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   arc          1            DEPARTMENT OF HEALTH, EDUCATION, AND -WELFARE


                2                      PUBLIC HEALTH SERVICE


                                   HEALTH RESOURCES ADMINISTRATION


                4
                5@i                  THIRTY-FIRST MEETING OF THE

                         NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS






                                                    Conference Room M
                                                    Parklawn Building
                                                    3600 Fishers Lane
               10                                   Rockville, Maryland

               11                                   Monday, November 26, 1973

               12            The meeting convened at 9:05 o'clock, a.m.,

               13  Dr. Herbert Pahl, Acting Director, Regional Medical Program

               14  Service,, presiding.

                   COUNCIL IEMBERS PRESENT:


                             MRS. AUDREY M. @RS
                             GEORGE E. SCHREINER, M.D.
                7            MR. EDWIN C. HIROTO
                             DR. LAWRENCE FOYE
                             JOHN  P  @RRILL,  M.D.
                             BLAND W. CANNON,  M.D.
                             MRS. IMRTPL S.  MORGAN
                             RUSSE LL B. ROTH,  M.D.
                             BENJAMIN @@T. WATKINS, D.P.M.
                             MR. SEWALL 0. MILLIKEN
                             MR. C. ROBERT OGDEN
               21 I!i


               2@



               24



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                                                                                 2


                                            C 0 N T E N T S

                 2                                                              Page

                 3  Opening   remarks                                              3

                 4  Remrks  by,.Dr. Endicott                                       6

                 5              Dr. Margulies                                    28

                 6               r. van Hoek                                     40

                 I  Report by Dr. Pahl                                           52
                 8,,/Resolution re allocation of additional @S funds             6o

                 9  Resolution re status of RNPS, compliance with review
                      requirements                                               80
               10
                                Motion                                           81
               11               Vote                                             82

               12.  Report by Dr. Sloane                                        101

               13   Status of kidney activities., by Mr. Spear                  114

               14   Setting dates for future Council meetings                   123

               15   Budget presentation by Mr. Gh rdell                         127

                                Motion                                          132
                                Vote                                            132
               17
                    Status of RMP by Mr. Peterson                               134

                    Comments by Dr, Sparkman                                    142
                             ,@,,@",Motion                                      148
               20               Vote                                            148

               21   Comments by Dr. Reinschmidt                                 149
                             "I@,,-@@motion                                     153
               22
                                Vote                                            154
               23


               24


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                                             P R 0 C E'E D I N G S
                                            - -- - - - - - - - - -


                               DR. PAHL: Will the Council come to order
                 2                                                          please.

                 3             (Discussion off the record.)

                 4             DR. PAHL:  Now that we are all settled down,, includ ng

                 51  our own staff, maybe we can open our meeting.

                               Let me first welcome all of you again to a program

                     that is somewhat more viable than when we last met in July.

                 8             As we wrote to you, a very short time ago, a number
                 9   of things have been happening and we have a reasonably heavy

               10    agenda for today.  I will be getting into that in just a

               11    moment.

               121             I do hope we will have representatives from the

                     agency anq Dr. Robert van Hoek is already here.    We expect

               14    Dr. Hat"@rgulies to be coming and talk to us as  Acting

                     Deputy Administrator of the agency, and Dr. Endicott,

                     Administrator of the Health Resources Administration,, also

                     expects to be present this morning.

                               Invitation was extended to Dr. Edwards or his rep-

                     resentative.    Weexpect to have someone representing Dr.       I

                     Edwards here to address us.
               20

                               Before proceeding, I would like to welcome Dr.

                     Lawrence Foye, Assistant Chief Medical Director for Academic
               2@)

                     Affairs, Veterans Administration, sitting in for Dr. Musser,
               2

                     and we would like to note  as you will, that our Council grows'
               24

                     progressively somewhat smaller.


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                                                                             4

                 1             We have excellent attendance this morning and the

                 2   usual long table with the empty chairs  merely  means  replace@n
                 113 have not gotten through the official process, but  I  assure     @5s
                                                                                      1

                 4   you nominations have been made and the  Secretary's  office,

                     presumably before our next meeting, will be able to act on the3e

                     nominations and we will be.able to bring the Council  up  to


                 7   full strength.

                               Dr.Ochsoer is Unable to attend because of a  long-

                     standing commitment and Dr. Merrill will be here a little bit

                 10  later on this morning, will not be able to  be  present  with

                 11  tomorrow.
                 12            In connection with the membership of the Council,

                     I would like to point out Dr. McPhedran resigned this August

                     because of a changing position and now as a result of a, com-
                 14
                     plicated salary arrangement, he is considered to be an employe@
                                                                                      I
                     of the Veterans Administration and as such, he is no longer

                 17  eligible to sit with the Council.    Much to our regret,  vie

                     htLve to accept his resignation.

                                                                                   to
                               In connection with Council matters,  I  would  like

                     point out we are fortunate in  having  the  Council  meeting, if I
                     you will, just a few days before the end of this month, because
                 21
                     when November 30th arrives, we will no longer have  with  us  Dr.'

                     Cannon and Dr. Roth, who have served since 1969 on this Council.
                 2
                               We also have, because of the termination of their
                 24
                     employments, Mr. Milliken and Dr. Watkins.
                 2

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                                                           The latter two are eligible for reappointment  and

                                2'ill   we do hope to be able to call upon their services again;

                                3       whereas, Dr. Cannon and Dr. Roth, having served more than

                                4       their share of time with this Council, are not eligible  for

                                5       reappointment.


                                                           I know that I speak on behalf of Dr. Margulies  and

                                        the many administrators of this agency, the staff of this

                                        program      who      have      worked      with      Dr,      Cannon      and       Dr.       Roth       for       thes

                                        many       years,       our       very       best       wishes       for        their        future        endeavors

                              10        and        to        express        our        appreciation        officially         and         personally         for

                              Ili,      the  fine  work  that  they  have  performed  with  this  Council.

                                                           I     am     sure     that     they     have     seen      the      ups      and      downs      of
                              12

                                        the      programs      many      times      and      they      have      weathered      it,       and       I       am

                              14        sure     that      even      in      the      course      of      this      meeting,      we      will      be      able

                                        to  again  benefit  from  their  advice  and  perspective.

                                                           So       we       appreciate       having       you       here,       Dr.       Roth,        today.

                                           understand       you       can't       be       with       us       tomorrow,.       But,        again,        we

                                        look      forward      to       perhaps       having       your       views       on       the       program       and

                                        assistance,  and  Dr.  Cannono  as  we  go  into  the  future.

                                                           Dr.  Endicott  was  to  havebeen  with  us  first  thing

                                        this       morning,       but       we       will        arrange        our        schedule        to        accommodate
                              21,

                                        his  presentation  sometime  over  the  course  of  the  mornin
                                                                                                                                                   9

                                                           Now  a  few  housekeeping  details  if  I  might.                                     I   utnder@l
                              2"Il

                                        stand  coffee           will  be  brought  in  about  eleven  o'clock.
                              24

                                                           MR.  BAUM:    That  is  f or  lunch.


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                                                                                  6

                                DR. PAHL:  About 10:30?

                  2             l@. BAUIA:  Coffee break in the cafeteria.

                                DR. PAHL: Coffee break in the cafeteria at  10:30.

                  4             Then what we have planned  today  is  to  have  a  luncheor

                  5  brought in to this room.  We hope this meets with your appro@ 3.

                     We would like to have an  opportunity  to  have  the  Council  niem-

                     bers interact with our staff  in  order  that  a  full  expression

                     can occur concerning the developments in the individuals regi ns

                  fj and that you will have an  opportunity  to  find  out  first  hand

                io   what is happening in the regions.

                11              Following that, we will take up the actual review

                12   of applications.

                                Now                                       details   later..
                13i                    can go on with the housekeeping
   0
                JAII I think it is  very important,  since  we  have  Dr.  Endicott  here
                151  as Administrator  of  our  Health  Resources  Administration,  and

                     Dr. MPrgulies in  his  new  capacity  as  Deputy  Administratoro  to

                     '-urn the meeting over to  Dr.  Endicott,to  welcome  you  for  your

                     first meeting with our Council  at  least  here  in  the  Parklawn

                     Building, Ken.  Wewould appreciate anything you have to sa
                                                                                    y -

                                DR. ENDICOTT: Well, I think  perhaps  you  might  like  a i-

                21   brief progress report. would you  not,  on  the  way  things  are  goi pg

                     and what
                              the new agency is all about.
   0
                                As most of you know, on the first of Julyo the Depart-
                2:@

                     ment reorganized the  health  'Lunctions  and  after  some  subsequent
                24

                     changes, ended up with six separate agencies.  Two of them are
                25

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                                                                           7

                    essentially unchanged, IIIH and FDA.  And what had been Health

                    Services and Mental Health Administration finally split into
                 2

                    four separate agencies.  The Center for Disease Control, the

                 41 old CDC in Atlanta, was split off formally.   It always  has

                    operated essentially as an independent  field  station.  And

                    with that as a nucleus, several programs were transferred, in-

                    cl,uding the National Institute for Occupational Safety  and

                    Health, to constitute the agency primarily  responsible  for

                    public healti; preventive medicine and control of the environ-

                 lo,l ment.

                             @lhat had been the National Institute of Mental Health

                    became the Alcoholism, Drug Abuse and Mental Health Administra@
                 12

                    tion.  It is in the process of being organized as three insti-
                 ]@3

                    tutes, one on alcoholism, one on drug abuse, and one on mental
                 14
                  1 health. That is most recent organization, and the final plans
                 l@5

                    for its internal structure have yet to be announced.

                             Those programs which either provided direct services

                    to government beneficiaries, such as the Indian Health Service

                    and large grant programs given for the purpose of providing

                    health service, usually in the form of grants to states such

                  l@ a,s rnaternal and child health., migrant health, and so on, be-
                 21
                  icame the Health Services Administration, which was assigned one@

                  1 new responsibility, that of quality control as a function, back@;_
                 2
                    ing up National Health Insurance, A special bureau was created
                 2
                  @@for this purpose, Bureau of Quality Assurance, within that
                 2 5

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                                                                          8


                I  administration.


                2i           And then finally the Health Resources Administration,

                   whch includes the national Center for Health  @Otatistics,  a
                411 National Center for Health Services Research and  Development,

                   the K,),npower Program which was transferred from NIH, and the

                   Hill-Burton Pro,7ram, CHP and RMP.

                7            One of tne major functions of the new HEA is to
                8@ function as the policy development organization as it  relates
                   to the delivery of personal health services, so in  a  manner

               10  ot speaking, we become sort of a think tank backing up Nationa,

               I I Health Assurance,
               12!1          The reorganization of HRA was envisioned as a two-

                 i stage proposition and we are just moving into the second phase

               14            The reason for approaching it in this fashion was th@t

                   there were a number of programs, such as RMP which  had  been

                   scheduled to be p@iased out by the Administration, but  which

               @!7 Congress had declined to phase out, at least for the time

                   being.  So we felt that we had to maintain sort of  a  flexib
                                                                               le


                   poscure keeping In place the organizations which had been  set
                   up to administer these programs @7iaose fait was somewhat Qncertal In

               2-11until the final decision was made as to whether they were to be

                   continued or not.
               2@,

                             This has turned out to present some management prob-

                   lem5, as you can well Imagine.
               24

                             There was a reduction in force carried out at the end
               25

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                                                                                                                                                     9

                                      of the last fiscal year. Additional reductions in force were

                                 2    envisioned in tkie President Is budget, to have taken place in
                                      September. Another one along about the first of the year.

                                 4                        The reductions in force were at least postponed and

                                      all of us           are uncertain as to just what our year end ceiling on
                                 5

                                    i employment may turn out to be.
                                 6

                                                           I have a rough notion, give or take 300, as to what

                                      it will be. And I am trying to get some firmer notion as ,@lle

                                 @4   go along.

                                    I
                                    I                     This has a noticeable effect on morale and presents
                               10   I
                                      some problems in terms of recruitment, replacement and reloca-

                                      tion.
                               i 2

                                                          One additional complicating factor, from a manage-

                                      ment  standpoint,  was  the  decision  to  decentralize  the  ma.npower
                               14

                               1,5    programs. The manpower programs for which we are responsible

                                      are  operated  under  four  different  pieces  of'  legislation,  and

                                      in  aggregate  amount  to  some  42  district  programs.

                                                         To  decentralize  these  to  10  regional.  offices  creates                                                  1
                                    @lsome  420        decision  points.   And  it  is  a  complicated  proposition

                                      requiring  transfer  of  some  300  people   from Washington  to  10
                               20  i;

                                      regional  offices.    Most  of  them  declined  to  go.    So  we  had                                                  to
                               21

                                    !ter  inate  the  positions  and  simply  transfer  vacancies  and  try

                                    i'to  recruit  in  the  field.
                               2
                                                         @Te  are  still  actively  recruiting  and  carrying
                                                                                                                                                       out
                               2,1
                                    i@orientaluion  programs  for  the  new  recruits.     It  is  too  early  at

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                                                                            10
                 I  this point in time tD tell just how all of this is going to  wor@

                    out.


                              Fortunately the manpower awards are mostly forward

                 4  financed, so that awards made in the fourth quay-ter of  the  fift

                 5i year are actually finance operations In the ,-chools the fol-
                 (;I lowing year, so we won't know how this is going to work really
                    until early next summer.

                              Now, our future is also made somewhat uncertain by

                 @l the fact virtually all of our enabling legislation expires on
                 ioil@ the 30th of J'une and Congress has yet to act on  any  significant

                 11 piece of our legislation e-,,,cept emergency medical services, whi,lh

                 12iI neglected to mention, and I suppose I did because we  have  de-I

                 3  cided that this program really doesn't belong in HRA but bel,on

                 14 in Health Services Administration and have just arranged to

                 1  make that transfer.

                              As you know, Congress has just passed  again  -  and  ths

                    time the President signed -- an ambitious emergency medical
                    services program which is no longer a demonstration  program  but@
                  jlan implementation program, the net effect of
                                                                  which is to  put  in

                  i@ple,ce and have operating appropriate medical services across
                 20

                  ithe country.

                 22           Now, there are two of our programs whose legislation

                  @expires which are relatively noncontroversial.  They are the

                  ,,National Center for Health Statistics and the National Center
                 4

                    for Health Services Research and Development.
                 2')

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                 I            The Administration has nct yet sent up a legislat@,v

                 2  proposal, for either of these, but when it does, I am sure tha

                 3  -it will contain only small technical amndmentsi

                              There is no intention of cutting back either of these

                    prograras. In fact, the expectations are both will be strengthen

                  1 ed and expanded.


                              Now,, the House has already passed, or has  reported

                 P,iout;, it has not yet passed,, a, bill which would consolidate these

                  i two organiztions into one,, and would place some dollar  and

               io@l project ceilings on what could be undertaken in  each  area.

                    The dollar limitation is @,,5 mil.lion and 20 projects.

               1211           We have opposed this limitation and  the  consolida-

                    ti,-on, 9.nd I am hopeful that we will get this straightened out

               14   in the Senate. But the truth of the matter is  that  at  our

                      -be t scale oL' operations, these limitations would not inter-
               15   p@e  n

                    fere with anything that is actually in progress. It simply

                                            ojedt for the coming two years,
                    limits what one might pr

                              Now, then in the manpower area, last January  a  new

                    federal policy was announced.  It is a part of the new fed-

                    eralisiii and proposes for the entire area of higher educatioo,

                    that the federal government get out of the business of supporting
               21

                    institutions and limit its support to student aid  aimed  at
               2

                    making sure that no one is denied a college education  sim  ly
               2:@                                                             p

                    for lack of financial resources.
               24

                              The policy proposes primarily guaranteed loans,

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                                                                           12

                    supplemented where appropriate by direct loans, and even

                2   scholarships.  This to tak@e place:of any support of our sub-

                    sidy through .!.nstitutions of higher learning.

                              The policy provides that in those special circt)m-
                4

                    stances in which market forces would not operate to meet the

                    needs, exceptions would be made.  And at least for the cur-

                    rent fiscal year, the Administration proposed to except from

                    this general policy schools of medicine, osteopathy and den-

                    tistry,. and proposes to continue several forms of institutional

                 i  support, including capitation, grants a,s well as special pro-
               10

                    ject grants for the support on@@' institutional expenses for un-

                    dergra-duate  and professional education.
               12
                              They propos@ld to eliminate from capitation support

                    schools of nursing,  optorietry,, podiatry, pharmacy, and vet-
               14
                    rinary medicine, and proposed to eliminate formula grants to
               15
                    schools of public health and any formal support in the allied

                    health area.

                             @Tow, the legislation-vihich authorized support to

                    public health and allied health expiredcn June 30th, last, and
                    the Adm-Lnistration urged Congress not to extend that legisla-

                    tion.
               21
                             Congress extended it anyway and so now all of the

                    manpower legislation terminates at the same time, 30tll of June
               2
                    next.
               24
                             The Administration is still considering what its
               2 5

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                                                                                13

                     nol icy and strategy should be In the@ area of  health  manpower.

                  2  As a matter of fact, I have a, meeting this afternoon at 5:30

                  "31, to work out the details of the package to fyo  to  the  Secretary
   40             41 for decision,   So that it would be premature  to  report  to  you
                  5  what the Administ-r,ation's policy will be since  the  Department

                     hasn't yet reached a decision and that,  of  course,  is  subject

                     to approval at the @@hite House and OlvM.

                               Ho@iever, I think it is safe to assume that the

                  9  Administration will propose a consolidation of the four separate
                101  pieces of legislation into one, and that with regard to in-

                     stitutional support,, the Administration is not likely to

                12   request institutional support for schools other than medicine,

                     osteopathy, and dentistry, at least in the form of capitation.
                13

                               One assumes that the Adaiinistration will seek a
                14

                15   broad special project authority of discretionary funds with

                     which to influence the schools  to  improve  curriculum,  shorten

                     the durriculuxa, emphasize team training and encourage the

                     enrollment of minorities and, in general, improve the education      I


                     process,

                               I-Tith regard to students  aid,, I think it  is  safe  to
                21)
                   i'assume that scholarships will be deemphasized and that stu
                21

                     dent guaranteed loans will be strengthened.
                22

                               I think it is also predictable that any assistance to

                   i' educational institutions for  Construction or capital improvement
                24

                   @would be heavily oriented -Ln   the direction of the guaranteed


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                 !I' loan perhaps with the interest subsidy.

