;
John Poleski: pr, Larsen, an orthopedist from Iowa City;

Frank Schmidt, an arthrologist from Chicago; Dr. Schulman,

po

arthrologist from Johns Hopkins; Mrs, Silverstein, occupationa

therapist fron Baltimore; Mrs, Tilson, a social worker fron’ |

California; lirs, Yarborough, who is a physical therapist fron

 

 
 

 

 

6)
a

.

2

Geordia,

u

I served as a swaying bridge from the technics]
review committee on one side to the natisnal advisory
council on the other, over the stream of action that the
review committee was floating der,

cle committee worked long and hard, In fact, after
a day and a half of establishing guidelines for fair
assessments of the applicaticns, they took another day and a
half to review individually and collectively each
application.

This was not the easiest occupation, since, I
believe, there was a little trouble getting the Parklawn
Building to keep the air-conditioning working Saturday; but
they persevered and adjourned in the afternoon on the third
Gay with a self-laudatory comment which Matt Spear had
included in the minutes presented to a They said that
the efforts of this committee have been exemplary, as far
as acting to the best interests adhering tc the guidelines
proposed,

We consider this to be a very meager effort toward

a tremendous problem, and it in no way begins to provide a

solution of any definitive kind, Oe :

Now, they also made one very important point.

The additional funding to include many of the projects

that were rejected, as well as the bulk of other projects

 

 

 
 

 

 

\

which should have been submitted but vere not submitted

because.the guidelines provided by the legislation or by
the constraints of time should be consicered when such moneys |
‘would become available,

In other words, the. committee really looked Upon |
itself as a waystation in a4 truly pilot program that has
national implicaticns and should have a long-term payoff,

I think that there is one other comment that is worth

making, and that is that it is typical of RMP flexibility and
viability in that this program could be thrust upon on a
crisis oriented basis and that the staff could come up with

a proper administration to effectively get the prrogtam to
the state: itinow. is, in'a very short period of time.

A great deal of credit is due Mr. Spear, Dr. Pahl,
and the entire staff,

DR. PAHL: Thank you very much , Dr. Gramlich.

Are there questions for Dr. Gramlich on this rather
brief survey of what was intensive effort of the arthritis
center program?

The minutes ef that meeting, that have been
distributed to you, as Dr. Gramlich stated, are quite important

because they contain the resolutions and guides, that is
g ’ '

the premises upon which the committee later evaluates the

2

 

application; and also there is in that document recommendations

for follow-up by the Division of Regional Medical Programs,

 

 

 
 

 

97
SO as to try to make it an effective national program,
even though it be a one-year effort, as John has stated.
And I think it would either be appropriate now or at a later
point in the meeting, if you have not had time to read those
minutes, to have a fornal council adoption or endorsenent of
those resolutions and guidelines, as well as ‘the recommenda-
tions to our agency in program for an appropriate kind of
program involvement following. the awards for the approved -
programs,

And iflit is the council's wish, this could be
done at a latér stage. But I think it would be well for us
to have that formal endorsement of the committee's processes
and basic underlying premises, because this is an initial
thrust, and we believe the committee not only did an out-
Standing job, but they set for themselves certain rules and
procedures so as to try to carry out, to the best of
their understanding, the mandate that was given to us,-

I dont know to what extent you have had an oppor-
tunity to read these materials that Matt has. ‘These
materials are at the desk today? ‘

MR. SPEAR: The ninutes aren't here, unless they
have been distributed, They were mailed out.

DR. PAL: Okay, they were mailed out to you,

If you have had an opportunity, perhaps you would care to

discuss that point, or, if not, that could be left ~~ we need

‘

 

 

 
 

 

 

Some extra copies, which indicates to me that this is not
the appropriate time, then, to take any action,

I would susgest that ve get sone extra copies and
give them to you, and perhaps later today, or at such a tine
as we talie up the arthritis applications, these could be
gone over and that action instituted,

Are there any points of discussion for either Dr.
Gramlich or Mr. Spear at this time on the arthritis
activity?

Well, “thank you, John, very much for your report,
and we will be getting into the detail matters early this
afternoon,

I would like now to take up one or two items of
usual business before the council, and that is to ask for a
consideration of the minutes of the last meeting of the

council, the February 12th minutes.

If there are any changes or amendments?

%
a
O
ct
fe-
oO
i
bh
QO
Ky

£ not, the Chair would entertain
adoption of the minutes,
MRS, MARS : ‘I 50 move, ‘
MRS. MORGAN: I second,
DR. PAHL: It has been moved and seconded,
All in favor say "aye",
[Chorus of "ayes", ]

DR. PAHL: Opposed?

 
 

[No response, ]

DR. PAHL: So moved.

,
1
‘

Io woulc also like to call to your attention that tha
next meeting dates for the council are August 8th and 9th, and
_ would hope that this two-day scheduled meeting is still
appropriate for you. It has been very Gifficult to arrange a
meeting in August, and we do urge all of .you, and those who
are not present this morning, of course, to make that -
meeting, because at that time there will be applications
from 43 regions or so, requesting something in the
neighborhood of $42 millions.
/ . So there is a reasonable set of responsibilities
involved in that statement, so we would hope that all of
you would try to make that August 8th and 9th meeting.

At this time we are not attempting to establish
a meeting date beyond that, because, very frankly, we would
not know what date to suggest or what the needs and
responsibilities are, so if you will bear with us until
August 8th and 9th we will bring in a large calendar and see -
what we need to eco at that time, ‘

Before we get into the last item of business, I
would ask for any public comments or comments by members of
the public on any of the matters that have been brought up

today by us or other matters relevant to the council

consideration that you care to make,

 

 

 

 

 
 

 

 

 

 

 

 

\ 100

If there are individuals who care to make staterents

or comments, I would ask vou to identify vourself for the
record, and if you are representing an organization, that
is, someone other than yourself, please identify whom you
are representing. |

So the floor is open at the moment for anyone who
feels so inclined to make any general statement or comment
upon what has transpired so. far.

MR. POPPER: My name is Robert Popper, and I have
been on the New York Regional Medical Program almost since
its beginning. “and for the past three years, or something
like that, I have been chairman.of the RMP. |

Now, I have watched RMP as a concerned, interested
citizen, because Iam a volunteer. Nobody pays me anything
any more. And also as a taxpayer.

Now, I take that responsibility very seriously.
Considering the alternatives, I would rather pay taxes than
not, but I do want to get my money 's worth.

I have watched RMP over these years and have
watched some of the things it does, particularly in our city,
that I have never seen done hefore. tt has managed to
convene some people who never before could have believed
that today was Thursday, and I have managed to get these

people, to sit them down in’ a room, to establish priorities

and implement programs; and it has been really quite a

 

'

 

 
 

 

 

101
-remarkable thing.

A lot of these people have nothing to gain from
RMP, they are not people who submit grants, they are just
people who think that RMP is worth something. -

I think this is good, and I think it's important.

Now, I come to you particularly with an unusual
problem with New York, I hate to bore you with statistics,
but the fact is that I memorized them on the plane coming
down, and I'll be damned if they're going to go to waste. _

We have ten million people, nine counties, twenty-
one congressional districts, two hundred hospitals, and, so
help me, seven medical schools.

Now, if you think that that's an easy group to get
going on anything -- you are quite right; it is extremely
difficult.

In December of 1972, when we had our site visit,
our director had just resigned, our grantee was asking
permission to withdraw, the RHE was acting under wraps
because we never knew from day to day what our powers were,
and I can assure you when I cross Fifth Avenue the cops
didn't stop traffic for me.

Today this is all different. We have a grantee
who is responsible, respectable, and who cooperates, but

does not interfere,

We have relationships with our comprehensive health

 

 

 
 

=,
2

 

 

102
planning agencies and other planning agencies in town that
have never been better, with a good deal of cross~-federaliza~
tion and a great deal of conversation, particularly with CHP,
we are in good shape.

We have a staff that's absolutely devoted and
competent, and works just as hard as the staff down here, and
we have a strong and vigorous RHE which attends meetings, |
and which deliberates and which does everything it has to.

Now, I'm not going to go into all the projects,

You have them here. I merely want to say that if you think
all urban areas have problems, we, with our ten million people
and seven medical schools, have ever so many more problems
than anybody.

But we have the solutions to solve those problems,
and all we ask from you is consideration of money. “We are
five percent of the population of the country, we are putting
in an application for roughly five percent of the impounded
funds. Anything you give us will be deeply gratifying, and
if you give us more, that's even better.

Thank you very much,

DR. PAHL: Thank you, Mr. Popper, I am glad we
received those statistics also into the record.

Are there other members of the public, or are there
comments by the council at this time relative to this

Statement?

 

 
 

 

 

 

103

“If not, are there other general statements to be
made before we go into the last item of business I have
in the open session?

I would like to have you turn your attention, then,
if you would -- I am not sure in what form this was given to
them, Ken, is it in the agenda package?

In the material which contains your agenda, the
last two sheets, there are two staements there which the
ad hoc review committee for the RMP applications formulated.
and addressed to the council for their consideration, and
I would like to, at this point, have you consider them in
this open meeting because they are not related to any
individual application or the review of ahy individual
application, but rather are matters of general interest to
the review committee and to this council.

The first statement I have is the CHP review and
comment. Do you all have that statement in front of you?

MRS. MARS

oe

Who drew this up, Dr. Pahl? What is
it?

DR. PAHL: This statement was drafted by Dr.
Teshan, who was sitting on the review committee, but I
believe that there were several. He's the one who presented

it to the full review committee,

The full review committee considered this statement

and passed favorably upon it for submission to an action by

 

 

 
 

| brought to you from the review committee, and we are serving

 

 

104
this council. So this is a proposal to you to consider and

adopt it, amend it, or not act upon it at all, but it is

in that capacity.

In introducing to you this statement, you should
be aware of the fact, and this is particularly addressed to.
new members of the council, that there is a procedure within
the RMP guidelines and policies whereby applications from the
local RMP are submitted to the local CHP agency for review
and comment, and that these comments by the CHP agency are
returned to the local RMP, where the comments are to be
considered by the regional advisory group and the RMP, and
some kind of positive response made,

That does not mean that the advice by the CHP
agency has to be adopted in all cases, but the comments have
to be seriously considered and an appropriate kind of action
taken following the RAG consideration of the comments.

In some areas I think it is fair to say that
there has been very good close working relationships, and I
think we just heard a statement from Metropolitan New York
RMP, where such activities seem to be working out very well.

In other areas of the country I am afraid things
perhaps have not always been as smooth,

Consequently, there has been a spectrum of both

the kinds of advice given RMP's from the CHP B agencies as

 

 
 

 

 

105
well as the kinds of responses that RMP agencies have made
to such review and comments from the CHP B agencies.

As Dr. Margulies and Mr. Rubel have already
stated this morning, much of this is past history, because
we are moving into a new direction, and I believe that the
sources of friction are much less widespread than rumor
would have it.

In many places things are proceeding very well. ;
Many of you who have sat on the council know that the local
RMP's have done much in the past to stafé and help establish
the local CHP B agencies.

They are sitting on the RAG's and on the CHP B
agency councils and boards, people from the other agencies;
so there is good collaboration and cooperation in many
quarters, but it is not uniform.

As a result of still this divergency of interest
and activities,this statement was drafted by the review
committee for your consideration, and I would like to read it
into the record, and then you may take whatever action,
following discussion, that you care to.

Mr. Rubel is here, and I think this is appropriate,
because he has these two sets of responsibilities, and that
is not only as Acting Director of the CHP Program, he is

interested in such activities, but in his more major role, and

that is the Associate Director for the Health Resources

 

 
 

or

 

 

 

106
Planning. It is his reponsibility to try to make a more
effective program both internally and externally, between

the CHP and RMP functions. |

So I would like to read this review committee

recommendation for your consideration into the record.

“CHP Review and Comment.

“Recommenation for Council Policy and Request to
Health Resources Administration: -

“While recognizing legislative mandate and Division
of Regional Medical Program regulations regarding RMP-CHP
relationships, Council requests that the national CHP
leadership transmit to Areawide CHP (b) agencies nationally
the mandate for fully reciprocal relationships with RMPs,
especially in calling upon RMP assistance for professional
and technical input into ongoing CHP plans development; and
in the interests of fairness and full reciprocity Council
furthermore agrees and instructs ad hoc RMP Review Committee
and Staff to set aside any influénce of negative CHP

comments upon an RMP application unless the commenting CHP (b)

agency has provided the RMP with (1) the criteria and a

description of the b-agency review-and-comment process and

(2) a list of the b-agency objectives and priorities upon

which at least a part of the RMP response should be focused."
Perhaps it might be appropriate, since Mr. Rubel

is here and has already treated this, in a sense, in his

 

 

 
 

 

 

 

me this statement is an attempt at raising issues that have

107
earlier statement, to first make a comment or two which I

.

think may be helpful and then ask for council discussion.

Gene.

' MR. RUBEL: As I tried to say before, it seems to

been very bothersome and troublesome in the past, and, very
frankly, I don't see it as providing any positive effect for
the future. :

There is no question that there has been an awful
lot of each agency trying to further its own means within
the RMP world. There has been the question of “who sent you
out to be our master" kind of a feeling, and it is certainly
evident in the discussion of the review council, that that
was a major one of the problems.

« "We don't respect you, anyway; we know what we're
doing, and who the hell are you to tell us what we should do?"
That has been the attitude in many places.

On the other hand, there has been an attitude on
the part of many CHP people, one of, in many cases, jealousy,
envy, “you have all the bucks and we're struggling; and
we're going to sabotage what you're doing." A lot of that
has occurred as well.

I think the Congress is in the process now of trying
to reconcile the problems that we've had in the past. We

certainly, I would say, over the last three months, four

 

 

 
 

a,

 

 

108

months, have tried to do it here as well.
, When the applications went out to the RMP's back
in February, we sent copies of them to the CHP agencies as
well, The first time that had ever been done, -

We tried to explain what the rules are, where we
also try to lay out some priorities, as we saw them, where
they could be working together.

As I travel around the country, I have found an .
amazing amount of interaction that people are trying to work
together. I think perhaps some people feel the problem we
have as bigger than what really is there.

There is no question in the context -~ the first
part of the statment, I am not sure I know what it means; but
in terms of reciprocity I think that is happening, people
are talking to each.other.. And I am not sure what making that
statement really means. |

Well, let me-stop there, and I will certainly be
glad to respond to any comments you have.

MRS. MARS: Personally I don't think this is a
responsibility of the council, and I don't think it comes
under our prerogative to try to settle internal politics,
so to speak, in that this is more or less a political
issue. And I would be very much against recommending it.

DR. PAHL: Dr. Merrill,

DR. MERRILL: I agree with both those comments.

 

 
 

7

and I think the issues which are involved, which are much

hang all the Laws and Prophets,

 

 

 

 

109
Since I have read this thing, I wondered where the other
eight commandments were,
I think it's calculated to raise the hackles of

the people who receive this. It's extremely high-handed,

dealt with by a soft sell rather than an extremely hard and

irritating sell such as this one,

DR. JANEVWAY: John, on those two commandments -

DR. PAHL: Mrs. Flood?

MRS. FLOOD: I would inquire as to the interpretatio
of the CHP(b) agency by the wording of this comment. Would
this encompass also the areawide. planning agencies that are
unfunded, that are strictly voluntary and functioning in
areawide health planning without any federal or State
Support, but who fill the role of review and comment for
these levels?

MR. RUBEL: Under currént Department policy, there
is only a requirement to get review and comment from those
agencies that are funded by the federal government. I think
in practice it has turned out that there are many other
agencies involved as well.

Hopefully, in the relatively near future we are
not going to have that difference, we are going to have

Planning agencies covering the entire country; but there is

 

 

 
 

 

 

 

110
no way, there is no requirement that an RMP get comments
from anybody other than a federally recognized and funded
areawide planning agency.
| MRS. FLOOD: But in reality they do, they go to the
areawide planning agency, recognized though unfunded, that
does fulfill this role. So my question would then lead to:
If this policy statement should be adopted, would it be
forwarded by your office, Mr. Rubel, to these unfunded yet -
functioning areawide groups? Through the (a) agency, perhaps,
if you use that mechanism for dispersing information.

MR. RUBEL: Well, we certainly would be telling it
to the (a) agency people. We have no formal communication
channel to the unfunded areawide agencies,

MRS. FLOOD: Well, that is an interesting fact when
you consider that the regional offices would require a review
ad comment from even the unfunded agencies before they conside
applications that are not directly related necessarily to RMP
but to other funding sources, .

In light of the fact that this particular policy

Statement then perhaps dispersed through the (a) agencies
would reach even thse unfunded agencies, I would also feel |
that it is a high-handed approach and would cause many
problems for Regional Medical Programs.

Thank you.

DR. PAHL: Thank you,

 

 
 

See

 

 

 

111

Dr. Gramlich.

DR. GRAMLICH: Dr. Pahl, a question of information.
Is there anything in DRMP regulations which requires that
DRMP staff and council not fund an otherwise appropriate
project which has received a negative comment?

DR. PAHL: | No, the regulations, policies merely
require that the applications before being considered have
gone to the CHP(b) agencies for review and comment, and that
such comments be received, considered, and in some way disposed
of, affirmatively or negatively; but beyond that there is no
requirement.

And I should say, and this will come up as we go
through our RMP applications, we made a very strong effort,
as we have in the past, to make sure that despite the short
time periods for the present applications, that our applications
did go and be reviewed by CHP(b) agencies, and this placed a
very heavy burden on the (b) agencies.

The time requirements Were very, very strict.

We have received the comments from the RMP's about the (b)
agency comments and what theix actions are, and I think we
have tabulated these, and both Mr. Rubel and I are quite
satisfied that everything that could be done in the periods
that everyone had available has been done and it has been
really a remarkable performance by both the CHP(b)'s and the

RMP's,

 

 
 

=,
oF

 

 

 

112

That is not to say sweetness and light exists in

s

all quarters, but it is far less than what people believe,

And, as with most things, a few cases of dissention seem to
color what is not truly a generalized situation.

MRS. SILSBEE: Well, in practice, some of the (b)
agencies did have difficulty because they have such a
tremendous load on -- and have been sending in comments that
-- to Mr. Rubel and copies to us and to the Regional Medical
Programs.

In some cases the review committee had those late-
comers. In every instance we felt that the information would
be accepted, but the real forum for discussion was back at
the regional advisory group, and we have been trying to get
information about what the process is that is going on
locally.

DR. PAHL: Thank you, Mrs. Silsbee,

Dr. Sparkman.

DR. SPARKMAN: I'm John Sparkman. I am Director
of the Washington last-guard unit, chairman of the steering
committee coordinator; rt can't speak for them, but I think I
reflect their views, and I would like to take a different
approach.

It seems to me that the approach so farlas been to
tell RMP's, you just must abide by CHP review and comment,

and we have had this mandate laid on us.

 

 

 
 

“hes

 

 

 

113

On the Other hand, I think what the authors of
this particular statement had in mind was that the CHP should
at the Same time be told, Yes, you have a mandate to cooperate
with RMP's,

I would agree with what Herb has said, or what Mr.
Rubel has said relative to the fact that in general relation-
ships between CHP's and RMP's are good, and they are better
than the general rumor has it. | -

I agree further with what Mr. Rubel has said, that
there is no point in looking back and having recriminations,
when we should be looking forward.

But the fact remains that everything that has come
out of the central office has not seemed to be to this effect,
and I don't have specific comments, but I know from speaking
to my fellow RMP coordinators that they feel that ur. Rubel
doesn't quite reflect to his colleagues in CHP what he says
here to us.

Now, I don't question his honesty, but this is
the feeling that still exists, and it seems to me that the
first part of this, down to "furthermore agrees and instructs"
does in fact include a positive recommendation to say:

All right, RMP is going to cooperate, CHP's are going to do
likewise.

But I think I would agree with the scratching of

an ad hoc RMP review committee and Staff, to set aside any

 
 

mo”

not a negative thing. And I further think that it is the

 

 

114

influence of negative CHP comments. But then I would
think it is reasonable to ask the CHP agencies to describe
the criterion and description of the review and comment
process,. and to list the (b) agency's objectives and the
priorities, and the basis on which their judgment was made.

I know from the facts that our own region, but I
don't know on what basis a judgment was made, and I clearly
think they should be told this, and I see no objection to thisi.

It seems to me this is a positive thing to do, and

responsibility of this council to look at this and act.on it.

Let me say that the coordinators hold this
distinguished group in great respect. We recognize that
from the beginning the national advisory council have played
an exceedingly important role in RMP and de trmining policy
and quality by actually setting policy, and I see this as a
policy, and also by the careful review of applications which
we are all going to do, which is an important part of
determining quality.

So I see this as a positive thing, and I see it as
your responsibility. . |

DR. PAHL: Thank you, Dr. Sparkman,

Are there other comments?

Dr. Merrill,

DR. MERRILL: I would just like to reply to that.

 

 

 
 

 

 

 

115
In my comments I did not mean that I didn't think
this was at all a fine thing to do, but I think this is
entirely the wrong way to do it.

What this proposes is that this council formally

request that the national CHP leadership transmit; now I

have a very strong feeling, perhaps shared by other members
of the council, that it will never get any further than that
and might simply irritate people. | . .
| I think there are other ways of effecting the kind

of thing that is intended here, and I think this might be
done without a- formal statement. from the national advisory
council of RMP,

I would suggest perhaps that it might be done on a
personal basis, or a man-to-man basis. I think you're
quite right, it would be nice for a local RMP to know the
(b) agency objectives and priorities; but I think for the
(b) agency to transmit these to the local RMP by reason of
a request from the national advisory council, coming from
national CHP, has the effect of making more of an issue out
of it, I think, than is warranted,

DR. WAMMOCK: You're talking about that local
people make this comment rather than the national level,
is that right?

DR. MERRILL: Well, I would suggest in this stage

that the national RMp people and the national CHP people get

 

 

 
 

 

 

 

 

 

 

116
together at the request, when and if it originates ~- and
I think it's reasonable -- should come from the national CHP
without the tag of the RMP, which would only serve to be a
sting.

MR. RUBEL: If I could just make several comments.

First of all, in terms of our attempts at suggesting
that RMP's and CHP's work together, I would point to the °
covering letters that went to both organizations when this ;
funding cycle first began, and I will leave that for the
record to judge whether we have or have not attempted to
suggest that there are very meaningful relationships to be
carried out.

The second point, the very essence of the planning
process, within a comprehensive health planning organization,
is its openness and the ability of virtually anybody to
participate in that process. |

If we have to have a mandate from Washington that
tells people, Well, we've already told them what they have to
do, it's very much in the open, to open it up some more,
then we have failed even more than some of us here think we
have.

It is very true that there are many planning

agencies that have not articulated very clear objectives,

 

but that same thing is very true of RMP's.

It is very clear that we have CHP agencies that have

 

 

 
 

aoe,

 

 

117
not responded very well with specific comments to a
proposed project, but it is also true that many RMP ‘s
have not justified a project in a way that a CHP agency
could respond.

What I am trying to say is we have a lot of
problems, To the extent that you ask us to communicate with
CHP agencies, I promise you we will so communicate. My
own personal conviction is that all it will do is exascerbate
problems that we have, and it will not be a positive
influence. Let's face it. |

The July applications are just about on the way.
Who are we telling, you know, you've got to communicate |
before you submit applications. For what purpose are we
doing that? . |

I would wholeheartedly agree, to the extent the
current legislation will continue, that we need to find
better ways of communicating with each other, and if I have
anything to do with it, if concurrent legislation were to
continue, we would seek to do that.

| But, in light of where we are, I think it's
a little meaningless to try to start doing that from this
point on,

MRS. MORGAN: I don't believe we as a national

advisory council have any control over CHP agencies at the

present time to demand what they should do. We can over

 

 
 

 

 

118
RMP's groups, but we certainly cannot over CHP (b) agencies.
° DR. PAHL: Mrs. Mars?

- MRS. MARS: I would like to make a motion that we
do not adopt such a resolution as being inappropriate for the
council, and perhaps along with that, however, adding a
directive, such as Dr. Merrill stated, perhaps you would
like to phrase that a letter be sent or something in softer
terms, rather than adopting such a motion.

Would you like to add an amendment to that?

DR. MERRILD: No, I think that the thrust of what
we all are thinking is very clear to Mr. Rubel and Dr. Pahl,
ad I don't think it really needs to be put into writing. |
I am sure they could follow our wishes. )

MRS. MARS : Well, leave it then just as a motion
to not adopt such a resolution as being inappropriate on the
part of the council.

DR. MERRILL; I second it.

\ ' DR. PAHL: It has been moved and seconded to not
adopt the proposed resolution.

Is there further discussion by the council?

[The question was called for.] |

DR. PAHL: All in favor say "aye",

[Chorus of "ayes", ]

DR. PAHL: Opposed?

[No response. ]

 

 
 

 

 

119
DR. PAHL: So moved.

: The second statement, which I believe is one that
the review committee was very interested in bringing to your
attention, I think is fairly obvious, particularly from this
morning's presentations by all of the speakers, namely, we
know we are in a transition period. Each speaker has
indicated that it is necessary, essential, highly desirable
for the local RMP's to order their own affairs, and seek
closer, more effective relationships with those groups in
their own regions, be they governmental or non-governmental,
so as to look in a positive way to the future developments as
we perceive them at this time.