                 2'i           Some attention could probably  begiven to the shortaEe

                  i  of doctors for E@,overnment agenciesdoctors  and  dentists,  and

                 4   I would anticipate some expansion of  the  kind  of  scholarship
                 5@l program which carries an obligation of equal time in government

                     service in return for scholarship assistance.   But as -.rL say,

                     this is still subject to final decision and it may not come

                 8   out this way.
                 9 @           No@i,, that leaves us with RYIP, CHP, and  Hill-Burton

               io    Hospital Constructioo Program unaccounted for.

                               There   has been a Lot of discussion  in  the  Department

               12    a, s t o h (y@,i these might be consolidated. -And as  Harold  I  am  sur

               1,@   expands  upon  during the day as he has an opportunity to spend

                     more time  with  you, the debates within the Department have

               15    been intense  if  not acrimonious.

                               (Laughter)

                               And this still is  unresolved.  Even  in  the  Departmen

               181   not to say the OPIB, there are two genera,l propositions under

                     c o ns id e,-,-e, t i o n.

                               One ,7ould simply eliminate virtually evexythi.ng e
               20                                                                 xcet

               21    regional health authority, nonprofit, private consortium


               22
                     arrange- nt made up especially of providers.

                               The other would place rather heavy emphasis  on  the
               2;,,f
                     state function, encourage the develop,,aent of state health
               24
                     authorities,, -,iit-h the decision be-ng left to the states
                                                      L


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                                                                            15

                 2  as to @io@,7 they- -would handle their substate or interstate arrani,,,e-

                 13 ments.

                 4            The second would provide, in effect, that RMP's desii,p-r-i

                    by states could in fact be continued tinder q. somewhat different;

                    arrangement, but performing essentially  similar  functions.
                 711          God knows how the argument is going to come out

                    within the Administration, and I would hesitate even more to

                    say hiN it is going to corn out on the Hill.

                              The Administration has been trying for some years
               10

                    to get rid of the Hill-Burton Program  without  success.  My

                    guess is that any program which does not provide in some orderly
               1211

                    fashion for the three different types of agencies, Hill-

                    BQrton, CHP, and IU4P, any proposal which doesn It take into

                    account all three of these things is probably not  going  to

                  i pass on the Hill*

                              MNj assessment of the temper of the times is that the  e
                 711

                    will be some effort to consolidate, but just what form thlj-S


                    will take !.s certainly not clear to me,

                              We have appointed a task force within the agency to

                    assess the current situation and develop our own plans for or-
               21

                    derly transition into some as yet unknown new system.  And I
               2")

                    hope we will be ready to act in a sensible fashion when the
               2

                    time fLnally comes for action.
               24
                              As you are more aware than I, since I was sweating it@
               25

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                     out In the manpower area when you went through your soring
                 21@ crisis, you were scheduled to be liquidated on the 30tla of

                  il June last, and weren't.  Legislatively  you  have  been  extended
                  1
                     to June 30 next.


                               Functionally the money has been  sort  of  doled  out

                     without exactly clear guidelines as to  what  you  are  supposed

                     to do. The only thing that is different  today  is  that  it  is


                     November.


                               I can't tell  you what is going to  happen  to  RMP.  I

                10   can't tell you how much money we are going  to  have  to  spend.

                11             We are in the courts with regard to last year's mone

                12   and preliminary actions would indicate, as has  been  tkB  case


                                                                                   is
                     In all of our other suits, we are probably  going  to  lose  la

                14   one,  But that is by no means certain.

                '15            So we don It know yet licw much money we had last  year

                     to sc@end and we also don't know how much money you are going tp

                     have this year to spend s,,..noe the appropriation has yet to  be

                J8   1acted upon.  As you know,, it passed both Houses.  The Congress

                     finally re-ached an agreement, which under normal eircum tances

                2()  iwould have led to, enactment by both Houses.  But the House

                21'@ recommitted it to the conferees, presumably to negotiate a lower

                     -icure which would be acceotable to the President
                                                                          and
                2@.

                     which would therefore not  be vetoed.

                               That negotiation is now -Ln progress. Of course,  we  are
                24


                                                                                   to
                25   not privy to the transactions.  We are not even certain as

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                       an acceptable compromise figure mi)7-ht be as it relates

                 21'to RMP, or to anything else for that matter.

                                                                                  h
                 3           So that when you act  today, you will be  sharing  wit
                 41'@e the joys of administration in a period of uncertainty.
                 5           This is not the easiest thing in the world, but my
                  '@eeling is that one ought to exercise commonsense, to stick
                  i
                  @pretty much to your previous standards of excellence., to  maice
                  i
                 81the awards with the expectation that they will be awarded for 8.
                  ,,@period of one year from the project period beginning date q,s we
                 loil@ave id the past, and let nature take its course.
                             If it turns out that they have to be terminated sooneri,
                  ioaky.  We will worry about that when the time comes. But from trip
                 12

                  "Standpoint of what is to be done today, I think you have to
                 ,3
   0
                  largely ignore the existing uncertainties.     Otherwise you really
                 14
                  !have no basis to do anything.
                 @l 5

                             I apologize for having to present a  picture  of  this

                   ort to you. It wasn't my idea and I am  having  my  own  troubles

                   ith it but, frankly, I see no other  way  to  proceed  than  the

                 ,Ilone that I have outlined.

                             It is no secret that this 'Ls a difficult time  for  us
                 20
                  li,in many different ways. The most recent thing, of course, is the:!
                 9

                  energy crisis, but it is -ust one more thing in  a  long  list  of
                 22

                  difficult problems at the federal level,
                 2
                               have taken much too much time, perhaps spread an
                 .4
                  i,undue amount of cloorii  Things aren't really quite all that bad.


   HOOVER REPORTING  CO,  INC,
   320 Massachusetts Avenue, N.@--.
         Rr






                               I think my personal assessment is that the reorgani

                    zat@.on  was long since overdu(-,; that in the main, the decisions

                 3.i were good in terms of how to break up the problem into manage-

                 41; abie segments.

                 5!!           I am impressed with the men who tiave been recruited

                 61 to fill the various slots.   They seem to be working together

                    well, as a team. -And I am satisfied that given a little bit

                    more time, perhaps a year, the Department will be stronger in

                    the health area than perhaps it has been in the last ten years

               10              This is on the encouraging side and it is a thing

               11   that persuaded me not to exercise my option to retire, but to

               12   hang in there for a little bit longer.

                               Thank you.

                               (Lg, Lighter)
               14

                               DR. PAHL:  Thank you, Dr. Endicott*

                 I             Iam sure Dr. Endicott would be pleased to stay a

                    few minutes and answer any questions on this or other matters

                    that you have.
               18

                               DR. ENDICOTT:  I got off easier than I expected.

                               DR. PAHL: Perhaps it was not such a gloomy report
               20

                    after   all.
               21

                               Dr.  Schreiner.

                               DR. SCHREINER:  Are you saying people who are writin
               2

                    the legislation 9.re contemplating a kind of optional RMP on a
               '14

                    state level?
               25

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                               Not federal, but one that would be chosen by

                 2   groups of states?

                               DR. ENDICTT:   One of the major proposals would have

                 4   provided support for the kinds of things that are done  by  RTvl?o
                 511 to the states through a state health  authority  which  would  the
                     have both funds and authority to  enter  into  agreements  with

                     appropriate consortia, with  appropriate  consortia  or  things

                  i  equivalent to RMP for implementation of approved plans.

                               DR. SCHREINER: Is  the  thought  there  wouldbe  federal

                10   grant funds to encourage tl-iis?

                               DR. ENDICOTT:  Yes.

                1211           DR. SCHREINER: Or you would then be go-.Ing  only  on


                     state funds'?

                               DR. ENDICOTT:  Yes,  that  proposal  would  provide
                i5iii funds at a fairly generous level  through  the  state  health
                     author-j-t '@T That plan envisioned having within an umbrella.

                     several ca,pabi I-IL ties. One, for planning,  which  would  not

                I,s  have operational responsibilities, would  not  be  responsible  fo

                I,) ii the allocation of sources, federal or state; but would,, in

                20   eL'fect,, be a staff planning organization.

                21             -A second function would clearly  be regulatory;,  it
                                                                                       t
                2'-) is- one which the states have anyway, and this would cover a broad
                2@)  ran.;ze of' things, including licensure and accreditation, whatever

                2,-,,' control there may be over construction -iacil.-Lties and so on,

                     including the control of institutions  of  hi  her  learning.

   HOOVERREPORTI       GCC,INC.
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                                                                                                                                              20

                                                                                                     function,  that  of  allocation
                                                        And  tnen  a  third  Da,'O
                               21      of  resources,                         ly  financial  resources,  both  frorf,  a  feder  I
                                           well  as  a  state  level,   this  ral-L@",ht  well  include  iaoneys  for
                                4      construction,  faoneys  for  health  services  of  one  sort  or  another
                                       and  moneys  for  the  training  of  health  raanpower.                                       That   is  one

                                       concept.
                                                         And  Ri@  would,   in  this  iieii  framework,  where  this                                     -L Lt  ed

                                       in  with  the  de,--:Lres  of  the  constituents,  cont-Ln@,ie  to  function.
                                       But  it  would  no  longer  derive  its  direct  support  from  the
                              10       federal  government,  but  as  instrumentality  of  a  state  or

                                       states.

                              12
                                                         DR.  SCHREINER-.    It  would  be  kind  of  Like  a  sanitary

                                       commission?

                                                         DR.  ENDICOTT:    Sort  of  like  trial  yes.
                                                         DR.  ROTH:    Do  I  understand  that  these                               two  somewhat
                                       opposing         concepts    ,ire  being  currently  debated  within  the  a,gen  y
                                                                                                                        ese  do not. particularly
                                       and  within  the  Administrat.i.on,  and  that  th
                                       ly  relate  to  the  formulations  that  are  now                                  going  on  in  the
                                       Rogers  subcorrLrrtl.ttee?    -Or  do  these  include                             the  Rogers  Sucommitt                   e

                                       concerns?
                              211                         DR.  ENDICOTT:    Well,   they are  taking. place  largely

                                       independently.
                                                          DR.     ROTH:    I  mean,  they  have  announced  they have
                              24       legislative  overview  of  this  thing  and  are  putting  the  three  RIR,
                              25         CHP,  and  Hi.LI-Burton  together.    But  beyond  that,   I  don't  know

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                                                                                                                                                   2 1
                                i-     much  a.'bout  lacx4   they  are  doin,  it.

                                2                          DR.  ENDICOTT:    Well,   there  have  been  no  hearings  vet

                                                           There  is  one  bill,  onlv-  one  that  I  am.  aware  of,,  end,

                                       that  is  the  Roy  bill  which  has  been!-n'u-roduced.

                                                           I  don't  believe  Mr.  Rogers,  or  Staggers,  or

                                (i     Kennedy,       or       Javits,       or       any       of       the       other       major       figures,       have

                                       actually  introduced  bills;  at  least  if  they hoveI  am  not

                                8      aware  of  them.

                                                           There  are  al@iaysp  of  course,   informal  contacts  and

                               10      discussions,,  especially,  at  the  staff  level.                                        Committee  staff

                               11      with  people  on  my  staff,   for  e)@ample..    But  this  is  In  the

                               12 iii  very  early  stages  so  @ar  as  I  am a-ware  on  the  Hill..

                                                           I        think        the        more        intense        discussions        are         probably
      0
                                       occurring           within       the       Department       at       the       present       time,        but        it

                                       is  unresolved  and  there  are  very  strongly  held  views.     I  thi.nk

                                       we:have          a  reasonable  consensus  within  BRA,.which  leans   in  the

                                       direction           of  the  state  health  alithor@fty.                            But          the          Assistant

                                       Secretary           for  Planning  and  his  staff  are  very  high  on  the  region-

                                       al  consortium  probably  and  have  riot  really  spelled  out  in  any

                                       great  deta.'@@.1  what  they would  do  with  Hill-Burton  RMP  and  the

                               21      existing  CHP.

                                                           So    it  is  still  in  the  talk stage.
      0
                                                           DR.    SCHREINER:    What  happens  if  they  don't  get  it  re-,
                               2@l,

                                       solved          by  June  30th?

                                                           (Laughter)
                               25

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                                                                            22


                               DR. ENDICOTT:  Well, I suppose we will have  anotl-ie-@-,

                 2
                     extension.

                 3             Now                                                 n
                                    it is difficult for me to see at this point ,
                 4@  time how anybody can resolve this thing without providing at

                     least one year of continued support in theex@Lsting framework

                     @7h@,.Ie we sort these cats out and come up with something else.

                     So that I would qssume at the ver,;, least we will have a six-


                     month extension of the legislation pretty much as it is

                     while we work out what is going to replace it and take the

               10    steps to effect a transition,

                               With every passing da,y, it would appear more ra,tion

               12    to have a full year of extension rather than six months.

                               DR. SCHREIIER-.  Has this been a recommendation?

                               DR. ENDICOTT: No.  Nothing as firm as that.

                               (Laughter)

                               But, you kna,7, common sense often prevails,after all,


                     at  debate.

                               (Laughter)

                                    MORGAN:  Thank God.


                               DR. ENDICOTT.
                                              So I wouldn't be too surprised if tha

               21    is what happened.

                               l@IREL MORGA N: Dr.,@Endicott, what division do these
   0
               2     PR.S 0s or insurance come under in the organization,, or has


                     this been decided either?
               ')4

                               DR. ENDICOTT:  Yes, it has been decided simultaneously

    OOVER REPORTING (,@0, INC.
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                                                                             23
                 i il in about three different ways.

                 2             (Leughter)

                               One way is that the primary  responsibility  is@  sup-

                 4 l@i posed to be in the Health Services Administration  t,  Bureau  Of

                    Quality Assurance. The second  decision  is  that  it  should  be,

                 (;il the responsibility should be located in the Office of  Assistant

                 7  Secretary for Health.  The third decision is that it    should

                 8  be in the Social Security Administration and Social Reliabilita

                 9  tion Service.

                10             There are several different  committees  on  the  Hill

                    involved,  especially the Senate Finance Committee, and they hav

                1:21sort of bought the concept that it should  be  in  the  Office  of

                    the Assistant Secretary for Health.

                               Now, at the moment,  the  Deputy  Assistant  Secretary
                l@4

                    for Health, Dr. Henry Simmons, has among his other duties

                    responsibility for PSRO.

                               We are building, developing within H@'-A  staff,  there

                   iare staff  also in SSA and SR,9


                               There is continuing  effort on Dr. Edwards'  part.  tu

                    consolidate and coordinate these things.    -And I suppose  it  is
                20

                    coming along about as well as anyone could expect with the
                2-1,

                    jurisdictional problem that are built into it     as a result   of
                2@'

                   l@ assi,,znraent of health insurance to the moneys committed  in  the
                2'

                    House and Senate rather than to the Health Committep-
                24

                               It is interestin  that so far as we can tell, in thisi
                                               9


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   320 Massachusetts Aveiiue, N.E.
   Washinzton D.C. 20002






                                                                                    24

                   I  Ion[,, battle, the Health Committee  in  the  !louse  seei@o  to  be

                   2  winning Dut -since ostensibly it will  have  the  pri.raary  x,espons-,L

                      bility for legislation on national health       insurance.    But the. t

                   4  battle  has  not  yet  been  completely  resolved  even  in  the  House,

                   ,5 and I don't think it 'is fairly joitied in the Senate yet.

                                 Now, I-IRA has managed up  to  now  at  least  to  stay  out

                      of the regulatory aspects of PSR,O and to concern itself in -i

                   8  more, I hope., detached and objective fashion with how do you

                      really go about assessing quality; what techniques,dev@ices,

                   io end so on, should one use; what data, what sets of data need to

                      be collected  in  what  fashion  in  order  to  permit  PSRO's  to  make

                   12j, an objective evaluation of the quality of services?

                                 1,Te are continuing to work in that ,irea and to oro-

                   1411 vide quite a, lot  of  technical  backup  to  HqA  as  they  try  to

                   115 @et their program off the ground.

                   -1            There  is  a  certain  nightmare  quality,   though,   about

                      all of this, especially as it relates to data.         I can  envis@l-oi

                      really  tremendous  data  collection  activity   with   archives   after

                      a,rchives being @Loi-lled a-nd memory  bank  after  memory  bank  being

                                                                                         s
                    11 stuffed with data on every hosp-I tal administration and d

                      charge, oatient contact, and so on, with even these modern

                      mechanical brains blanking out under this        just     staggering

                      weight of -Lt.

                                 T@ hope  this  won't  come  true.  But  it  could  get  away
                   24

                    i from us .


   HOOVER REPORTING CO, lt@C@
   '1120 Mamch setts Aveiitie, N.,@.





                                                                                                                                                                        25

                                                                    DR. PAHL:  Are there any other questions?

                                                                    Well, thank you very much, Dr. Endicott.                                                       I particu-
                                         2

                                              larly appreciate having our own staff here to hear som of the

                                         41   comments,   so  the  goverti.raent's   position  is   clarified   on  RMP

                                         5 li and  CHP.

                                                                    I  would   like   to  emphasize   that   from  the   point   of  vie,4

                                              of trying             to  manage   the  program  in  this   environment,   it                                                has
                                         s@,  been  difficult,  but  we  have  been  receiving  very  excellent  slip-
                                         ii
                                         f)li port  of  everyone  within  the  agency.

                                    10                              From  -my  own   point  of  view,   this   has  been   invaluable

                                    11        over  the  preceding  months.

                                    12                              I  think  that  we  would   like,   if  we  may,   to  have  a

                                              report  from  Dr.  Margulies     who,  as   you  [<:now,   Las  been s ervi.ng

                                    14.       as   the  Acting  Deputy  Admin-!Lst-y@ator,   therefore  working  extremely

                                              closely  with  Dr.  Endicott.
                                    15

                                                                    Be-lore,  Harold,                  having  your  comments,   in  order  to

                                              put   them  -'ust   Into  a   little   perspective,   I  would   like   to  re-
                                    'i   7                        Li

                                          fresh  your               memory  o-L'  two  points  which  I  think  we  wrote   to  you,,

                                    l'i)ltl   one   of  which  was  discussed  at   our  July  meeting.     This   has   to

                                              do  with  the   priority  oroption  areas   that  @,iodiscussed   in  July,
                                    2

                                         it   and   the  second   point  has   to  do  with  what   the  Der)artment  has   ccio-
                                    2'i

                                              sen   to  place  a   restriction  on   local  R@IP's   in  terms   of   their

                                              expenditures.
                                    2

                                                                    First,                   respect  to  the   priority  or  option  areas,
                                    24

                                              you  will  recal I  that   in  July,  there  was  much  interest  on  the

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                                                                                26

                     part of the Department to have, some information from R.@IPS

                         -o      -areas expenditures would be ciiqde by@ RIvIP@,,
                  2  as 'u


                  :3 fiscal 174 funds.  And as a result of' ,nuch internal    d ia, log ue


                  4
                     to the Department, a set of priority suggestions was made

                     which over the months became rather than suggestions, rest
                                                                                    r,.L  c


                     tions. And these live  priority  areas  were  ones  that  we  dis-

                  7  cussed with you in July and  also  I  believe  listed  them  in  the

                  6' materials  which went out to @rou immediately prior to


                  9  this Council meeting.

                10              This has turned out to be quite a restriction on RMP!3,

                11   particularly as more  funds  become  available,  and  the  program

                12.  has become extended and staffs  have  had  to  be  recru"tdd  agqi

                     at the local level.  And R.IIPS has been very busy in recent

                   1 month- making formal appeals within the Department to have

                15   some decision relative to both these priority areas as well as

                     to broadening the pro@ram  to  include  all  of  those  activities

                     in ?.ddition to the priority  areas  that  RMP's  -formerly  engaged

                     in.  And I expect Dr. IlarE-ulies will be addressing this point,

                     because it is one of major 'lritei@est to thi-s Council,  ,ind  par-

                20   t@cularly with respect to the action to be taken by this  C  c)  Lin

                21   cil at this riieeting.
                2;@             The second,point which, Harold, I hope you will

                                                                             to do I.,, i t h
                  ii amplify upon nnd which Dr. Endicott touched on has      u

                     the time or the lifetime o-l' Local IU4P's.   Since we  last  met,
                24

                     the Department has formally indicated to us at the      program

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   Washinyton D.C, 20002





                                                                           27

                    Le-,ie.L that not only woul.d RTvi?S terminate June 30th, bLAt t 1-i,-q
                                                                                t


                211 expenditures by local. RMP's could not be continued beyond

                             ng  JtAtie  30tii. And 9.s you will ,ippreciate, this
                13  this cora",-

                4   also placed a severe restriction upon the prorpra.nL
                511           In addition to being contrary to Government tradition

                G   whereby although a program is being terminated, grantees are

                    permitted to expend funds awarded prior to that date for a

                    period up to 12 months, in this case the Department has chosen

                    to place a restriction of June 30th.  Again, over intervening

               10   weeks and months, we have been formally appealing this dec!Lsioi

                    to the Department and I was most pleased to hear Dr. Endicott

                    indicate this morning to you what the perspective is relative
               12

                    to this riiatter.

                              I would hope, Harold, you might be able to amplify

                    a bit upon      on the basis of recent understandings which

                    have been arrived at within the Department,  Because both of

                    these are very severe restrictions on the program and certain-
               18   ly would compromise both what the R.MP's can do between now andi
                    June 30th as well as what they would be able to accomp
                                                                           Lish


                    in ter@ oi. evolving into those kinds of organizations which
               20

                    would be necessary under either of these proposals that are
               21

                    being discussed within the Departi-,ient.

                             So with that as an introduction and hopefully not
               2:@

                    restricting you to those two points, I would like to have

                    you address the Council 9,nd have as niuch time as you care to
               25

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                                                                              2

                     present matters from your point of view as we II as to   have
                                                                                   an),
                 2   0,Liest-lons and discussion by the Council.

                               Harold.

                               DR. 14ARGULIFS:  Thank you.

                               I explained to Dr. Pahl not long ago,iihen I was

                     Director of RI,4PS, we didn't have these kinds of probleiwo

                 7   I don't know what happened after I left      but it is very COM-

                 8   placated.

                 9             (laughter)

                10             DR. PAHL,.  Come back  Dr. Margulies.

                               DR. 14ARGUL17S:  I will address those issues specifi-
                1 2, cally Dr, Pahl raises.   I am not going to make a long statemen@

                     to you, because I think Dr. Endicott covered the missues of

                     primary concern very fully.    However, T would like to
                @i4

                     come back- a little to the question of what kind of legisla-
                15

                     tive proposals are under consideration, because I think, they

                     require a certain kind of amplification.

                               Fortunately, or unfortunately,  depending upon your

                     i-vew, end from my point of view it is fortunately, one cannot

                     prudently discuss new legislation for RI,4P in a combination

                     with other programs without also having  clearly  in  mind the
                21

                     implications of National Health Insurance and any of the
                2
                  i',associated regulatory postures                           dopt and'
                                                     which  government  must  a
                2;@

                     procedures wh@Lci-i it must develop. And I will jLJSt- touch on
                24
                  11 those in passing and respond to what extent I can.
                2,')

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                                                                              29

                                I think you may all remember that I  tried  to  follow
                 2   the general practice of telling you what I knew and telling y@u

                     when I didn't know something, so that I didn't have  to  stra.1-n

                 4   MY memory to remember what it was I said when 't.t  was some-

                 5   thinrr  cooked up at the moment.
                         CD


                                So let's talk f,,.rst of all about the issue of


                 'T  the term',-nation of the pro@-,;rara.  Well,, first of all -- small

                     glossary, it used to be we operated on  the  basis  of  decisions

                 9   and those were replaced by agreements. Now  what  I  will  report

                10   to you %fill be understandings.

                11              (Laughter)

                ]@2             So at least we have some understandings there are

                     no decisions.

                14              (Laughter)

                                The June 30'uh date was adopted because there  was  to
                15

                     be termination of legislation and there was to be no new logis-

                     lat-L.on sought and no new appropriations sought  and  presumably

                     passed,

                                Thati,7hen referred to other similar situations


                     becomes a little difficult to defend, because the same situation
                2(@)

                     is true of programs across the board.
                21

                                As a consequence,, there was a formal request  to  re-
                2:)

                     consider.  and replace that Jure 30tt-i date with something which
                2@

                     riiade a little bit better sense  particularly as time passed and
                24

                     it became apparent that any increased grant  award  of  the  kind
                2')

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   Vlashington, 20002-





                                                                                  30
                       that you will be considering  in  this  session  @iould  be designer
                  2    in such a way that     viould not be ava@@-lable  to  RMP's prior

                       to the be,@,!.nn@l-n,7 of the next calendar year under any
                  4[i  circtrastance.  And if they were then to close shop by June 30@h,
                       it i@iiade it a little difficult to defend.

                                 This request for a, change culminated in a meeting

                       i-n which I represented Dr. Endicott and H.R.A. with Under

                  8    Secretary Carlucci and others.

                  9              I think Dr. Endicott may have  been  referring  to  tha

                 10    and ray presence there when the word acrimonious entered his

                 ii    presentation.

                 121              (Laughter)

                                 We had a fresh understanding as a, consequence of'
                 141   that discussion, and it really evolved around tvio issues.        On

                 15    of them was the June 30tia date and the other  was  the  question

                 If;   of the option which had been selected.

                                 I left that iaeetin@ with the understanding, as did
                 18@l  the others who attended, that the June 30th date was not a i,7i@e

                 1!)   one that there should be an e,,,,tension which 'is appropriate to

                 20    the heeds and to effective Management  and  to  good  use  of fed-!,

                 21    eral funds.   That is how I left the  meetino.,,  That  is the

                 2;-j  understanding Dr Endicott and I  have  and  that  is  why  he   said
                 2@'   uo you that we would act on the ass.wnption that a grant ?,wg.rdi

                       @s as us ug, Ifor a per-@od of one year.
                 ,@4
                                 Now, that is not different front the understanding that
                 25

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   320 Massachusetts Avef)ue, N.,.





                                                                                                                                                            31


                                         we reached with the Under Secretary.                                             I am told  by  telephone

                                   2 'I  which 'is a, level- of cor@LrriLinication @4h,LcLi any glossary cotltl.dn't

                                   3 1 @@ cover at the present tirfie because it isn't even seeinc,, some-
                                   411   body directly, that this particular decision may run into

                                   5     some problem with 'U'lie OMB.

                                   6                          I can't reo@ct to that fact.                                    I can ree.ct to a@

                                         Deper'@-1:11e@ital position, a @)osit-,Lon in HRA a,fid basis upon @@il-iicl,i

                                         you can make your ki.nd.c; of decisions, which is that we are

                                   9     talking about a grant 9,iiard which would be available  for  use

                                   10    by the RIT Is to cover a period of one year.
                                   -1,

                                                              Now, what are the understandings iiithi[i th,),t?  Well,

                                           ne of them that I think is perfectly fair and I will get back
                                   12    0

                                         to  that  for  a  second,   not  Inch  longer,   is   that  this  may  be

                                   14    altered        by        the        passage        of         new         legislation,         whatever         that         new

                                   15    legislation  may  be.  For  example,   if  there  is  a  new  combination

                                         of        the        three        programs        under         discussion         today,         this         raay         influ-

                                         erice      the      use      of      grant      awards      for      R14P's      ,i,@id      maybe       q,       reason       for
                                   -i7i

                                         redesigning  o'l'  activities  somet-,i-,,n.e  during  the  course  of  the

                                         ne,lt   14  months*
                                   J!)
                                   @,o                        There         also         is         the         possibility         that         the          legislation

                                         would       be        rewritten        in        a        different        fashion        or        that        new        approp-
                                   21
                                         nations  would  occur,  or  new  olirposes  for  appropriations  would"
                                   2
                                         be  assigned  by  Congress.    All                              of  these  would,  of  course,
                                   2@)

                                         affect  the  subsequent  use  of  grant-  awards.
                                   24
                                                              But        ti       the        absence        ot@        @nything        definitive,        what        ,ie
                                   25

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                                                                                  @2

                      will have to say Ls that what was pu'@ out by liRA over

                  2   Dr. Pahl's site                                                   s
                                      nature as areas of pcininry interest for    RMPI

                  311 remain areas   certainly of high priority insofar 9,s HRA is

                  4   concerne4 insofar as the Departi-@tent 1
                                                              -s concerned.    They  shoul

                                                               -ve areas o@ grant award.
                      @iov7ever,, not be looked upon as exclusi.

                      Those options are probably best described -- and this is a,

                  7   fresher understanding that you  vyill  have  to  live  with  it  --
                      these options should be understood as areas of continuing hi,--"@

                      priority in the view of the Department  and  in  the  view  of  I-IRA

                                 No@7,, the reasons for those are I think readily appar-

                  L   ent if you cons.',-der some of  the  potentialities  for  new  legis-

                      lati-on end soiqe
                 12                     of the on-gol-ng issues of  concern  in  the  De-
                      partment and throughout the country.  The qQestion of PSRO has'

                 14   already been raised.    PSRO would need to have variety of'

                 1;)1 kinds of support mechanisms and H.L@ in its various kinds        of

                      progrqm@-c elements  will  have  some  concern  for  a  very  close

                      i,7orking relationship between us and H@o-P) and  specifically  the

                   11 Bureau of QualLty Assurance ,ts Dr. Endicott has indicated.

                                 There also  is  the  major  new  and  extremely  important

                 ,@o  program  under  299I  of  the  Social  Security  amendmentst'at  is

                 21   the amendments to Social Security  which  inalce  end-stage  [,cidney

                      disease a defined disability ,),(id provides for payment for rena

                      d ia ly--- is and transplants,

                                 That program  is @@Lmporta,rit not only because it  pro-
                 24i

                      vides  services of a critical kind for people who have
                 25

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                                                                               33
                     end-@stage ki.dney disease, but because it represents the    first I

                 2   great opportunity, we have had to develop a systeraetized,

                 31  regionalized program which has the f'ull backing an  cooperati-o

                 41  of the scientific nongovernmental community, in cooperation

                     with federal and local system---.  It is, therefore, of  cons'!-d-

                     erp,.bl.e interest. Consequently-, it should be of interest to th@

                     R14PS and other programs at I-IRA.

                                Beyond that, -if there is to be indeed some combinnti- n

                     of R14P and CHP specifically along with Hill-Burton, 'it means

                10   two things which have to be looked at seriously and continu-

                11   ou@ly.

                121             @i'hen Dr. Endicott indicated some  differences  within

                     the Department, he was describing q.  situation  which  Is  reach-

                     i.ng resolution and probably will be resolved  in  the  neyt  week

                     or two.

                                One of the things which is of pertinent interest

                     now is that there are some points of complete agreement

                1811 Which I think would be all through the Department and would

                      nclude O.,MB, and that is that there is a growing state re-

                20   sponsibility for certa-Ln regulatory activities.     One of  these

                2-1  has to do with another kind   of amendment -I,ri Social Security
                2    regulations which requires a plan for  control  of'  new  hospital
                2!   construction, i,7hich 'Ls linked in with reimbursement under

                @)4  'Social Security amendments.

                                This becomes a, very important mechanism which will
                25

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                                                                                           34

                         be  supplemented  by   plans   'or   certificate   of   need   legislation

                         in the states and it becomes necessary if one is to control
                    2
                    '3   hospital construction in a 1091-cc9.1 fashion to have some

                    4i   basis for doing it.      There will be increased concern as

                         there is a plan    Lor  the  extension   of   hospital   beds   or   construc

                         tion of new hospitals for evidence that there -i.s a service
                    6

                         requireraent arid that there is manpower available to be linked


                         Ln with those hospitals.

                                    There also @,7@Lll be along with that a continuing

                    jo   requirerpent for rate regulation.  And there will be a continuing

                         requireme-ti-u u@ er the Cost of Living Council for the kinds

                         of controls  which  have   recently   been   announced   and   which   are
                    12

                         obviously of p--ofound interest to hospital administratorsv

                         add others concerned           health care delivery.

                                    Beyond that comes T@letional I-lealth Assurance and

                         with  the  combinations  of   national   Health   Assurance,   control   ofll

                         hospital  construction,  control  of'   all   physical,,construc,,t@,!.on,  i

                     ii ti and with the Cost of Livi-ng Council concerned with the gen-

                         eral probleras of inflation, there will be most          certainly     soberl

                         consideration of a mechanism for dealer ng with         rate and   fee con-

                         trol in th-I.s country.     It will be i,lmost certain.    ly agreed'  tlaat,
                    2',

                         rnis :Ls primarily a state function and that there needs to be

                         strengthened  state  systems,   state   competencies,   to   deal   1,7ith

                         those questions.
                    24
                                    As a consequence, when we look at RIvIP's as one of
                    25

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                                                                              35


                 I   the, p                                                        an
                          artners, potential partners, in 9. state structure or

                 2   intrastate structure dealing with planning, allocation of'     re-I

                 3 i sources, and with regulation in  some  manner,  the  options  which

                 4 11 were described in the process of developing rac-iterial  for  this

                 5   Particular raeetLnC@ becorae at least issues of  high  priority.

                               Now, I am sure I are not telling  any  of  you  anything

                     that you are not aware of, at least in  some  c@'eneral  way.  But

                     I think the specifics as they become clearer have, if' not an

                 f)  aura -- feeling of inevitability about them, at  least  a  feel.iii

                10   of plalisability in teriTis of Department  having  some  general

                11   agreement within itself and  with  this  being  fairly  consistent

                12   N,7ith what is being Linder consideration in Congress.

                               Dr. Roth asked about  whether  we  are  describing  in

                14   the combination of three, perhaps,in one     ler-is I,ation,wllich

                     is consistent with that which is  being  developed  by  the  Rogers


                     committee.


                  t
                               I think in addition to the  answer  which  Dr.  Endicot'i
                1-8 i'l gave that committee is havi.ng its own dii@ficLilty drawing up th@

                     legislation frora my understanding and so  they  have  about  reach
                     ed the point of @,@mpasse that we have.  And that is the questi-ok

                     which was debated dur,!-rk@the last 2-1@2 years here in government,
                2
                  t
                2;)  never    very well  resolved,ttie  effective  relationship  between

                     the  lann-,,nr-- ftAnct:',-on and an implementing function, and a,
                2;       p

                                                                                -inds
                     direct prograrq plann.Lng.fiincti-oll. @Tliese are different L
                24

                     oL' modal'L.,'U@i.es and when i,7ise people begin to look at o. pl,,inninr-
                2

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                                                                              @6
                     u r) c t.Lon aid realize we have and wish to continue with t, priva.@e

                    deliverer system, how you work out an  effective  planning  -Luncti n
                 2

                 3  and then carry it frorq there to a  voluntary  --  ml@ed  voluntary

                    state and local system 'Lc one that  always  causes  people  to
                 4

                    pause a, lon@, time and he,%@e L' @@Lrial problems ri coming up with

                    spec@f'ic legislative specifications.

                                                  here they stand and I suspect it
                               That @,Ls,, I thinlc,@it


                    where we stand also.


                                 i,ioLAI.d lik,@ to say just ori@,, other @iiirir,. I n  t't.Le

                                 that I have had in the Departraent,@,heii there has been
                10

                    an ,,.ncree,sed attention in the Department and in 01,4B @iltli what

                    they call consortium  activities,  it  very  frequently  represents

                    some of the best elements of ri-l@T, our version of an area  heo.It

                14  education center, regional systems for kidney dialysis

                    and transplant.   Our methods of getting people to act     together
                15

                    to improve the effective use of what is there, rather     b !,ia n

                    addi.nr@ unconscionably end continuously to it.

                              But I often have the  feeling  when  the  people  who

                    are proposing consortium activities  avidly  discover  that  it  is

                    a little like      experience I had when I was a youngster in
                20
                    South Dakota and used to work occasionally out at Mount RusL=oi@e
                21
                    during the sunil@ier end there would be people from the hinter-
                2
                    lends who T,.7ould come out !).nd look at those faces of Washing o

                    Lincoln, Jefferson, and Teddy Roosevelt, and say, "Hol,7    car
                24
                                                                      S?tl
                    di0i     have to dig before they -LoLind  tried f<nce
                25

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                                                                              37

                                (T-,aushter)'

                 2             Well, sometimes when I listen to the discussions

                 ,"3                                             that they think
                     in the Department, I get the sariie -Loeel-'Lrg

                 4
                     that all of that Has out there to be discovered       you would

                     somehow go out cind discover it and make use of 'Lt.