And this recommendation by the review committee,
I think addresses itself to that statement.

I would like to read it into the record, and then
have the council consider this.
"Action to preserve RMP Experience and Relationships
"Recommendation for Council Policy:
"In view of legislative developments now underway
for further evolution of RMP, in association with the CHP
and Hill-Burton programs, in the interests of national health
planning, Council encourages RMP's to develop organizational

readiness and any remaining regional relationships which are

appropriate to lead, participate in and accommodate the

anticipated new operating structuzs and requirements,

 

 

 
 

 

 

 

, 120
The purpose of this orientation is to preserve for the new
formats within the States and regions the capabilities and
voluntary cooperative relationships which the RMP experience
has created,"

I believe I should convey to you the committee's
intent here when they say “organizational readiness", that
they are stating that the local RMP's should look to their
own internal staffing patterns and structures so as to be in
a better position to be responsive to both the regional
needs and the developing legislation as we all see it.

So this is not encouraging, by any means, RMP's
to adopt different forms of grantee organization, but
rather to look internally to their own staffing, structural
patterns.

Now, with that as background, I would like to
invite council's attention to this recommendation.

DR. JANEWAY: I believe that this is anticipatory
of'federal legislation, and one cannot read the intent of
people who propose this to council, and I think it's open to
a variety of interpretations, and in its present form I
could not support it, a resolution such as this.

DR. PAHL: Mrs. Mars.

MRS. MARS: I would just reiterate what Dr. Janeway
has said. I feel the same way about it.

DR. PAHL: Dr. Watkins?

 
 

 

 

121

DR. WATKINS: I helieve ~- I was going to say that
I don't even believe that we should have the responsibility
of voting on either of these things that came up today; we
should have returned them to them with the comments that were
made, without a vote at all. Because we are negating somethin
that we're not responsible for,

DR. PAHL: Dr. Schreiner?

DR, SCHREINER: This reminds me of a story about
a Czechoslovakian sheriff in Colorado, and due to local
budgetary difficulties they had gotten down to one deputy,
and they had a gang of about thirty outlaws holed up in a
shack, and the sheriff said, "Well, men, since we're out-
numbered, I suggest we split up in groups and surround them."

[Laughter. ]

I think the RMP's that have lost a lot of staff
know that they are in trouble and are trying hard. T don't
think they are going to be helped by this kind of a
resolution, | .

I think the ones that have the staffs, the reason
they have good staffs is because they know this is a problen,
and they are getting ready for possible future legislation.

I don't see that anything is going to be accomplished by
this type of resolution.

DR. PAHL: Well, I think, unless there is further

discussion, the Chair understands the sense of the council,

g

 

 
 

 

 

122
and we will transmit such discussion back to the review
committee, so that they will know the disposition of
these, |

Before we break for lunch, I would ask once again
whether there are any further points to be made by council
members or the public on any of the matters we have discussed
this morning.

pr. Haber?

DR. ABER: Yes, I would like to comment at this
meeting about the proposed outreach of the arthritis
proposal. I construe this as being very important and
possibly a mechanism in which the treatment of arthritis
can escalate and elevate itself up to a much higher
plateau. | |

The reason for this is that most arthritis is not
treated in hospitals, it's treated on an outpatient basis by
a variety of practitioners, some of whom may not be
qualified. .

And I think if I sense the meaning of outreach here,
there will be an opportunity for physicians who are a tertiary
kind of physician, who are involved with research and
teaching and so on, to be able to relate much more closely
to the primary-care physicians.

That is to say, the resources of the hospital, the

school of medicine, and all the rest which have been devoted

nn

 

 

 
 

CO

 

 

 

123
largely to life-threatening diseases on an inpatient basis,
will now be turned toward this very important area of
arthritis.

I would commend you for this, Dr. Gramlich, and I
think it's a very important step which could raise the whole
complexion of arthritis treatment in this country.

DR. PAHL: Thank you very much, Dr. Haber.

Are there further comments by the council?

Mr. Rubel, I lieve, had a statement.

MR, RUBEL: One further thought. I mentioned
before that we have reached a settlement or at least there
is a proposed settlement of litigation, and that we have —
agreed at least that unless any RMP objects, that $5 million
will be used under Section 910,

it is our current intention to spend all of that

Pa

money, using the contract authority, and that would therefore
not require review by this council, ~

On the other hand, by the time we meet in August,
we have to have our plans, very hopefully, firmed up and
I anticipate that. we will be discussing with you how we
intend to use that money. | |

The thrust of that effort is to help us do research
into the technology of planning, as I call it, the

methodologies to be used, I believe the coordinator says,

with major emphasis on criteria and standards for expensive

 

 
 

 

 

 

 

124
services like open-heart surgery and the like.

But we will have a very complete plan worked out
by the August 8 session, ‘and we do want to share it with you,
and get your -- whatever suggestions you have for us.

We are going to be a little bit in the middle of a-- we
can't go ahead until we get the court order signed. - I am not
sure exactly where we are going to be on August 8th,

Wherever we are, it's my intention to fully
report to you exactly where we are with regard to that $5
million.

DR. PAHL: Thank you, Gene,

Mr. Rubel has just distributed to you, because it
will be important to take this up in a closed session, which
we will convene following lunch, the minutes of the ad hoc
arthritis review committee, wherein you will find the
premises, guides, resolutions and recommendations for
follow-up by this agency in the arthritis program.

And if you should have a few minutes that you
could look at those, I think our discussion and adoption of
these would be more meaningful following lunch,

\

I would like to also thank Mr. Robert Tarr, the
the HEW Committee Management Officer, and Mrs. Robert
Skinner who was our agency Committee Management Officer, who
is attending this morning, and just state again that we could

not be. here and have the paperwork done that is before you

 

 

 
 

end em

WD fls

 

 

125
without really the great help and assistance that they have
given to us in establishing and moving forward through a
rather complicated complex process.

The papers for the establishment of these two
committees that we have been reviewing this morning, and
thank you for attending; it's nice to have you here.

With that, I will adjourn the meeting for lunch,
and suggest that we be back at five after two.

{Whereupon, at 1:05 o'clock, p.m., the committee

recessed, to reconvene at. 2:05 o'clock, p.m., the same

day. ]

 

 
 

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“AFTERNOON SESSION 2:15 P.M.

DOCTOR PAHL: The Council will please reconvens,
now that the Acting Director is here. I apologize for being
a few minutes late.

We continue to get communications from Regions; we

review cycle, but I think we have to call a halt to it at
this point and get to the. business at hand.

“I think that -- Judy, just let me ask whether you
would prefer to give your general comments now, or after
Doctor Gramlich treats the arthritis program?

MRS. SILSBEE: i~think it would be simpler if vw just
concentrated on the arthritis. |

DOCTOR PAHL: Because of the schedule, which permits
Doctor Gramlich to be here today but not tomorrow, we have
decided to ask him at this time, again, to present now in
this closed session, the Arthritis Review Committee's consider{
ations, together with a specific recommendation on the appli-
cations, and to give you a full picture of those events, and
then to ask Council to take appropriate action.

Now, in opening this meeting, I would again remind
you that the proceedings from this point on are confidential,
both the materials that you receive as well as the discussions

that will ensue, so we ask that you keep that in mind, and

also, should any application, either within the arthritis

 

 
 

 

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127

a)

program or within the Regional Medical Program, be discussed
from the area from which you come, or if you knew of some
other, conflict of interest as a result of your own involve-
ments in consultantships and so forth, please’ excuse your-
self from the room during the discussion of that specific
Region's application.

Are there any members of the public who are here,
because if so, I will have to ask you to leave the proceed—
ings at this point.

Doctor Gramlich, will you please proceed with your
discussion, and in that connection, I have been requested to
announce that because of the low ceiling and the aircondi-
tioning, it is hard for the Reporter and the staff to hear
the comments, 50 please use the microphones when you have
occasion to make comments or address the Council:

DOCTOR GRAMLICH: I think there are several things
that merit emphasis that I didn't pressure quite enough this
morning, in terms of discussion time limitations.

First off, just a small subjective observation,
which, in addition to the listing of the Technical Review
Committee members, which I described this morning, I would
simply comment that this was a very hard-working, extremely
conscientious group of people.

DOCTOR PAHL: Pardon me, Doctor Gramlich; can you

put the microphone a little bit closer? I am afraid the air-

 

 

 

 
 

8
WHD3 3 t2

conditioning units & this end are makkng it difficult to hear
you.

DOCTOR GRAMLICH: Is that any better?

° C: — | DOCTOR PAHL: Yes, thank you.

| | DOCTOR GRAMLICH: This Committee was an able group
which devoted a great deal of attention to the problem, as
witness they went to work at 8:00 o'clock in the morning --
none of this’ 9:00 o'clock business, and on a couple of .
occasions worked until 8:30 or 9:00 o'clock at night, or on
one occasion they worked that late. The Saturday morning --
or the Saturday session -~ lasted until mid-afternoon, so

in effect they put in three days of hard work in reaching

the conclusions that they did.

That's a small personal aside. I was there as an
observer. I have been credited with the good work they have
done, which I would like to assume the responsibility for,
but my position merely ws that of, hopefully, a bridge between
them and the National Advisory Council.

I did not contribute because I have no “expertise in
arthritis or rheumatolosy. .

Now, down to the work. I think it is extremely
important that the council is quite cognizant of the guide-
lines that this Technical Review Committee developed, because
it was the basis on which they made their objective decisions

as to which grant applications should he funded, which should

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129

oy

be disapproved, and the numerical ratings and prioritization
of the ones that were approved.

The purpose of using this format was to make it
considerably easier, hopefully, for the Council to do its own
job. |

Now, I have very summarily named off and listed,
briefly, the guidelines that they came up with. But you have
only just recently received an opportunity to read them in
detail.

I would first off ask Council whether they would
like to discuss these in detail, or whether they feel satis-
fied and comfortable with the guidelines as they have been
given to you on the written sheets that you have? If you
want to discuss them, I will be very happy to do so; if you
think that there is no need to waste time on that, that is
agreeable to me.

DOCTOR PAHL: Is there any comment by Council as
to whether we can proceed? —

Have you had an opportunity to review these, either
prior to or over the lujich hour?

I think, Doctor Gramlich, we might assume then that
they are in agreement with the understandings reached by the
Review Committee, and you might proceed with the report.

DOCTOR GRAMLICH: If that is true, then I would

suggest, as a matter of the least confusion, that it might be

 

 

 
 

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own guidance were done so with a recognition on their own part

 

 

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appropriate for me to move that Council accept the report
listing the guidelines.

DOCTOR PAHL: Is there a second to this motion?

DOCTOR WAMMOCK: Second.

DOCTOR PAHL: It has been moved and secondea for
the Council to accept the report of the Review Committee in
which these guidelines and recommendations are given: in
detail. _

Is there discussion about any of -- Doctor Merrill?

DOCTOR MERRILL: Yes. I have one rhetorical ques-
tion which I have asked Doctor Gramlich before; I know the
answer to it but I'd like to have it for the record.

I assume that there were no sticky points in any
of these recommendations you made which you felt needed the
advice and concern of the Council? There were no problems
which you felt should be dealt with at this level?

DOCTOR GRAMLICH: I recall none. Matt, were there
any that came up? -

DOCTOR PAHL: Mr. Spear, would you please comment?

MR. SPEAR: ‘T can't recall any. There were
specific cases -- having established these specific guidelines),
there were specific cases -- I think the best answer, if To

interpret your question correctly, Doctor, is that the recom-

mendations and guidelines that the Committee adopted for its

 

 

 
 

 

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that these were not carved in stone, and if there were a
reasonable basis to violate them, they would do so, and at
the moment,’ off the top of my head, I'm aware that they did
so in only one case. |

DOCTOR PAHL: I think it should also be perhaps
noted for the eecord that the guides and resolutions, in part,
form the basis for the recommendations for follow-up by this
Agency, and in that sense there would be continuing involve-
ment by stare to help make effective the recommendations of
te Committee, insofar as these guidelines were utilized during
discussion of any specific application.

So the two together are the package, the recommenda-
tions of the -- to the Agency, as well as the premises on
which they discussed the individual applications.

Is there further discussion by the Council?

If not, I would ask the question; it has been moved
and seconded to accept this report.

All in favor? ~
(Chorus of "“Aye")
Opposed? ”
(No response)

So moved.
Doctor Gramlich?

DOCTOR GRAMLICH: I would then think that perhaps

the next step would be the assessment of the list of the

 

 

 
 

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132

recommended disapproved and approved grants, and the allowance
therefor.

. In the sheet -- or, in the folder which has been
titled "Arthritis," which has been just recently handed to
you --

Now, you will note -- these are alphabetized -- that
there were --. you'll note several things first off. 7

There were grant requests totalling $15,866,581, for
the payable funds $4,275,000, but the Committee, of course,
was always cognizant of the need to keep the approvals and
the funds recommended within the $4,725,006 figure -~ I'm
sorry -- the $4,275,000 figure. .

Therefore, they went through the grant requests one
by one, with a primary reviewer reporting on his or her
objective observations, and a secondary reviewer either con-
firming, denying or altering the review of the primary reviewer.

in each instance, when each grant request was con-
sidered, this process was followéd by total discussion by the
entire Committee. That is one of the reasons it took three

7

days. /
There is -- the recommended funding for those
approved programs came out surprisingly close to the amount
that was available. They didn't realize at the time this was

being done whether it was going to come out close, below or

above, so they took the obvious route of prioritizing them,

 

 
 

 

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133

and ranking the score, giving them a numerical rating as
well as the collar figure.

Out of the 43 applications that were considered,
12 were disapproved en toto; the remaining 31 were ranked,
and the recommended funding noted.

I have just discovered a minor discrepancy, I'm
afraid, in that on the first page of my listing of the
Committee's recommendations, the rank score has been left _
out.

Does yours have the numbers on it?

MR. SPEAR: We didn't put it on the first page,
Doctor. |

DOCTOR GRAMLICH: Oh, okay; very good.

So what you see there, then, is on the basis of
zero to 100, the Committee's estimate of the quality of the
grant ers “- on the second page, now -- the total amount
requested and the total amount recommended by the Committee.

I would -- e

MR. SPEAR: If I could inject one comment, Doctor,
the rank score is a ranking after the application had been
modified by the Committee.

DOCTOR PAHL: Thank you very much, Doctor Gramlich.
I think this give you a picture of the recommendations --

that is, the final dollar recommendations for the approved

programs, and before asking for any action on this, I would

 

 

 
 

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amount. What we would intend to do, following Council action

 

 

134

indicate to you that the earmarked funds for this program

are $4.275 million, and the approved programs exceed that

on approved and disapproved programs, is to notify those
Regions that have had programs approved that we are also
sending some dollars with that notification, to the extent
that we can, but for those programs that were approved by
the Review Committee but which go beyond the ‘actual earmarked
funds available, we would indicate that the Region may, at
its discretion, use its RMP funds from the June and August
Council awards if it is in their best interests to do so to
fund the programs.

In other words, we would assume that they could
incorporate that into their total consideration of priority
listings as to how to use the RMP funds that we are making
available to them through this next June 30th.

Those programs that have been recommended for dis-
approval by this Council would receive a letter stating that
their application has been recommended for disapproval, and
therefore they may not lise RMP funds for the support of that
program, and that the application basically is ended from that
point of view.

So, with that, John would you care to introduce a
motion for the Council to consider?

DOCTOR GRAMLICH: It would seem to me the .easiest

 

 
 

135
WHD-10 oa

* , *

way to solve this problem, if the Council is comfortable in

|: so doing, would be to accept the list as prioritized, and
suggest to the RMP's that those programs that fall within
the total finding, starting from the top and working do ==
of $4,275,000 -- be approved en bloc.

Now, that leaves a question about the ones that
were approved but ranked low, and therefore do not fall
within the funding purview of the amount available. -

” If you look at the list on the second page, the
gross total after Albany _- sixth from the top -- comes close
to the funds available. That figure is $4,239,750. After

Albany, and before Puerto Rico.

You probably also have noted that Puerto Rico has
the same score-rank as Albany. This poses a minor problem,
in that if Albany is accepted and funded, we stay within the
$4,275,000, but Puerto Rico has the same rank, according to
the Committee's deliberations. So there is an element of
unfairness to that. -

. _. If Puerto Rico is added to the list, the figure
that then totals out for the funds to be allocated is
$4,332,950, which is about $60,000 over the allotted $4,275,00C
I would suggest -- and this is an independent
suggestion, that if we deem it possible -- if Council approves

~- that an additional $60,000 might be found somewhere which

would allow Puerto Rico as well as Albany to be funded, and

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136

therefore would make the following motion..

That Council approve the fumding of the arthritis
grant requests within ranking limits, and if all Regions --
all RMP's, including Albany and Puerto Rico -- accept the
recommendations of the Technical Review Committee and Council,
that additional. funding to include Puerto Rico be found, if.
possible, from other sources, so that it also would be
included in the approved and funded list. , ; .

That's long and complicated.

DOCTOR PAHL: I think the Council has the sense
of your discussion, though, and I would ask if there is a
second to this motion?

MRS. FLOOD: Second.
DOCTOR PAHL: It has been moved and seconded. Is
there further discussion?

Mrs. Mars?

MRS. MARS: . How does the incidence of arthritis
in Puerto Rico compare with Albany, and what is the compari-
son between population figures? |

. That in fact might be a very decisive factor.

MR. SPEAR: That -- we don't know. To the first
part of your question, Mrs. Mars, no one knows, other than’
that there is a higher incidence in deprived areas and in,
areas in which family income is below $5,000 a year.

MRS. MARS: Yes, but the climate also has a great

 

 

 

 
 

 

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137

deal to do with it.
MR. SPEAR: The field discourages that. They do
not believe that that is true, according to present thinking.
With regard to present thinking, I regret to say
we do not have those figures.
MRS. MARS: Well then, how can you hase it as
being equal, so to speak, that one should have as much money
as the other? | ;
DOCTOR PAHL: Well, there were a number of elements
that went into the consideration of the review, which ulti-

mately led to the ranking priority of 40. It is just coinci-

dental that it comes out with Albany in the ranking.

MRS. MARS: I meant to say in rank, rather than

money.

 

' DOCTOR PAHL: Surely.

MRS. MORGAN: Can we really give them more money

‘than what has been appropriated?

DOCTOR PAHL: I think the sense of the recommenda-
tion -- or, the motion that is before us, is to fund througr
Albany, and if it is possible for the Administration to find
additional funds, to fund Puerto Rico.

That is the sense of the motion, and this merely
gives us guidance as to what the Council wishes to do, and
we will attempt to carry out this request if that motion is

carried. If it is not possible for us to do this, obviously

 

 
 

. WHD-13 138

we will then fund as far down the list as possible.

- It also could be that one Region or another would
find it inappropriate to accept their award because of the
modifications that have come about as a result of the Review
Committee deliberations, and thus we are not certain that
these will be the final ultimate ones in all cases that
would be the approved, funded projects.

’ | That is why we have a slightly longer list to take
care of, which must be the result of negotiation following
Council -- Doctor Merrill?

DOCTOR MERRILL: Because perhaps Puerto Rico is a
favorite of mine, but would it be feasible, let's say,
instead of dropping Puerto Rico entirely, in the event that
you can not find $60,000, to take $2,590 from each of the 24
above it and allot it to Puerto Rico? It's nota lot to take
away, and yet it would assure that Puerto Rico was funded.

DOCTOR PAHL: I think Staff has the flexibility for
negotiating within this rather strange dollar figure as a
ceiling amount, and I believe we can receive the guidance of
the Council and feel réasonably sure that there is a possi-
bility of funding Puerto Rico without actually being able to
~. commit to you definitely, sitting here at the table today.
MRS. FLOOD: Also, Puerto Rico is a favorite of

mine, but also with a concern for equal ranking, and an arbi-

 

trary line drawn for equal ranking, may I ask -- I would doubt |

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that any Region would turn down any funds that might be
offered, even though I find it interesting that Ohio Valley,
for example, with a request of $711,000, receives a recommen-
dation for $46,500, and another marked one, although perhaps
not quite as large, would be Wisconsin, with $267,800 and a
recommendation at $62,000. ‘

May I -- there is one other here -- He

DOCTOR MERRILL: Look at Iowa right below it.
Compare Iowa and Ohio Valley.

MRS. FLOOD: Yes. Then there is Mississippi.

Might I ask of Doctor Gramlich, how would -- with
such extremely high ratings of these regions above could
their funding recommendation be so starkedly lowered?

MR. SPEAR: There are many reasons, and I will try
to recall some of these to you.

Many of the Regions went the usual RMP route, in
which they came in on their applications with a full-fledged,
Region-wide care-delivery kind of. program, and we had tried
to make that clear in the guidelines that with limited funds,
and with the language in the Congressional authority, this
was not what we were after; that we looked for pilot efforts.

And one of the reasons in some of these where you
see such a stark distinction is where there was a very sharp

cutback to just a pilot activity.

For instance, in a number of states where they had

 

 
 

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WHD-15 |
divided their states up into a number of various areas, and
then down into sub-organizations of other kinds, and they

C, | | had pooled people, activites, in all areas of the states, the

Committee said: only go for one or two of those and try it
out, and see if it works, and provide yourself a working basis
which is demonstrated and proved. That happened.

Some of them had very large requests for things that
by resolution the Committee had decided not to -- film-making,
videotape-making, development of publications, and the print-
ing of them. Large computer data operations, patient =
registries -- all these are much néeded in the country, but
this is not the program to support those kinds of things.

I know there are two or three other reasons; they'll
- come to me. Maybe if we take a case --

MRS. FLOOD: Choose Mississippi.

MR. SPEAR: Choose Mississippi? Let me think about
it. |

Mississippi has a very fine, very gorgeous hospital
being built in the state, I believe in Jackson, and the
application surrounded ‘that installation, that facility, and
as the Committee looked at all the various components in that
application, they came to the conclusion that what the program
was really being asked to do was to underwrite the first year's
operation of that institution. | |

And they said: "Thanks, but no thanks. What we will

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141

do, for those kinds of very small but meaningful out-
reach. activities you propose to do with that institu-
tion, we would like you to start them now and do them."
And that is what they funded.
MRS. FLOOD: But you rated it 80.
MR. SPEAR: We rated it 80 with that modification.
Without the modification, they would have turned. it down.

These rankings are with -- at the lower recommended

amount, the ranking relates to that, and not to the request.

MR. BAUM: Matt, there was also in that one, as:
part of an example, a request for something like $385,000 for
making motion pictures related to arthritis, and that is one
of the reasons for the sharp drop in money, since that was
completely chopped out of the approved project. |

DOCTOR PAHL: Thank you, Mr. Spear and Mr. Baum.

Doctor Haber?

DOCTOR HABER: The same question was bothering me;
here comes Iowa, way down the list with 97 percent of what
they requested. But I think the explanation is clear, that
the rank-score relates ‘to the excellence of a particular part
of the project, and the total sum may be unrelated to what --

DOCTOR PAHL: Mr. Spear?

MR. SPEAR: Just an idea, there.

You see, you have -~ like yourselves -- many people

sitting together makig these kinds of determinations, and it

 

 

 
 

 

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is hard to tell on what basis a particular reviewer will make
his ratings.

Sometimes it was the excellence of people who were
underwriting a program. Sometimes it was the excellence of
planning; sometimes it was the specifics of what they ware
trying to do, in which they knew, by similar activities, 7
for some other reason, that this was going to be a going con-
cern.

All of these things came into it, and we are not
quite sure in some cases what was the balancing factor.

DOCTOR PAHL: Is there further discussion on the
motion?

MR. HIROTO: One.

DOCTOR PAHL: Yes, Mr. Hiroto?

MR. HIROTO: Does the. RMP plans which were dis-
approved -- were they primarily disapproved because they fit
into the resolutions of "non-activity"?

DOCTOR GRAMLICH: They- were disapproved on a multi-
plicity of bases.

Some were disapproved because the program that was
recommended was entirely outside the guidelines: other were
that it was felt that the personnel involved were not capable
of doing what they claimed to do.

‘I think in this guise it is important to emphasize

once again a point that Doctor Pahl has made, and so has Matt

 

 
 

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Spear, that of the approved programs, if there are other RMP
funds available, too, the Council says in effect it is all
right; if you can find the money someplace else, go ahead with
the part of the arthritis program that is not funded.

For the disapproved programs, as Doctor Pahl has
pointed out before, no RMP funds of any sort can be used --
should be used for that particular program. |

DOCTOR PAHL: Is - there further discussion, comments
questions?

MRS. MORGAN: I don't know whether I understand or
not, when you say that they may use other RMP funds.

You're not saying they can use other RMP funds for
making movies and that sort of thing, are you?

DOCTOR PAHL: No. It would be within the --

MRS. MORGAN: Within the guidelines?

DOCTOR PAHL: Within the guidelines.

I would like to act on this motion and the come back
to that point, in view of Council's consideration last
February. I would like to act on the motion to accept the
Committee's rank-ordering and overall recommendations,
together with funding through:the rank score of 40 to the
extent that Staff can negotiate this or obtain permission to
exceed the earmarked level that has been given to us. |

If there is no further discussion, all in favor,

please say "Aye."

 

 
 

WHD~-19 144

(Chorus of “Aye")

Opposed?

(No response)

So moved.

Now, in connection with what I indicated to a
before, as to our interest in sending letters to those Regions
that did have approved applications, but are not within that
funding range, to provide them the opportunity to use their.
own RNP funds to Support the approved programs as modified by
the Committee, I have had my attention called by Mr. Baum to

a resolution that the Council made in February, which I would
like to read into the record, so that there is no misunderstand-
ing or conflict between the two Councils, particularly in view
of the fact that we have a large membership.

In February, the Council approved the following
resolution in relation to the arthritis centers, and that is
on page 6 of the minutes of the Council meeting. Quote:

“Whereas the Congress has earmarked in connec-
tion with Public Law 93-192 certain RMP funds for | Planning
and development of ‘pilot arthritis programs, be it
resolved that the National Advisory Council on Regional
Medical Programs recommends that activities in the field
of arthritis be recognized for Support under Title 9 of
the Public Health Service Act to the extent that funds

have been appropriated for this function."

 

HOOVER REPORTING CO, INC.
320 Massachusetts Avenue, NE.
Washington, D.C. 20002
(202) 546-6666

 

 

 

 

 
 

WHD-20

HOOVER REPORTING CO, INC.

- 320 Massachusetts Avenue, N.E.

Washington, D.C. 20002
(202) 546-6666

 

 

145

Now, I believe it is fair to say that the spirit
of that resolution would be contrary to what I have just
indicated to you, and very frankly, in the press of things
which I have been concerned with, I had forgotten that we
had this, and so I am glad you reminded me so that we can
bring it to the surface and ask this Council, now meeting in
June, whether you would like to reaffirm, if you will, this-
resolution that was passed by the Council, which would limit
then the funding of the total arthritis programs to those
that can be fitted within the earmarked, or whether you wish
to reconsider that, since it is the Council's resolution,
and endorse the position which I indicated to you was my
intent, and in all honesty, having forgotten the earlier
resolution, for which I apologize to Council.

MRS. MORGAN: Could we Say, take two percent or one
percat of all the others above and be able to fit Puerto Rico
in?

DOCTOR PAHL: I wasn't referring to Puerto Rico; I
wad referring to the fact that there are below that, four
additional approved applications which obviously are beyond
the earmarked. |

And so it is in the interests, I think, of this
Council to consider whether it wishes to permit RMP's to use

their RMP money, if they see it to be their priority, in those

approved Regions, to support the programs, or whether you wish

 

 

 
 

WHD-21

HOOVER REPORTING CO. INC.

320 Massachusetts Avenue, N.E.

Washington, D.C. 20002
(202) 546-6666

 

 

 

146

Ga!
not to make that opportunity available to those additional
Regions.
MRS. GORDON: Could you give us the rationale for
this particular decision?
‘ DOCTOR PAHL: Well, I think the rationale -- I am

trying to reconstruct; I am afraid our minutes are perhaps

seem to me that that was the

+e

abbreviated here, but it would
interpretation of what the earmarked meant at the time, and.
also at that time, when the Committee met in February, we

were very uncertain as to just what level of funding -- I am:
sorry; when the Council met in February,we were very uncertain
as to just what funds we would have to support the RMP program

Having the Court order before us, we felt we knew,
but there was also some uncertainty because of various con-
siderations that had come into play, and at one point in time
a rather large sum was thought perhaps to be better used for
other purposes, and I am making a report to you now that some~
thing like $110-115 million will’ be available to support pro-
grams -- the regular programs of the RMP's.

So there is a’ question here of whether the Council
feels it important to permit RMP 's to support programs <-— |
approved arthritis programs beyond those which reach the
ceiling mark or whether it is not.

Doctor Merrill?

DOCTOR MERRILL: I wonder whether the Council might

 

 

 
 

WHD-22

HOOVER REPORTING CO, INC.
320 Massachusetts Avenue, N.E.
Washington, D.C. 20002

(202) 546-6666

 

 

147

consider, in that light, modifying the February resolution to
gay that these other funds not now earmarked for arthritis
might be utilized for this upon application to the Director,
and with his approval in special instances?

DOCTOR PAHL: Mrs. Silsbee?

MRS. SILSBEE: Doctor Pahl, I think Council's |
resolution in February related to the earmarked and the way
in which we administer the earmarked. .

Once those funds are put out under the earmarked,
the Region does not have flexibility. That money must be used
for arthritis.

DOCTOR PAHL: That's targeted.

MRS. MARS. Well, I also think it was also to not
dip into RMP funds at the time, to be used for the specific
arthritis prograns, that we felt that some had been allocated
and was adequate and ample.

And I think that the resolution should stand, even
in view of the fact that we neu do have further funds.

DOCTOR PAHL: All right.

Is there additional discussion on this point?

Mrs. Mars?

MRS. MARS: Certainly there can be somewhat of a
distribution of funds, as it stands now, and send it back to

the Review Committee to see if they can reallocate.

 

 
 

WHD=23 148

DOCTOR PAHL: I am afraid we dc not have the time
available for us to obligate these funds by June 30th.

(Discussion off the record)

DOCTOR PAHL: I think that obviously the Staff al
do its best to negoatiate with ‘Regions to fund as far down
the list as possible, but I think we need a clear statement
from this Council as to the reaffirmation of the early resolu-
tion, which is your point, or whether that resolution should

“not stand, because I have misinformed you, in a sense, quite
out of ignorance, if you will, or of not remembering that
earlier point. |

.So let me suggest that, Mrs. Mars, you make it as
fo a motion and let's test it.

MRS. MARS: Very good. Yes; let the resolution
stand as it was previously passed.

DOCTOR PAHL: All right. The motion has been made
that the February Council motion stand.

Any second on the motion? |

Mr. Rubel?

MR. RUBEL: I would just like to ask if in 1971 or

'72, if the Washington~Alaska RMP had put in its proposed

os, || project for $175,000 for this kind of activity, would that
have been accepted -- acceptable at that point?

Is this something that an RMP could have done?

DOCTOR PAHL: Under the original guidelines, yes.

HOOVER REPORTING CO, INC.
320 Massachusetts Avenue, N.E.
Washington, 0.C. 20002

(202) 546-6666

cic Sas 2 eases aaaaaaaaadasaaaamaasaaamaaasaaaaa aaa amma tesa enn

 

 

 

 
 

 

WHD-24

. HOOVER-REPORTING CO. INC.
320 Massachusetts Avenue, NE.
Washington, D.C. 20002
(202) 546-6666

changed between the two applications.

 

 

 

14g

MR. RUBEL: Do we have any other kind of quotas
that we are using here for kinds of Special projects? Have
we said in here that we could only use -- I understood that
the essence of the RMP philosophy was to allow a Region itself
to determine what its priorities were.

MRS. MARS: I don't think that has anything to do
with this at all. This was simply that we did not want to
supplement this four million -- whatever it is -~ and take it
out of RMP funds.

I don't think it interfres in the least with the
idea of a legitimate project on the part of any RMP, whether
it concerns arthritis or anything else.

DOCTOR MERRILD: Still, with the uncertainty that
has prevailed, perhaps between the time of the original
application, let's say, for other funds, and this arthritis
application, priorities might have been reassessed, and if the
total amount of money from out of our pocket was not changed,
but simply an intramural reevaluation from one pocket to
another, in light of changing priorities, if this had the

approval of the Director with proper application, would it
not be the prerogative of local RMP rather than perhaps the
Council to have a flat "No" to this kind of thing, without

knowledge of the fact that priorities situations might have

DOCTOR PAHL: Is there further discussion by the

 

 
 

WHD-25

 

 

 

 

150

Council on the motion?

DOCTOR GRAMNLICH: I am not sure I understand the

motion.

is that in effect saying that we can not support

Puerto Rico from funds other than this grant?
J
DOCTOR PAHL: te is saying that we would not support

:
with funjs beyond the earmarked any approved -- beyond earmark |

lvel, any of the approved applications.. That is, we would

not be giving the right to Regions to utilize their funds for

the support of these applications.

DOCTOR GRAMLICH: I put a little different reading,
then, on this resolution in February. You know, it is easy
to put all sorts of readings on it, since I wasn't there and
Gon't remember what the Council had to say about it.

But it strikes me that the Council, in its February

action, where it says:

",..be recognized for support under Title 9

7 ri .

of the Fublic Health Service Act to the extent that funds

 

have been appropriated for this function." 0 |
LS DeXxhaps serving as caving: “we don't know what Funds we -
t

Let's take these while

vo en ee te. ew ts Td
we Can Without naving to cbligate

nything else,. cut of moncys .

fy

x

t Knew that welre going to get, and that perhaps

ail they were doing was

tobe

ust accepting PL 93-152 and the-money

epee >

 

 

 
i5i
WHD-26

t

| that went with it under Title 9 without considering any
i supsequent possibilities.

{ -

 

DOCTOR, PAHL: Well, I would suggest that since we
are a full Council now, that this Council act as to what it
ees to be the best interests of the program, because there
i dis full knowledge before you as to our current situation and
the applications and the funding recommendations, and I.
believe you have the right, as the Council, to make whatever
reaffirmation or change you wish from an earlier point.

MR. MILLIKEN: This is going to be an amendment;
is that right?

No? it's a restatement?

MRS. MARS: NO, it's merely reaffirming the motion
made in February by the Council. Reaffirmation.

DOCTOR PAHL: Mrs. Flocd?

i MRS. FLOOD: Perhaps being a little repetitive, but.

 

let me clear now in my mind -- we are saying that should we

 

-

overrule the policy action of the February Council meeting, or

.

i substitute a newer, broader policy statement, nonetheless, we !

 

as

“Medical Programs to expenditures of

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ned funds plus their own funds, to the categories of

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|
activities approved by the Review Committee? |
}
fa In essence, we would not allow Migesissippi to go

ahead and

ae my yn “1 4- wes ~> ++ : :

use genoral funds to briny their expenditures in an _

. t

whine dende ae 2 one 7 4 - ake sn + bael “ac
arthricis project, for exawple, up to the level listed here as

.
!

 

 
 

WHD-27

 

 

 

 

 

152

rr

eneas roquest; we would give them only the authorization to
augment their -- well, they are above the cutoff. Let's
take someone else. :

Lakes Area, for example, that is below the cutoff
line. They would only bein a position to use $45,000 of
their funds for that component part of their application.

his:is the interpretation I'm hearing?

oe

DOCTOR PAHL: Yes. - . ‘

MRS. FLOOD: Thank you.

DOCTOR PAHL: In other words, what we have is a

preliminary review group that has looked at the technical
merit and has established guidelines for a national pilot
arthritis center program.

In order not to abuse the whole process, we would
apply the same restrictions on all approved Regions so that
they could not do lecally what wasn't really approved
nationally; otherwise, there would not have been much purpose

in going through a national review process.

v1 : des nee : ca ‘ , Tate!
The mueston hore is that we will pay through as mtcn,

- - ~ Ue ete ee meg pe ts : heine.2 2g 7
G&S WE Car UUr.ty, dno tnrecugh tre NETOCLAcLiONsS Whicn have to.

Ty Sy aN , ; -~ : . % “4
The Further consideration is whether Regions who

 

 
WIID-28

marked, and that.represents, I believe, the consideration

 

 

 

 

where there is insufficient money, whether they may use
their own RMP funds to support what we can’t out of the ear~
that is before us.

And the motion, as I undertand it, that has been
made-and gsconded, would be to limit the 53 RMP's in the

pilot arthritis center program to those Regions' approved

7 -

applications to the point where the earmarked funds have run
out, wherever that point happened to be.

All in favor of the motion, please say “Aye."

(Chorus of "Aye”") , . .

Opposed?

(Chorus of "No"}-

Well, perhaps we might have a show of hands, if you
vill, please. All those in favor of the motion, please raise
your hands. |

(Show of hands)

 

 

Four hands.

,
vane re eye oF
Cprosea Z
&

Dine Ae tnt
EnaQvy OQ2 ROnUS?

‘Phe motion is not carried.
Now, we will entertain a different motion. !
DCCTCR MERRILL: I would dike to make a motion that
the funds aworopriated for the arthritis project -- that thes

matt ee ee i Doel Fae OT ee i c se Te
APP LeCALicss rer which Dumas are not avaisabpise Trom ene

wey

 
 

 

WHD-29

 

wae eee

$

 

 

 

artnritis project be allowed within the limits of the recom-
mended total, to apply other funds now in their possession
to the arthritis. project, upon application to the Director
of RMP and subsequent to his approval.

DOCTOR PAHL: All right. Is there a second to

hat. moticn?

VOICE: Second.

DOCTOR PAHL: AI1L right, that motion has been made
and seconded.

For clarification, I believe, Doctor Merrill, you
would want to state not necessarily the funds "now in their
possession,” but funds currently available to them or those
which are to be made available to them as a result of June
and August Council decisions, whatever they may be.

DOCTOR MERRILL: Yes.

DOCTOR PAHL: Is there discussion on that motion?

MRS. KLEIN: Miter Chairman, I didn't get that’
limitation straight in my mind. Is it a limitation on the
amount they applied for, or the amount that was granted,

within which they may use their other funds?
. t

MR. HELLINEN: The amount that was granted, rigut?
Is that what you mean? the funds that were granted.

eT ne Pim, oe Rin de ~ 4 2 OER
wee te PLE ae 2cS.« Not apmywiea Lory; granted

.

 

 

 
WHID- 30

 

 

155

MRS. KLEIN: Well, Mister Chairman, that, then,
would Le an extremely limited motion, would it not, and
would apply really to these last two applications, possibly,
because -- is it my understanding that there are sufficient
unds available to fulfill all the other commitments?
DOCTQR PANL: There are sufficient funds to pay
all except perhaps -- $500,000 total amount of recommended
applications, so it only has impact to that extent. It's
impor tat to those regions.
Thank you.

MRS. KLEIN: I see.

DOCTOR PAHL: Is there further discussion?
If not, all in favor of the motion say "Aye."
(Chorus of "Aye"™)
_, Opposed?
° {No response)
The motion is carried.
Bll wright. Doctor cramlich,. are there any comments

you have, or Mr. Spear might have on tne arthritis activity?

 

TAO ey, A wat r may tet wee my bed et : '
DOCG Glow kui t LvWOuULG Movi One O©rLer comment, '
.
. ' ;
us ve - 4% aw TF Rend of ia on ik, m. + + .
woctor Pehl, and that is that the Technical Review Committees

|
’
1
: + : sot ae _ . {
considered the follow-up activities, at intervals
t

< tf gis ant a A nae te ated . :
ring the grant year anf at the conclusion of the grant year.
i

ye Council urge the RiPfs to

'
~

a ar pds wing r Toe eee ee eS ee bth du Rh ‘ ~
carry out their folleowean accivities within the limits of

 

 
 

WHD31

 

 

 

feasibility.
) Does this require a vote?

DOCTOR.PAHL: No, I think -- |.

May I just please pass along the comment that it
is not vossibic for us te get a record of the meeting with
multiple conversations going on in the room. It is just a-
poor rocm for the acoustics, or perhaps it's overly sensitive
for acoustics, so please fee the individual conversations.
down if you can so that we can get a record of the Council
meeting.

Doctor Gramlich, the Staff, I think, understands
through the discussion of the Council and the acceptance of
the minutes and so forth that the Council would wish us to
engage in these activities that were recommended by the

Committee, endorsei by the Committee ~- the Council, which

hovefully would lead to an effective program cver the year,
i ¥

‘which would mean that we would be calling together the ©

Directors of these projects, asking for periodic reports, and

ct

Gata retrioval, systems, provide assist-

ta
0
3

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". an
aoa DG

uy

reas &

4

n

&

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j

ance in finding am

a =

w

of audio-visual aids and things of this nature.

»

So I Gontt belicve we need a formal Council action

sea yaa + on * OF = ae, .
on this, but wa wouia accept it ce

a
H

tuinly as the Council's

 

ryince to work with them and give assistance to them in these

ronriate limited sources for the production

mye

ere

 

 
 

WHD-32

 

 

wee ee

 

li

 

 

 

157

DOCTOR JANEWAY: I just wanted -- I'm new, and I
would like to ask a question for information.

Would you define for me, to make me a little bit

more coimfertable, about the meaning of a priority score of 20?

oo“

DOCTOR PANL: I would like to ask either Matt or
Docter Granlich. I think it’s important --

DCCTOR JANEHAY: Because it's a little bit different

‘then I'm used to hearing. AN

HMR. SPEAR: I am trying to recall, Doctor Janeway,
just what that meant, and it doesn't come to me at the moment.
I can look up the records, if you want to take a few moments
while I do that.

DOCTOR JANEWAY: NO, no -~

HR. SPEAR: But -=- those Regions listed below Puerto

Rico have had their successes, and lesser successes along the

way.
What the Committee was looking at were in some cases

“~ amd these were some of them, certdinly -- in all cases to
. ral .

the Recdons that hec an extremely short time to put these pro-

 

eee ey eo ne wy Taek eae 24 = ay mri sta t
Gtans together, and the anplications reflected th =

eee amauta Fler eye ty et
personal CONTAC CS ana Tho

5 = : ot 43 Legg To ae +
PARR OWACUGa OF the fiwld, £0 know where

eos m ete- il wd er oe 4 - . 3
tee sirecwths endat: 2 tye Werte not evun reflected in the
tips ¢ : Wee : me SSce@-Mivl~Seue) 5
AbpaiCaltions, ana I Weul.l take -“WWInGSsée-hiueScuth as an

 

 

 
WHD-33

 

rae

 

 

 

 

158}

example, although I'm not sure it applies specifically to
this case.

Where there was an underlying feeling that there
were better resources there and a better capability than
they were seeing, and it raised a little question in their
minds as to the real intent and the real commitment to what
they were reading was in terms of carrying out -- insofar as
carrying out those things the Committea, was willing to recom-
mend.

In some cases -~ for instance, Puerto Ricdé would .
~- which is a 40 -- in the area of known extreme needs for
this kind of thing -- not that it doesn't have many, many
other extreme needs, and it was sort of a joke among the
Committee, because in the Central Hospital of Puerto Rico, |
there ara 14 rheumatclcgists, and there are large areas up
in New England, for instance, that don't have that.

. And as they went through the rest of it, they kept

saying: "I wish we could pass cut some of those rheumatologists

 

Burt you know, their plan never told us who was

|

going to direct it, and that is something that, going back
: : 1

to them win this Council's approval, that is the first thing

o
we are going to ask them: "Who's your Director up there?"

ues am
NO Oon® Was mamed. 1
. t

t

'

"y 7 4 aseart
Vy rc wieae
But tre nooed

.

waco known, the 14 rheumatologists and

 

 
 

WiiD~ 34

orem

Fe pte ee epee cnet le ae

24 '
ve might ne nee -

 

 

cf the questicn was different than that.

 

i593

some allied health people -- the capability was recognized

and there was seme outreach in it that looked like a good |
thing to do. But they would have had a .much higher score
if they had told us who was going to run it.
or instance, ypu eee) these kinds of things i
affected rankings of this kind.

Am I being adequate for your question?

MR. CHAMBLISS: Maybe I can help just a bit there,
Doctor Janeway.

Rank~score is simply a technique that the’ad hoc
Committee used te sort out, and in its sorting out it assigned
certain numbers to each of them. Some of the ones below had

rankings below the 40, or below the 20, and it was just a way

cl laying out its work so we could cstablish a pay-line and

DOCTOR JANEWAY: I understand that, but the intent

 

 

QUPAaN an the

Secres, but regardless of that other action, they would have |

to Work within the framework of recommendations established

Lane * Stee TL mt 5 % tn to, :
OY Une Comutifes Lisaulf, the resolutions, ,
i
a deh apne Dele < an “Q pyee nt
SO onan tncy coulan't, for exarnle, develop the ‘
f a fF 2 .

Pasa ee es G4 mete yn ~ wyh wed aT a . Y Sata de.
Q¥tnrkdelLe oregram as sabmitted, but it would have to be within

 

 
 

WHD-35

 

wee ee oe

 

 

certainly clements that enteréd into the ranking score; yes.

Soy te on
Variagoies.

the -cuidelines developed by the Committee, which is an
answer in support of your question.

MRS, co RDOvis In conjunction with his question,
would tuis then be -- would your ranking be sort of'a combin-
aticn of the aeed anc the Committee's feel for their ability a
to mest tne nosu? would that be a combination?

DOCTOR PAnL: Yes, I think those were essentially

HRS. GORDON: You. could conceivably have a tremend-—
ous program, but yet you really didn't it as much in this
area as positively as you did in another, and this then would

ive the one with the greater need maybe a higher score or
gy g

DR. GRAMLICH Competence of staff to carry out
tne progran, the abilities of the organization to supervise, !

to maxe Sure that funds were properly spent, and all these

 

QCTCR PAHL: I would not” know which element went
into any one tarticular score, but those were considerations »

Se ee emt eel mye ep Beret lw ee Les a fog 7 aw 3
aOf €A0.. Ghia 2000¢ QP PaLocllcn «-<- pare CL Lae CrLUCELrLa; Yes.

we Wial, as Staffl, subsequent to tue Council meet-

a wee em dow: ey ey ae he cm 37 : Se
SO You, certeiniy at the next Council meeting, the disposition

= : . ee gee mars Toot .t Ste a te - ~.
Ol LSE meneys 2nd the exact Ge LATS SaCuULs Urey Cnange
J e 3

 

 
 

WHD-36

 

 

 

 

within the earmarked. .

161

‘ We also will make the awards for the arthritis

applications within ‘the same official award statement, after

tiis Council, that we have for the regular RMP applications,

so that on the one award statement there will be shown the

funds for your arthritis applications and there will be

arately identified so it will be used for that purpose

Again, we remind you that certainly the rankings |
and the dollar recommendations and actions are confidential
and we will be working with the Regions as soon as we can
to effect Council's decisions in this matter.

Now, I would suggest that we just take a five-

minute break -- Doctor Gramlicn?

DOCTOR GRAMLICH: May I make a final comment? I

 

won't delay the stretch more than 30 seconds. i
° . AS an exercise in crisis management, this has been |
; |

very interesting. You must remember the Congress only author-)

ized these funds last fall. RHP was not even sure they were
going to be available until mid-March, and in that interval it

©

mee teiniat L344 wat - wea hy : aah
program which will have measurable impact

aa om ay ae .— ee eae
saci T fab ee ee GG webol a et he SP we 7
- t
—— tay epee pete £ :. mae * ta
on the henitn care of the American Civisrch.
aa ¥ a = ae we yb me - tae = ~ 7 ed -4 _
But more importantiy,it again domonstrates the vie
to “tT - ot -34 744 ~~ t Welk a TAN 4
bility and thea flexibility and the ability of RMP's.

DOCTOR PANL: Well, thank you very much, Doctor

are Lm is frye eerpytee eA pe be ot ” . t ”
Graniich, for your report, anc Mr. Spear, and let's take a few
162

 

 

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WHD-38

 

 

 

 

163

DOCTOR PAHL:

We are going to reconvene now with

some introductory comments from Mrs. Silsbee, and then we

Wiii immediately move into applications in general.

We wished to take these up alphabetically, but

because of the schedules of some individuals, not only on

the

rt
counc

fu

to contribute, Will be some departures from that alpna-

betical arrangement.

I am going to have to ask the head table particularl

if they might wish to refrain from smoking, because I have
hada request from one of the charming members here that this
isn't conducive to thinking about all these complex resolu-
tions.

Judy, why con't you just proceed now, if you will?

ERS. SILSBED: Ail right.
Dick, would you come on up?
This is the operations vart of the Staff that is
pecple tend to talk
"Silsbee"

27 thai rine oe .
Sta, UCNSV Mav Mean Mey mean

- t .
aoe Don Ma ~ Tt a 7 x he - ~ ~ MT as -
Van Vinhic, they ucgan Postiland they mein Cardsll and all of
ae 2 mt 7 7 tau _ = ma 2 ,
their statis. They don't mean Gilshbec;

they mean collectives

We started back, whan we realized we were going to-

nave

ay 7 + mer = + me ry de
CHO review oveles, to ret

FOucather a list of people

1, buc who are in the audience, and have something |

meen ee eee ae eget «

 

 
 

 

WHD-39 | . 164
we could use in ad hoc review capacity, because as you recall,
{| tne Council Last Novencser hac to do this themselves, and in

February when they were faced with this vrespect, asked

 

Doctor Endicott specifically for a tirst-level review to help

them, so that Council could concentrate on the policy. issues
that were involved. ‘ / . Lt.
And Doctor Endicott promised to do this, and we
; ware operating under two possibilities for quite a while. But
in contact the people we explained this; it was important for |
this review to have people who knew something about Regional
Medical Pregrams and had had experience in either the Review
Committee at the national level, the Council, or in Regional
| Medical Brogtems. | .
In the material behind your Agenda is 7 list of
individuals that were contacted and who are going to serve on
the Review Comittee, which as it turned out, did become a

x

Committee. Three cf the members that were listed on there

 

 

were unable to make it at the last-minute, but we did have

 

23 people scheduled criginally; 19 of the original list, pius

orier RMP member,
t

a
de

Because we had 33 total proqram applications, it

 

became apparent in the three days that we had set aside that.