                               And back of it lies a tremendously well organized,,

                     thoughtful shrewd exercise which made consortia of people

                     acting together .9, reality and that reality,so far as I am

                     concerned,, continues to deoend upon some  kind  of  systematic

                 jo  approach       -makes it exist and function and prosper.

                 11  And that is just being discovered I am             rather late.

                 121           But ho@i the legislation @il.11 finally come out  and

                     i@i lia t the f I na I e f @L e c t of it will be, as Dr. Endicott has -Lndi-


                 14  cated, is still uncertain.

                 1,            I think I have answered most  of  the  questions  you


                     are concerned        Herb.

                               DR. P-AHL,: Tkiank you very rauc@i.

                               Ai@e there questions?

                               DR. ROTH:   Harold makes  an  interesting  projection
                     I or national Health Assurance and to me this i-s an extraordi-nal-ii

                     vague terra covering everythinL, from what  the  Administration   i
                 21

                  l@ has proposed, might propose,  on through to the Dellurfis bill.

                               Iraqi, what do you mean when You say that it has got t6

                     be ti.ed i-n    Nat'lonal Health Assurance and what sort of
                 24

                  i@ a  t@lirae  frame  are  you  talking  about,  Senator'Long's  this  session
                 25

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                                                                                      38

                       of Congress, oi, Russ Roth's ten years hence?

                                      -!*RGULIES:
                                  DR.                let rae f,ive you  two  answers  to  that,
                   2

                       Russ


                                  Clearly nobody, knows when and if there will be

                       14,,ritione-1 Health AssurD,nce, what form it will be in.    No doubt
                   5

                       about that.


                                  Everyone now has his own view of it and I woqldn It be-


                       gin to rpuess at what the time will be for it to pass. I can It

                       engine it happening very soon.

                                  The impressive point     to irie,, though, in trying  to  get
                  10

                       this in terms of program rev-Lew and act@i on -.i.s that we are qu-i

                     il well committed .1-n the development of for,@@iard plans and in the
                  12
                     il creation of budgets based on those forward plans in the Depart@

                       ment to L@llie concept o,l"' National Health Assurance coming at

                       soraetime.  So what occurs as a consequence is not so much
                  15i
                       what 'Lt will be and when a.s the very powerful effect that        4L t

                       has on our thinking., le Lslat.-I-vely and progr,,-i,nunatically.
                                  1,Te do operate. in those kinds of terms,  -And if it -@Lsi

                       true that  there i,7111 be some ic.'Lnd of lia,tLo@ial Health  Assurance


                       it  will  be most Injudicious for us to do anything other than
                  2'
                       for us to  prepare for it.
                  2 -i
                                  On the other hand     if it isn't go-.Lng to 1-iappen @t all

                       it       have been injudicious for us to strain too much in that

                       direction.   It is not an easy one,
                  24
                                  @fe also, as you recall,    prepared a-vidly .'L'or  sometime
                  2,5

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                                                                             39

                    for HiiO's which were about to pass next week.

                2              (LaL,,gl-iter)

                3              DE. R OTH: Little tiny lilviOls,


                4


                               DR. PAHL:  Are there other ooints to be discussed?

                               Well., thank you very much, Harold.  I  appreciate  the

                    c o-rarrie n L@'s


                               DR. @IARGULTFS:  You are welcome.

                               DR. PAHL: Befox-e we go on, I think I  would  like  to

               lo   merely state we do have several members  of  the  public  sitting

                    1-n today.  I don't knoqhoi.7 many are present but we do  iqelcom
                                                                                    e

                          I would like to identify th
                    you.                               ree I recognize.

                               Dr. Sparkman, who is our Director  of  the  Washington-

                    A las ke. RI,4P, and Chairman of the National Steering Committee
               14

                    of RL,,IP Coordinators  and  Dr. Reinschmidt, Director of the

                    Oregon Ri@, and Dr.  R@ikli with the Missouri RMP, they  are  mem-

               17   bers of our Ste.ering Committee and are attending here, and

                    pass on the comments directly, of course,  of  Dr.  Endicott  and

                    others,,  and I am sure will have something to say at the

                    appropriate point in our agenda prior to the executive ses-
               20i


                    Sion.
               2 1

                               Even though we have an energy crisis, I  think  we  do
               2

                    have to refuel, so perhaps it, might be well if we have a 20-

                    minute coffee break,
               24

                               I would appreciate if we could return at about  that
               25

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                                                                               40

                 'I  time,, because we have a number ol' things to do.   And before

                 2   doing that, also I would j,L@ce to welcome Dr. tAerriLl to the

                 31  Co nc@@@-1. I am sure we are all pleased  to  have  him  presen

                 4              So perhaps if we could take no  more  than  20  minutes

                 5   and reconvene in here,, we can then  proceed  with  Dr.  van  Hoek's

                 6   presentation.

                                (@Thereupon, a, short recess was taken.)

                                DR. PAHL:  May we reconvene the Council,, please.

                                We would like to turn to Dr.  van  lioetcls  presentation
                io,l f or a, f ei@7 minutes dealing with some of the reorganization
                fill matters and those activities i-n which  he  has  been  engaged

                -@2  relative to our program.

                                You will remember that Dr.  van  Hoek  has  been  serving

                     as and continup-s to serve as the -Acting Chief of  the  Bureau  oil

                     Health Services Research, The reorganization plan is still

                     under consideration by the Depzrtraent but it has taken its

                     major form now and we in PYIPS are one  of  the  major  components

                     w@L@-,hln this Bt@reau.


                                Dr. van Hoek.

                2011            DR. VAN HOEK:  Thanks   Herb.

                                Much of what I anticipated discussing was covered       i
                2

                2    by either  Dr. Endicott or Dr. Margulies,, but I would  just  litce:

                     to, in general, review with you  some  of  the  BQreau  activities
                2

                     @ihi-cli relate to Health Serv-@ces Research and  Development,
                24

                                In the reorganization of the Bureau,,  which  is  still
                2

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                                                                                   4 1

                  I    pending, the phase  I  oortion  of  it  included  in  addition to talk
                                                 th Services, research and development,
                  211  National Center for Heal

                  3
                       the regional medical programs, the emergency medical services

                  4    demonstration  activities,  and  the  long-term  care   improvement

                  @5   program,  nursing  home  improvement  program  activities   were

                   i   transferred to the  Center.  These  were  primarily  in  the  areas

                       of  training  of  professional  individuals  and  nursing   home

                       activities and  long-term  care  programs,  and  some  other  demon-I

                       stration activities.

                 10               In phase II, with  the  passage  of  the  emergency  medi( -al
                       services legislation,  that  program  is  being  transferred  to  the

                       Health Services Administration.     But the remainder  of  the  pro.,
                 'i2
                       grams and activities will  be  part  of  the  Bureau  of  Health

                       Services research.
                 14
                                  The major portion  of  the  activities  of  the  Bureau,

                       aside from RMP, rests under the section 304 authority of the
                 '7    P ub@ 1,.'Lc Health Services Act; namely, Health Services  Re 'i earch

                       and Development.
                                  As Dr. Endicott  indicated,  this  legislation  recei-\7e@

                       a oiie-yeareytension and  exp4-res  this  coming  June  along w.@ uh
                 20
                   i   trie authority for  the  National  Center  for  Health  Statistics.
                 21
                                  In the Congress at the present time, in the House

                       Subcommittee, there is  a  bill  pending  which  calls  for  the    i

                       extension  of  those  authorities,  but  with  significant  changes
                 24
                       in  the  program,     It  calls  for  the  combining  of  the  Nat!-onal


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                                                                                                                         42

                           I  Center  for Health Statistics  and  the  Health Services  Researc
                           2   and  Development  activities  into a single  National  Center for

                           3   Health Services  and  Statistics,  and  there are a  number  of other

                           4   Major  provisions.

                           5                   For those.of you who are  interested,  the bill  is

                           6 H.Ri 11385.

                           7                   There  is  no  comparable bill at  the  present  time  in

                           8   the  Senate.   There  is  another bill  in  the Senate which was
                           9   passed,  so-called Bell bill,  which called  for  the  establishment

                          10   of a  National  Institute  of Health Care Deliveries.
                          11                   What  the  resolution  of  the  conflicting  legislative

                          1211 proposals       will     be  is  uncertain.
                          13                   In     the     spring     the      Administration      did      submit      a      legis-
                          14   lative        proposal         which would  extend  the  National Center for
                               Health Statistics  and,the  National Center  for Health Services
                          15
                               R&D  legislation  for an@,indefinite                     period and  with  no specific
                               authoriziog  --  no specific,@@dollar,authorizations.    In  other
                          f7
                               words,  in essence,  an  open ended                     legislative authority with                   the

                               funding  to be         based     on   appropriations.
                          19
                          20                   There         were no hearings         held  on  that legislation at  th@
                               time    and    we     did     have hearings  in        the  .3pring  on  the  recodificati  n
                          2 1
                          22   lof     the     Public      Health Service Act,          which      was      HR-7274,      a      portion
                               of     which      then      became the    new       legislation       for        health        statistics
                          2 '3
                               land  health services@R&D.
                          24   1
                                                I    will     for the    moment  not  include RMP               in    some    of     the
                          25
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                                                                         43

                    information I am giving you.  At the moment the Bureauls budg(@t,
                2   excluding @ would be approximately $60 million, of which a
                    little over $15 million was in the President's budget identi-
                3@l
                4   fied for emergency medical services activity. So the  basic
                5   budget for health services research is approximately $45 mil-
                6   lion, and of that amount approximately $38 to $39 million is

                -   avai lable for grants and contracts to conduct research and

                    development.
                8
                              With the reorganization,, we realigned some of  the
                9
               10   primary activities which had been up to now  centralized  al-
                    most solely in health services research and development,
               12             One is that the Center had begun research and devel..
                    opment effort in developing improved health data@@systems  of
               131
                    a national scope.  The responsibility for this R&D effort vil"
               14
                    now rest primarily with the National Center for Health  Sta,-
               15
                    tistics, which had been collaborating in the  development  of

                    that program.
               i7
                              Another area of health services research is in the

                    manpower field,, which is felt to be more appropriately  con-

                 1  ducted in the Bureau of Health Research Development, which
               20
                    includes the former Bureau of Health  Manpower,  particularly
               21
                    the areas oi' research which deal with manpower utilization
               2 --@)
                    and professional education.

                              The health services research activities of this
               24
                    Bureau have been outlined or categorized into three major
               2,5
                    priority areas.  We have developed a program statement which
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                                                                          414

                   we can make available to the Council members which go into

                 2 great detail on the research questions that we feel need to be

                  ,addressed from the standpoint of national need, not J.ust from
                 3

                 4 the standpoint of the Bureauls program activities.   And this

                 5 program statement has been disseminated to all the major institia-

                 6 tions and investigators in the country to stimulate ideas for

                 - research in the field of health services delivery.  But the

                 8 six major categories are, one, studies dealing with the  planning
                 9 licensure and, regulation with particular emphasis on studies  on

                   the, impact of certificate of need legislation, and studies to
               10

                   improve planning techniques which would lead to strengthening  of
               11

                   the capability of comprehensive health planning or whatever
               12,
                   planning mechanisms develop in future years.
               13
                            A second, area is in quality of medical care  or  health
               14
                   care  and here, as Dr. Endicott indicated, major effort is in
               15
                   developing better methods for assessing the quality of medical

                   care and for developing methods for disseminattng,those findings.
               17
                            But in addition, very practical considerations are in-

                   volved in dealing with the implementation of PSRO'S, implemen-
                  Itation of the kidney disease provisions under'.-,the Social Securi
               20
                  lamendmentsoand also implementation of the HMO  legislation  shoul
               21
                  !that pass.
               22
                            One of the major difficulties currently with  the  reso-
               2.'
                  @llution of differences on the HMO legislation between the H-,Iuse
               2
                 4
                  i@nd the Senate is the question of the Quality  Commission,  which
               2,5

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                                                                           45

                1   is in the Senate provision which deals Yiith mechanism for

                2   monitoring under utilization and quality of medical  care  ren-

                3   dered by HMO'S.  And the staff have been working with other

                4   departmental st@ff'in identifying ways that quality assessment

                    could be carried out in HMO's regardless of a QLI&Iity C
                                                                            onimis -


                6   sion provision.

                              Similarly, studies or ideas for projects are being

                8   developed in the area of implementing kidney  disease  legisla-

                9   tion.

               10             Two other areas which are related deal  with  studies

                    on the financing of medical care and the productivity of the

                    healthcare system,, particularly productivity dealing with man-
               12
               13   power productivity. This has been carried out as  a  part,of  a

                    development of a manpower legislative proposal for the
               14

                    Department.
               15

                              Similarly, a number of the economic and ,firka,@nc@ing

                    studies which have been supported have been used  in  analyzing
               17
                    the various health insurance options and have been used,.@to
               18

                    develop the Department's position on national health  insurance

                              The final item is in the area of data,, in which it@,i@
               20
               21   clear to us and, as Dr. Endicott indicated,, with the data
                    requirements that might develop during the implementation   of@@
               22
                    PSRO., ode of the critical areas in health services delivery
               23
                    at the present time and being able to monitor and evaluate    s
               24
               25   tom performance is the inadequacy of the current data systems,

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                                                                               46


                  1  the tremendous fragmentation and duplication, and in many areas
                  2  gaps in having  adeouate  data  to  make  appropriate  decisions.

                  3             However, as I indicated earlier, a significant portion

                  4  of this activity will be  assumed  by  the  National  Center  for

                  5  Health Statistics and our major effort will focus on the de-

                  6  velopment of improved medical record systems In tle ambulatory

                     and institutional settings.

                  8             Finally, one priority area  that  we  are  involved  in,

                  9  based on the reorganization, is the whole area o       ong-   erm

                     care in which we have major  efforts  under  way  with  the  Social
                  10

                  1.1 Security Administration and with Medicaid in improving the

                  12, nursing home and other long-term   care programs.7 both.those tha
                  1.3 are fna need by the HEW funds as  well as long-te3mcare in gen-

                  1.4 eral.

                                Now,  one  major  p'olicy'issue,decision   ratherwhich
                  15
                  1  affected us las yea,r,vas  the  policy  on  support  of  research
                  17 training.  And the Bureau,, in the same way that NIH was affect(@d,
                  18 was directed to begin the phase-out of the training support for

                     health services research,, and  that policy has in effect been

                  20 implemented and the only support@. that is:  currently  under  way,
                  21, either through training grantsmen or  fellowships,  are  those  com-

                     mitments which have already been made and they will continue

                     to be met until the individualssupported by the training

                     have completed that training, but no new training or fellowships
                  24
                     have been awarded since early this calendar year.
                  25

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                                                                             47

                 1             Now, as you know, the  Department  or  Administration

                 2  did reverse the policy decision and isin the process of im-

                 31 plementing a modified policy with regard to the support of
                 4@ biomedical research training,

                 5             We have submitted a  specific  proposal  toreinstitute

                 6  health services research,training and also the training, of

                    individuals in health statistics and  health  data,  because  we

                 8  feel and are able to document the fact  that  there  are  insuf-

                 9  ficient numbers of individuals working  in  these  very  important

                10  fields and have also been able to  have  some  evidence  that  he
                11, curtailment of the training support has already begun to
                121 show a decline in the number of  young  individuals  entering  the

                13  field of health services research.

                14             So this proposal to change, to reinstitute  a  form  of

                15  training, It might not be  in the same-" be administratively

                    ha,@dled in the same fashion, but at least  to  reinstitute  some

                    form of training is currently under review.

                18             Now, with regard to our responsibilities in the Bureiu

                    both in health services research area as  well  as  with  regard

                20  to regional medical programs and its future, two areas,, two

                    activities seem to me to be-- or  responsibilities  seem  to  be
                21,
                22  most important.   One is it is clear to us  and  many  individuals

                    in the field that a major problem has to  do  with  the  dissemina
                2
                24  tion of researhc  findings.

                               We find that 8t nLunber of activities that the  Center
                25
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                                                                          48

                1   significantly assist organizations and institutions in  dealing

                2   with health services delivery problems,, have not adequately

                3   been brought to the attention of those individuals.  They  just

                4   don't know those programs, those studies have been carried out,

                5   nor what their findings were, and in many reboects are  repea  -

                6   ing the studies over again with significant delays in imple-

                    menting changes which have been shown to be effective.

                8             This ties in with the whole question of technical

                9   assistance and the role of departmental staff in  the  regional

                    offices, as well as the role of other programs that  we  suppor
               1.0
               11   particularly regional medical programs.  And I had always

               121  viewed RMP as having that as one of its primary missions,

                    and that is the dissemination of research findings at both

                    clinical research findinEp, biomedical innovations, as well  as
               14

                    health services research findings.
               15

                              I consider this is one of the key issues we  need  bD

                    address in the Bureau with regard to the futurecf  our  program.

                    As I say, both the RMP and health research efforts.

                              Another major responsibility that I see is  some  here
               20   there has to be a focal point for carrying out studies  or  sup-
                    porting studies which can answer questions of the effectiveness
               21
               g;   of the medical care process.
                              This is particularly important at the present time
               2 '3
                    with regard to the increasing movement toward regulations of
               24
                    the health care, of health care and also such implementing
               ')5

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                                                                             9

                    legislation as the PSRO, the catastrophic health coverages

                    such as kidney diseases and the need to develop or have an
                 2

                    understanding or develop better indices of standards of medical

                 4  care and also the effectiveness of the medical care process.

                              Dr. Edwards' office has established an interagency

                    committee to, over the next -- during the reminder of this

                    fiscal year, to, in essence,, develop a plan for a program which

                    would begin to deal with the question of clinical effectiveness.
                 8
                 9  And we would keep you informed of the status of that activity.
               10             That has only been under way a Little over a month.
                    It is just getting organized*   But it relates as well to the
               11
                    role of Rte in other activities,, such as the disease control
               12
                    activities:of the National Institutes of Health,, and the
               13
                    educational programs that are being developed and supported
               14
                    through those institutes for disease control.  Wc-.@ha-ve repre-,
               15
                    sentation on the committee from NIH from the Food  and Drug
                    Administration, from CDC, and from all the health  agencies.
               17
                              DR. PAHL:  Tharkyou, Bob.

                              Are there questions for Dr. van Hoek.?

                              Dr. Roth.
               20
                              DR. ROTH.-  Yes.  I think my question is @in@the
               21
                    quality assurance programs, this is specifically  in BQA as far i
               22
                    as your remarks go, or is this separate from BQA.?
               2.3
                              DR. vAN HOEK:  No, it is basically a joint effort,
               24
               25             BQA has the primary responsibility for implementation

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                                                                          50

                i  for quality assurance, or processes which are legislatively
                21 authorized.