» Lt couid not operate as a total comnittte during that entire

time, so the format was to have the committee cpen as a grou;

 

 
165

“
at
’

THID-40
to discuss th2 general policies under which they were going to!
| | be operating, and tnen we broke into two panels, with the

|
i
Regions that were served by the south-Central staffs and the
|
Mid-Continent staffs in the one panel, and the Regions served |

+

by the Eastern Operations Staff and the Western Operations
Essentially, this was gort of an even group. the
first panel was chaired by Mir, Chambliss, and the second by
“Mr. Peterson.
Each of the applications had a thorough discussion
by its respective panel. The applications have been sent to

two reviewers, and they served as the principal spokesmen for
y Pp i

 

the Kegion, but the issues that were involved quickly became

cr
2
©
Q
9
Ey
| ahd
(t
ct
oO
QO
foe

ssuécs and were discussed, and each Region was

discussed by the panel.

 

Then on the third day, one panel hac chosen to go

 

 

ti bach over its entire array of recommendations and make sure

that they felt thev hed not acted in a different fashion for

 

4 art _ = = - = 2 hee , _ *, Po _
| geyiewed tnueir-actionse, anl-oin three instancten changed theixz
Mi - t
I n
| uy wep ree aye Tap team based on their veeroaviow
i POCorGiGA Lagi y a23cu Of eine hy Dw OoV IG.
;
no . - at wee ee coe Fe - im pt we my he ~ coe ee iN J
Luan the tivo .unnlse 2. 2 teyether, with Doctor Pahl
~ pee Pe te 204 Lt otk Pe a 7-1 a eae
a5 the Chaiicman, and heare the cther panels’ recommendations.

They were Given the brief synopses of the Regqicns and their

 

 
 

 

 

 

panel had made some’ recommendations and they began to wonder

166

. . ?

. At that point the two panels recognized that one

if some of those recions had been in their panel, whether
the same recommendations would have come out. But .in those

instances where an individual thought there was some discrep-

 

ancy, tusse issues were discussed. oo

The Comittee as a wnele did not make changes in

the panel recommendations, and I belie¥Ve you have all received
both the comsosite recommendations and the individual recom-
mendations on each Region. That constitutes a review process.

Now, this afternoon we originally were going to

', thsse Regions alphabetically. But because Doctor

 

Merrili can oniv be with us today, and Doctor Gramiich today, '
i
i

and for a couple of other Regions that have people here today,

. i.
we are not going to uss that methedolocy.
We will get through the ones that Doctor Merrill

a |
and Dectoz Graulich reviewed; we will then include Inter-
|

i

LE age tery toe

~ . .
Mourntein amd South Carciina.

co
.

om

this Will be the order in which we go. today:

 

 
WHD-42

 

 

tot cr

 

 

 

167.

South Dakota:

"4p “wan

ARS. MARS: Would you mind repeating those, please,

MRS. SILSBEE: California,

Georgia,
- : Sa - Be

Louisiana,

Fusrto Rico --

 

Now, this is not alphabetical, because Doctor
Merrill isn't leaving alphabetically.
Mississippi,
North Carolina,
South Dakota,
Inter-HMcountain, and
South Carolina.
All right; just one general statement, now.

. ‘In both the instructions that were, sent to the
Regional Hecical Prograus and the instructions that were sent
to the Review Committee, there were certain materials that |
were wullined, and we asked the Regions to brovide information
An whois apelicetisons thats would allow the revievers to mane |
Soma judement along these lines, andi we asked the individual

Io am net goine-to read out the specifics on each

general points mighn be important to

 

 
WHD-43

 

 

 

HES ie

 

one peng te ee ene EEE SRST SE REE LE

 

 

168

you at this point: =

Program leadership,

Program staif,

Regional Advisory Group,

performance and accomplishments.

Objectives and priorities as outlined in the -

'

Proposals. .

Feasibility.

Likelihood that these activities and projects
can be successfully implemented with some results in the
time and bucget proposed.

CHP relationships.
thon the overall aesessments-

Sucgested way of moving today -~- and it is
you will proceed this way ~- is
some general statement on the

action, and because the

 

such a late date, I will ask each

wae oo = : = eant
Senc to you wos sent at
of + reanuec we SSF erst ers fe Mann 4 briet statement on
G2 Tilt: PSevecr.Ve 2rano. WALES LO MaAY a OT.et & var /
- a

of Council

to carry on the discussion, and if that format is all right

with you, We vill proceed.

material we

 

 
 

“~

Wiib-44

TRE ab ARETE SG IT

 

reser beter en at

SAT RT FS

tees ERE THERM) me Ie SE eT! TEE

Sema mrt

imate spat

eae SE SR ER SS SRR RET SHOR

fF sein 9, he

Sra Tee TORS ae SESE 5

anager = ema gt

 

 

 

“does control

~ mrt o

ea L TIONAL waar V anORe

has absented himself from the room.
Mr. Russa@ll? _ . :
=o Sg
Mh. RUSSDLL: The California Committee on Regional

Medical Proyrams,as”

above average.

Regional Medical Programs.

Mrs °

excellent, with the

KF]
a
@
h
t 4
it 53
ps
t a
the
fi Yi
‘i
uw
QO
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het
@
/a
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wm
be
7
p
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cr
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oF
ka
o
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g
“tg
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Cu

the

‘The Bn good track “record

Silsbee mentioned,

169

A

COUNCIL On REGION MEDICAL PROGRAL.S
CALIFORNIA REVIEW

Let the record show that Mr. Hiroto

shown on the green sheet, was rated as
In all the areas that

the program was rated from good to

exception of the proposal, which was

 

regarding continua-

tobe alee eee A py oe om
tho green Shect,

 

eel wee Volo} @S Moveaq am wee g
t
‘
i
tid pe newer TAL e ee tenet tae + ain Tate on —s at =
the prshiuis afa@ psuaartid i; the Bay area of -the San Francis %
\
~ %
oe ees aoe Ed Fe + epee +. 7 =a ~y we ¥- + :
aren, and in Gan Dieco, onl speaking with the eputy Director
.
hoe Bhs dar patavSs varterday See “pas a4 a +
yuck the day poferé yesterday, these areas are be1ng addressee.
:
e Bonar oF > Yee rep toe Drs ey oe adifte OTE . he
ana th. Qre NOG lnc tneGhr adiirerences.
 

sWHD-45

!
Ne

SEIS Sapte ee one

ae Wat

TST REET

 

art aR TSN

 

 

 

 

170

DOCTOR MERRILL: I. would like to preface my review
with & counle of remarks which I think are applicable.

My review of these things will be brief, but I
think I can tell you why they will be brief.
wep Ce mroposals arrived before the
rest cf them, ahd there were some eight of these which “I was ™
te raview, without th benefit of Staff or the Ad Hec oO,
Committee, and I read through them, and as you might imagine,

was totally confused except for the specific proposals.

There then arrived this wonderful little series of

fe
ns
$a
he!
0
jo
$3
a
n
rd

green “eets on which all the questions I was sup-

thoroughly researched and had been

g
0
is
%
Cb
cr
QO
my
th
4
(9
H
rs
i
Qu
be
@
(D
3

answered, and not only did we have a typewritten evaluation --

several typewritten evaluations, but we had tape recordings

1.

and transeripts, complete with laughter but without expletives;

and Geletions.

And it was a very thorough evaluation which

answered just exactly the kind of questions that a member of

 

this Council can not answer by himself. Of course, some of

Wofere Know about preblems that none c=’

at. £ +
: : ;

us could have been avere of, about the reliability of the

4

io

Director cf the Procram, his relationships, let's say, wih -

.
m4 neeariaten Se poe medi angtotn a fae rhiat ahd : wet
nis assécieate -- His essociate'’s wlie, ror that macrer -* bul.

 

 
 

| | i : 171
WUD-46 | | ee . :

.

which are critically important. All of these things are

Se ART ap

contained in herve, and were really a tremendous help, and I

to : Ls ele ~ -.

new system is going to facilitate certainly our

sen ee mt

tt
7
ht .
He}

“w
fF
0

=
6
ny
x

All of you remember the classic example of Puerto

REISER TEST EET

tr
fu
Q
G
fa

4
ce)
re

iowas the principal reviewer of that, and cer~- |

tainly on paper, it looked just awful. When we went down and

found out what the real story was we found that it was a very!

good proposal.

I think the kind of thing I was looking for previously
is all in here.

Now, as far as California goes, I have read it, I-
have marked some questions, things that I thougnat were gocda and
things that I thought were bad. ‘Tr dia this before the other

sheets arrived, and I found that most of the things that I had
marked were in ajreement with ‘the other reviewers.

Their overall pregram report, for those of you who

 

 

7

| have tne big thing, which begins on-page 123, I think, explains

 

 

 

what they have accomplished, explains their structure, it

 

4

- os = + ~
ae Sader ac eA Hass basn Jaro
Sewer be eke Neh WEL LOit Grave oFER Ueye

oped for such things

semis $22 wd enteral
L

aS development programs in monitoring of operations, and for

" review and progress of_application proposals with a view to.

SATA FIGS TC ERTIES

moroving the overall quality of project proposals while they

R
E
a

 

 
 

SST se, sient re

 

seme TREES“ ee tes ae

So FERRITE FETE TESS YS EO

 

 

 

 

 

~- they have, for instance, emphasized the thing that we think

.d0 with manpower, and I note, as again did the reviewers --

,Of more chan a -- more than a hundred colleges and universi-

172

shnents, which is listed on 134, I think is very |
|

Y cpalled out, it seemed to me, with some of the excap-j;

tons noted by the Reviewers, which I gather are being

corrected. They've done a good job.
The proposed programs, which you will find on page

- 4 a) .

137, for those of you wno have it, seemed to me quite reason"

|

able. They have, for instance --'well, before we get to that |

is so important, the continuation of project activities
beyond the period of RMP support.

66 major project activities have terminated since
July of ‘Tl, and of these 86, 76 were designed as on-going
efforts which have been continued by other sources of funding.
That seems to me a pretty good track record.

Wath regard to their proposed programs, tey seem

to me eminently fitted to the aims of RMP; cone of them has to

 

the reviiewors' work -- so that woe certainly are in the sama

ULtaa the cooperation
i.
ties and 120 hoswitals and clinics, as members of the consortia

ee en tle 3 2 st mae s ny aed . “ =~ a3 Benmwntd :
to work on their regional health services and educational

ne: ns a 3 wet SO  gte Dobe
cy have | begun QA OLGA PLOTUK-rressure centrol, Wai Cae

 

 

 

 
 

 

nae bee oe

i
BEER STE eo eee

tema ihe intrest eee Oe

rit ae

 

nae HY

 

 

 

 

 

 

 

174

probably more effective than it was in the past, in terms. of

managenent of the activities.
ARS. SILSSEE: Doctor Merrill has been -- has made

&@ moticn, and it has been seconded, to the: effect that the

wy”

«

approved at the level of $7,353,000
‘any Giscussion? | |
DOCTOR WATKINS: Just a simple question.

I would like to find out how it is that California’

is in a seven million dollar bracket, and others are three

million? I wonder if they had any inside information?

MRS. SILSBEE: Historically, Doctor Watkins, the

Califs=nia procrem, since it has about 18 or 19 percent of the

Opulation, has been at a fairly high level.
¥ . _—

This particular application represents continuation,

primarily.

MR. RUSSEL: That is correct.

BRS.

these Regions will be coming

eat Re

Oh oe ee

Rost einen? |asrjliane: oO Ee
GOGQsatTLonags EPPLLIAtlLons Va

 

more funds at ahother

SSSsentlally is a continuation cuestion.

Kr

 

 

 
 

SES SE

 

 

 

See EE ET

ew

 

 

mer ore

Fee att

Jessep mam ora ads an aot

 

 

 

 

175

NATIONAL ADVISORY COUNCIL ont REGIONAL MEDICAL PROGRAHS
- GEORGIA REVIIW
MRS. SILSBLE: “The next Region will be Georgia.
Mr. Van Winkle? |

~. Taypasns

ER. Vit WINKLE: Well, I am only going to give a

Tis reviewers had nothing but good to say for the

state of Georgia. The reviewers rated this Region as a

-~ 7

superior Region; they gave it excellent remarks in terms of
its experienced leadership, its strong Regional Advisory
Group, its committee structure,

The same blessing was bestowed on their experienced

program starl; they noted they had good CHP working relation-

f-t-

suips, and considered it to be a well-managed and well-

administered Regional Medical Program.

Georgia had requested $3,629,757, and did not pro-

.

pose to come in July 1 for any further moneys. ‘The Commities

recommended approval at the requested level.

 

TROPA pre, r
Awe ae UR a a

- . a t .

cn Georgia, because jin viewfng their proposals, I was not

Seqegnee wo dele 5 ~~: £ SG . tae
gsuruck by the same decree cf thought, precisicn, and possiziy

ine to ask abcut, to begin

~t Yee ee * - Sen pe te
aAmMLiy etucation proposal, which

 

 

we aan tf opa ty te oe AR De em + oe ee te
wWa& CGolichted to heave that reroert

epee ee

 

 
 

shee rhe

 

tom

sean eat

 

Week Gee.) Seen are:

 

 

 

 

176

coucned in the most general terms, wnich is a Kini of "God,
love and motherhood” thing, which gives no specifics whatever.
an Gxample o
"Specific activities of this program will

implement aud expand patient and family education pro-

grams. Projects should be an integrated type of activity;

projects should be patient centered. Projects should

@ modern instructional technology."

Oh, yes; and it is "anticipated" that ten hospitals»

Will be selected from many requests to develop and to expand

@

Well, I see no specifics in this at all. Do they

s?

hae

th

ty
fu
< .
wy
A
Oo
rf
3)
ct
wv
bao
73
co;
By
o
MH
0)
ct
o
fr
vd

MR. VAN WINKLE: . Docter

ae)

ferrill, what you are read-

ing there is the request for proposal that went out to all

provicers in the state. That was the broad general guidelines:

that they were sending out, saying: "This is what we will

s a 3
aay eee he . t .

“
OQ
ct
rt
fe

or)
oa
un
o
ct

1 ot

oy
oO
Hes

oF
Q
or
ct

 

wham 3

Medea eS

cr
g

re ™ TIT ATIT ws rr te +}
HR. VAN WENSLE: That is the proea

fis
0)
t
py
wo
iD
0
G
cr
ar
a}
Q

wy te ad be 4 Te wit eye et - um
mo ou G thea provisers, faying: "T

a
"A
p
H
0)
ct
ry
0
ww
H
0
Su
in

that we are interested in supporting."
eb a

 
 

 

WHD=-52

ae oper oe

 

PA EAR SH IE aL

 

 

 

 

“here is typed up as a proposal from Georgia, not as a guide-

‘line sent to Georgia.

177

DOCTOR MERRILL: But this Section D says:
"It is anticipated that ten hospitals will be
selected for any requests to develop..." ‘
MRS. SILSBEE: Hr. Jewell is the Operations Officer
who is responsible for this Region. I wonder if you could
give us sone insight here?

“wR, JEWELL: Doctor Merrill, this morning in the

ios

mail we got some further amplification on this. Would you’ 4+
believe it? I have a letter dated June 4.
i have it here, and I didn't want to load you up

with another piece of paper, but here are the ten hospitals.

They sent out this request for proposals, and here is the

list of hospitals they arc going to fund these activities
through -- prososed to fund these activities through.

i
5

DOCTOR HERRILL: But nevertheless, what I am reading’

 

cf
i
rs
ws
O
yn
a
he
(tT
fy
K
(9)
6
6a
ct
ph
ct
1
ct
}e
pee
te
~~
E
a
Q
un
rh
Qo
G
in
Ss
sy
4
pu
W
K
fu
td
oe
u
«f
zs
Hou
pe.
Q
on
n
ip
wy
a

, Veouc. Tt sounds to me as thoush they may well
c ot a

f
un
Co
m4
rh
ct
6
oe
fi
C1
re
ct
QO
ke
oO
&
s

. an gee ye 2 oo + ep ent yay 3

have copied your Lnestructions ana
cet TIT T . Tie ep ee ee a oy ; Sa
HR. JEWELL: What you are reading, Doctor, 1S pre

posed by Georgia. We don't have any guideline on that patient’

DCCTOR MORRELL: That is exactly what I am sayiny-

 

 
 

WHD-~3 3

 

 

 

 

.

I thought Lee was saying these were the guidelines.
MR. VAN WINKLE: No. They are guidelines that
oat to the providers within the State of Georgia.’

MRS. SILSEBDE: Doctor Merrill, I think perhaps the

genoral statcment on the a nplication from Georgia might be

This ‘program -- in order to get this application
in, they wanted to have a year in which to do things. It
did propose this umbrella operation, with the specifics under-
going review after we received the application.

What Mr. Jewell has there are the specific areas
in which this activity is to take place.

DOCTOR MERRILL: All right.

Well, t will chen say only that the comments I have
made apply also to the application for stroxe, cancer and

kidney, and I gather that this is the reason they did, and if

WRG, SILSBDL: lirs. Morgan, is this cne that, you

te
wate : a -
. °
t
wees arom rte vy ,ta et 3 3
Phase wb isiziines & Widrm

B corge oF 7 ane 4 ot mr
& GO OVabl tire mtare progran.
‘ ~ TG ey 7 3 Pr am Te my oe armed yy i

Ihave gone over the vellow and ¢recn fncect, sha t second

- Pee yt = Tm Al ge ene ten 4 veade te
Dornor Der riai S motion wt 7 Ga You Mase of meoiLicon?

Te ee ETT ~ r ~ aon om Te 7 : : a
EMOTON MOTMRILE: Yes. <i masse ai me rion, in Light

so aot « aye te - ~ fn toy Ww a mame e!lt
of the more recent commants, via the application be approv--

 

|
i
|
|
i

 
 

f a _ - - ; ;
bf oe 179
WuD-54 / - —— a |

in the amount of $3,629,757, which is the same as that
[ ii requested. - -
7 ; ~ MRS. MORGAN: ‘I second this motion, ana it is on
the basis that they do not come back in for our August meet—
unas. This would carry them through.

—- They nave a Ccordinator who has been there for some
time and is doing an excellent job, and I second it. :

MRS. SILSBEE: The motion has been made and seconded

 

that the Georgia application be approved at the level of
$3,629,757.

Is there any discussion from the Council?

 

 

DR. GRAMLICH: What is meant by "target figure" on

the yellow sheet? $3,528,000.

3
| .

a . -
|

t

ot

‘

| out these instructions in March, it was thought to be important

 

F _ Te, . a, . .
ji that we give them some ballpark figure in which they might

 

i
i . ~

» apply for funds. We took the '73 level, and I won't attempt

SPSS PRES” ST Yee) SETI IES et

 

Serer th ma sm fe
lee

# to explain how that was arrived at -- Mr. Gardell could do

that if you want particulars ~«- and based on the amount of

- cay, took 140

 

sort of a target

ome 7 14 hea ay ete oe wad Rk g yp
Fzeure. It a8 Just a botipark figure whicn doasn’t mean any

U

a See Se Qa ae yp kia Ame + i fe ers eye
sy Gost Ehat. And that was Gooxrcdia's figure,

ing, you sent us

 
 

 

 

 

 

eaeest Tait er

 

180

tad
Woo

fie

the Regional ? cal Prodram and the panel and then the

s' overull assessment, and the Review Committee

CEVLisvers

recommendations, and that reflected a percentage of the

request that was being suggested.

Miave are several in here that were called supericr.

wnat are not receiving 100 percent of their requests. "Is thit

because your reviewers may have been on the different teams,

MRS. SILSBEE: I think we'll have to talk in terms

.
or is it for more specific reasons? , : |
|

!

|

of the specific reasons. I think there is no overall prin-~
I

}

|

ciple you can derive from that.

in the case of Georgia, the reviewers -~ one of then

on a site visit to Georgia, so understood the whole |

‘am, Which has had a long history in

terns of the area facilities development, thought the program

was weli-managed, and in terms of the criteria they were

operating acainst; both of them thought tt was excellent, ana

rat is why the 100 percent figure came up- Dee

wees eps art. Pe a at .
WR. PLROTO: Tuam You.

arn Pedardivaae iain * yee See te ye - oat x s

bord oe Loree Are? TUN emer GEiscuseiones

All right; atl i favor of tne motion to approve at

te on be ge om : * _ . 7? —- Wren W
the three million-slus level, say Ayes

 
 

181

WHD-

Tne motion is carried.

 

 
 

WHD-57

‘satiny fea Ie

aT

 

ap mime Seer eet Pe pee:

 

 

 

eter ee a

 

FS IR SES te

el

 

 

 

 

1e2 |

“NATIOUAL \DVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS
. LOUISTAUA REVIEW
MRS. SILSBEL: The next one is Louisiana, and this
is
DOCTOR HERRILL: Louisiana was an interesting one
to me, because, again not having read it over without benefit
of the review and the stafi Work, I _— it was rather a
goad program, and that it hit specifically at the areas in |
which Louisiana was weakest, and attempted to correct these,
and it had some specific methods by which they proposed to
correct them, which I thought were singularly appropriate,

knowing something about Louisiana.

 

i
'
|
i
t
i

private sector into the Rup programs, and waile T don't see

bt ce em pet Stee they mee ed ~- a
thal upecliicaiay menuionec here, perhaps | someone could comment
_ - Los ora _— .
Sete fe = 4
OYL Tisive - |
¥
i
eR ~ 14 Fr = ~ 4 “ aco >
wee Past COusa ££ Give you & GuULcn CVELVLEeW OL
wets aw Ba me nee em ey t my oben % 3 a * > Reeve ps _ we SPT tae
wWaak Nagccned at the ad net group? Tf have a&Sscu ... vilavew.--
an ty ye i 4 ne we ws dew 3 twee aa ot - J a ce
eho Omerations Cificer, to Stand by in case you wantea to ais
a f ft
~ eS fel oe ype de 2 “to “wae = ey Daya th .
cuss Sin WAT LAcCR oy Boo LLoabkion £UrEAcLe.
De owe tyme eet sa71e 7 ae pw re a Vente PO tes ° ae ++ :
Yae ga hoc review pantl Concgi.erou ene. Louisiana
Tiog pe ce DON aD eg Te Teepe See ea We, Betne eee bee tee
Regional Nailcai-Pragyam to be peiow averacc, and we obtained |

way Tt Be Te +4 .
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183

application and had graded it individually, and we came up

with a composite score.

Louisiana has never achieved a triennial status,
and appears to have content in the past to apply for the
annual type of grant application.

The Coordinater has been, up until recently, servinc

wee ee cre ee enn en

on an only 25 percent basis} as of July ist, he will be
increasing his time to 50 percent. ‘

The Regional Advisory Group has several outstanding
members, particularly its Chairman, and its Evaluation
Committee leadership.

Its track record in the area of management of funds

has been good, and its unexpended balances on previous grant

ts
awards have been relatively nil.

The grantee itself is a not-for ~pr rofit organization |

{

in contract to medical sce hools, and its indirect costing has

The reason that the Review Committes app proved the

. : f

= = oOGmt mI “ = a 1p &
St of $895,222, which in essences, sncaking of

 

i

 

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WhQ appenyvaec to-have bean denied them up to the resent tins.

Sy eyeeteee eee L
SoLV OR TIDAREDI: il

met ~ +3 Slaw & = Te Ty - T we E :
mo, wromure thal Lovenucctly what T said befoerc T heard vou.

 
aan ne = 184

 

 

 

 

 

\
WHD-59 .
| oT
_ i Ani that appears to me to be the real strength of that pro-
. (| gram. _
Without gcing into too many of these things, they
,
: | do have = pregram for surveying medical education and physi- .
i | cian ‘eilication in’boaisiana, with the ain of finding, out 4
, : L al
i aS a : - ce / ™~ . :
1 how mony gqraluntes <r trainess etayed in Louisiana, why they
ES lesve, why they go into the specialties they do, and how thoy
midk be persuaded to go into specialties which are more r
K.
| neaded. And that certainly is singularly appropriate for
| Louisiane.
i -
They have a pregram on the assessment of quality
i medical care, which certainly -- and consultation service,
| which certainly is important, because again, as pointed out
| in the transcript here, one of the revi wers suggests that
i | they have two kinds of medical care and that the two don't
' i . a .
I iy :
° necessarily go tegetncr.
i
| =
1 ! Now, voerhaos he is referring to, the problem which
i ft
t “ i brought up earlier; is that correct?
: MR. FROST: Les, Sir. ”
i DOIION MERKLE: “Arai HAS anytning ween aone to ;
E i!
f _ ~ 1 on
| » reecify-that?
: MR. POSTA: ZT would a lot rather have cir. ‘Ziviay ai
t : - -- . _ +
i | Le
[ answer that. =
h .
MR. ZEVEAVSEID: Could you be a little more speci-~
| | ;
fie? ; oF
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. | _ - 185

DOCTOR MERRILL: Yes.
It was brought out at one of the Council meetings
enat the problem with Louisiana was that there were two

systems of medical care; one for the indigent patient, and

the other run by zrivate clinics for the more affluent
wotients, and that the so-called private doctor did not

’

necessarily see eye to eye, and indeed tended to resent the

=

activities of Rips.

fa

MR. ZIVLAVSKI: Several of these project activitie es

here -- the new ones, specifically 55, the Earl K. Long

Charity Hospital, this is one of the activities on-a new

proposal; project 54 is a Charity Hospital of New Orleans

Project 49 is the Lafayette, and the main thrust

for the indigent in the inner-city is Lafayette.

In project 53, they are talking about the inner-c

and the rural indigents -- .