                             in other words, BQA has the responsibility for pro-

                4  viding the professional input and standards on Medicare and Meci-

                5  caid, also for implementation of PSRO, and implementation of

                   the kidney disease provisions of Medicare.

                7            Our responsibility is to participate with them in

                8  carrying out some of the research that needs to be done which

                9  would either substantiate or modify those standard settin g

               10  functions,

               1.1           DR. ROTH:  Then that gets to my question, which is

               12  really are these two efforts basically a dollar funnel, throLAg@

               13  which grants are put out like, say, the current half million

                   dollars to Kaiser for a three-year study on quality assurance?
               14

                   Or do you have actually a@,@substBntial staff working and doing

                   the individual research or is this all granted but tocperating

                   programs'?
                7

               18            DR. VAN HCEK:  At the present time it is almost

                   entirely grants and contract funds through the Bureau,

               20            DR. PAHL:  Dr. Schreiner,

                             DR. SCHREINER:  Yes.  You know, the Department told
               21

                   everybody who had training grants, as late as March of this
               22

                   year  thatanybody who was registered before the twenty-ninth of!
               23

                   January would be continued through to the end of their train-
               24

                   ing frants
               25

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                                                                                                                                                 51

                               1                            But when I called last week, they said no money

                               2        spent after June.  That since most training programs are two-

                               3        year programs, that becomes pretty hypercritical.,

                               4                            It seems to me we are wasting an awful lot of money

                               5        on planning expanded facilities when all of these people are

                               6        going to be dead as of July 1.

                                                            How can you plan if the commitments of five months

                               8        ago don't           hold five months later?

                               9                            DR. ROTH:  That is what                       you have got to plan for,

                                                            (Laughter)
                             10

                                                            DR. MARS:            Planning element,
                             11
                             121                            DR. VAN HCEK-.  Dr. Schreiner, are you saying you

                                        have been           informed that there would be no training funds@

                             14                             DR. SCHREMR:  For people who began programs,

                                        which they won't be extended beyond July 1. I was told.

                                                            DR. VAN HOEK:  Even those who had commitments prior

                                        t':@anuary?

                                                            DR. SCHREINER:  Right.

                                                            DR. VAN HOEK:  That isn't the rules by which we',


                                        are    playing the game.
                             20
                                                            DR. SCHREINER:  That is the rules they are explained
                             21,
                                        ing  to  those  who are  working  in  the  field.
                             2',-'
                                                            DR.  PAHL:    We  are  accustomed  to                         these  dilemmas,,

                                        Dr.  Schreiner.
                             24  1
                                                            (Laughter)
                             25

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                                                                          52

                 1           I don't know,, however, we can offer you very much


                 2 advice.

                 31          Are there other questions or points to be directed


                 4 to Dr. van Hoek?

                             If not, I would like to thank you and hope you can

                 6 stay as much as possible today, Bob.

                             DR. VAN HOEK:  Thanks.

                             DR. PAHL-  In the interest of time, because we have
                 8

                 9 much material to cover,, I would like to ask Mr. Baum If

               10  he would hand out a sheet to you which summarizes som of the

               11  budget information and while that is happening, I would also
               12! like to Inquire whether each of you on the Council received I
               13  think about a five- or six-page letter immediately prior to
               14  Council in which we went over anumber of  points  of  information?
               15            Have you received it and had an opportunity  0  ea
                   it? Because if you have, I think that what I  would  like  to  do
               17  is merely ask whether there are questions pertaining  to  any  of

                   those items.

                             We don't mean to gloss over the many, many things
               20  which have been happening. Giving  this  in  written.fom  was  an
               21  attempt to shorten this report of mine, but we are willing to
                   have any one of staff or myself expand on any  of  those  topics,1
               22
               2@            Dr. R6th.
                             DR. ROTH:  Well, I got it and I would like at some
               24
                   point to  raise a, couple of questions about it whenever that  is,
               25

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                                                                            53


                 1  appropriate.

                 2            DR. PAHL:  I was going to go into budget a little bit

                 3 more at the moment.  But if you would care to discuss other

                 4 points -- all right, let me just s      rize for you -- are those

                 5 handed out,, Ken9,

                 6            IvM. BAUM:  Yes.

                              DR.PAHL: Let.me summarize for  you  some  of  the  items

                 8  on  budget.

                 9            It has been very convoluted since July and I wont

                10 attompt to give you an exact  chronology,  but  rather  an  overall

                11 summary 1 believe might encompass the following major points.

                              As you recal4 at the end of fiscal 1973.,  there  was  a
                1,2,

                   balance remaining of $6.5 million and  this  balance  was  di@8trib
                13

                   uted to the RMP's  but instructions from'the Department that
                14

                   each RMP not use  its portion until such time as so ins@@ reacted
                15
                   by the Department, presumably for those priority areas    'cir@l,cot o@n.,,)

                   that we indicated to you earlier,
                17

                              There is no lifting at  this point in time of  that
                18

                   restriction, Thus the $6.9 million  is  still  withi;n  the local

                   RivIP's,, but unavailable to them for expenditure,-,,
                20
                              We. of course, have appealed this both   in specific
                21

                   instances and on a generic basis,, but the position that we
                9
                2 @'i have at the moment is that that money remains unavailable,
                              Fiscal 1974 has proven to be most difficult and   again!
                24
                   suffice it to say you will recall a number of MP's were
                25

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                                                                            54

                 1  scheduled to terminate over the summer and fall months.  But

                 2  it has been possible for us to work with  the  Department  and   1

                 311 in acquiring sufficient funds to keep old Rlels viable and

                 4  as of today we still have 53 RMP's   the Large  majority  of  whic

                 5  are in good: to in some cases very excellent shape.

                 6            There are a handful that are quite understaffed

                    and that have some problems, and I believe we wil I be discussing

                 8  these as we go through the individual  applications,  but  by  and

                 9  large., the RMP's are recuperating and are in many cases in

                io  very good shape.

                11            Now.. the fiscal 1974 picture has been  one  of*  again,

                12  delay and uncertainty.

                1.3           I believe it was late August, early September, that
                1411 we had $L7.1 million released to  us for distribution  to   RMPis
                  i                                 @i
                15  and this was done by a formula arrangement.

                              You will recall.'we have no review  committee,  this

                1 7 having been abolished in June, and an allocation mode was

                    devised which is described in the material that  we  sent  out

                    to you which we and I,believe the coordinators feel is as
                20  equitable as is possible under the time  constraints  and  lack  o
                2,1 full information that  @exists concerning the status of each  RMPI

                              We had submitted i n August a spending plan  to  the   i
                22
                2   Department which requested a total of $4i ml Ilion for distri-
                    bution to RMP'S, or a total of $46 million by the  time  we  take@
                24
                    into our own operational costs at headquarters and other         i

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                                                                                                              55

                        1   matters,, and this spending plan has been under  consideration

                        2   for quite sometime and I am happy to report to you  that  very,

                        3   very recently the Department approved the release of the total

                        4   Of $46 million to u4 and so we actually had in hand at  the  time

                        5   of    this    Council    meeting    the    total    of    $4L.2    million    of     fiscal

                        6   1974    funds    for    RNP'S,    of     which     $17.1     million     were     distributed

                            earlier this  fall.   And  in addition to which $2 million has

                        8   been earmarked and most  of It distributed  for support of

                        9   specified      pediatric      Pulmonary      centers,      those       being       identified

                       lo   again    id    one    of    the    attachments    to    the    material    we     sent@you,

                                           The     National     Association      of      Regional      Medical      Programs

                       12   has entered a class action  lawsuit, again described  in the

                            letter,    and    this    hearing    will    be    scheduled    I     believe     for     Decem@

                            ber 7th, and asks  for the  total of whatever is appropriated
                       14
                       15   in   1974 of fiscal 1974, as well as some $94 or $95 million

                            of    ni-eleased fiscal  1973 funds.
                       10
                       17                  The Department at the moment has approved  our spending
                            plan    of $46 million,  so depending on what happens  over this

                            next    month, we may have considerably more money to spend, both

                            f  rgta fiscal    1974    funds    as    well     as     possibly     fiscaLI973     funds.
                       20

                                           We   will   have   some    discussion    in    a    few    minutes    a    out
                       211@
                            some    action    which    we    would    ask    you    to    consider    relative    to    this
                       22

                            funding status.
                       23
                                           Now,   it    has    been    most    difficult    for    both    the    local
                       21
                            RMP's and      RMPS  to go through this  past few months with the
                       25

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                                                                           56

                 1 uncertainties from day to day and week  to  week,  and I think  I
                 21 would like to merely say It is to the credit  of  the RMP's
                 3  staffs as well as to a good number of people  on  our own staff,

                 4  and within the agency that the RMPS, 53,,  have  been able  to
                 5  survive this period and approach some level of stability.

                 6            At this point in time, we do have funds so that
                 7  after this Council meeting, we will be distributing  the  remain-
                 8  ing parts of that$46.4 million total fiscal 1974  allotment  to

                 @g US to the RMP'S.

                              Each RMP has received a ceiling figure  for  fiscal
                 10
                 11 L974, on the assumption that we would have gotten and  in  fact
                 12 now have received the $41.2 million for support of' RW Is,  and
                 13 they have been.able to plan their activities and  staff  levels
                    for the remaining portion of this fiscal year on that inform-
                 1,4

                    tion,

                              As you heard this morning, it Is  the  Department's
                 17 position now that RMP's have these funds available  not  only
                    through Zune 30th, but through December 3Lst, that  is  through

                    the calendar year, not through this present fiscal year,,
                 20           It is not at this point clear what OMB's -- Office 0
                 21 Management and Budget's position is relative to this, but
                    I am pleased the Department sees our funds to the RMP's as      I
                 22
                 "-3 being available to them for expenditure through December 31,
                              There have been some moneys this year devoted  to
                 24
                    its activities. We had a contribution of  $338,000  to  continue@
                 25

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                                                                                                                                            57

                                1   certain  HMO  contracts  which  you will  recall  sometime                                            back
                                2   had  been  initiated  with  RMP  funds,  and  there  is  an  interim
                                    1
                                3   1measure,       We       do       not       anticipate       having       to       place       more       money       into

                                4   these  contracts  or  other  HMO  activities.
                                5                     We       also       have       received       moneys       to        carry        out        evaluation
                                    studies,  but  at  the  moment  RMFSis  not  carrying  but  evaluation
                                    studie@       although       I       think       this       is       still       under       discussion       with        the

                                8   Department.
                                9                     We  have  set  aside  some  moneys,  of  course.,  for  those
                                10  kinds  of  contract  activities  and  direct  operations  activities
                                11  so  that  RMPS  can  go  through  June  30th  next  and  after  that,  It  I
                                121 unclear,  of  course,  whether  we  will  be  extended  as  RIES  or
                                    be  combined  or merged  with  some  other  organizational  unit.
                                13
                                                      Now,,      that      is      what      I      wanted      to      summarize,      I      think,      as
                                14
                                    to      the      budget      status.      But      I      would      like       to       say       we       have"a'@,,proble@
                                15
                                    in  a  sense  which  we  would  like  to  share  with  you,                                      and           while I
                                -   do  this..  I v7ould  like  to @ve  two  more  handouts  come, to  you                                             if; I
                                17
                                    might,  Numbers  two  and  five.

                                                       In         the         current         fiscal         1974         appropriation         measure,
                                    !which  is  in  conference,   there  is  a  level  of  $81.9 million                                                   being@
                                20
                                    recommended        for        fiscal        1974        for         RMPS.         We         now         have:,had;lr6leasedi
                                21
                                2-,) Ito  us  $46.4  million,   thus  if  we  do  get  the  full  amount                                            that   is
                                    appropriated  andlif  that  amount  is  $8i.g million;,  we  will                                                    have
                                2'?)
                                    ]approximately  $35  million  additional  out  of  fiscal  1974  funds
                                24
                                    to  distribute  to RMP's
                                25

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                                                                           58

                            We would propose that this additional  fiscal  1974

                 2 laoneys be distributed to RMP Is in the same manner as we have
                 3 Distributed the present fiscal 1974 funds, that is, through  the

                 4 use of this formula that I referred to and which has been employ@-

                 5 @@,d with those fiscal 1974 funds already distributed, and those

                 6 Under consideration by the Council today.

                             This would be quite appropriate in our opinion becaLse

                 8With the use of those moneys by RMP's through the-calendar

                 9year rather than through June 30th, this would merely.keep the

                10 RNP Is at approximately the same funding level as we are attempt-

                11 ing to do during the first half of this year.  In other words,

                12!it would merely be compensating them for the kinds of activities

                13 hich they are engaging in over these  coming  few  months  and

                14 continue them on from June 30 through Deemeber 31.

                15           Thus our position within the agency  is  that  any  addi-

                  tional fiscal 1974 moneys that might  become  available  to  us

                  would be distributed to  RMP@ls,,'through this  formula  arrangement
                17

                18           Now, when we., look at what may occur as a result of the

                  Lawsuit which asks for'release of   the fiscal 1973 moneys, we
                J()

                  leave something of a different problem.  Because  if  you  will
                20
                21 Look at the total picture, we may  have  close  to  $8o-$8i  million
                22 out of fiscal 197LI appropriations, we  already  have  $6.9  million

                  4eld in reserve within the regions from fiscal 1973., and regions,l
                2 @'i
                  iave zero to significant balances  at  this  point,  depending  upon
                21

                    number of variables. And if  now  we  have  an  additional  fiscal


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                                                                          59

                1   1973 release of up to some :'p9LI million, you can begin to see
                2,  that there is a different type of problem which faces us.
                3 1           It is for this reason that we have drafted for  your

                4   use and consideration a proposed resolution,, which is the
                5   longer of these two statements just distributed to you, and  T

                6   would like to go through this with you and then ask your  con-

                    sideration of this, but make sure that we understand what is

                8   involved.

                9             This is a proposed resolution by the National
                10  Advisory Council recommending allocation of additional RMPS fund.c

                    in fiscal year 1974:

                              "WHEREAS:  RMPS has established a mode for allo-
                12
                         cating the funds for Fiscal Year 1974 ($46.4M),, and
                13
                              tvi-MMAS:  The balance of $6.gM remaining from
                14
                         Fiscal Year 1973 funds was awarded but restricted for

                         use until further notice, and

                              "WHFREAS;  A lawsuit by the National Association
                (7
                         of RMPs requests Fiscal Year 1974 funds be released in
                18
                         the amount of $SL.9M, and

                              "WHEREAS-. The same suit requests release of  Fiscal
                20
                211      Year 1973 funds in the qmount of $94.OYi in addition to
                             $6.9M unexpended balance, and
                22
                              "WBEREAS:  The suit further reques ts @. re lease
                2
                         from limitations on the time for, and purposes of
                24
                         expenditures by RMPS,,
                25                                                                t

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                                                                         6o

                             "BE IT RESOLVED THAT: The National Advisory Council

                2       recomiaends that the Regional Medical Programs Service

                3       allocate by the established mode the full amount of

                4       FY 74 funds made available,, and

                             "BE IT FURTHER RESOLVED THAT:  The National Advisory

                        Council recommends that any funds the Regional  Medical

                        Programs Service may be directed to obligate in  excess

                        of $81.9M during Fiscal Year 1974 be distributed in a.

                9       manner that is determined by the Director, Regional

               10       Medical Programs Service, to make best possible use  of

               i@l      funds in accordance viith existing legislation. If
               1211         End of proposed resolution.

               13           Now,, that is rather complicated, but what lt'basicallf.,
               14 lagain, states and what the implicatio@ns of It are as follows:

                  Any additional fiscal 1974 funds that become available to us

                  as a result of either decisions by the Administration or as a

               17 result of the court action now pending would  be  distributed

               18 to RMP's by the same kind of formula that we have already dis-

               I!) tributed the present $41 million, or will be distributing the

               20 present $41 million of fiscal 1974 funds.

               21           Tdz formula distribution has been determined to  be

                  as equitable as we can make it and I@belleve has been endorsed
               22

                  by the coordinators through consultation with their qteering
               2@'i
                 IConuiiittee.
               24
                            Funds in excess of $81 million, that is if the lawsuits
               25

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                                                                          61

                1  is successful on the part of the plaintiffs and fiscal 1973

                2 funds of up to $94 million become available  to  the  Departnent
                3@ and to us for distribution,, pending any requirements that  are

                4  placed upon us, we would propose that these funds not  autoina-

                5  tically be distributed by formula but that this matter be left

                6  to the discretion of the Director of RMPS in  the  following

                7  sense, there are certain inequities which have  occurred  in

                8  the distribution of these funds by formula to some of the regiois,

                9  some of the regions were caught In an unfortunate period in

               10  their history, and I am sure that there are some adjustments

               ii  which should be made to specific regions.  Again., these can be

               12  discussed in appropriate time if this becomes an issue*  And

                   some of these excess funds certainly could be used for that


               14  purpose,

               15            In addition, some of the regions  have  continuing

                   needs and additional projects which could well be supported with

                7  funds which might become available to us from FY-73.

                             In the Senate version of the appropriation b      ther(@

                   is a statement that should $81.9 million become available,, up..,

               20  to $4.5 million should be devoted to the planning  and  develop

               21  raent of pilot arthritis centers. If this occurs, this would
                  ,require special action by RMPS such as we took in the  case  of
               22

                   Initiating the emergency medical services program,
               2 tl
                             In addition to that, there a-re certain 9-10 activities
               24
               25  which would need continuation funding. Hence,  it  would  be

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                                                                            62


                    RMPS's position that we ask the Council to schedul e  a  mid-

                2   March meeting date as well as an early June meetinv, date,  and

                    one of the functions of the Council at that  mid-March  meeting
                3

                4   date would be to consider the distribution of any funds that
                    ultimately are available to us in excess of the $81.9  million,,

                6   which is the level of fiscal 1974 funds.  But that prior to that

                    meeting date., should it be necessary for us to make some slig t

                    adjustments as a result of formula inequities to regions  or  as
                8

                    a result of the needing to continue some of these 9-10
                9
                    activities or whatever, that 1, as Director, be  given  discre-
               10

                    tionar  authority to use a limited portion of those  f nds
               11         y                                               u
                    to make such adjustments or initiate if necessary  the  Pilot
               12.
                    arthritis center program,
               13
               14             The bulk of funds beyond $81.9 million,  however,  we
                    believe should be a matter of discussion and  recommendation  by
               15
                    the Council; hence, we believe that this matter  coub  be  well

                    handled at a raid-March meeting,, which we Propose to you, and

                    see if we can schedule one@approximately at that time.
               18
                              Now, this resolution  is, of course, open for  your
               1!)
                    questioning and full consideration and I would merely, @say
               20
                  I again, building on Dr. Endicott's remarks and Dr. Marguliess
               21

                                                                                m
                    remarks particularly, that the total funding of  this  progra
               22
               2t3i and the uncertainties which continue to exist  make  planning tht
                  I                                                                I
                  I program on a day-to-day basis somewhat difficult.  And It is
               24
                    our belief that it would be most fair to the regions  and  in their
               25

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                                                                         63

                I  best interest, and in the best interest of the Administration,
                2  to distribute any remaining fiscal 1974 funds,.as I have suggested,
                3  by formula, particularly since they now will be able to  use

                4  those funds at least within the Department's  consideration,

                5  not only through June 30th but through calendar year  ecem)er

                6  31., 1974.

                             But that moneys above the $81.9 million do pose  a

                8  special Problems, because there are review considerations and

                   there are considerations that will be made above my  Leve
                9
               lo  within the Department and OMB, and because of these uncertain-

                   ties I am not prepared to indicate to you how as a program

                   director I can best;proceed,
               12

                             I believe it is best to indicate to you  my need for
               1 3
                   discretionary authority in that limited sense  which I  ha ve In-
               14
                   dioated to you, but to bring back to the Council  in early  or

                   mid-@rch, whenever we can assemble again, the problems  and
               10
                  @'IssLies that we have, so that the Council can make reco@ndat-Lois
                  ,for the proper use of somewhere possibly up to $90  millions,

                   which is a significant increase over and above  what the program

                   level is at this point.
               20
                             Noiq, wth that as a background to that  resolution,
               21
                   I would like to open it for any kind of discussion andImodifica@
               22
               2   tionl or whatever your pleasure is.
                             Mr. Gardell Is here if there are specific questions
               24
                   concerning budget figures, and we will try to clarify anything,'
               25

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                                                                               64

                  1  because it is i complicated issue*  So let me throw it open.
                  2            DR. ROTH:   Is the very last word of the long resolli-

                  3  tion the right one?
                  4           "In accordance with existing legislation"9  Or should
                     that be guidelines, priorities,, and options"'?

                               DR. PAHL: I think it would be  better  if  we  added  to
                  6
                  7  it rather than substituted for  i4"j,n  accordance  with  existing
                  8  legislation and departmental policies and guidelines."

                  9            The reason I say that is  we  are  trying  to  emphasize
                10   the Department's understanding no@7, if  you  will,.that  our  pri
                     ority areas and options are no longer restricti've,,but the
                121  full scope of activities that are authorized within the legis-
                     lation, of course, are endorsed by the Departmen4 so I think
                13
                     rather than substitute, perhaps it might  be  better  to  add  the
                14

                     additional phrase,

                               Mrs. Mars.

                               MS. MARS:    I am not opposed in any way to delegating
                t7
                     th@ authority to you to use the funds,  But I do object to
                18
                     all these preliminaries;, because I think that it makes it

                     appear that the Council is sponsoring and sanctioning the
                20
                21   lawsuit that is going on.
                22             I do not believe that we should in any way be
                     connected or involved with that part of the procedure.
                21
                               DR. PAHL:  Well, that is certainly true, and     it  was
                24
                     not written to imply that it was--
                25

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                                                                             65

                              MRS . IVJA Rq- This is what it implies and  this  is  the

                2   way it appears, and I very seriously object to that.

                              DR. PAHL:  This can be certainly modified.

                4             MRS. IVARS:  I think all that part really should be

                5   eliminated, more or less.

                6             DR. PAHL:  The third whereas?

                                                                               if
                              MRS. lv%RS: Well, up to"the  same  suit  request,%  and

                8   so on., Iffurtherrequests,," and "Then be it resolved."  That is

                9   the part that I object to,

                10            DR.,FOYE:  These are statements of fact.

                11            NM. MAILQ:  But many things can be read into that
                12 ii which are certainly not there.  But if -it goes on public recorc

                13  as such, I just object to it, for that reason.

                              DR. PAHL: Would you care to  delete  it  or  to  modify
                14

                    it in  such a way that it made it clear?

                              MRS. MARS:   I would rather delete most of it, and
                7   rewrite somewhat the beginning here, the resolution.

                              DR. PAHL:   Is there discussion on this point.?

                              MRS. MORGAN:  I agree with Mrs. Mars,, I@think   if  we

                    can delete the point as to where these funds are coming-  from--I
                20
                              MRS. IMRS:  Funds areooming from.
                21
                              MRS. MORGAN: -- and say if there   is $94. 0,a! I lion
                22

                    released, this is how it be done.
                2.1
                              We say nothing about as  to where these  funds  may  be
                24
                    coming to us from, as far as this  resolution goes.
                25

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                                                                               66


                 1            DR. PAHL:   ure I y.

                 2            Dr. Roth, were you adding a Comment?

                 3            DR. ROTH:  Well  it can certainly be written just on

                 4  the assumption there might be additional funds of any amount

                    from any source,, without specifying it. Wouldn't even need  to

                 6  be--that specific figure sort of tags where you are looking.

                              MRS. MARS:  Right. Just funds available.  Become

                 8  available.


                 9            DR. PAHL:  Mr. Milliken,

                10            MR. MILLTEEN-.  This may be unnecessary, but I am won+.

                11  dering if in the responsibility of Council there exists

                12  statements that indeed do give the Council this privilege?

                13            If that could be made a part of this?  So  that--  of

                14 cb legating this?

                15            DR. PAHL: Th,.s is  a recommendation by the  Council.

                              MR4 MILLIKEN:  It  is a r'i ecommendation only?
                17            DR. PAHL:  Yes,  that is why we have phrased it. "The
                    National Advisory  Council  recIonunends" that we do this,

                              MRi  MILLIKEN:  Okay.  I think alot of people, genera.

                20  public,, wonder what the role  of authority of the Council is.

                              DR. PAHL:  I  think  on the basis of discussions  with
                21
                22  our own general counsel, we  purposely used the word "recom-
                    mends  here, rather than "delegates."
                2,'

                              MR. MILLIKEN:  All right.
                24
                              DR. PAHL:  The Secretary,  I believe, is empowered to
                25

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                                                                                     67

                 1  delegate authority to those he chooses, but the Council certainly

                 2   does recommend on policy and the distribution and awarding of

                 3   grant fQndb, and, makes recommendations on those points.

                 4              MP,. MILLIXEN:  Okay.

                 5              DR. PAHL:  Yes, Dr. Watkins.

                 6              DR. @TATKINS:  You are going to add to this proposed

                 7   resolution the fact we will meet  mid-March  to  distribute  those

                 8  additional funds? Are you going to add it to this?

                 9              It is not stated here.


                 lo             DR. PAHL:   It is not stated here and we certainly

                 11  can add It,

                 12             DR. WATKINS-, Fro eyaraple,, the formula grants which  1:

                 1,31 believe you will be responsible in making decision, but that

                 14  we will meet for anything over and above the formula grant'?

                 15,            DR. PAHL:  Well, what that last paragraph says is that

                     there was  discretionary authority  or is discretionary

                     iuthority  being given to me to act in the  interim  period,  as  I
                 1 7

                 18  'have had to do over these previous months.  A@       I  am  trying  tc

                     give you  a sense  of  what  that  discretionary  authority  might  be

                     without ;9. very clear understanding on my part as to just the c r-
                 20

                     c@tances that will occur between now and mid-March.
                 21
                 22             I want to make  it  perfectly  clear  for  the  record  and
                 2   for your understanding that  what  I  am  asking  for  Is  limited  dis
                 24  cretionary authority  to  carry  out  those  kinds  of  special  adjust

                     ments for a, few regions that  v7e  find  may  be  necessary,  because
                 25

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                                                                                68

                 1  of inequities in application of the formula,, or to initiate if

                 2 necessary that new program which is in the  Senate  report  and

                 3 which Is termed a planning and development  of  pilot  arthritis

                 4 c enters.  We can discuss this more fully with you.

                              Nothing has happened at this point  beyond  some.dis-
                 5

                 6 cuss ions ,but if the appropriation comes through in  the  full

                 7 amount, I  may have to make some kind of special  effort  before

                 8 our mid-March Council meeting.  But I was trying to Indicate

                 9 that the bulk of the funds that would  become  available  within
               10  fiscal 1973 release would be brought back to  the  Council  for
               11  recommendation, discretion -- recommendation as to how to
               12  distribute these,
                 3            Now,, that is the sense I am trying to give you rather
                   than to spell oLt the detail, beoa use, I really am not sure  of
               14

                   the details.


                              Dr. Merrill,

                              DR. NERRILL: I certainly agree with  what  has  been
               1.7
               18  proposed here, Iv7ould like to recommend that.
               1!)            I wonder, in view of v7hat we have heard this morning,

                   In view of the uncertainties which have been expressed, whether
               20
                   there is really a,ny.viable alternative to delegating this,
               21                                                  CD
                   other than a series of emergency meetings of the Advisory
               22

                   Council?


                              DR. PAHL:  Pardon me, T would like to respond and
               24
                   say,, of course, 'vie would be most pleased to suggest some
               25

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                                                                                   69


                 1   alternatives to you.

                 2             I am not overly happy, personally, about having  to

                 3   bear, if you will, the responsibility for making wise decisions

                 4   on multi-millions; even with ci good staff to assist.it is a,

                 6   somewhat indefensible position for a government official to

                     -withstand the kinds of pressures, and so forth    that obviously
                 6                                                    0

                     come about from those decisions.

                 8             We also have the difficulty of,calling together the

                     full Council without announcements and certain time delays
                 9

                io   that I don't know-- Ken, what are the time  delays  now,  a  few

                     weeVs?


                               MR. BAUM:  Yes.  You mean gettin  the Council toge-
                12                                               9

                13   ther?
                14             DR. PAHL-.  Yes.
                15             MR. BA TJM: I would say usually it would take    about

                     four weeks, three weeks.. or so.

                ]@7            DR. PAHL:  There is something in the neighborhood

                     of three and four weeks.

                               Unfortunately when these understandings    'are reached

                     within  the Administration,, sometimes immediate action   is  re-,
                20
                     quired, so vie don't have the luxury of calling e-met   ency meet-
                21                                                         9

                     ings.
                2@
                               I would be very pleased if you would    care,, from
                23 i
                           your number, to have an executive committee that     could
                24   among

                     be empowered to act within the interim,
                25

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                                                                                                                                                     70

                                 1                     is this possible under our federal--

                                 2                     mR.  BAIR4:    With  the  Federal Advisory  Committee  Actp

                                                            I  am  not  a  lawyer.,  but.,  a,  ain    it  would
                                 3 @I imagine                                                                                             have to be
                                 4  a  public       meeting.

                                 5                     DR*    PAHL-.    Announced.

                                 6                     YiR.   BAUM:        Announced        in        the        Federal         Registers         six

                                 i  weeks  reqLared  for  that.

                                 8                     DR.  PAHL:    We  are  only  in  a  time  requirement  of  call-

                                 9  ing  together  a  group without  going  through what  are  now  the
                                 10 federal  regulations  of  weeks  of  notice,  and  so  forth,  and  one
                                 ii,doesn't  have  the  opportunity  to wait  for  that  period  of  time
                                 12 lbefbre             acting,

                                 13                    DR.  'CANNON:    You  are  here.    We  appp@tnt  you  as  our

                                 14 !,Council  representative,  George.

                                 15                    (T-e-ughter)

                                                       DR.  PAHL:    I          might       say  that  is  a  very  great  restric-

                                 -1-1 tion  in  terms  of  program management.

                                 18                    We      would       have       to       honor       those       new       regulations;       so
                                 1!) ithat,  in  essence,  what  I  am asking  for  is  discretionary  ,-iu  hor-
                                 20 ity,  but  trying  to  give  you,  therefore,  a  sense  of  what  I believe
                                 21 to  be  reasonable  l@Lmits@on  RMPS  of  this  discretionary authority,
                                    recognizing  that  either  departmental  or  OMB  actions  may modify
                                 22
                                 2t'i these      as      you      have      heard       this       morning       from       Dr.       Endicott       and

                                    'Dr.           1,4argulies.
                                 24

                                                       mRs.MARS:   Couldn't  this  then  just  be  rewritten  today,                                             1
                                 25

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                                                                                                                                                      71

                                1     SIMPIYO and stating that fact, and present it to us again Iotei

                                2     in  the  day  or  tomori,ovi  raorning?

                                3                        DR. PAHL:            Yes, I think so.

                                4                        MRS,.  MAR,-:          I  think  that  is  really what  we  are  get-

                                6     ting  down         toi

                                6                        DR.  PAHL:    Yes,  I  think  these  are  all  very  good

                                7     points  and  we  certainly would  be  very  glad  to  redraft  this

                                8     with  all  of  this  discussion  and  present  it  to  you again.

                                9                        Now,  we  have  to  present  this  In  an  open  sessioc.

                              10      I  just  have  to  indicate  that.  And  so  prior  to  the  close  of  the
                              11 I    clay,,  we  will  have  to de               cide  when  we  cad  have  the  open  session
                                      so  that  people  can  comment  on  this  action  by  the  Council

                              13 11   if  they  choose  to  do  so.

                              14                         Mr.   Ogden.
                              115                        MR.  OGDEN:    Herb,  I  think  when we  come  down  to  the
                                      additional  corament,"additional  legislation,,  existing  depart-
                              17   Menta,l. policy and  guidelines,,"  I  would  like  to  have  some  state
                              18   @.ment,mlade  in  there  that  you are  also  to  hew  to the  Councills

                                      policies  and            guidelines.

                              20                         DR.  PAHL:    Yes.

                                                         14R.  OGDEN:    And             vihatever  you  do  should  be  brough
                              21

                                      back     to  the  Council              for  its  review  and  approval.

                                                         MRS.  MORGAN:    For  passage.
                              2!'))
                                                         MR.   OGDEN:    Even  if  you  have  to  contact  us  within  a
                              24
                                      relatively           short  sequence,  in  order  to bring                              it  back  for  rev@ie@
                              2,5

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                                                                               72

                    of the Council.

                              I suspect we have very little authority to deleg
                2                                                               e

                3   to somebody else our responsibility for the allocation of

                4   funds.

                5             I an not quite sure we can divest ourselves of that

                    responsibility merely by recommending something be done.

                7             I think it is a very complicated field here.  I
                8   don't thin you have ever had any direct set of by-laws, of
                9   this Council, and I don't recall that we have ever had any
                10 authority to appoint an executive committee of this Council.

                11            Perhaps that is an oversight on our part,, but I thin@
                   it has come up before over the years as I remember,
                12
                             I do agree with the comments made here a moment ago
                13
                   that your whereas clauses are statement of situations.   I
                14
                   don't think this necessarily applies to any kind of ap
                15                                                        proval
                   on the Part of this Council for existence of a lawsuit.  Tt d6(,-s

                   reco6nize the fact it Is there.
                i7
                18           Ilevertheless, if you choose to rewrite it,, we would
                   be happy to review the proposal.
                20           DR. PAHL:  I appreciate those comments and we will
                   incorporate them as appropriate into the redrafted resolution.
                21

                             Yes.
                2
                             @q. MORGABT: This December 7th hearing will a decision
                23
                  be made at that time or could this go on for sometime before
                24
                  decis on is made?
                25

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                                                                                                                               73

                          1                     DR.@ PAHL:         It is my u derstanding fr
                                                                                   n                       om consultation


                          2     with Department General Counsel that the government will de-

                          3     cide to appeal any matter within 20 days after the December 7th

                          4     hearing,

                          5                     So presumably if no appeal does take place,, then we

                          6     would know no later than December 27th as to the ultimate dils-

                                position-  and  if an appeal  is  made,  I am not  certain as  to

                          8     what  the  time  table  ]is.

                          9                     On  this  point,,  I am not certain  --  is  anyone  from

                        10      General Counsel  Office here?

                                                Dr.  Sparkman,  do you have  any information  relative

                        12!i    to the  timing as  seen by the  lawyers  for  the  plaintiff?
                            ii
                                                DR.  SPARMMN:   Nothi-ng beyond what  you have said.

                                                DR.  PAHL:   We  do expe6t  to have a  final decision  from
                        141

                        15      as  I say,      our conversations  within  the Department as  t  "the

                                month of December as  to how many funds  we will have  out Of

                        1 7     fiscal  1973 end what  the disposition  of  fiscal  1974  funds                               may@

                                be.

                                                MRS.  MORGAN:   Should we  look towards  maybe having

                                the  National Advisory Committee meeting earlier than March if
                        20

                                this  is  the  da8e?
                        21

                                                DR.  PAHL-.   Well   that would  certainly be a  possibil
                          2

                                ity.
                        2.3

                                                The  reason we  had  tentatively set  it  for mid-March w                             s
                        24  1
                        25      because we  thought  it would be  completely resolved by that  t@l-

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                                                                                74

                 I            MRS. MORGAN:  Right.
                 21           DR. PAHL:  We were trying to give ourselves-- becaus@
                 3; of this publication of the committee deadline, if we miss by  a

                 4  week or so-- but we certainly could schedule a m,,d-January or

                 5  late January meeting and one again in March and subject  to

                 6  cancellation.

                 I            It is very difficult to determine these dates and,

                 8  unfortunately, it is then very hard to rearrange it.

                 9            MR. OGDEN:  Herb, would you ask counsel to give you -an
               10   opinion as to whether or not you have to establish  dates  for  a
               11   subsequent raeeting or would it be possible at this meet@ing  for
               12   us to say that in the event that this lawsuit  is  a  successful
               13   action and the government chooses not to appeal it, that we
               14   here at this meeting give notice that we will immediately
                    thereafter hold a special meeting of this  Council  to  consi
               15                                                               der
                    what to do when such funds  become available and that this  ac-
               17   tion at this meeting then  constitutes that legal  notice  of

                    six weeks or whatever is required?