DOSTOR MEERIELE: Uxcuse me; What pages «re these

cre? - ee .
wee ” . t 7 .

tivity Project 53 again is Earl K. Long Charity Hospitai- .

MR. BIVLAVSNI: I am using the project numbers on

we RUE Waasds

er, The stati summary on

i

Tr ~~ “ _& pte a2 %
ho second page of tne yeiiow Sn

|
|
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the yellow page. —
DCCTOR MEEARILI That's all right; I just wanted ce

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186;

MR. ZIVLAVSKI: Looking at Louisiana's history,
these new propcsals probably reflect a change in the leader-
ship of the RAG Chairman, and more of an outreach in the rural
communities of Louisiana, as well as some of the indigent
populaticn in the cities.

L think these are some plus marks, where previously.
in the fast thay haven’t had a goca track record in the
cities, because of what your’ ~~ ‘

DOCTOR MERRILL: ‘Yeah; now, that is certainly one
of the plusses, and I’ll mark those that you have.

I think the Lafayette plan is particularly good. I

 

think tne EMS, thehigh-risk neonates, the transportation

system for the indigent -- are all things which are eminentl

te

But again, my concern wast are there two groups of.
y Z os

physicians in Louisiana who do not see that these kinds of

 

an ee te a = x « ae 2 “
Pproegrans are important tor the indi age ant of Louisiana? And
are 2yay swwewlste sc an Harmon
FE UNSY WOrnanNg ah marmony’s rd
AT TRAP, ™m ~ ee ee » +A = 3 at
MR. POSw:: Doctor, could I respona a Little bit
: i
t
wit Sees Pat t. 2 4 gem fee lon are . xy. OT
with just &@ ibtile ble ci sackgqround informavion on this cul
- ft . :
~ a ee my te pre 3 RS Sy teay wee 4 7
health gyrotam that han been identified hy Counc in the rast:
ah T ost mt aoe = ones ‘ a ae oe % me 3 en
Tho Lovlalana procran -- or, the State of Louisiane
a ~ 4 f ” w > eH one wo fe ts ca or
hus What 2S ennown an a chaerity-hespitdal system. Close to 7°
hotwvs 22 te and wp +o woe ep fae ee wour ir 34 Att oor
a Spe Vaan, AMG Aad Reh a keke bed de yp a arulLgenec Pp
t
str - 5 ~ ~ Os = 3% on so, 7 =" :
mave gone gpociltically to th hospitals for care, and

 

 

 
 

 

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a

specifically to vour question: have they done anything about |

 

 

 

 

187:

threuygnout the reviews of the Louisiana applications by both '
the Review Comnitteés and Councils, this has been hard-hit
as far as the overall philosophy of the state in having this |
dual system.
Now, that is not to say anything at all as far as

- 7 a!

the taxpayers going to the charity system, but to respond

this, are they doing anything about it?
The ex-Surgecen General, who is living in Florida

now, has been elected as the Chief of the Dcsartment of Social

 

fits in. Specifically just where, and how far that would lead

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DOCTOR MERRILL: Well, I think -- and particularly
because of the thrust of the burdens of the new programs, and

rations about the personnets I would

agveac «= althouch not as enthusiastically as with the other
x = ft

 

~“- and make a recommendation that be funded at the full

 

mayen toy ye 434
22 iin se 1S ,2i2.
- 7 ,
wns eTTraenms Saat eye OT tay Se : '
Pile LOD t WOCLOL. Saneway, Giu You nave an

opportunity to losk at this?
“DOCTO! JANERVAY: No. The same questons come to
my mind as did to DSctor Merrill, but you den't have a Title

6 violation, or anything dike thai?

 

 

 
 

WHD-63

 

 

 

spats ere

 

 

 

 

 

188

DOCTOR SCHREINDR: I just wanted to make a comment

that although those charity hospitals are separate, and they

customarily recard a orivate sector, they are very closely
¥ S x !

ed into Louisiana State Medical School.

£4
el

-- - s

hi

was.just going to say. that I am familiar with
some of the lateralization of the charity hospital systems,
and ‘this was originally designed under state aegis to follow

the horizontal east-west main transit line across the roads,

tied trade areas together in Louisiana, from east to west,

hat
and tnis hospital system, while it’s true it doesn't tie into

things lixe the Gxner Clinic in Tulane, it does tie in very
> schools, and there are rotating

There are rotating full-time faculty members

example, to the

 

State Medical School,

I Gon't think they would suffer much by comparison.
Yhoy might by comvarison, perhans, with some of the

 

|

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WHD-64

 

Pst Nae EE

 

 

ea ae a

 

 

 

 

 

Lou

kind of territory, has been their enlistment of private
physicians and private hospitals in cooperation with these
other kinds of activities, and that, I think, has not been |

true of Louisiana.

 

BOCTOr SCHRLINGR: Well, it is pretty tough on the

peeps, Hscxuse all chese people: are on the state payroll,

and they are really on a full-time salaried basis in thé vy

““It would be pretty hard for a private doctor; most
of these doctors arc on a full-time salary.
MRS. SILSBEE: Doctor Merrill, would you like for
us to ask the Region to address itself more specifically to

.

this in their July application? In how they see this working

 

DOCTOR MORRILL: I think, since the question has

been raised a nuisber of times, I think it might be well to

mA

Goa that, and I certainly would like to know the answer. I

te tae a ee et oe eee ae
think £ understand why the question has not been raised in

ariave Coauned ape in ergot a nied erantkiey
previcus Council mectings with creat fervor, up until recently,

$
1
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cc wt pte oF So Rare Adee Sy ow dn We tn : sf
but = Ga think it is somethinae that ocucht te ke answered.
: - ~ ‘ |
moe ere ee “ te Ve ae tay 4 '
MAG. CILSELD: Yow have Made a motion; I don't

= ioe wae yey 4 Sage 7
waa eon enes wat ys 5
MENGACLON Tor anyproval at $325,242. .
:
wae ee ee co. ~ os }
eee a wo eb rt VSCOM Ge :

 
 

190
WHD-65

MRS. SILSBEE: The motion has been made and

Is there any discussion?

Nee a
Vpn Saa?

(No response)

“fhe motion is carried.

 

 

 

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2 y .. a 191

NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS

_ PUERTO RICO REVIEW

MRS. SILSBEE:

Tne next one is Puerto Rico.

Oh, I fcrgot; tir. Nash, who is the Chief of the

rae hme * “veer in : .
TaTatTions Brauch, has beer

called away because of.

moss, and so I am going to wear that hat For

--But since Doctor Merrill and Mrs. Flood are much

more expert on Puerto Rico, I am going to defer to Doctor

DOCTOR MERRILL: Well, as you know, we site-visited

Puerto Rico, following a very unfavorable review, simply

from their aprlication alone,
We ware, I think, very ple tly surprised by the

the Dix rector, and

 

particularly of the Associate Director, at that time, and ©

beg.

the lovalty of the people, and particularly by the number and

raéwdmby Af teeileniel:
VarLe@cny OF AMC LVLau

1€is who were intereste€ in the progran.
_ ~ - : ~ o - _ . “4

3 7 tty te Ms a e .
77 @ma f— think the rest of us, too -- were

wen mses el = pee ee ee nw deta Lain mw 4. de -~ dey on, -_ = Sod
Very Hutt inpresscu-wlen ths fact that their preogranms seemed

selves, acain, exactly to tna kinds of things

wiich were needed in Puerto Riec, such as

evalus-

things I mentioned a moment '

ip services in which a private

 

 
 

WHD-67

fpr sever tore

SEH SSS or Tae pet

tue ite te

oSiaR Sem

 

oe Sn SS 1 EROS.

me

 

meee gies eeged) sie

 

 

of the

effort in the instructio

to se

QO

Lipa dk h
uwnac tn

Essentially, this grant request puts on paper ‘some -

things we saw at
it. ae

It apparently
reviewers, but it was re
$695,862,

at the rate of

I wouid like t

question on Stari:

wnern

who have left the program have come back in anticipation of
tis, or will come back?
You may remember that one of the things that struck

us was that althcuch some of the staff
. . nied ~ . —

 

192
|

n and vlanning of the administration,

{
= ; |
although two new hospitals were being built, they made every |

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that time, and I am enthusiastic about

was called above-average by the
commended that it be funded in full
and I would agree with that.

o know if anybody could answer this

or not some of the staff people

er

 

*

had worned very hard

= t+.5 RB =) . Fass _ wit my be tae me + , - =mee . Le my , rae . . 7 : 7 a + 4 :
On the Rus Rad Left when they believed that Funding was not :
. ;
a i
going to ba adequate, they had gone into otner jobs in the —
. ; . !
~7 7 i apes ot ley cep go feet Dba ree te toe te - :
Mearey MeartcaL SCHCOlL, abu were ac fualiy working part-time
. o mak thea wet ta pm get pee Eee | ~ ££ . .
or occasional hours without salary, ii many of tnem had
t
.; i
wey ee De 7 3 ~ oon a - 5 34 3 : . t
Qxepressda their wiliingness tae come back full-time into the
5 " ,;
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= oy ok §
& TOYLTEN » whe ds. Lt Worea EUNMeEU. . t
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von 32 waa vigor, b,. co < Yo mre ni :
iowonder af anyhocy has any answer to that?
_ ¢ - at
: i

 

 
 

WHD-68 |

 

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FREE AmaSS “TEES FEMS TAS AIOE ETE

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Se eh ete

 

193

MRS. SILSBEE: Doctor Merrill, you have now hit
bore: as far as tue sastorn Operations. The Staff member |
who accompanied you on the site visit in January has now gone
to work in the VA.

ct

 

he sum total of direct

oy
cf
Q

fre
Q

th
Ry
J

iR. STOLOPF: Mr. Peterson.was Chairman, and from

the delibera

tion there was indication of what happened to

the stati Z thought he wanted to say something there.
MR. FRUSRSCN: “Well, I think Bill Furman was one
of the reviewers, and he had been on the site visit with you,

and I was trying to cuickly refresh my memory from the tran-
scevapt ~- laughter included,

have no first-hand knowledge, either

x from other things,

9

'
fy

D

but Bill described

one, that did not cause him

- ae
thet the tion dow there is
+s mr oes —, sie Soe eee ° ne ¥ . str oF aes . at on
any concern, cecausc it was sort of like a flonting crap game.
Yn mye a eyae tn qe ete he Dae
abla OFS MY WOrcS, Mott Aim.

Daa
floated tact we thr alo oemsean] ana ounblite
HLOETEG VCH LMIO weet MeaLCal SConcol t Gna UNLLIG certain

 

 
WHD-69 |

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————

wey oe

 

 

194

sav this a3 2a way cof doing business in Puerto Rico, and did
oO as perhaps in-a few other similar situ ations where the

VELYOERE &

a rip-off, w
is based on
he had been

arry,

particularly

frembers

lem

oF
od

fis

miich sometimes had been -~ also,

what I quickly recall from Bill

 

Review Committee have had concerns cof two kinds:

quate staltf, because they con't -- except for = — .

am de me ye

~
VOGUE IS

=e ne

wao chase red, white and blue dollars

substantive concern.

s

certainly didn't have a concern that there was

but again, this’ fF
Furman's review;

there, and I have less knowledge than you and

the panel and listened closely,

to recall some of his com-

point specifically to this point,

Well, I saw that situation actually

 

that-they were available, and.

that same prob~

beon replaced

“yy _— Fat. . .
timy bbe nan WS; Zodid neu

a

THAT

 

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ae wit

red there before.
 

 

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av not have a part-tine Deputy Coordinator up there now. We |
whave a full-time Assistant Coordinator, at least by virtue

 

 

 

195

MRS. SILSBIE: Mrs. Flood?

MRS. FLOOD: I might add some explanation.

They have a lengthy list of staff people in the
application, and as Mr. Chambliss commented, there are few

familiar names there, but there are some new names, and we

this particular core-persorinel breakdown.

They certainly seem to have a full complement of
staff, although they have a few positions vacant, and some
are at thea health educating level, and one, a secondary
associate coordinator siot here, and perhaps that was where
the other chysician was in.

But they certainly seem to have more staff than

wien we visited them, and I would like to reiterate Doctor

 

They are definiteliv involved in concept cevelovment

accomplishe,
sector
they have’
ntcrestingly, nave the most

ever Soanvin a tejgie.nl edical Program

 

IGOSSloly the only

aera Do peneret pd ep eM ab te US Tes eee, Ud pe fe Tle BG -
MeuUlra. GKGuNY AValisanvic 2h buerto Rico to winch ehey can

 

 

 

 
 

WHD-71

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SRW ST OE RE TS SR SRS

1 sires

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I would second the recommendation for the funding
as recommended hy the Review Committee.

MRS. SILSSEE: The motion has been made and seconded
that the Puerto Rico application be approved at the requsted

‘ I

we de ee me wee ke eps 4
Ys there Further discussion?

{Chorus of "Aye")
Opposed?

: (Jo response)
The motion is carried.

Doctor iierrill, we appreciate your rapid-fire review!

 

there; I'm scrry you have to leave.

 

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WHD-72 | 1
‘ NATIONAL ADVISCRY COUNCIL ON REGIONAL MEDICAL PROGRAMS

— of | MISSISSIPPI ROVIED

E °
F MRS. STLSBLE: Now, Doctor Gramlich, we are going
7 to put you on the grill.
i
i Br. Van Winkle?
| , |
t BR. VAN VINRDE: IT am sorry: Doctor Merrill couldn't |
E : '
| . o : = a: . oe Le : : '
7 Stay for this ons. lie Gid site-visit this Region.
ii -

: One of the reviewers was a former site-visitor, and
ro . ~“ “
he was highly complimentary of Mississippi. .He felt they

a deserved.quite a few pats on the back.
They were considered to be an above-average to
. superior region, their program leadership was considered to
| be strong and viable; they have a competent leadership staff,
i . e
[ ; their past perfermance was -- program Saif, I snould say
j | their past pexformance was impressive, and we felt they were
F { : 4 . :
f il Very percestive in establishing goais and objectives to support
x i oa > !
i i! 2 / . 7 - |
i the accomplishment of those coals. ' a |
i The proposal as submitted was felt to congruent |
i i Se - : 7
‘ with one goals, and tey mesh well as a total program. :
|
Excellent (CNP raldticnshics, a well-done proposal
k .
4 An : . ‘ -.4
. Bee beet ee oe De See eee kee ee . - . : eat
i. Ree ere ee eee eee he te SEY AN nee Set bed :
: NOW, Lo EPevaswars, im arviving at the reconmendaticn,
, ~ =; a on - + >
. hace = tu Btef: in &@& munmber cof
, . .
i Lik protects, bul the overnii thine seamed te be based on a -
i Paths Lavenc famicar Gn new activitics, and whother that could
. | Loe - i
;
:
I

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WHD-73

   

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7 mR TEETH ERE

198

cally accomplished in the timeframe remaining for

“Mississippi requested $2,850,409; the Committee

 

recommendation -~ $2,200,000.
HRS. STLSSIE: Doctor Gramlich?
SCCTOL CRADLICH: Iowould Like to commant, firs

cr
tet
th

off, tha

arrival
which would have been very helpful had they been early enough,
when I had had time to read chon. |

Could I make a comment about those?

Those transcripts are put in the folder and we

don't want them to get out of the -- out of this room. We

Gid@ think they would be helpful; we would have takes to have

sent them to you in

of the proceedings, we chose this method.

.

But I agree; I wish we could have had them, too,

advance, bu t because of the confidentialit

find in uy yallow folder, which we received on “i

today, a transcript of the Review Committee's comments,

+

 

but because the Com mit tee didn't KNOW that they were going

mest = *.. , - . RL
poCTOR GRa ici I suppose than &s5

a corrollary

+ ea oe he 2 4% ~ > tL + tp 7 £4
to thet, wo would leave these books with you?

generically speaking, unfortun-

that all of the Regions to which I was assigned as

a primary revieeer_were su}

 

 

arior' or above average to superior-
 

 

7 —_ | 199

Wub-7 4 TO an |

-~ wiich makes the job easier, of course, and I was interested

inthe figure tnat was reached , because I reached mine in a

PERE Eh Re ee oe ers aes Set

somewhat different way, in a more programmatic fashion.

 

I leoked in some detail at the projects request,
‘ and noted for example, that there were several programs,
: - as was observed somewhere by Staff, that really raised a lot ~

questions as to whether they were RMP-oriented or not..

For example, scolid-waste management training, which
is a program whereby the State Board of Health -- or, through
the State Board of Health, aims to train landfill operators,
which seems to be pretty much a Public Health operation,
rather than a flat-out RP pian.

I am looking at the yellow sheet, and the number of

 

this particular one is C-137.

C-145's Food Service Training Program might more

appropriately be. Public ‘Health Service.

Sreaist ¢

 

‘Also in the yellcw sheet, in C-140 to 144, I had

i : 1 ive - ee
| a specizi observation about this, hecause these four programs -

were cancer-related, butt were all to be managed by the

Prerican Cances Eoclety A ugional program, and although they |

were small amounts, it struck me that perhaps” these were

 

  

programs hat would

roally just supplementing things that

the American Cancer Society has already done.

   
 

I have had sone concern about REP visibility, and I

read into these programs, pr obably crroncously, but, r can

 

 

 

 

 
|

WHD-75

SRR ee

ara SEL we ete fe ieee

+

 

 

mie Ft

Tt RITE

 

oR Ngan 1 At sris tm

searuet

cen meta id [ise emerson pa ot

 

 

 

 

 

oo . 200

imagine the situation whereby the RMP would provide the funds

and the Cancer Society would get the credit for it.

Now that may be paranoid, or it may be realistic.

They were small amounts, I grant.

I nad some guestion about C-159, which called the

Quality of Service for the Mentally Retarded; it struck me

‘

this was an unusual request. It didn't really lay out any
program at all. .

I had an equivalent question about C-162, which was
a hypertension Survey, Pearl River County Hypertension Survey,
in which they proposed that the emergency room nurse would
take blood pressures on all patients who came into the emer-
gency room, and a flag went up that perhanos that nurse who
takes the blood pressures shoulc take the Diccd pressures .

wnecther she is Peang Supported by RMP program or not.

Again, a sma all program -- $lo, 000° -- but it did

a little costly for. the. doing ofa routine . auey

PTASre WAS a@ cable FV program for $38,000, and I
on't understand it care-

sea io m= OF, snoroughly, but as I read the pregram, I wondered

S63 -~ C-164: Medical Costs at Home
nis *S peck Neslty 4 Velfare Dcpartisent fun ction, and again,

~. Paolichy-Gwned Vater ysten ' the

  

 

  

 
 

201 |
WHD-76

rogram sought to pay for nalf the costs of installation of
flouridation ecuipment.

I wonder if RNP is interested in that sort of pro-

 

| ject?

| Wet ee TS * nN
In “New? Projects,

whicn are the last several on
that page, I was struck by the last four -- 0-36, 37, 38°

and 39, seach fc which appear to me to say:

FE
4
fea
HN
wa
~
oO
oo
«>
™“

“Well, these are some new projects that we
think are pretty good; give us some $600,000, we'll

spend it as we can develop the projects."

It sounds geod; the titles are fine, but this

looked like a blank check saying:

 

t "We are a gocd outfit; give us the money and
we'll spend it wise ely."

Now, just as a matter of philosophy and policy,

 

an appr cpriate way to go for RMP, fine, and there

.

i is no question but that the titles of the projects are good,

bee
Fh
“ot
ty
{+
a
ya
tr

| ;
t ' but there is no substance behind the projects, in terms of

' Olanning and process,

 

MRS. SLLSEUD: 7 fir. Van Win ?
} - t .
MR VAN WINK *%e apolication itself does address.
those, Doctor. Other than this yellow sheet, these four itens

are, the same thing that you were looking at on the Georgia

‘ application; these are-where they had sent out written requests

 

for proposals. They do have the request in-house; they have

 

 

 
 

~

WHD~77

292

many more requests than they have money to support.
Now, at the time that the decision is handed down
i by Council as to how much money they received, their RAG

will meet again in terms of their priorities of what they

can fund within those general areas.

Now the primary reviewer raised the almost identi-

cal same questions on the same projects that you were men-
tioning, and they did -- we do have a list of all of those.

oder ae =

They will be communicated to the Mississippi RMP. However,
he did not choase to say that "You can not fund this, func
| that, or fund the cther."

= | He said that he thinks they have a very low prior-
ity, and felt that they should be allowed to determine within

.

that unless it was against Council policy to decide.

 

| MRS. SILSBEE: Mrs. Ficod?-
i MRS. PLOOD: Is this an A-rated region with a tri-
ennial status?

| MR. VAN WINKLE: Yes, it is, or it was at the time

 

that we wete doing that type of thing.

MR. CHAMBLISS: I might mention aigo, Doctor, that
we in Staff have raised the same questions, almost to the

“

t

 

letter, that you have.

 

co Ee ae
We need the halp of Council here on the solid waste,

 

,

and "Peter the Pelican" and his other brothers here, and to .-

 

i . get your guidance as to whether we should specifically deal.

igi

   

 

 

I

 

 
 

\ , , 203

WHD-73

. ‘
t

with some of these projects on an individual basis, and seeing

that they are eliminated on the grounds that they do not fit

within historical RMP operational activities. ; .

DOCTOR GRAMLICH: Incidentally, and somewhat tan-+

: gentially, for the benefit of the Council's advice, Pierre

 

the Pelican appears to be a how-to-raise-children progran.

1

MR. VAs WINKLE: That is correct.
Now, back to the original point about the $450,000 t

request. You said that information was available justifying

these, but is it anywhere in these grants requests? Because

So ar pe ee ate ret me er

I didn't seem to find it as I went through.

Anyway, the point is tbat it made it hard for me
to sensibly review wnat appeared to be a blank check sort
of request for funds. I nealize that in some Regions, some
RMP'S, that probably is a perfectly legitimate way to go,
just to get the funds, but how do we know that as we go
through this? | 7 . |

MRS. SILSELE: Well, I think all reviewers are.

 

 

 

concerned about just depending on the written word, and it

| dis hard to convey this.” . ‘ .|
t

Did you have an opvortunity, Doctor Gramlich, to

“ ~
talk with Doctor Merrill before he left?.

- . — ene a?
“DOCTOR GRAMLICH: About Mississippi? No. .

 

f MRS. SIUSEDD: I am sorry he had to leave, because’ |
| . So Le

| he had been on a previous site-visit, which was a couple. of

 

 

 
 

WHD-79

 

 

 

 

 

 

 

get’ whatever little mileage there is to be gained from saying:

204

years ago.

You mentioned that you went through this program-
matically. Did yau come up with any kind of a level of
funding?

DOCTOR GRAMLICH: A figure? It was interesting.
There were some that I had question marks on a programmatic
basis entirely, some that I felt -~ like this cancer society
business here -- maybe if you fund one or two of them you

"Yes, we are indeed in support of you, the
American Cancer Society." |

I scratched the ones that were obviously Public
Health Service and should, in my opinion, be in that area,
unless Council decides otherwise. There were some that I
had some question about: I didn't diminish on that basis.

I think the four items that were $159,000 apiece, |
the four projects, that qn the basis that it was a superior
RMP, I diminished it by half, subtraéting the ones. that

obviously should be in the Health Department, the one that

r

MRS. SILSBEE: What figure did you come up with,

DOCTOR GRAMLICH: I cam2 up very close, within

 

$200,900 ef the same figure.

MRS, SILSBEE: Well, they may have very well gone

 
 

WHD-80

 

 

 

 

 

295

through the same process in their review. Do you feel that
the $2,200,009 -- the concerns you have will be conveyed to
the Region; there is no question about that.

The figure I came to was $2,031,000, which was so
close they shouldn't worry

Do you want to do hat in the form of a motion?

DOCTOR GRAMLICH: Just to get out of Mississippi,
I would move that we accept the figure of $2,200,000.

A

MRS. SILSBEE: I would prefer the proviso. Do you
want to word something in general terms, not specific projects?
DOCTOR ‘GRAMLICH: Let's have a little discussion |
about it, and then make a separate motion.
MRS. SILSBEE: The motion has been made.
MRS. FLOOD: My comment would be that I think you
are being a little generous. |
| This is blatantly transfer of ‘funds to Public Health:

Service; it's not just sort of obviousty, and they are in

small amounts, but this is traditional public health work, and:

 

i don't see anything innovative about it. It certainly does

. : , oo oe de
not show tuat it will develop into any reputable state new

.

Look in the way you are goin: to address these | pro rams, ‘that ©
going |

you could use across the state. ~

yoo :
tds os peyton ae -

Tais has no im spactuall program as such; I can't find

  

  

we

any objectives or goals listed An the pplication that this

 

eee tage ae apmadninty 2 oe

adéresses itself ‘to. eeod nas .diers' cias ses? ‘Hy goodness!

 
WHD-31 | — 296
Really, that's exactly what it is. —

MRS. SILSBEE: What action do you want to take

with this concern?

MRS. FLOOD: Well, I wasn't the primary reviewer or

*

the secondary, so I didn't have an opportunity to look at

the Form i5's to see now many of these are new. ;

I hope all of them are new and that they haven't
been continuing for some time.

DOCTOR GRAMLICH: All of these are new.

MRS. FLOCD: I would take a closer look, and it

would take me a minute to figure out how much I would give.

them, but I certainly would delete the public health issues | .

 

more strongly than just to recommend to them that they do it.

DOCTOR WAHMOCK: ' Why don't you list what they are,
SO We will know?
MRS. FLOOD: 137, Industry employea education;

there's another one. ‘

. “
DOCTOR WAMMCCK: Solid waste management, C-144.

 

 

MRS. FLOOD: C-144, 145.

 

o
8
HI
O
ed

GRIMLICU:. C-168 is the Public Health one.

DOCTOR WAMMOCK: Then there's another one'in there.

 

(Discussion off the record.)

DOCTOR GRAMLIC!: 165, tedical Foster Homes, is

really not Public Health; that-is a welfare program.

bo -DOCTOR WAIRIOCK: 1687.

 

 

 
 

 

 

: WHD-82 . | oO . ant
ee DOCTOR GRAMLICH: 168 is flouridation, another
Public dealth.

“That is roughly $80,000, Mrs. Flood, which doesn't
really --

MRS. FLOOD: I know; it doesn't really slap their

x
H
pe

.
ct
ui
e

DOCTOR GRAMLICH: I wonder if it would not be
simpler if: we accept the figure, vote on .that, and then dis-
“cuséed the problem of reassignment of inappropriate areas,
. and too, the open-ended request, which I am not totally satis-
fied with. | | |

But there are two separate areas, and I think they a

 

might be separated, and this might apply to other Regions.
MRS. SILSZEZ: Doctor Nammock?
DOCTOR RACIIOCK: For information, at the risk of
exposing my ignorance, what is a "Smoking Withdrawal Clinic?"

HR. CHAMBLISS: Maybe I can answer that there,
, a

h

Some yeers ago, the smoking and health activity

 

was an integral part of our RMP's, because we felt -- we feil

: . : : + ae . t .
heir to it from the Chrtnié Disease Program, ‘and we have

moking and health activities under the »

fos

Hh
g
3
Oy
i
flu
fea
Hs
ae
@
ni
rf
ur
ny
te
7)
ct
mn

 

This is simply a throwback, <I would assume, to a

 

‘ a4 red be - - a BY ; . : ;
previous activity, funded by RMP in the past, and it is

;; Simply a method of controlling the smoking as a preventive

~ poe = oe

 

   

 

 
WHD-83

 

 

 

 

that it does not fit a program emphasis.

208

measure to stroke and heart disease, and so on.
DOCTOR WAMMOCK: Do you know what has happened
since then? Public Health Service gave its report in 1966

on smoking, and the purchases of cigarettes increased, and

so forth and so ch.

MR. CHAMSLISS: We are very much aware of that. Yes

DOCTOR WAHMOCK: I'm sure you are.

MRS. FLOOD: Doctor Wammock, the application refers

to the faxt that they will have smoking withdrawal clinics

that will run five nights consecutively, for two and a half

hours, in which trained laymen will assist doctors in the
presentations, and the objective of the smoking withdrawal
clinic is to offer aid and assistance to the public, and

they'll hire a staff man to find_such things as interested

‘Clientele, procurement of meeting hall and availability of

trained personnel and medically accepted procedures to man

.

the clinics. And it is the Cancer Society's application.

'

It is a very small amount’-=--
DOCTOR WAMMOCK Don't think it belongs ~—
MRS. SILSBER: ° ovens Wanmmock, if you would like,
we can get you some additional information on this smoking

withdrawal project.
a

HRS. FLOOD: The problem is not the item; it is

«

MRS. SILSBEE: I think we are in danger of trying to |

 

 

 

 
WHD-24

 

 

 

 

209

do Review Committee work or do Regional Advisory Group work)
here.

Doctor Gramlich has suggested that you’ take a look’
at the funding level wnich he made a motion would be at the
Committee recommendation.

DOCTOR GRAMLICH: | $2,200,000.

MRS . SILSBEE: which is $2,200,000.

_wNow, there has been a motion made.

DOCTOR WAMMOCK: I'1l second it.

‘MRS. SILSBEE: Do you want to discuss that further?

All in favor?

(Chorus of "Aye”)

Opposed? Two Council members opposed.

The motion is carried.

Now we have the simple issue of the advisability
of Regions pursuing this particular course, and Z think you

are really trying to get back to the Region in terms of their

-

*

decision-making.
MRS. MARS: And I assume those three million doliars.

they are going to request in uly and August‘will be reviewed?:
| MRS. SILSBEE: Oh, yes.

MRS. MARS: Because this is something, I think,

 

that we should look at very carefully, this further request.

DOCTOR GRAMLICH: May I ask, is it appropriate here

to discuss the principle involved in the last four projects,

 
Whior35 |

 

 

 

we should have some guiding principle.

lars.

210 }

which were for $150,000 each, without particular justifica-
tion or programmatic support?.

Now, this applies, perhaps, in this area, but it
may well apply in other areas, and ic is a matter that came
up a couple of tines during the arthritis Technical Review
Committee meeting, where a good strong RMP said:

"Give us the money and we'll do the job,"

but they didn't exactly say what the job was.

Maybe this doesn’t occur very often, but if it does,

MRS. SILSBEE: (There is an application that you
will be considering latar ~~ Texas -- that: brought up this

very same issue and the Review Committee told us to take a

different kind of action, Waiting until they got the particu-

So this is --

DOCTOR GRAHLICH: Does that solve the problem?

MRS. SILSBEE: No, not as far as Mississippi is

concerned. .I think you have solved it, probably, in your

Syn ett Janus ao
EUMAING recomnentiation.

 

 

MR. VAN WINKLE: That.is precisely what the Committes

attempted to de, to resolve it by their funding level.
MRS. SILSBEE: Doctor Janeway?
DOCTOR JANEWAY: Just an observation, that if one |

makes the assumption that the funding level, as recommended,

2 oy .
on etter tale + careet seers mamtenmremanmtemmenpiniet oer eee oe
na nO . . +

 

 
 

 

ID-36

 

 

 

211

deletes these programs speifically. That is his one set.
T= on the otner hand the funding level is set

on the basis of certain other things having been deleted,
and then one specifically proseribes the utilization of
these funds, thess funds for Public Health purposes, then
he --then it gives even more latitude, wider latitude for
the use of RiP -- in the use of non-programmatic-oriented
‘funds.

-MRS. SILSBEE: Well, it seems to me you have a
lever here that you would not ordinarily have, and that is

that they are coming in with a proposal in July, and you

could very well insist that you have, at the time, specific

information about how the Regional Advisory Group has chosen .

to cutlay these funds, with advice, in terms of the concern

that you have, and you could look at the Region again.
That is not an opportunity you have very often, in

‘

terms of this short timeframe.

DOCTOR GRAMLICH: That solves one of my concerns,

” +
which is simply that it is entirely possible that the pro-
gram will be very good, exactly what it should be, but since

t .

the request is the cpen-end technique, it makes it very diffi

cult for us.

I would hate to say: "No, you can't do it; because

tnat is not wnat we are saying at ail. I would like to not

oniy ~~ Since the request is open-ended, I would like to

evolve a way whereby we could leave the response open-ended |

 

 

 

 
 

 

s+HD-37

 

 

 

 

 

‘.not be destroyed or undermined by any actions the Conncil

tions, to take over American Cancer Society functions, or

‘either of those things, Doctor Gramlich. However, I think

212

too, so that if a good program could be developed, it would

took adverse to it.

MRS. SILSBEE: In terms of the advice we give to

3

- as
; t

the Regional Medical Program, this concern will be conveyed,

r

and certainly in terms of the July application, if there
were any repatition of it, I think we would just say abso-
lutely no.

But you have two issues here. One is these

inappropriate type of activities you think they are proposing,

 

and the other is‘the open-ended part, and I do believe you

have a better chance to see how the Region responds to your ~
concerns in July. |

DOCTOR GRAMLICH:, Thet answers my problem.

MRS. SILSBEE: ‘Is there any further discussion
about Mississippi?

DOCTOR GRAHLICH: Yes. Let's take up the point
about the inappropriate funding in Departments or. agencies

waich snould be oterwise funding.

Is it RHP policy to take over public health func~

support them, or have nothing to do with them?

ERS. SILSBEE: No, it is not RMP policy to do

 

it is, in general; the fact that it is sort of blatant, the

 

 
 

 

 

1

 

 

 

ing. Eut it doas have to ba 1

213

fact that we don't have sufficient knowledge as to why
thay do it -- I think you can direct this back to the
Regional Advisory Group, as to why they chose to’ -- you are

looking at the quality of the decision-making there, and

stone

we could ask for additional information on that for you, too.

DOCTOR PAHL: I think we would like to go back to

‘Mrs, Flood's point, that a lot of their activities don't

fit in with their own objectives and goals and programs, so

that I don't like to have a policy that rules out anything

that smacks of public health. It may make sense for that
Region if it is part of their program, but in general, we
are not designed io take over those kinds of activity, and
there are so many good uses for the funds that I would think
the RAG couid receive this advice and perhaps act more
appropriately.

Certainly they could look at their objectives and
overall programmatic goais and how these would Fit into it.

; a . : a
That is the kinuct thing that we are interested in, but I
merconally don't believe we shouid have an absolute rule
tnat public. health is therefore inappropriate te cur fund-

MISS WARTINGES: Iwas
going, to ask the local RAG for

are we going to get it by July’

 

 

we ome Re emerteer

 

 

 
 

 

 

allocate these dollars, and we will get that information.

DCCTOR GRAMLICH: And ‘there is one other element
in this same preblem that relates .to grantsmanship.

It is entirely possible that these were in their --

: rc
CIty an ry ates oc maAYt
Gus ~ ODLNLOnS per i

ty
3
©,

ectly legitimate, but the reporting

received was insufficient: to @nable us to make a judgment.

sect
{8
GQ

. oo.
Now, I think this message might be conveyed, because
if we misinterpret what we read, it is either because we

read it wrong or because it was written wrong.

MRS. SILSBEE: Is there any further discussion on

Mississippi?

 

 

 
 

THD-99

 

 

 

rise EE

 

 

215
MATIOUAL ADUISCRY CCUNCIL ON REGIOUAL MEDICAL PROGRAM
NORTH CAROLIUA REVIEW
HRS. SILSBDE: Okay; how do you feel about North
Carolina, Doctor Gramlich?

R CURMLICH: Have I got some ideas about

In the first place, that airplane. I am taking
the programmatic apart.

It has a superb RAG, it is well staffed, it's a
good organization and has done a good job. Its track record
is fine.

$50,000 for air transportation. That is hard for
us to see - 001, second item.

North Carolina has a lot of outreach clinics
throughout the state, and it's a big state ~- not as big &
some others. They like to transport their residents, their
~- nursing staff and consultants to these various outreach

prograns by air, and this makes some sense, but as I read

ae .- sew ~
oe . . ih

the grant request, it raised a questién in my mind about

whether it was an omorbitant expenditure, or whether it could

a

perhaps be supported for a year with the understanding that
if it is that important, then the state legislature of North

Carolina ougnt to sponsor it.

There is some hint about this in the grant request, i

but not a spacific answer as to whether it was an opportunity |

 

 

 

 

 
WuD-

Law
t-

 

}
|

IIIT

 

 

‘approach, and I think most of those were pretty good programs.

216
te pick up some fungus that might otherwise not be tnere.
The only thing that struck me significantly about
North Carolina's proqram was that they have their -- they
are big on hyrertension, and beginning at 66~-A through 66-L

they nave a total of apout a dozen programs all related to

J

hae o ge

hypertension, and in terms of dollars they represent $459,739.

I realize that North Carolina is a very good RMP
and they might be able to pull off all these various and .
sundry projects successfully, but it did strike me that that
was a lot of expenditure for one particular disease, when
most of it was related to screening and education and develop-
ment of service personnel.

They have some very good programs.

On the second page, again, there was a very large
block of programs, starting.at 67-A and ending at 67-G, on

the providing of rural health care, and I like this general

It seemed to be well integrated and tie into each other

without a lot of duplication, waich I caldn'tt say for sure

about tie hypertension biock.
- a 1’

There seamed to be some overlap in that area.

 

 

mt
iil

q

rest of tha Tagion -- the RMP -- seemed to be

Pte

top-flight, and using a somewhat obscure technique, came up

with exactly the same figures.

MR. VAW WINKLE: The Committee was also quite

Lee emmeane cont satmenelamin on ot

 

 
 

WHD~92_

AC cr’ ateanre
AY tas Heese

sta,

 

“pe

mee

BO ger bu gereupe

 

 

 

wee. +

 

 

 

/Was something that these hospit ais should ke doing anyway «

217

concernau aucut the medical air operations. They singled
that out imaediately; they also were concerned about 63,
which they considered, as near as they could determine from

the informaticn provided, to be a pure PSRO, and thus con-

Sidered inappropriate for funding by RMP.

i.
‘4!

we »” ea

DOCTOR GRANLICH: May I interrupt just one second?’
& pick that up when I was reading it. 63
appears to overlap directly with 41-E, which is called "Area [
Health Systems," but when you read the request, it is a

PSRO training program.

MR. VAN WINKLE: They also expressed considerable
concern about 69, Doctor, which was the university~linked
hospital libraries. They thought this was completely over-_
anbitious; they didn't feel there was any guarantee it would

ever be continued, and more appropriately, they felt this

hey said libraries were nice, but they didn't really see that

this was going to have any great effect on the system there.
That one they had real concern with h; they also

mentioned the tan compohants in that rure healta clinic,

and they only made mention of it. Their concern wasn't ,that

great. I think they , fol much as you do about that.

Toney also expressed some concern about the fact

 

 

 

 
 

TID=-93

 

ee i a a a Oe as A en

: 218

went along with it based on their past performance.

wep

MRS. SITLSEEE: Mr. Milliken was the secondary
reviewer. Did you have anything?

ME. HILLIREN: I would agree with what's been said.

misappropriations to be not challenged. Ja should certainly
challenge them in terms of allowing them to stay in.

MRS. SILSBEE: Doctor Wammock?

DOCTOR WAMMOCK: I would ask a question here which
was raised in 63. This matter pops up at every turn, and I
know that some way or antoher we are going to have to address
ourselves to this. |

MRS. SILSBEE: We are trying to work with the PSRO
stafi to try to get that resolved.

DOCTOR WAMMOCK: I realize there are implications.
|| here, and I am asking for information as to -~- well, -what is:
the relationship, or what are they endeavoring to accomplish?

. . — . .
I mean, 1 say this with lots of reservation. TI

 

 

, Gidnt' want to bring it up, but in my own particular mind, I
am -- well, I'm for a peer review system, perdod. I'1l say

tnat without any reservations whatever.

I think we could simply not go along with allowing these . . «J.

 

MRS. SILSBME: Well, as you may recall, back in .

epee en yey oc o+g4 he Daetaun me 2 ~ . +
Sevtember of '73, the Regions were told to coma in wit!

 

 
 

 

tension. So some of these things which you see in here were

the result of that directive, which has not been turned

around.

DOCTOR WAMMOCK: Putting it in PSRO?

HR. RUGEL: If I could, I have had some discussion

xs
t a
ct
ty
(+
mr
Q
ws
mM
cs
tet
bw
ta
bs
He
cr
no
tft]
ty

Department responsible for PSRO, and

oo
m

there is at least the possibility that some of the specific

applications here as well as some that might come in in the
July cycle, at least to the near view, aré an attempt -- a
| possible attempt ~- an alleged possible attempt, at circum-
: . Venting the PSRO program, and we are very much concernd with

that. I doubt very much that the Department would fund any .

activity that would do that.

We are in the process of working with the PSRO

staff, locking at the specific applications here, to make

Sure that that doesn't happen. ‘ :

DOCTOR WAMHOCK: Well, I am in favor of this business

of quality assurance, or whatever you are talking about here,

because I mean, we grope with this problem every day, the

 

ge

| question cf question of whether you are going to call it PSRO,!
- L .

or whatever it is -- quality assurance or survival --_

 

|
|
| - MRS. SILSBIE: Hr. Rubel talks about trying to cir-
! -
|

 

cumvent tne thing. That is Locking at it from one point or

| . : .. 8 - ; ; = oe.
| » Vaew, and I was trying to look at it from the point of view
7 oe ee ee ae rn ae

| of the continuity of the directive that we gave tnem last.

| . :

fo gee wpe tages * neh on, -
“ we eet eae

 

he

 

 

rants

 

 
 

 

 

 

7

220

September.
I do think that we both agree that we can't have
this funded in two different places with two different sets

of priorities.

DOCTOR WAMMOCK: That was what I was thinking about.,

|

,

MRS. SILSBEE: Mrs. Flood?

ERS. FLOOD: Well, I would just like to reinforce
the Review Committee's statement about Number 69, which was § |.
the ‘network of hospital libraries throughout the state linked
through the University Health Science Center tied with
library resources.

This is appropriately -- there was a time when
funding for this was available through the National Library
of Medicine in small library development resource grants, and
possibly some of that funding could be available, but it is |

a massive undertaking, even at this funding, for a one-year

Gevelopment, and should net appropriately be addressed, becauss

 

indeed, this never finds continuaton support if the hospitals

have not already shown 4s

pe
rs
ct
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MURS. SILSEEE:° gust from listenince, Pector Gramlicn, :

. . 4 i . : : q
you had arrived at the same relative figure that the |
}

Committee had, and then I began to hear a lot of other concerns. _

wt.

 

Where do we stand?

   

DOCTOR GRAMLICH: Well, the full funding was not

 

recommended by .the Committee; they were reduced by something |

 
 

WHD-96

 

wet ee eee

 

 

 

221

.

over a million dollars, which seemed reasonable. That
seamed reasonable.
So I move that we accept the Review Committee's

recommenGation of $2,375,522.

HRS. SILSBES: All in favor?

(Chorus cof “Aye") | -

Opposed? - ‘

{No reply)

Carried.

viow, we will get this back to the Region, your

concerns, to the Regional Medical Program.

   

 

 

 
 

WHD-97

|
|
;
|
|

 

 

 

 

.

1

NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL pRecrats :
| SOUTH DAKOTA REVIEW

MRS. SILSBEE: | South Dakota. Mike?

MR. POSTA: The South Dakota Regional Medical
Program request is $729,417, which was approved in the total
Peers requested.

As some of you might récall, South Dakota used to
be, several years back, associated with the Nebraska program.
They got a divorce, and I think the separation has caused
both programs to impfove tremendously.

Because of the divorce, both South Dakota and
Nebraska have been among the most funded regions of the 53

that we have funded now.

For instance, the 12-month annualized current

funding level for South Dakota right now is $428,152.

Although the Region has never attained triennial |

status, it has been considered up until, if you remember the

last Council, as a planning Region rather than one that has

one. Tne uniqueness cf the South Dakota program is in the

fact that it is the only one that I know o

bh

222

t
'

wheteby the CHE, |

 

5

Council and the RAG RIP are one and the same. They do provide’ -

 

great strength to the state.

 

 

 

 
 

sWHD-98

 

 

cs FEET po et

 

cat ee Reet eg ee

b
t
i
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report. I would make only one comment on the staff assessment;

223

Program proposals wore considered well defined and |
had priorities well. meshed in with the identified health
needs of the Region. ‘

All there is is a small staff that is being paid
by the RMP; there are many other consultants who have given
additional extra strength to the program.

I think that would suffice as an opening.

MRS. SILSBEE: Doctor Gramlich?

ae

DOCTOR GRAMLICH: This is going to be a very short

and that is the Region was assessed by reviewers as not above-
average out as superior. |

MR. POSTA: I stand corrected, sir.

DOCTOR CRANLUIC - I could Find nothing wrong, I
have no comment; I move that they be funded at the rate of
$729,417.

This is supplemented by a 17-page ccnfidential

.

report, which says exactly the same“thing. he transcript -of

the reviewers' comments, a l7-page report, that they couldn't

tee fee Ft aaah bt? - 4 : 4
aa A SlGNlseacance Caand wrong with it.

iS. SILSBSE: irs. Flood?
MRS. FLOOD: Well, I only ‘have concern about one
program, and that was the project Number 12, which I felt.

ted a.sort cof a middle management in nurses

capabilities, rather than a nursing skill development in the | 7

 

 

 
 

224.
“
Manwover program, but with the newness of their independence,

| and with their well-documented analysis of their objectives

for the Region, ad the fact that this might in truth be the

 

cause of a tremendous nursing personnel turnover, I.would
concede that it might possibly be an adequate manpower develon-
ment type of project, ani I would accept the others' recom-
mendaton. ; :

MRS. SILSBEE: Is that in the’ form of a second, L

Mrs. Flood?

 

MRS. FLOOD: Yes.

MRS. SILSBEE: Any discussion?
All in favor?

(Chorus of "Aye")

 

Cpposed?
The motion is carried.

All right. The Reporter has asked for a short

brean, and we still have two Regions, and because Mr. Sidel

 

tw 3

{ from the Region ~- or perhaps it's

Doctcr Sidel; I don't know
-~ Will not be here tomcrrow, and Mr. Rubel will not .be-here,

en tee, Ret

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MLSE VOW, We medy Zntor

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(Mnereuson a short recess was taken.).

 

 

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tion.

225

7 t

NATIONAL ADVISORY COUNCIL OW REGIONAL MEDICAL PROGRAMS :

R-MOUNTAIN REVIEW

tit

Inv

MRS. SILSBLE: ALl right, let's get started.

UY

I have been caught between a dilemma: Mrs. Mars and
Mr. Rubel, and vir. Rubel has given way, so we are going to
take Inter-Nountain up first.

MR. POSTA: Inter-Mountain. The reviewers rated

.
the Inter-Nountain program above-average. The program has
good leadership, a talented staff, and a most active Regional
Advisory Group.

The Committee recommended funding in the amount of
two million dollars, which was a substantial reduction below
the $3,249,425 requested.

Suppert for the reduction was based on, one: the
relatively large, unexpended balances in this Region over the

ast couple of years; two: the large amount of re uested funds
Pp bP ; . 7

ie

was considered overly ambitious, and an example of this was
—_ te a, —
that 33 new proposals are included in the particular applica-

Iam sure that Mes. Mars and Mrs. Flocd.will wish’

to go on with some more specifics of the pregram, and perhaps
they might want to bring up the funding of the’ Health

 

x

Developacnt Service Cornoration, which had been brought up
at the Ad Hoc Review Comnittee meeting as a potential problem.:

HMO. TIARS: I really was rather incensed over the

 
WHD-191

[
|

I
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Review Committee's cutting this program down to 52 percent
of their requested funding.

This program I have site-visited twice. The last
time was -- how many months ago, Mike?

um. POSTA: It was January 15th.

* iRS
+lihs s

ft was January of this year.
Tne program is under new leadership, very capable

; . .
new leadership, and before I go further with it, I think that

to cut this program down to 52 percent is plainly a slap in

the face. I think it will absolutely kill all of their
incentives.
The program had a man running it previously who did

run a very tight ship. However, he also did not get much

cone as far as outreach, and this was one of the recommenda-
tions that the site-visit tean made at that time. This was

béing corrected, and of course, partly this HDSC does carry

on that philosophy to a certain degree.

ae

The outreach program is benefitting minority Groups,
aadcing ~~ the program itself is adding minorities to
caliber that is required is something that

is very difficult to find in thet area; howaver, except for
£

are very much in -- well, the

ts

that the site-visit team recom-

interrelationship between the

 

 

 

226,

 

 
 

 

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oad

 

 

 

Mountain States Re egional “Medical | Program, the Colorado-
Wyoming, and the Inter-Moun 1tain, This is being carried for-
ward, and they have ‘kept me apprised of their activities.

This was another thing that the site-visit team

reccmmenced and was very concerned about, this turf problen.. ..

4

Everything that waS asked by the Site-visit team has been met,
and the whole thing here is, I agree the program has been over
funded in the past -- I can't argue about that, but I think,
under the new leadership, that this money will be expended
and used very, very wisely.

The HDSC -- Health Development and Service Corpora-~
tion, which should parallel a non-profit independent corpora-
tion, this IRUP was developing as a project, and it is going
to be totally separated from the IRMP, which cert ainly should
relieve some of the concerns that were expressed by the
Research Administration of the University.

I see no reason why this can not materialize. The |

L . . . 7 wl oe . oO
relationship that the organization has now with the grantee

organization is a very much imoroved one, and I ‘thin iS they _

will work very closely together to eliminate any problems and |

to eliminate the NDSC frem really becoming a support project

Tah

 

Tie Trt m . es PTE . ££ ,aie -
The HDEC has applied for funding £ rom otHar™ sources,

ag wee od nt wo yee ot +
this funding from the

    
 

 
 

t
:

WID-103 ji

— L j : - 1

| ; has een Successful, so that continued funding of the project
nt .
| i is assured and snould not equire the funds to support it.
E i .
I teld you the Tri- ‘Regional Coor dinators have met
k
b . on owe oy . ‘ . . : - . .
i twice; they have a new RAG Chairman who is one of the most .
io 3 t .-

 

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‘developed; the system now is very good, this is the assess-

because I think the discouragement is going to be so great.

doe this to a@ program such as this.

enthusiastic dcdicated members of the public that I have ever®
come actress. Ne is giving more of his time than any indivi-
dual that I know of that acts as a RAG Chairman .

There has been a tremendous amount of rapport

ment of their projects, and I simply feel that if we accept
this degree of detrimental funding here, it is just -- the

money is simply -- the whole program is going to fall apart,.