                              DR. PAHL:  W@ will take that up with counsel,

                              MR. BA TA4: I have to check that.
               20
               21             DR. PAHL:   We had invited them to attend  the  meeting
                    and apnerently conflict--
               22
                              MR. OGDEN: I don't thin[,, the would  give  you  an
               2'.31                                        y
                    opinion off the cuff anyway.
               24
                              DR. PAHL:   No, it is an unusual situation, but we
               25

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                                                                                75

                 1  will try to@toke that up and come back to you with it.
                 21           Regardless of that activity, if you feel the need fcr

                 3  it, we would be pleased to have a, meeting In January  anyway.

                 4            The reason again that we I-ad thought at least of

                 5  having a mid-March meeting would be helpful, it  would  follow

                 (i the President's message and we hope at this time the Admi.nis-

                 7  tration's lep,,Islative package would be known and this would be

                 8  something then the Council could discuss and take appropriate

                 9  action and make'recomraendations to the Department,

               10             Dr.  Foye,

                              DR, F OYE: I am wondering about this resolution.

               12             Typically the national advisory oouncils,' to ensure
               i,31   '-Uhe  necessary continuing administrative flexibility and re-
               14   sponsivetiess of program staff, you delegate certain similar

                    authorities to program staff.
               15

                              Where it involves the granting of funds, usually

               i7   iIt is limited in the sense that program staff may adjust a@,

               18   grant within plus or minus 10 or plus or minus  20  percento--

               1!)            DR. PAHL:@, Y,--s.

                                                                       Iv
               20             "R. FO'YE:  -- of the Council approved le el on

               21   s orae th i ng like that.

               22             It seems to me the danger of this resolution that

                    might compromise the recommendation above is that it is in  e.

                    sense an unliniited one
               24

                              DR.  PAHL: It is open ended.
               25

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                                                                                7'0-

                 I             DR. FO@    It gives the Director  authority,  let's

                 2  say, conceivably, if 100 perce tit of the f unds become ava,i lab le

                 3  regardless of their amount and regardless of their relationship
                 4  to the funds already allocated to the ongoing program,

                 5             DR. PAHL:  That is correct.

                               DR. FOYE:  It seems that might threaten its accep-

                 7  tance as a recommendation.  It falls so far outside the ordih-

                 8  ary limits of such delegations.

                 9             DR. PAHL:  This we recognized and troubled with

               10   some language end the reason we left it :open ended  was  merely

               11   because the circumstances are difficult and  therefore  I  was
               12   trying to give a sense. But you are  quite  corrects  In  fact
               1.3  I am glad you made it expLici4 as written It is open ended and
               14   perhaps -vie can try our hand again at some limiting  authority.
               15   Because I certainly intend tha@ as I have indicated  in  my  re-

                    marks,

               17              It is difficult to know, because these  aren't  going
                    just for adjustment of existing grants but  for  other  ma  ers,
               18
               1!)  but your point -is well made and we will see if we  can  perhaps
               20   accommodate some language which will certainly  make  it  more

                    acceptable to both you and us.
               21,
               22              DR. F O'YE I certainly know of no time when such
                    flexibility and delegation of authority has  been  more  needed,
               23

                    so I am in favor of,it.
               24
                               Cleugkiter)
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                                                                             77

                1            @o-. MORGAN:  I wouldn't like to see this March
                2@ meeting, coming back and serving as a rubber stamp-of $gc)
                31 million that had already been spent, you know.

                4            DR. PAHL: We recognize the limitatiorB of the  drafti

                   perhaps we can try again and have some additional assistance  )-j.

                6  we don't try to get-- if we don't meet all the points you  have


                7  Made.

                8            Now, if we may turn from that,, I would like to men ion

                9  two points, which have to do with our plans -- three @poi@hts,

               10  which have to do with our plans for the future, which is  apart

               11  from the funding. That is, now we know we hafe  fiscal  1974

               121 funds available regardless of the leve; and whether we  get

                   fiscal 1973 funds or not is inimtetial to the point I am men-

                                                   e        r        we believe
               @14 tioning,  We have as a central h adquarte s staff

               15  a responsibility to reinstitute certain activities  which  vill@-

                   be of assistance to the regions and which we, as a more@ l@imi tec

               17  staff than we formerly had, can accommodate.

                             The first and foremost of these I believe is
               18

                   review by central staff of RMP Is review processes.

                             You will recall that before phase out, RNFS had a
               20

                   program whereby we placed the responsibility on local FM  Is
               21

                   for reviewing the merit of their own individual  activities
               22
               2@3 and we therefore, as a Council, removed ourselves from  project
               24  review and got itibothe posture of program review,
                             During phase out, of coQrse,, this activity ceased   i
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                                                                                                                                                         78

                                       and as of this date, I believe there are something like 17
                                21     regions which have never had certification by R@TS of their

                                       local review process.
                                31
                                4                         Since vie knovi we now have funds and some lifetime

                                5      and we do          have the staff to accommodate this activity, we propose

                                6      immediately, that is between now and a March meeting as was our

                                7      recommendation, to work closely with those regions and to try

                                8      to get each region's local review process certified.

                                9                         This  is the form of technical assistance which has

                              10       been of great value to the regions which have received certi-
                              11       fication, and I believe will Improve local regions during this
                              12       period of their existence as they are trying to restaff and

                                       reconstitute  their  own  advisory  apparatus,
                              14                          In  addition  to  that,  we  intend  to  reinstitute  manage-
                              15       ment  assessment  reviews,of  regions.    AgaLn,  this  was  one  of
                                       the  most  useful  activities  that  RMPS  performed,  I  belJeve,,  in

                                       helping  regions  to  improve  their,local  management  processes,  a  d
                                7

                                       we  have  again  the  capability still  -'Ln  the  personnel  that  we  haxe
                              18
                                       to  work with  regions  and  assist  them  in  this  matter.

                                                        We  would  propose  immediately  to  start  our  program  of
                              20
                                       management  assessment  'Visit's@  Some  regions  have  never  been
                              21
                                       visited  at  all  because                  the  phaseout  came  and  other  regions                               have
                              22
                                       had  visits,  but  quite  sometime  in  the  past.,  and  much  has  changed
                              23
                              24       in  ter=  of  personnel  and  activities.                                  I believe  that  we  shouldi
                                       do  this  as  one  responsibility  of  headquarters.
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                                                                                 79

                              And lastly,, you will note from the July discussion a3

                 2  well as the size of the staff sitting around  here  today  that
                 I  we have had to discontinue certain functions,, one of  which  has
                 31
                 4  been Our mOhitoring and evaluation of  individual  activities  an

                 -  program directions of regions,

                              ITe have had probleras in having sufficient number  of

                 7  staff and also in terms of dollars for travel of  staff  to  re-

                 8  gions and consequently we have much  less  first-hand  intelli-

                 9  gence about regions than we formerly had.

                              We now have our fiscal 1974 funds at  a  level  which
               10
               11   will accommodate reinstituting our  intelligence  gathering  and

                    evaluation activities,
               12
               13,            We do not have a full complement of staff  in  our  of-
               14   flee of systems raanagement , which Is our information  computer-
                    lzed.,information network, but we do have practically intact
               15

                    a system; o'l' operati-,6ns.-.and development.

                              Most of the individuals have  stayed  throughout  this

                    difficult period and have been in touch with telephone and

                    correspondence andoon a. limited basis, first-hand visits to  the

                    regions.
               20
                              We would propoGe to step this up  over  coming  months

                    so that again we  have a flow of staff to the region  a.@  will
               22
                  1 be able to know  first hand what Is going on and  provide  first

                    hand technical assistance.
               24
                              One of the things again we believe we  would  like  to
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                                                                                   0

                   1have you consider, because we believe it  is  important  for  the
                   2regions to know of the Councills Interest, in this  matter,,  is
                   3the subject of this second  shorter  proposed  resolution  which

                   4has to do with the existing policy by RMPS  and  Council  for
                   5having regions comply with the local review process requirements

                   6that had been distributed sometime back.

                               This says,-.

                   8           "VTHEREAS: RMPS has established a mode  for  allo-
                   9      cating the funds for Fiscal Year 1974, and
                   10          "WHEREAS: Some RNPfs still  have  not  complied  fully
                   11     with the IRMPS Review Process Requirements and q-tande-rds'
                   12i    and administrative management requirements, then

                               "BE IT THEREFORE RE@QOLVED:  The National Advisory

                   141    Council reiterates the necessity for all RMP's  to  be  in
                   I
                   15     compliance with the IRYIPS Review Process  Requirements

                          and Standards' and administrative -management  require-

                          ments as soon as possible, and therefore  requests  the

                          Director, RMPS, to report the status  of  RMPS"  compliance

                          at the next Council raeeting."
                   20          Now, we had certainly in mind 9.t that time a  Yia rch
                    Council meeting, which would give us a period of approximately
                   21
                    three months to engage in these visits. But  we  would  amend
                   221
                   Ithis by bringing you a status report certainly  at  the  next

                    Council meeting and In 14arcii.
                   24
                               Again,, the reason that we feet that this is an
                   25

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                 1  appropriate resollition'for you to consider is we feel It
                 2  important that the regions knoiq of the Council Is interest  in

                    ha,vin,@ them meet fully those requirements which ',love been set
                 31      C>
                 4  for a good local review process.

                              This is the only assurance that we  have  quality  con-

                 6  trol will be.exerted within the program.  Our own staff is less

                 -  than one-third of what it was. And we do  not  have  the  manpowe

                 8  nor the preliminary review cori)i-aittee to engage in projects
                 9  review again and It is not our desire to do so,  But  if  we  are

                    to maintain overall program responsibility  we have to delegatE)
               10
                    to the regions the responsibility for  maintaining  quality  of
               11
               12   their projects.
               13             This basically means meet'ng  the  requirements  that
                    have been set forth and for which many regions have been cer-
               1 4

                    ti--L-ied.
               15
                              So it is an expression of continued  interest  in  exis

                    ting policy, that is the subject of the resolution, hot the   in-
               17
               18   Production of the new policy,
                              I would like to open it for discussion  and  get  the

                    sense of the Council on this matter.
               20
                              IVIRS. MA@l- I think this is a very essential  res o I ii- i
               21,
                    tion and I move the Council accept it as it is written.
               22
                              MR. MILLIKEN:  Second.
               2.11
                  I
                              @IR, OGDEN: May I offer a comment,  perhaps  an  amen
               24

                    ment?
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                                                                             lul 2

                1            I would just as soon drop the first "whereas"

                21  because  Ithink the Council ought to be allocating the funds.

                3            I don't thin[,, the first "wi-iereas@@ is necessary,

                4            @1q. 14ARS: I accept that amendment,

                5            DR. PAHL:  All r@ight.It has been moved and seconded

                6  to amend the proposed resolution by striking the first


                    whereas


                8            Is there further discussion by the Council?

                9            If not, all in favor say it aye,

                10           (Chorus of "eyes.'')

                11           DR. PAHL-.  Approved.

                l@2          Now, those are the two actions that I wish to have
                1.3@ you take and I would like to come back to Dr, Roth's statement

                   sometime earlier, that perhaps there were some questions on
                14
                115 matters within that lengthy letter which we haven't touched upcn

                   3-n terms of budget or these othe-r@aspects,

                             @S. @RS:  You didn't state when the open meeting
                1 7
                   was going to be to discuss this resolution rewritten.
                18

                             You said it ha d to be presented at an open meeting,

                   so tomorrow morning
                20
                             DR. PAHL:  Our plans for today I believe are such
                21
                   that we will go over into tomorrow, because of really the need,,
                22                                                               i
                   in 'fairness to the re8ions,, to discuss some of the problems
                2 'i

                   which exist,
                24
                             Let me just digress, if I might, for a, moment,, Mrs,
                25

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                                                                                83

                 1  Mq.rs,, and say as you are well aware, you have not  really  seen
                 21 any application from a region for practically a year, and it  i@:,,

                 3  the sense of our staff that we would like  to  give  regions  the

                 4  utmost opportunity to have their strong points as well as some

                 5  concerns which we would like to present to you to have the

                 6  time for that.

                              I believe it would be 'inappropriate because there ar(,@

                 8  a number of things which you must  consider  today,  before,we

                 9  can take up all of the applications.   So that we will be  havinE;

               10   a session tomorrow.

                              Noii. with that in mind,, perhaps we can just@@set a

               12   time and as far as our own staff is concerned, the first thing

               11)                                                              at
                    in the morning to have the open session would be a-ppropr    e iJ'

               14   that is satisfactory with you,

               15             @iould you care to meet at nine o'clock tomorrow or
                    8: 3 O?,

                              MPS. MORGAN.- 8:30?

                              DR. SCHREIIER:  Nine o'clock is fine,

                              DR. PAHL: We are only allovied to drive  50  miles  an


                    hour.
               20
                              Is nine o'Glock all right? Let's meet at nine olc ojk
               21

                    tomorrow and that will be an open session as  long  as  is  neces-i
               22
               23   sary to accommodate this and any other  matters  of  open  busines@
               24   and then we will again reconvene in exebutive  session  to  con-
                    tinue the discussion, actions on individual grant  applicati-ons.@
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                                                                                  84

                 1             Are there any other matters dealing with the  mater@L
                 21 we sent to you or po-Lnts which have been raised as a  result of

                 3  this discussions

                 4             Dr. Roth.

                 5             DR. ROTH:  Somewhere along the line I would like

                 6  to give a  reaction. As I said to Bland Cannon,  I  am  willing

                 -  to leave the swan song to him,, but ma@rbe I will take the  last


                 8  gasp.

                 9             It seem to me that this is relevant to virtually

                10  everything 'vie have been discussing this morning, because I

                11  came into the program a number of years ago  with  some  obvious

                12. enthusiasms which,, for a.while,, increased. Ard then have  been
                13  subject to a nuraber of setbacks, And it seems  to  m  that  in

                14  understanding @hy RMP as a government program Is  in  the  con-

                    dition it is in now is because of a basic instability -- not in
                15
                l@(; any sense a reflection on the staff, but a  fundamental  insta-
                -(7 bility in programming and a tendency to shift objectives

                18  which started out very close to the beginning.

                               We made an irresolute start for a  program  directed

                20  at specific categoric ones and it was almost no time at all
                21  before the effort was on the program to decategorize it.
                22             Certainly in terms of taking limited numbers of
                2 @l dollars and making them visible locally in programs that would
                    be recognized by the public a,s contribution to this federal
                '24
                    legislation, which would make it acceptable to the health care,l
                25

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                                                                                  35

                 1   industry in all of its aspects and which would ma.[,,e it a
                 2   source of pride to the Legislators who achieved its  this  was
                 31  made more difficult by :I. diffusion of the areas in which
                  I
                 4   you could dedicate your dollars.
                 5             So we rapidly 'tended to decategorize, we tended  to
                 6   begin lumping things under the 9-10 section which changed the

                 -   regionalization concepts
                 1
                 8             Then we began to be tugged towards support of povert
                 9   programs and with our very small number of millions of  dollars.,
                10   this could only be an insignificant drop in the  bucket  among
                11   the wjor poverty program which were launched by the govern-

                12   ment.
                               And then we came alone, withthe  interesting  thought
                                                     C>
                14   of extending this into st@tti. another categorical diseases rena  11
                     disease, and this had iiiuaense appeal in the public alnd in Cong-
                     ress and we got into that which  further  extended  our,resources.
                               Along that line,, then, subsequently we added
                17
                     emergency services, which put further strains on achieving
                18

                     visibility.
                20             But I think the most disastrous things that
                     happened were when it was put upon RMP to somehow or other
                21
                     get into the health maintenance act, which had a lot of' polit
                22
                2.1  cal charLsma downtown for a@7hilel which was really not within
                     the concept of the law as originally passed a,nd which gave
                24
                     us no additional visibility as RYT, and now this has been
                25

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                                                                                          86


                      compounded by getting us into the act of ouality assurance

                   2  concern which has no visibility.

                                 After all the P@-'RO law and its implementation  is  in
                   3

                      a state of cl-iaos at  the present time. There fill be no operating
                   4

                   5  PSRO's to which we may have contributed and  gained  any  visi-

                   6  bility, probably none or almost none for the next six months.

                   7  And it has got two years to get anywhere and it is going to

                   8  take most of that time before you get  anything  operating  and

                   9  evaluations of PSRO have to be retrospective, they can't be
                 10   me-de in advance.    So this is no way to achieve survival value
                 11   for RMP.

                                 Now) I happen to think that R14P has done a@.great  man
                 12
                 13   good , and useful thing,,J.   It seems  to  me  that  RMP  will  survive

                      even if the  pro,,ram  viere  terminated  on  June  30th,  as  antici-
                 14
                 115  pqted.  Because it launched     so ma- ny programs and projects

                      which locally become sel4f-sufficient, self-continqing, and the-..,&--

                      fore it ha@s spawned a generation of plans which have some  slir-


                      vivcnl ,talue.


                                 I would like  ,to  embrace  the  concept  as  I  leave  the

                      Council of  feeling that, all    right,'we  have  got  some  money,   it
                 20

                      seem to be highly debatable      how much we have got.  But it
                 21

                      seems to me that the jurisdiction, the delegation of authoritv@
                 I?@).                                                                 i   s
                 231  ought to  be  in  the  direction  of  Identifying  those  good  th  ng
                      that the various  regions  have  under  iiay,  oarticula,rly,  with  a
                 24
                      categorical focus,, because these      lend themselves to the
                 25

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                                                                                                                                                              87

                                 1      greatest visibility. And to this I would add E@,

                                 2                          I  think  there  is  a  high  degree  of  'visibility  inherent

                                 31     in  E14S  where  somettij@i ng  has  been  accomplished.                                       An  ambulance

                                 4      witL-i  a  tiio-way  communication  system  in  it  is  something  you  can

                                 5      look  a@ whereas  a  contribution  to  planning  through  a  CHPB

                                 6      agency  has  no  visibility  at  all.    At  least  nobody  has  been

                                 7      able  to  see  it  for  seven  years,

                                 8                          So  I  feet  that  the  priorities  that  are  listed  here  I

                                 9      this  material  which  has  been  sent  out,.A  and  B,  and  I  don't  Icn

                               10       that  they  necessarily  mean  that  that  is  a  first  and  second

                                                                                                         I
                               11       degree  of  priority,  but  I  think  they  are  both  disasters.,    And

                               12,      I  think  we  ought  to  pull  oQt  of  them and  dedicate  as   little
                                        money  as  possible  and  to  the  extent  that  you  can  get  t                                            h.             f@
                               13                                                                                                                       :Lngs     o

                               i4       high     visibility  support  in  the  categorical  areas,  I  think  you

                                        would  imDrove  the  survival  value  of  RkP.
                               15

                                                           It  might  be  that  the  best  thing  that  could  happen

                               17       to   Rle     iiould  be  no  resolution  of'  the  problems  for  the  next  six

                               18       months       and  you  get  another  year  on  a  continuing  resolut@Lon.
                               I,,,I'Then  you  have  got  a.  year  and  a-half  to  achieve  more  visibility.
                                                           I  happen  to  think  that  there  is  enough  that  has  been
                               20

                                        accomplished  in  these  seven  years  that  if  we  go back  to  build-
                               21
                               22       ing  on      those,,  vie  will  E.,et  somewhere.                          And  if we  are  tagged  enter

                                        programs  which  are  now  the  responsibilities  of  other  agencies',

                                        after  q.11,  PSRO  has  its  own  administration  somewhere  or
                               24  !I
                                        eventually will  come  out  with  one,  You  have  got  the  BQA.  which
                               25

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                                                                              88


                1  has the problem, and in no way is this germane to the  philoso-

                2  phy of our RI,4P or a place to squander our few dollars.
                3@l          The same thing is true of the HMO legislation,

                4  there is some little thing going to come out of Congress,

                5  I assume from the conference committee, and it is going to be

                6  probably picayune, probably towards the $45 million 4..@year of

                   the scale rather than the Kennedy $805 million a year.