*

The doctor is a pediatrician, I believe, by profes-
sion, was he not, who. is now the Coordinator?
MRS. SILSBEE: He is an orthopedic surgeon.

MBS. MARS: I couldn't remember what he was.
. .
He is giving so much of his time to the program now

~- he was not oxiginally a #oll-tims Coordinator, T believe?
is thal correct? His tine was --- but he is giving more of

his time now to it, day after day, and it is justa shame to -

 

 

' EF would certainly recommend that the amount of:

funding oo increased at least to $2,349,000, penta amillicn =~

  

      

off of it. the progran is obviously ab bove-average; there

    

 

 
   

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WHD-104

   

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Spe polaron ee ry rel eel eee ee sree

So ERS ER SRS SO Be SE GS eS TT

 

 

229

so many things waien come into this program that you can't
read in the book. | |

There. is a religious philosophy there... The Church’
has dominated the program until the last few years, and
certainly now, under Doctor Studt's leadership this is not
true.

I have nothing against the Mormon faith; I thik it
is a great, faith, but it has dominated this entire area, and
I think these are things ~~ the philosophy has also dominated
the University. The grantee was milking the program at one
point, but this is no longer true, and the whole thing has
completely reversed itselé, and I think they should be given
a fair chance to carry on their program.

So I would recomaend $

Jt

a
t

2,849,425 against the

bell:

$3,849,425 that they had requested, taking a million off but

raising the level of funding that the Committee has recom-

mended. And I would suggest that when they do apply for this’
a _ .

extra $49C-560,000, we can look closely at that, and if at

any time we are going to deny funding, F think it should be
at that tine rather than new. .  *
5

 

So this is my motion.

 

 

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1 ar’ . :

 
at

 

 

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a a

230 :
wooo - - - . Oo =“ Soe 4

| |
University of utah, and by its very nature, that of the Mormon

Church, dic permcat this program, bt I can not Speak as

strongly to the facts as Mrs. Mars presents, that. that is no

long true.

I feel that there is still a strong controlling

influence toward the attitude that only the things which

emanate from Salt Lake City can be done in a quality manner.
x

Doctor Studt, the Coordinator, is making an extreme
effort to bring this program away from that concept,. and move
projects from the strict University base.

There is, though, a lack of professional capability
in the Region to the degree that has been expressed in the,
past, both by the RMP and its RAG, but not to the extent that.

we have been led to » believe.

 

The minority issues in the state have not been

addressed. I do not feel that they are adequately addressed

-

yet, and the addition of one miriority administrative staff

Person, an American Indian, does not in any way soive the

=~ St . . Te ww Jae cad a ae
ehS Gl the realistic linking cf attitudes toward the
- .

. t
a $- Tn wees z 4, moe : ~ oe had os
necas cr the mincrity pecple in the areas that are served by

 

 

 
 

 

THD-106

 

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Set gpRES 9 SST

 

GEE cmER Score

a nn re

 

 

231.

would leave ther m se than $300,090 for new project start-ups

with this year's funding.
But their request is excessive, even with the

skilled stati that hey have, in Tight of the fact that the

a) 1G

majority of the projec ts presented in the application still.
are based from the Salt Lake City area reaching outward, |
and not reflecting strong interest in developing their Limited
capabilities of the Region to stand alone and develop its
wn expertise in attempting innovative projects on their own.
This Region had a belief, whether erroneous or
not, that they could only use the contract mecahnism to pro-
vide funding for projects in their Region and they never
indeed offered a fa1t grant project fund to a ‘a proposer.
The ite-visitors recommended that their administra-

tion anc core sta ££ investigate broadening the scope of this,

and if they have indeed done SO, there is more | potential there

“ee

for developing the capab ility at the Local level that they | had

<—-

. _ s aut - »
ignored in the past.

 

plus that firs. Mar 5S suggested.
I would alternately offer $2,300,005 plus ‘the odd 4
figure to give

cents and dcllars, if ros sSLole, 235 a Suitabie

them the capability tomdress some of the Region ‘priorities.

- |
|

 

 

 

 
 

WHD-107

 

 

 

 

 

232

I also must inquire, in Doctor Studt's letter

of transmittal to Council, to RiPS here, he stated that

ct
ty
Qo
ry
&
Q
i
QO
"I
fo
fe
Q

cordinators -- the Tri-Regional Coordintors --
first part of May, and Mrs.:- Mars tells us

2

and Iwuld lixe to inquire for my information.
if Doctor Curtis did indeed attend and participate in the
Tri-Regional Coordinators’ meeting?

MRS. MARS: I do not believe he was there. Just

a minute; I have the letter here:
"On Friday, June 7, representatives of the
Regional Advisory Groups of the three RMP's serving the
Inter-Mountain area met in Salt Lake City.
In attendance were Mr. Thomas K. Young, RAG
Chairman of Colorado-Wyoming Regional Medical Program."
This is not what you are referring to. But however ,
they did meet, ‘the RAG’s met. I have the other letter; rai.
find it ina minute, So

we might as well get on with this.

MRS. SILSBEE: Mrs. Mars, answer her queston speci-

t

’

t

 

ficalily; Doctcr Curtiss was present.
MR. POSTA: All the RAG Chairmen and all the

 

Coordinators were there.

MRS. HARS: This

mH

eeting was purely the three RAG's

from the various Regions, and there were representatives of
ye) iQ : :

24-8

ine mecting was a fruitful one;

it included

the RAG Level any detailed type —

 

 

  

 

 
 

ub

WHD~-108

 

 

 

regularly issued exchange of information among reporting _

the other two

 

Sia

233

of information of any project plans that will involve over-

lap areas, how each RMP is to handle notification, coordina-

ects that might move beyond the overlap area,

o

Tr

tion of any; pro

and impact communities served -- situated in locations served

ween asset m te cae vil, an sory
SKCLUSLVELY vy another Nir.

“ 7 . . > oe

t

h

.gzeenent to urge each Coordinator to implement a
activities any activities that other Coordinators should be~-
aware are contemplated or under way. .
Agreement that each RAG sees that internal communi-
cation is strengthened within its staff organization so every

member can ke expected go support and foster each RAG's com-

mitment.

ta

futual cocperation among the three RHP's.
At least twice during the year, each Coordinator

will ba urged to attend at least two RAG meetings at each of

RMP 's. Coordinators, with at least one other

 

. . _
fi menbver, ave excected to attend all Turf meetings, and
after each RAG meeting the Chairman will telephone his counter-

Ruip's whenever, matters intro-

i
_
shared. : , i

Chairmen will meet together at least

RAG Chairman may call an interim meeting

A joint mecting of the Colorado-Wycming RAG will be

     

 

 
 

WiD~-103

1
|
|
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|
|
|
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\
|
|
|
|
i
. |
i
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|
|
|

i
|
|
|

 

 

 

 

 

234

neld at Jackson, Wyoming on June 23rd, so that takes care

of the RAG's.

HRS. SILSBEE: Well, it doesn't really, Mrs. Mars.
uri problem is one that they .are finally acdressing,

but it does leave -- it doas need considerable work. «<=

& tat

- WARS: Ch, I didn't mean it takes care of the
Turf problem; no, not entirely. |

MRS. SILSBEE: We have to keep on top of that all
the time. The minutes of the last meeting indicated that
a numoer of the activities had to go back to their respective
county Regional Medical Prograns, to make sure there wasn't
some problem, so they have not really gotten at the intent |
of the waiole Turi in the Regional thing. |

IRS. MARS: This is always going to bea problem

tnere. The way the Region is set up it must be a problem,

The Tri-Regicnal Coordinators hava met, this time _

+ Ce .
with two of the RAG Chairmen present. It was a most worth-
while tresting and wa are following it up with atrip to visit
a ; i
Mountain States RMP in Boise today. ‘ 4

"We mutually accepted each other's applications

 

: .@ provisicn that on certain specified projects .
we would coordinate clesely with the other involved RMD

Before vorocescing with the invlementation."

 

 

 
 

WHD-110

i

|
|
|
!

 

 

 

CHPB agencies and they were approved, the recommendatons.

235

“The only project which has been of any con-

a

funds to identify the proper role of the University
as a referral training center in what has been charac-

2

ceris

ically considered to be its trade area."
and sO cn anu so forth.

MRS. STLSBEE: And that is signed by Doctor Studt,
is it not?

MRS. MARS: Yes, it is.

MRS. SILSBEE: Well, the one that we got from all
of them has a slightly different tone.

MRS . FLOOD: Who is serving as Chairman of the
Tri-Regional Coordinators?

MRS. SILSBEE: te is.

MRS. MARS: The other thing that I would like to
say is that the projects were also all submitted to the eight

a

those that were not approved were also not approved by the

 

RAG's, so the relationshiv between the CHP (+) agencies, of

Wich there are eight is certainly a very cicse one and a very

As far as going back to the minority voroblem, ‘they .

‘rant workers; this is being

f
4
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ty
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Geveloped, and this is a mincrity croup, which of course

becomes a vary Lares tercentucc of the minority population

 

 
 

 

 

_ purposes, and it does have some continuation funding in this

- proposal.

. it is really a relatively small portion, when you consider

the needs of the rural communities of that area and the need

. based in the rural outreach area; it is based in Salt Lake

236

during the time of the harvesting, and certainly, the needs
of it are being addressed, and I would say that this program
will develop into one that will eventually fill the needs.
But I do feel that we must give them an opportunity. .
MRS. SILSBEE: Miss Martinez, you have a question? ie
MISS MARTINEZ: I would ask, of the migrant project,’ -
how community oriented and controlled it is? .
| | It is one thing to serve the population without "oF
their input or direction, and it is another Matter altogether
to have the community itself set the goals.
| What kind of a policy is it?

MRS. FLOOD: I might respond there.

 

That is one project I have always watched closely
in that Region, and they can point with pride to timt one,
and we don't need to view with alarm, too greatly.

It is a community based operation with a fund in

Salt Lake City for the services to the migrant. It is not

City, but it is a primary flow area, so it does serve its

But from the total anount of their funding request, .

 

 

 
237
to break away from traditional programs based based only in .
~~ the urban centers of that Region.
MRS. SILSBEE: Doctor Sidel, did you have anything
* you wanted to say? He is from the Denver Regional Office.
DOCTOR SIPEL: Thank you. | :
In view of- the discussion and’ the relationship 7 _¢
between RMP and some of the Regional programs in my region -~-
and my Region, incidentally, consists o£ the two Dakotas,

Montana, Wyoming and Colorado-Utah, so it's somewhat different : .

in the context that we usually think of a Region in.

But a major concern of mine and the Region I repre-

sent, which is that of resource development in the Denver 3
' Regional Office, has been to improve the level of expertise
in the planning area, and I am talking about specifically

. health manpower, and also, planning for all health resources
- development within the Region.

We find that the general level of many of the

 

| decisions are based not on practical information, but sort of --
decisions which involve millions of dollars, both in Federal |

and state money, as a matter of fact, so sometime ago, we
-dnitiated a contract action through a source of soft sttements
to establish a Regional Health Planning Resource Center. :
“the concept behind the Center is to provide -- to |

improve the level of planning through four different channels:

1. Technical assistance in the skill area,

planning methodology and these types of things;

 
 

WHD-113

é
‘
t
|
|
t

!

|
|

T

t

"

qt
a
i
i

‘response to the RFP came from HDFC, since we were more’ inter--

_RMP's itself.

the legal status of HDFC; it is a recognized non-profit corpor-

ation, they have had a ruling from the Attorney General on

_particular corporation, so we have had to ask for an audit, .

what it came in with at one time was a proposal perhaps to

form a consortium of all the RMP's in our Region, to get

, responded to the RFP -~ that's a request for proposal, and the

 

|

238

2. Education, and education based on-site;
that is, in a sense, in the work setting, so when people
ask for technical assistance it is provided in those areas

where it is needed, but then at the same time it also has |

4
i

educational content so that those people are trained to ,
do their own training more effectively. mS
3. The other is to improve the communication
between those groups involved in planning. ©
4. Through special studies; let's say in the
‘area of health policy determination, which may impinge

.On area designations or a variety of other questions.

 

In response to the source of soft statements, actually
development together and develop a resource center.

Now, this of course -- we sent him an RFP; he

|
|
7

ested in putting money -- in dealing with the non-profit |

corporation than actually putting money into the -- one of the

t t

Now the q uestion then arose, of course, in terms of

i

i
4d
?

that. We had had no previous experience dealing with this

' :

oe chee esl naman nea

 

 
 

WHD-114

239

both in terms of fiscal accountability, and in terms of the

institution and organizational arrangements, and in particu-

lar the conflict of interest question.

We do not have a receipt of that audit yet, which

should be in next week sometime, because we need that prior

to any contract action that we can take.

The response to the RFP in other respects is very

good. The Committee that we have reviewjng these in the

Regional Office thought that it was innovative, dynamic and

a superior proposal in all respects.

The Other question that has come up most recently

is basically a staff decision as to whether funds,

; is one that I will have to get some clarification on, which

that are awarded to IRM can be _transferred to HDFC, because

actually, in the fiscal proposal we received from them, they

list four proposals -- 132, 133, 134 and 135, as direct

allocation to their Health Planning Resource Center.

So unless you know they can in fact achieve this,

they are not in a position to follow through on whatever con-

tracts they make.

I have been rather amazed at the ability of IRMp

and Mountain States to get together.

MRS. SILSBEE: Thank you, Doctor Sidel.

Mr. Russell, do you have anything to add to this.

four mountain states,

in terms of your recent tour through the four states -- the

as far as the CHP-RMP or anything?

!
|
|
|

t

for example,

 

Feb’ ah ORD cake Fe RR LO RRS Rae ea me TNT Se 2 0 apqueneenemenimmememenmmmannee ss

Sage

 

 
 

 

 

 

 

240

MR. RUSSELL: I am really not quite sure what I
can say. If I decided what I could say, I am not quite |
sure how I should say it.

In our recent visit to the Mountain States Regional
Medical Program, to verify their ‘review process, we found
some evidence that there was conflict, perhaps hanky-panky _
involved, between some CHP activities and the Inter-Mountain |
Region. Mike may want to address this, because I didn't have
a chance to follow it through.

We also found that the Inter-Regional Executive
Council, which was set up to eliminate the problems associ-
ated with the overlap Turf, really had not been very effect-
ive; a lot of this was due to phaseout, but as Mrs. Silsbee
referred to earlier, we have to stay on top of this rather
closely. :

So we did, before this last Review Committee, send
out a letter saying that we had to have these assurances.
The Inter-Regional Executive Committee, or Council, as it is
called, did meet and give us these assurances, and we haven't
had time to analyze the multitude of projects involved.

I don't know if this helps, but --

MRS. SILSBEE: Mike, do you have anything, any
input?

MR. POSTA: No. Essentially I agree with what Dick

has just mentioned with reference to the CHP involvement, and

 

 
 

 

 

 

 

 

 

24a
why perhaps Inter-Mountain has a little bit more rapport
with the CHP(b) and (a)'s in that area. rt is primarily
because they funded a lot more things to them, and a lot of
things they funded have been good.

But again, this is only human nature, and maybe I
shouldn't even be on the record, but with reference, I do.
think, to the representative of Region 8 concerning the
Health Development Service Corporation, $415,000 in this
particular application that came in from Inter-Mountain was
earmarked to go to this corporation.

There are considerakle -- or, there are some doubts
as far as the a staff is concerned about this organiza-
tion, about his free-standing position, but you take that
primarily because we get the same views from the grantee
institution, and I think the grantee's institutional policy
will prevail; if the grantee recognizes the Health Development
Services Corporation as a free-standing organization, and is
convinced that their assets and their talent and staff -- to
be recruited -- will be able to carry on the activities of
HEW, particularly the RMP- philosophy, they will probably be
funded, but I think Staff's position here and in previous
conversations under this subject, would be to recommend at

this time that the -- to hold funds in abeyance to that par-

ticular corporation until all the concerns of both DRMP and

the grantee have been fulfilled.

 

 
 

WHD~117

 

 

 

DOCTOR PAHL: May I inject myself into this for
just a moment? | |

This question of the non-profit corporation is one
that we really do not wish to have a Council recommendation
upon, because we are not able to provide you with all the !
information on which you can make an intelligent recommenda- |
tion.

The reason we can not provide you with the informa-

tion is that we currently are in active negotiation, both

with IRMP -- that is, Doctor Studt and staff, as well as the

grantee organization, as well as discussions with the Regional

1
4

-- the HEW Regional Office, and I believe at the beginning of .
last week, the grantee organization had one of its representa-.
tives come and meet with our Staff.

t

There were a number of issues and concerns raised,

and the negotiation status is that we are now awaiting some
official word from the grantee as to how they respond to er-
tain questions that we have.

iad

So, we are not in a position, really, and I don't

tink Council is in a position, to act upon a matter on which :
we don't have the full picture, the full information, and I
don't really think that is important to this application,
very honestly.

What we are looking at is the review and the merit

on the funding level of the Region. The funds which are tied :

 

 
 

WHD-118

 

 

 

>
tJ

te

up possibly in this new organization are hard to identify if
the funding level is below -- that is, if the recommendation
by Council is below in the request. We are not sure; it is
up to the RAG then as to what it wishes to do.

So I would like to divorce, for your consideration,
the status, legality, appropriateness and so forth, of the
HDFC aspect and return, if you.will, to the merits of the
overall program, and we will be reporting to you at the August
Council meeting the conclusion of whatever these negotiations
happen to show.

We are just not able to make a determination our-
selves at this point.

MRS. SILSBEE: At this point in time I need some
help from a parliamentarian, because Mrs. Mars made a motion
to the effect that the recommendation be $2,849,425, whereupon
Mrs. Flood made a -- seconded the motion, but she suggested
that it be $2,300,000.

Now, what do I do to get this resolved?

_ DOCTOR SCHRIENER: ee has the option of
accepting or not accepting the amendment.

MRS. FLOOD: If I may, I believe I said $2,349,425,
and I will just run it to $2,350,000, which -~ you know --
solves all these small figures, if Mrs. Mars accepts.

MRS. MARS: No, I do not accept.

MRS. SILSBEF: All right; Mrs. Mars had made a

 
 

WHD-119

 

 

 

244
motion to the effect that the Region be approved at $2,349,425
and it has no- second. | |

Is there a second?

MRS. MARS: ‘Then we have another motion.

MRS. SILSBEE: All right, the motion dies for want
of a seoond. I am ready to entertain a new motion.

MRS. FLOOD: Mrs. Silsbee, I would recommend that
we approve a funding level for Inter-Mountaim Regional Medical
Program of $2,350,000. :

| MRS. SILSBEE: Is there a second?.

MISS MARTINEZ

Second.
MRS. SILSBEE: The motion has been made and seconded
that the Inter-Mountain Regional Medical Program be funded
at a level of $2,350,000.
Discussion?
MR. MILLIKEN: What would the insttructions be with

this to accommodate the difference between what they have

asked for and what they are being provided?

I have some anxieties that some things may be cut
out that we think should not be, if they are allowed to do
this. I see no assurances. |
MR. CHAMBLISS: The activities of the corporation

will certainly undergo some discussion here in Staff, and that

might very well be -~-

MRS. SILSBEE: Now, Mr. Milliken, if you take your

 
 

WHD-120

 

 

445 }

viewpoint to its fullest extent, the only thing you could do
is to approve the level they have requested.
So in terms of advice, if you would like to specify

something, we would be glad to follow up on that.

DOCTOR WAMMOCK: I only want to say one thing.
I looked at this and there are six states involved,

and that is a lot of territory to cover, and I can see some

inherent problems -- transportation difficulty and all these

other things, and I don't know what the answer to it is,

whether $2,350.000 because you have a large territory to cover:
there, and I do not know what the total population is of these
six states, whether it would be 6,000,000 people or whether

it would be 3,000,000 people.

MRS. SILSBEE: Well, Doctor Wammock, that same large

f t

j
territory is also covered by two other Regional Medical

Programs. |
We have a motion on the floor. !
MR. MILLIKEN: Do Staff have some insights into !

this, or recommendations for instructions to this applicant?
MRS. SILSBEE: I think the instruction that we

would try to interpret from your discussion is that you have

felt that on the one hand the IRMP needed to get into the .

outreach, looking at the needs and the -- try to assist in

 

the health care of population groups that have been under-

served, and on the other hand you feel that the Region is

 

 

 

 
 

WHD-121

 

 

246
overfunded and that they should concentrate on these areas,
at a reduced funding level.

MR. CHAMBLISS: We will express to the Region the.»
concern coming from Council about the minority issues in terms
of project activities; you have cited the fact that the
Region has hired one minority individual, and I seemed to |
hear’ you saying that this is a ‘continuing concern.

I further hear you saying that the project activity
touching on the minorities, and there are several minorities
in Utah ~- the Indians, the blacks, the Chicanos, that there
is concern from Council that their health needs be addressed
in a more positive way.

MRS. SILSBEE: The motion has .been made and secon-
ded that the Inter-Mountain Regional Medical Program be
funded at a level of $2,350,000.

All in favor?

(Chorus of "Aye")

Opposed?

MRS. MARS: No.

VOICE: No.

a SILSBEE: ‘Let the record show there were two
Opposed, but the motion is carried, and let the record also

show that Mrs. Klein has been absent during this discussion,

and Doctor Gramlich.

All right; do you want to call it quits for te day?

 

 

 
 

WHD~122

 

 

; 247
NATIONAL ADVISORY COUNCIL ON REGIomay, MEDICAL PROGRAMS

SOUTH CAROLINA REVIEW

MRS. SILSBEE: Now we will take up South Carolina.
Lee, do you want to put it in perspective?

MR. VAN WINKLE: It was considered to be an average
or above-average Region; they had requested $3,000,000, and’
the Committee recommended $2,200,000.

The basic reason for this reduction was that here
again, this Region had requested escrowed funds, if you will -
blank checks, as I heard referred to earlier. With another

Region, they were asking for authority to spend funds in the

area of regionalization of services -- health manpower develop

ment and improvement, strengthening quality assurance, and
other activities. |
The Committee did not buy this, or did not accept

it; they did not think that these activities had gone far
enough through the review process in South Carolina for it
to be acceptable, and that is how they arrived at their reduc-
tion. oS
There are many other things that could be said, but
E suppose they will be covered by the reviewers.

. MRS. SILSBEE: The primary reviewer for South
Carolina is Doctor Haber.

DOCTOR HABER: In reading the May-June review

on the yellow sheet, and the confidential comments in the

 

 
 

|

WHD 123 248
6:00PM proposal, I sometimes wonder if I am looking at the same pro-
7 ject. . :

Fae With four different perspectives, it became diffi-

‘cult to reconcile these all.

Very briefly, because the hour is late, their pro-
posal goes through a narrative history which is a very good

|
= |
focus. It shows the development of a typical Regional Advisory

|
Group.

There are a couple of comments in this that I think
are worthy of reiteration. One of them is that the Regional .
Advisory Group has maintained its integrity, quantitatively --.
and one must assume qualitatively -- in the face of what they
call a limited future outlook, but they proudly aver that not

one member has resigned.

The organizational structure has been modified since:

the inception of this program; they have gone through a number.
I

of changes since their inception in 1966, and they now have

a triple-headed Regional Advisory Group -- I'm sorry; a

triple-focused Regional Advisory Group structure which seems

 

very adequate to the task at hand.
The review process and their relationships with the |
CHP(a) agencies look good in spite of the somewhat tortuous

relationships in South Carolina, and the comment is made that

there are at least five different types of planning groups,

! CHP agencies -- (a) and (b), the Appalachia Group, the

 

 

 

 
 

 

WHD-124

 

 

249
Regional Advisory Group, and a new group composed by the

Governor, and the comment is made that this group is the
line to his office, through a dotted line which seems to
imply a tenuovs future.

The caliber of the people involved, although I have
not had the benefit of a site review, seems to be exemplary.
I don't think we can fault them on that.

The individual projects themselves, I think are
worthy of comment on reviewing. I would disagree with Doctor
Gramlich's previous expression of dissatisfation with concen-
tration in one area. They have a number of projects related
to hypertension, and I think this is good.

They have a number of projects which are related to
the detection of hypertension through kidney disease and
neuropathy, in black female children, in the adult male popula
tion, in general screening, and I think they are moving into
an area very solidly, conceivably with some overlaps, but a
massive approach on this important debilitating and life-

threatening disease is evident.

Some of their projects look a little naive to me.

There is one nm improving ambulatory care, which would apply
certain statistical models to ambulatory care. ‘There are
such models in existence, and it seems to me they ae trying

to invent the wheel.

I am concerned, although I don't have enough infor-

 

 

 
 

WHD-125

 

 

 

 

 

250

mation about this World Mobile Health project; it seems to
me it is inadequately funded for all the wonderful things
they intend to do.

I was concerned about the nurse-midwife project,
which has been approved but not funded , and then withdrawn,
apparently because of the difficulty of getting people. It
was very modest funding; it seems Like an eminently worth-~
while project, and I would hope the Council could somehow
help them in going ahead with this.

I think that this shows a good balance of projects
between rural versus urban populations, ,minorities, between
various kinds of diseases, and I would say that in total it
seems to me their organization is sound.

The Regional Advisory Group has fared better than

the RMP, which has lost, I think half its personnel. The

‘quality of people is good; the proposals seem in the main

well-balanced. . | , ne:
I think it has been judged average to above-average
and I would concur in that, and I would also agree with the

target that has been set for them; they asked ‘for $3,000,000

'

and $2,200,000 seems eminently reasonably.

MRS. SILSBEE: Mrs. Mars?
MRS. MARS: I agree with Doctor Haber and with
the Review Committee's recommendation. .

I felt that it is a particularly well-structured RAG,

 
 

WHED-126

 

 

251
* ‘ ' .
has a good review process, but there are SO many of these
projected activities that have not had time -- I have not

had time to go through this entire process by any means, SO

that they are really requesting funds for some projects which

are still very problematic, so I agree entirely, and I second

the motion.

MRS. SILSBEE: Mr. Rubel?

MR. RUBEL: I would like to address one specific
project that the RMP has proposed; I don't know how the
numbering system works here, but it is something like 32-F;
is that it?

Which is that -- an attempt at setting up an organ-
ization that would plan for the implementation of legislation
that I spoke about this morning.

I would like to present you with two facts and see
where it goes from there.

The Governor has expressed his very deep opposition
to our funding this project without approval by the Health
Council that he set up. Governor West has devoted a major

portion of his last. two years to working on health problems in

this state, and very frankly, he feels that setting up of

this organization is an attempt at by-passing the state
entirely and trying to position the RMP in such a way that
it would become -- or play a dominant role in whatever kind

of organization comes about as azwsult of discussions on

 
 

WHD-127

 

 

252
Capitol Hill.

Governor West has on several occasions discussed
what he is doing in health with the Secretary, and Doctor
Endicott, and many other people. The Department, for one
reason or another, is doing all kinds of things in South
Carolina -~ I don't even know about them.

There is a lot of interest; that's point Number 1.

Number 2, the HEW Regional Office in Atlanta has
expressed a lot of concern about this project for a mamber
of the same reasons. |

It is feared that the RMP is dominated by the
medical profession and that, as I said before, there is per-
haps an attempt at posturing here, that they are very concerned
about. While it is alleged in the application that the CHP

agencies are in favor generally, the Regional Office has been
, |

told by many of the (b) agencies that they are very much
opposed to it.

I don't understand all the politics of this state
of South Carolina, and certainly not the medical politics,
but we have a very difficult situation on our hands here.

I certainly think we would very much appreciate
getting your recommendation on how to proceed here. I would

like to just set out four possibilities, and while it is true

that the Council usually does not deal with specific proposals',

it has on many occasions said Yea or Nay to specific ones

 

 

 
 

 

253
when the occasion warrants.

Before I get, to the possibilities, in going through
all the applications in front of us, there are other states --
there are other Regions that are proposing something like
this, but I think it is fair to say that South Carolina's
is the most blatant, or perhaps the most forward, depending
on how you might view it. |

We certainly know, and as I discussed this morning,
that RMP's as organizations, and the people that work in then,
are thinking about the future, and are trying to do all kinds
of contingency planning, and in fact different places work
in different ways.

You just heard something about what goes on in
Inter-Mountain, and that is going on around the country, and
we can't ignore that.

On the other hand, to what extent do we want to
allow money being ~- coming through this channel to serve as
a base for one organization or another here?

Essentially, the four possibilities are:

1. Tell them, you know, you decide what you want -
to do, .based on whatever level of funding the Council recom-
mends, which essentially says that if that gets to be import-
ant they can go ahead and do it.

Second alternative is to say: “You can't do it."

Period.

The third alternative would be to say: "Go back and

 

 

 
 

WHD-129

 

 

 

254

you had better start negotiating with the Governor, and as
part of the application due on July 1, if you can get their
approval, or it you can't, at least if you want to propose

it again, please do, but we won't fund it during this cycle."

The fourth possibility is a conditional approval,
saying that there is a requirement for coordination here and
for working together which has not been demonstrated, that
you may proceed and do this but only after you have consulted.
and gotten approval of the other factions that are involved,
that are going to be involved, in whatever the legislation
covers. If you-can get their approval, then you can proceed.

Those are the four possibilities, as I see them. |
Perhaps there are others.

MR. VAN WINKLE: The Review Committee -- this was
one of the thrusts, Mr. Rubel, that the Committee addressed,
and this was what they based their reduction of funding on.
This was one of those that they said they could not consider
at this time. -

MR. RUBEL: It is one thing to provide the reduced

funding; it is another to preclude money being used for this
purpose.

MRS. SILSBEE: Does the Council have any suggestions
as to how we proceed? This refers specifically to that one
project.

DOCTOR WAMMOCK: Is that 32-F, did you say?

 

 

 
 

 

WHD=-130

 

_ing recommendation be cut back but that there be some kind of

 

 

255
MR. RUBEL: That’ is 32-F. They are proposing,

essentially, to spend $165,000 to set up a new organization.

DOCTOR WAMMOCK:: With the RMP funds?

MR. RUBEL: Yes, sir.

MRS. FLOOD: But all of the 32's -- A,B,C,D,E --
except for F, aren't. they rather nebulous? Or at least, is
it D that is sort of a blanket fund that will be spent on
non~-RFP's?

MR. VAN WINKLE: All of those are in that nebulous.
category; yes.

MRS. FLOOD: They add up to a million-four.

MR. VAN WINKLE: Yes. |

MRS. SILSBEE: That, as I understand it, was why

the funding recommendation was cut back.

Now -Mr. Rubel is suggesting that not only the fund-

outline or alternatives which -- and theyvwere all valid altern-
atives, and we need to have some motion in terms of the fund-
ing level and what you do about that particular thing.

DOCTOR JANEWAY: Can I ask a question, Mrs. Silsbee,
before we get a motion? So,

That is, can the Review Committee make any specific

comments relative to the areas that were discussed? Because

it could be circumvented and not be a Council policy if there

were specific recommendation from the Review Committee as to

 

 
 

WHD-131

 

 

 

 

256

deletion.

MR. VAN WINKLE: Not in terms of addressing this
particular issue, no.

MR. CHAMBLISS: As a matter of fact, there was a
correspondence that came in since the Review Committee.

DOCTOR JANEWAY: They were not privy to this infor-
mation; is that correct? |

MR. VAN WINKLE: That is right.

DOCTOR JANEWAY: Because it seemed to me the senae
of the Council, considering the second resolution of the Ad

Hoc Review Committee was such that we were not in principle
going to consider that proposal, that RMP organizations pre~
pare temselves for some possible future role.

MR. VAN WINKLE: They did not address that. All
they said was they don't think these activities are suffi-
ciently developed at this time for them to consider.

But if they come back in in July, then they will
consider them, is essentially what they say.

MRS. SILSBEE: Doctor Janeway is saying that the
Council's previous action with regard to that proposal ~~ the
resolution, that the Committee in a sense answers this. |

DOCTOR JANEWAY: It doesn't have to be dealt with
inany substantive sense on the basis of this particular :

Council.

MR. RUBEL: I should point out tmt this is referred

 
 

 

WHD~-132

 

 

257
to as a Phase 2, that the RMP has been involved in these i
activities. They did sponsor a conference back in January

which Doctor Endicott did attend. Then here they have a

very specific proposal here; this is not nebulous. This is

~~ it says:

"We're going to do something. We're going to
set up an organization, and un til we set it up we are
going to use RMP's staff to do it and what it is sup-
posed to do." |

So we can't fall back on: "We don't know what this

is all about."

 

DOCTOR HABER: Well, can we approve all save that
particular project? And then adopt one of the four alterna-
tives that he outlined for us? Can we do that?

f

MRS. SILSBEE: You can do -- yes.

DOCTOR HABER: Well, I so move.

I move that we adopt all -- that we fund this at
the level recommended, with the exception of that particular
portion to which Mr. Rubel has reference.

MRS. FLOOD: 32-F,.

MRS. SILSBEE: Now, in terms of that particular
portion, are you saying Option 2, no-go? They could not fund |

|

it?

DOCTOR HABER: I am trying to separate that out from

the rest of the program. If we can get a motion approved that

 

 

 
 

WHD-133

 

 

 

258

all but that would be approved,. then we can handle this for
those four options. That is holding up the whole thing.
| MRS. SILSBEE: IS there a second?

VOICE: Second.

MRS. SILSBEE: All right. ‘The motion has been made
and seconded that the South Carolina application be approved
at the level of $2,200,000, with the exception of 32-F.

Any further discussion? |

DOCTOR WAMMOCK: If you look up there at 32-D and
32-C, and 32-B -- I mean, I see no description here at all;
it is only just:by title here. It seems to me it all falls
pretty much in the same category.

MRS, SILSBEE: In terms of the issue that the 32-F
is directed at, which is that the Governor's Council -- that
is a slightly different issue.

DOCTOR WAMMOCK: It's got a different twist to it.

MRS. SILSBEE: That is right.

Further discussion? All in favor of the motion? —

(Chorus of "Aye")

Opposed? .

(No response)

The motion is carried.

Now, do you want to deal with 32-F?

DOCTOR HABER: Can we have those four options again,

Mr. Rubel?

 
WHD-s134

 

 

255

MR. RUBEL: First, you can leave it where it is,
let the RAG, based on the decision you just made, determine
its priorities.

Second is a flat: “You may not perform; this project
is unacceptable." Just as we said earlier that any of those
unapproved arthritis applications can not be done by the RMP.

Third is:

“Come back in your July 1 application, but
Satisfy us that you have worked together with all these :
other bodies and that they agree to it." |

DOCTOR HABER: That is the option I want, and I am
making a motion on that.

MR. RUBEL: The fourth says:

“You may use the two million whatever it is,
or part of it, for this project only after you have
, worked with the other groups and only after approval by
the Director of the Division of Regional Medical Programs

And that would only occur after he is assured that
those groups have been consulted. |

Three kind of puts it into the next cycle; Four
says it is okay under this cycle, provided certain conditions
are met.

MRS. EILSBEE: Doctor Haber, in terms of your con-

sideratimof this, of Number Three, it is now June 13th, and

they have to come in on July 1. Now, whether they can satisfy

 

 

 

 

 

 
 

QHD-135

 

 

 

260

all the things you are talking about by July 1, I --

DOCTOR HABER: We know they are mot going to satisfy
all -- .

MR. RUBEL: ‘perhaps i would be useful for me to
read to you a paragraph of a letter from Chairman of the
South Carolina Health Policy and Planning Council:

"I told you in Washington I would not consider

writing this letter without the full kmowledge and con- ~

sent of the Governor, and without my being personally

assured that he completely understood tthe issues involved.

This I have done, and I am mow writing with
his full knowledge and consent, and in fact under his
direction, at the request that any application or communi
cation seeking recognition or funding for any purpose in
this field in South Carolina, which might be filed with
the Department of Health, Education and Welfare, not be
considered without having been referred to the South

Carolina Health Policy and Planning Council, which is

the official State body created by the Governor's

Executive Order in January 1973 with the specific respons-

ibility for planning, reviewing and coordinating all
health efforts here in South Carolina."

DOCTOR SCHRIENER: There are two ways of saying:

don't do it.

 

 

 

 
 

WHD-136 ae Z6i
MRS. SILSBEE: I wouldn't want to enter into this,
_— but in terms of the Council, youare in a position to do
what you think is best.

DOCTOR SHCRIENER: Oh, I think that is best.

DOCTOR HABER: I would’ still make a motion for the
third alternative, and I do SO. And If put that motion before
the Board.

DOCTOR WAMMOCK: Would you so state what we are
going to vote on now?

MRS. SILSBEE : The alternative Three is that the
-- that Region may not do that with these funds. If they
choose to go back and negotiate with the agencies and the
Governor's Council, the Council would entertain a request in
the July 1 application.

MRS. KLEIN: I hesitate to talk about this because
I know so little about it, but it seems to me that the Ad
Hoc Committee did approve this, did it not? ‘The funding that
we are discussing, this aspect of it, and they had not had
this opposition expressed to them at time?

Well, it seems to me then that if they did, as far
as the merits of it are concerned, that we are agreed that
it is proper, then also, if they negotiate with the Governor,
. knowing how they sometimes operate, there is a possibility

that they could clear this portion up, and for that reason

I would certainly feel that we ought to go along with the

 

 

 

 

 
WHD-137

 

 

262
fourth proposal, and that is to approve it and then permit
them to make their peace, if they can.

So I suppose the. way to handle this would be to
vote on the preceding motion, or I might offer a substitute
motion, if that is in order with the procedure that you use
here.

MRS. SILSBEE: I am the poorest parliamentarian
going, but -~- Doctor Haber?

DOCTOR WAMMOCK: She is making an amendment now.

MRS. SILSBEE: She is offering a substitute motion.

MRS. KLEIN: This would preclude the other one, so
I suppose it would be a substitute.

DOCTOR HABER: I would accept that.

MRS. KLEIN: Well, I would suppose that was proper.
I would second the motion, then, as amended.

DOCTOR WAMMOCK: Well --

MRS. KLEIN: He accepted it and made a new motion,
which in effect I am seconding, just so we can get a vote on
this.

MRS. SILSBEE: Mrs. Flood?

MRS. FLOOD: I have a question, or perhaps it is a
concern, that by making the statement that we would fund this

type of a project, should North Carolina -- should South

Carolina RMP make amends and get friendly with the Governor,

we have set the precedent then for a request for funding for

 

 

 

 

 
 

 

WHD~138

 

 

263
just such organizational structure out of RMP dollars across
the country.

Now, we just said earlier that we did not want to
encourage, or at least we wouldn't accept as a policy state-
ment, a statement that said we encouraged the staff to start
investigating the administrative structure that they might
endeavor to approach in light of potential new legislation.

But here we are talkimg about setting the precedent
for buying the complete service or development.

| MR. RUBEL: As I tried to indicate before, this
kind of activity is going on in every Region in the country.

MRS. FLOOD: Yes, but not at $165,000.

MR. RUBEL: Well, you know; you can do it in various
and sundry ways. You know that it is happening; as I have
been going through the book here 1 have managed to detect
very similar kinds of projects, and some people have a better
way of hiding them than others, in I would guess, at least
a half-dozen other Regions. -

So it is not a question of: this is the only one.
They are the only ones that are doing it quite as blatantly,

bit remember this went through a review process and nobody
really picked it up. Nobody said; there is nothing I read,
and I mean, the first I heard about it was when I got this
nice cozy little letter here.

MR. VAN WINKLE: They refused to consider it for a

 

 

 
 

 

WHD-133

. Opposition from the Governor?

 

 

W)
Oy
ote

different reason, too.

MRS. SILSBEE: Mr. Rubel, I think there is, in ‘terms
of interpreting the messages that have gone out. to the
Regional Medical Programs, and in terms of the whole thing,
it would seem to me that the Region is trying to respond in
a way to a national initiative, and I guess I ama little
concerned about the idea that it is trying to get there
"firstest with the mostest."

Now they are there, you have asked them to get
ready, and they have used various ways of doing that. I
just don't think -- and they have the money, so the fact
that they have the money doesn't mean necessarily that they
are not being involved with the others.

Miss Martinez?

 

MISS MARTINEZ: In some of these other states that
you mentioned, that are doing this thing, is there the same

MR. RUBEL: There might be if he knew about it.

You know, I know of many, many situations where |
there is a fair amount of “conflict there. It is very diffi-
cult to say, because these applications haven't been reviewed
by Governors, so we don't know whether they are opposed or

not.

MISS MARTINEZ: I think whether or not it is

happening on a smaller scale, I think with several of the

 

 

 

 
 

WHD-140

 

 

 

265 .
smaller projects, and whether. or not it is a response to a
possible national direction, I don't quite agree with the
policy of spending program moneys on the possibility of a
change when they are -- there must be better ways to spend
program moneys.

I don't quite agree with that kind of. philosophy.

DOCTOR WAMMOCK: Mr. Rubel, what does South
Carolina have? What is her plan called under the Governor,
if you would please state that again?

MR. RUBEL: South Carolina Health Policy and
Planning Council.

DOCTOR WAMMOCK: Well, there you -are, see? He is
in direct control of that.

. MR. RUBEL: And that is right over the Department
of Health.

DOCTOR WAMMOCK: I venture to say they are the very
first state that have a program that is controlled by the
Governor. L

DOCTOR SCHRIENER: I just wanted to say that I am
not terribly swayed by the argument that some of these may
be buried in other proposals. The point is that we are dis-
cussing this proposal; I think this -- I personally don't
think it is a good way to spend RMP moneys, and I will vote

against any other proposal that has it, just like I am going

to vote against this one.

 
 

WHD-142

 

 

 

267 |
it until they have shown us - that they have already done
it.
MISS MARTINEZ: I still think it sets a bad prece-
dent.
DOCTOR WAMMOCK: Me, too.
MRS. SILSBEE: Do you want to vote on that motion?
MRS..GORDON: I would like an exact wording of the
motion. You are saying the same thing different ways, but
it isn't the same thing.
| DOCTOR JANEWAY: I was wondering, if we are talk-
ing about "safesmanship," if one really wants a motion? And
a vote, on something whereby you are going to establish policy
by exception.

And it seems to me that Staff could sense the feel-

 

ing of the Council with reference ‘to this particular portion
of the grant request and indicate to RMP the strong feeling
of the Council in this regard. | oe |
Because you are getting into two situations, it seems |
to me. One is, you are overruling a Technical Committee of |
the Ad Hoc Review Committee, which we have the right to do,
but it is not the general order of things. It is a specific
project.
-And if it is a motion, it is not only intent, it is :

policy.

Now, I think Doctor Watkins made an extremely valid |

 

 
 

WHD143

 

 

 

 

 

268
point very early in the meeting about whether we were indeed
required to vote on proposals that we elected not to have
come before us. And the sense of the Council would carry
the weight of a vote without having any.

MR. RUBEL: We in HEW are going to have to deal
with this one way or another; you know, if you decide to 1ét
it go to the extent that you disapprove it, that is the end
of it. There is nothing we can do.

But if you decide to let it go, we still have to
deal with it, one way or the other. You can choose to tell
us which way you would like us to deal with or, or you can
let us deal with it ourselves.

The problem is not going to go away; the Governor
is going to be there tomorrow, and he is going to pick up
the phone and call the Secretary and we are going to be right
in cthe middle of it.

MRS. SILSBEE: Mrs. Klein?

MRS. KLEIN: We would be setting another precedent
if we refused to approve. this, or approved it in such a
manner that it implied that the Governor's approval approval
would have to be had for every funding that we undertook
from now on.

That would be my concern; I would be more concerned

in that direction than I would be in the directimof asking

 

 
 

WHD144

 

 

 

269
them to cooperate in getting approval by the Governor and
these other agencies before they actually went ahead with
the program.

MRS. SILSBEE: Miss Martinez?
MISS MARTINEZ: Isn't the issue one of - the RMP

duplicating part of the function of the Governor's Council,

and isn't that why, rather than all that RMP -- I don't think

this would set a.precedent for approval of all RMP projects. _
It is simply a matter of RMP duplicating its committees.

DOCTOR SCHRIENER: Mrs. Klein has a point as far
as I am concerned. I don't think it is a very good expendi-
ture of RMP program money.

MRS. SILSBEE: Well, Mrs. Klein?

MRS. KLEIN: I am sorry to be so persistent about
this, but this, to me, would be sort of a flimsy reason for
disapproving the program.

If the Ad Hoc Committee approved it without knowing
of this problem, as far as I am concerned, it must have had
some serious merit, and I am not in a position to say there

wasn't -- you know, that it should be disapproved, possibly

‘because I don't have the information, but my problem here is

coupled with the Governor's need for approval and that sort
of thing, and I don't thik we ought to -- I think it would
be a bad policy to require that approval before, you know, we

do any funding. Otherwise it certainly would get us back to

 

 

 
 

:WHD-145 270 I
the point where we would -~ what are we here for?
—_ MR. MILLIKEN: Point of information.

Does the Ad Hoc Committee indeed approve or dis-
approve, or do they recommend to this Council?

MRS. SILSBEE: They recommend to this Council a
funding level. Yes.

DOCTOR WAMMOCK: I am sorry, but when you look at
the titles again across here -- whatever in the name of God
that means, I don't know; the specific categorical entries -—
prime Health care, and Advanced Health Resource Planning?

MRS. SILSBEE: ‘Are you looking at the print-out,
Doctor Wanmock, or the individual 15's?

DOCTOR WAMMOCK: It is the print-out here, you see,

 

for this whole thing. It is all described here, and it seems
to me -- Health Sources Development Initiated Phase 2, Advance
Planning, Corporate Mechanisms in South Carolina, and another |
one, "Program Needs on March lst announce Health Manpower
Development Improvements; one of the six really broad program

areas whichvwere eligible for consideration in the future con-
tracts for project funds."

I believe it is semantics; it is all semantics.

They are all going in the same direction.

. MRS. GORDON: Did I not understand you to say that

 

one of the reasons for the cut in funding, or for the cut, was

because the Review Committee did not see the value in these

 

 

 

 

 

 
 

yuD-245 , 271
146 4

particular programs?

MR. VAN WINKLE: Not that they did not see the
value. These are thrusts that this program is making; it
has been approved by the RAG. This is the way they intend to
get into it. |

| But in this application the program had not

developed far enough for them to consider it. They said: "If
it comes back in July we'll look at it," but they don't have -
who they are going to contract with, they don't know wno
the project directors are; we don't know the amounts of the
budgets. Until they provide us with that, they are just not
o going to look at it, is what they said.

So therefore, we are going to cut the proposal by
$800,000. |

DOCTOR JANEWAY: Then the Ad Hoc Committee has
already said this.

MR. VAN WINKLE: That is in their recommendation.

DOCTOR JANEWAY: That is all we have to say anyway.

MR. VAN WINKLE: _ They did not consider the proposals
at all. They just said: "At this time we dan't know enough
about it."

MR. MILLIKEN: Question, on the motion. 4

MRS. SILSBEE: There has been a motion made, and I

af

don't know that I have the exact wording, but maybe, Mrs. Klein,

you could reword your motion, since it has turned out to be *

 

 

 

 

 

 
WHD-147

‘approved the funding...

 

 

 

272

yours? Oo ,

MRS. KLEIN: I don't know that I have the exact
wording either.

I would prefer that someone else word it. My motion
~- all right; I'll make an effort.

As to these programs that we are discussing ~~ and
I don't even have the information about them --

DOCTOR HABER: IT is the Health Services Development
Initiative, Phase 2, Project 32-F. |

MRS. KLEIN: Funding was approved by the Ad Hoc
Committee, was it not?

(Discussion off the record)

MRS. KLEIN: They did not approve it?

MRS. SILSBEE: They did not specifically disapprove
anything. They reduced the funding level, with advice to
the Region that they should come back with specific informa~
ton in July if they wanted anything.

MRS. KLEIN: Well now, i have made all of my
motions. I am really gumming this up. I have made all of my

motions with the premise that the Ad Hoc Committee had

MRS. SILSBEE: They reduced funding for the Region.
MRS. KLEIN: They actually reduced the funding
without knowing of the Governor's opposition, and the motion

now would be to go contrary to the recommendation of ‘the Ad

 

 

 
 

WHD-148

the recommendation.

 

 

 

 

Hoc Committee by approving the funding?
MR. RUBEL: The issue, very succinctly -- given :
the funding level that they have gotten, $2.2 million, may
the RMP embark on this project?
And as I understood the motion that you made, it was

that they may embark on this project within the limit of the

' $2.2 million, only with the specific approval of the Director

|

of the Division of Regional Medical Programs, and that
approval is contingent -~ conditional on acceptance by this |
Council and the (b) agencies in the state of South Carolina. :
MRS. KLEIN: In effect, then, this motion would go

contrary to the recommendation of the Ad Hoc Committee.

VOICES: No. No.
, ,

MRS. KLEIN: I see. In other words, their approval |
was just on the reduced funding, and this motion would

increase the funding?

—

MRS. FLOOD: No, it would leave the funding the

same.

t

MRS. KLEIN: All right; that is the motion then, as

to these specific projects, that the funding be approved
subject to their obtaining the approval and cooperation of
the Governor and the other agencies.

MR. VAN WINKLE: One project. i

 

 

 
 

WHD-149

' the backing of the (b) agencies, the (a) agencies and the

 

 

274
MRS. SILSBEE: One project.
The motion has been made and seconded that the
South Carolina RMP be funded at the level -- at the previously
recommended leve] Council has already acted on of $2,200,000,
but that any funding by the RMP’ of project Number 32-F is

conditoned upon the Region indicating to DRMP that they have

Governor's Council.

Is there any further discussion?

All in favor?

(Chorus of "Aye")

Opposed?

(Chorus of "No")

MRS. SILSBEE: Could we have hands on the "“aye's?"

(Show of hands)

Six "Aye's."

Four "Nay's."

The "Aye's" have it. .

All right; now do you want to call it quits?

MR. CHAMBLISS: ‘May I just say this? I think the
Committee should know that there is one-sixth of its workload
completed.

I don't say that to deter the discussion; - simply

to let you know where you stand in terms of the overall work-~

load that you have accomplished.

 

 
 

WHD-156 275
MRS. SILSBEE: What time do you want to meet

tomorrow? The Staff will be present, because a lot of them
have already gone.

At 8:30? Would you rather start earlier?

All right; 8:00 o'lock it will be.

(Whereupon, at 6:25 P.M. the Council recessed until

8:00 o'clock A.M. June 14, 1974.)