                8  And I am sure they will be happy to have RMP money and I am

                   sure that it isn't going to give us any visibility.  Because it

               I0  is a very small amount of money when you consider that HMO's

                   have now been taken over by the commercial insurance  industry,

               12i by Blue Cross which has a commitment to start 287 of them or

                   something, an outfit out of Los Angeles that is running 50;  an

               14  outfit out of Saint Louis, investor owned for profit,,runhihg

                   30.
               15

                             This whole thing is out of our ballpark and we shouldryt

               17  waste any of our funds in it.

                             These are my sentiments and they are directed pri-

                   marily at those priorities and options which I think should not

               20  be determining for the use of any available funds and that is
               21  why I specifically requested the question as to whether they

                   belonged @n there instead ofcr in addition to legislation.

                             Because if they are to be put in there, then  I  think

               24  they are wrong.
                             DR. PAHL:  Well, thank you very much for the statement..
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                                                                                 89

                 1  and I don't know that we want to limit Dr. Cannon to later on
                 2      perhaps you would like to add to this, Dr. Cannon, or other
                 3  members of the Council, since I think it  does  point  upsome
                 4  of the discussion we have had this morning, particularly from
                    Dr. Margulies., relative to the way these options are now seen,
                               Before, however,, opening up, let7me say that  later

                 7  we will have a presentation and some material for you to con-

                    sider from Mr. Gardell, which again will give to regions, re-

                    gardiess of their former triennial or anniversary status, the
                 9

                    opportunity to exercise discretionary funding authority.
               10
               11              Of course, with headquarters trying @to monitor  e. nd

                    keep in touch with what the activities  are  within  regionEi bu
               12,
                    we are not limited again to the optior@s as liste(%  and  we would
               13
                    also have to indicate, as we  discussed  the  kidney  program a i@t-
               14
               15   tle bit later this afternoon with that whole activity under
                    SSA and so forth,. that this option is not one that is going

                    to consume either many dollars  or  be  particularly  productive
               j@ I
                    as it has in the past from an RN:P point of view.

                               We are very instrumental in starting up many things,.,

                    but we now have to fit into a broader set  of  federal  reglila-
               20
                    tions and positions.
               21
                               I would appreciate having anyone on Council,,  thought
               22
                    add to or comment upon Dr. Roth's statement, which I appreciate

                    very   much.
               24
                               Yes, Dr. Schreiner,
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                                                                               90

                 1            DR. SCHREINER:  Yes. In a smaller way, I think there

                 2  are many, many things that are very pertinent that Dr. Roth

                 3  stated. And I am a little bit bothered by  what  youjust  said.

                 4  Because the real objective of RMP was to provide seed money anil

                    facilities in the homes that other people would take  over  the

                 6  delivery costs and even to some exsent the administrative cost.,,)

                 7  as the program become valuable

                 8            Now,, what you are just saying to me is that  because

                 9  another agency has been set up to do precisely that,  we  shoul

               10   back out of the business.

               11             Actually we are in a very critical 8ituationv7ith
               12,1 respect to Social Security Administration; that is,  they  have
               13   the money for delivery of the medical care almost ahead  of  ti

                    before the facilities and the seed money has in fact been spent-,,
               14
               15   And I couldn't think of,anything that would fulfill what Dr. Roth

                    was talking about, the traditional role of RMP, other  than  to

               17   see that this great big bloc of federal money Is indeed well

                    spent by virtue of having appropriate facilities.
                              That is why the item this morning, you know,  it seel
               20   kind of silly on the one@hand the,appropriatihg  $150  million;
               21   on the other hand., taking away thelnephrologist for  this  pro-

                           hich is being done.
                    gram, w
               22
                              We have the first or second largest program in the

                 11 country. We have called people and told them they  are  out  of
               24
                    a job as of July.
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                                                                                       91

                  1             Tf you put the cart before the horse -- I am trying

                  2  to say you are almost  in  the  point  where  one  federal  agency  ha
                  3  an obligation  to  see  that  the  other  one  works  properly.  And

                  4  to get the people and facilities on deliveryline where there is


                     assurance,
                  5
                  6             Many times we  have  programs  where  we  took  the  absur-

                     ances from states or universities, or something like that, that

                  8  this program would be taken  over,  whereas,.We  all  knew  deep  down
                  9  inside of our hearts there was no way it could take over this

                     kind of financial responsibility.
                 10
                 11             Here we have got a sitLa tion where we know it can

                     be taken over and where we ban really interdigitate 'in'@-l'a
                 12
                     very, very  meaningful  way  rather  than  in  a  never-never  land.
                 13,
                                Now, what discourages me a little bit is we went
                 14
                     through;,the great  business  of  establishing  our  five   priorities
                 15
                     for the  limited money we thought we would have for the phaseout.

                     We look,@.@through the yellow sheets, we see this message didn't
                 17
                     get through at all.  Some have zero percentages in five, in one

                     I ran into-- nothing in two or three of the priorities we

                     assigned.
                 20
                                Now, with that  change  not  even  beginning  to  be  imple

                     mented,,  we were asked  this  morning  that  we  should  change  and
                 22
                                                  and start off wth something new.
                    !I relax the five priorities
                 23 1
                    i           You know, this   is like you  haven't  even  got  one  foot
                 24
                     in the air in,?.hop scotch   court and somebody put another square!,


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                                                                                  92


                 1   out.


                 2             I agree the instability of the programs has been

                 3   very, very detrimental to the image certainly in the legis-

                 4   lative eyes, what the accomplishments are,  I am wondering if

                 5   we took sometime to set these priorities,,if we have the wrong

                 6   priorities, we should change them,  reset  them?  Shouldn't  we

                     stick to them a little whileat least long enough for them to

                 8   be implemented at least in a few areas?

                 9             DR. PAHL:  Let me hasten to add, I didn't mean to

                 10  have my remarks interpreted RMP,Q should pull out of  this  area.

                 11  What I intended to say was that we no longer have an.open,-ende(I

                 ]@2 Option, if YOU will, for doing what we consider to be important

                 13  in the kidney area without complying with the regulations whicli

                 14  are being promulgated by another federal agency.

                 15            So that I would endorse what  you  said  wholeheartedly

                     we certainly should continue putting money into the kidney

                     program, but now we must merge whatever  the  local  activities
                 t7

                     and desires are with also the realities under  the  new  legisla-


                     tion and federal regulations.

                 20            Dr. Roth,
                 21            DR. ROTH:  I just wanted to be sure George understood
                 2;@) that the net effect of my comment was not to  start  out  doing

                     something newo but is to go back to doing something old, to
                 2'1

                     restrict the number of priorities.
                 24

                               I would eliminate that A  and B completely and  I  woul
                 25

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                                                                              93

               1   stick with the rest, which basically seem to -- EMS and, as  I

               2   recall,, that hypertension and kidney disease.  And the only

               3   way I would extend that at all, since that covers heart disease,

               4   to a degree stroke, I would get cancer back in there some  way

               5   or other because I think this program did develop charisma

               6   with cancer and I don't think it has been negated by the  sub-

               7   sequent legislative appropriations in cancer. I tit nk  there

               8   ought to be some cancer in RMP.

               9             So I am going back to heart disease, cancer, stroke,,

               10  kidney disease, and EMS.  There I think you have got some

               11  opportunities for visibility. And I dorit think this is  any-

               12; thing new,- I think it is a reversion to the solid part of the

                   old.

               14            DR. PAHL:  Well,, Ithink there are two points I would
               15  like.  One is in the initial resolution that we offer for your
                   consideration,. which will be redrafted, we were attempting to

               j'7 explicitly state that funds could be used in the best,possible
               18  interest in accordance with existing legislation,, which,-,.
               1!) accommodates all of what has been said, but it can be  stated

                   explicitly. And the other is it may be that the Council
               20

                   would wish to frame a resolution along these lines and make@
               21
               1)  recommendation, if you will,,,, as to its position, and a recom-
               -2

                   me data on to the Department*
               2'@
               24            We would be very pleased to honor and forward any
                   such official statement from the Council. This could  be  done
               25

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                                                                              94

                 I  so that it could be discussed again, ifyou,wish, tomorrow morning


                 2 or--

                 31'         MR. OGDEN-. Dr. Pahl, I would hope that if  we  begin

                 4 to make statements about categorical activitieso that we  on'

                 5 go back to assuming that our categorical activities  are  going

                 6 to be limited somehow to continuing education and  to  training

                 7 programs.

                 8           I think one of our purposes has always been we tried
                 9 to expand the accessibility and availability of care.  And I

               10  think it is too easy to categorically simply to say in the area

               11  of continuing education.

                             Whi Le I the nk I agree w i th much of what Dr. Roth is
               12

                   saying and Dr. Schreiner is saying about the fact that  we seem
               13

                   to jump all over the place as to where we put the emphasis  o-n
               14
               15  what we are doing, in these days, as,.we mentioned having coffee,

                   in these days of the dollar crunch, the new baby faced  is  na"

                   ti6naL. with necessity of spending large sum of money for
               17

                   crash programs on energy- the cost-effectiveness of everything

                   becomes far more vi a 1.

                             I think we woul d be amiss if we went back categorical
               20

                   to continue education.
               21
               22            DR. PAHL:  The Department, of course, has  set  forth
                   its opinion earlier in the year relative to so much emphasis onl
               2 tl
                   the professional continuing educational aspects and was the
               24I
                   rationale by the Department for termination of the program.
               25

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                                                                                   95

                 1             This is certainly a key  matter  for  Council  discus-

                 2,  sion and I feel that you should be given opportunity now or ag,) r

                 3 1 tomorrow morning to either continue the discussion  or  to  phras(@

                 4   something beyond the @matter of the transcript in the sense of

                     a formal position or recommendation to the Secretary.

                               Dr. Schreiner,

                               DR. SCHREIMR:  Yes     ou get into som conceptional
                                                     y

                 8   problems,, Mr. Ogden.  Because you see Social Security says wha,

                 9   they are hoping now in their preliminary talks is to have so@

                 10  sort of primary, secondary, and tertiary  care  arrangement  whLeli
                 11  we have talked about in relationship with EIC and other kinds

                 12  of facilities.
                                Well, you know  if you say  "Okay, I am going to

                     hook 10,, so many hospitals up to a@ center., - a@', raedica I center,
                 14
                     for anything,, whether transplantation, what  have you,, to  say
                 15
                     that you are going to do that without any professional educa-

                     tion or some kind of education along the way to develop the
                 t7
                     proper manpower-- because those people don't exist,  There
                 18

                     'is no@nurse spec:L      you know
                                      alist             out in the community hospital
                     in a. rural areai  If we are going to endow them with capabilities,
                 2,0
                     of performing, if we are going to hook them up to a medical ce@-
                 21
                  i  ter., therelhas got to be some kind of education.

                               But I agree with you  I think what you   are   talking  i
                 2
                     about, Ed is saying, okay, I am just  going  to  train  ten  people
                 24
                     in the hopes that they may filter some way  into  the  health  Sys+
                 2 5
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                                                                                         96

                   I  agree with you perfectly on that,

                   2             MR. OGDEN:    I am  also  saying  I  don't  think  you  could

                   3  ignore the necessity of local planning.  I dodt think you@can

                 @4   ignore  either  the  requirement  of  quality  assurance.   Even   If

                   5  it is category.

                   6             DR. SCHREINER:  But putting a man in charge of

                      quality assurance  and  putting  a,  chart  into  a  computer  doesot

                   8  give you a p;ephrologist.
                   9             We  are  expanding  facilities  and  you  can  put  10  milli @n
                 l'O  quality assurance out there, if there isn't a nephrologist in

                      the program you are not going to have it.

                                 I was telling Mrs. Mars the analogy is putting a
                 121
                 13   county agent in a county doesn't get the cows fed,

                                 Over a  long  haul  it  helps.  But  if  there  is  nobody
                 14
                 1.15 there to  feed those cows, it isn't going to be done.
                                 MRS. MORGAN: Can't do it.

                                 DR. SCHREINER:  So it seems to me you have this
                 17
                      irretrievable amount of training that has to be done.

                                 MR. OGDEN-.  May not be done anyway.

                                 You are assuming  there  is  going  to  be  a,  good  nephrol
                 20
                      gist.  That is where I disagree, I think, with Dr. Roth; I
                 21
                      don't think you can ignore EMF.       I really don't.
                 22
                                       OTH-   I don It think they  do  you  any  good  in  the
                                 DR. R

                 24   survival  of the program.
                                 I am lookina at this thing as a fight for survival.
                 25

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                                                                                 97   1
                               The problem, you know,  in  my  capacity  in  the  medicail
                 I
                 2   profession,, certainly in the last two years, I ha-ve been travel-

                 3   ing the  country,  talking  to  the  medical  societies  and  he  non-

                 4   medical people, and with my interest in RMP, I check it out

                 5   for the visibility  that  is  achieved  and  what  the  local  profes-

                 6   sion thinks of it,, and unhappily  it  has  not  impacted  in  most

                 7   of tne areas.  Even some of ttie areas 'vie have been giving

                 8   tiie RMP's the best marks,  the  medical  community  couldn't  ca,re

                 9   less if it vanishes.

                10             I think it is too bad,,  because  I  think  it  hasn't

                11   communicated.

                               I think it has done a great many good things in these
                121
                113  areas that the physicians ought to know about and the    nurses,
                14   and the welfare people.  All the people interested in   half It h.

                     They just haven't looked on RMP as having contribute     .very
                15

                     much.

                               And You sure aren't going to,  in  the  short'l@space  of
                17

                     time that we have got left to fight for survival,  or  you  have

                     left to fight for survival, I don't think  you@are  going  to
                J!)
                     advance it much by getting into this morass   of quality coti-
                20
                     trol or planning, neither of which has: achieved any     particula
                21

                     visibility.

                               If we think we are in troubles actually  the  publ3-c  i
                2  7';i
                     evaluation of CHP is in general at a lower level  than  it  has
                24

                     been for MO.
                25

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                                                                                                                                                        98

                                                          Great concern about the 9.ccorri@)lishi-aents o' i'A@ agen-

                                2     cies or B agercies manifested by the fact that many states are

                                3     now going the dertificate-bf-need legislation way,, as somethin@

                                4     in addition since CHPS and Ph-B didn't get very much of any-

                                      where.

                                6                         It isn't that I don't think these things are i,lmpor
                                      tant, I think they contribute no visibilityat least effectiv(@,
                                      way of trying to ensure two years from now ,7e have an PM

                                9     program.

                                                         DR. PAHL:            Thank you, Dr. Roth.
                              lo

                                                         Dr. Cannon, you indicated you have some comments to

                                      make,
                              @12
                                                         DR. CANNON: Yes. My friend RQssell said                                           he was go-
                                  i   ing to       give his last gasp. I though.t6that was sort                                            of typical;
                                      he always does that -- and gets everybody else hyperventilating.
                                                         (Laughter)

                                                        So to follow his usual                        plan. I suppose that I am not
                                7
                                      going to have a. swan song to say                                for.@'the both of us, Russell,

                                      but  I will  say    probably because  of  my  visceral  reaction  for

                                      lunch,  I  do have  a  gut  feeling  for RMP  and  it  sort  of  sums
                              20

                                      up  the  whole  picture  for me,@like  I'came  in  to  sit  down  to  a
                              21
                              22      delicious  and  pleasant  and  delightful  experience,  a  fine  meal
                                   land  I  ended  up with  hash.

                                                        (Laughter)
                              24
                                                       Hash  is  not  so bad  if  you  are  hungry  enough,,   if  you
                              25

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                                                                               99

                1  remember, some of us in the Depression years.  And  I  think  if
                21 we can take that hash and put it where it really is needed,,
                31'1 that we may still gain that visibility.
                4            I would agree with everything you have said about the

                5  change of the focus and messing around, and  about  every  facet

                6  of the health care Industry which we have  done.  But  it  really

                7  hasn't been any fault of ours  Russ.

                             DR. ROTH:   No.

                             DR. CANNON: It has been the fault  of  what  has  come

               10  down throui-,h the Administrations and others.

                             Just like we get the directives of where this money i3

               12,- going to be spent before we even discuss it,  And  that  sort  of

               13  has been typical.

                            @l would just plead that, well, one other thing,the
               14

                   visibility of RMP     and I have said this before, many years

                   ago    's'that if you are going to paint a p:Lcture that somebody

                   sees some@t ing ido you can't      all your paint together befor
               17

                  'yo,Li,,start painting, because it all comes out gray.

                             You have just been running around the country finding

                   out that everything is gray., and there i-s no perception as  to

                   what RMP has done.  But RMP has done,, it is just hard to get th@i-t
               21

                   perception.

                             I would like to see the suggestions  that  Russell  has
               23
                   made to you, I would like to see what is left  over  now,  hash,,
               24
                   applied in such a way that the program can get to  an  area  that
               25

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                                                                              loo

                1   not only is needed, but gives visibility.

                2             So far as swan songs are concerned, Russell, we

                3   have heard a good many of them -- not many from Council members,

                4   but tie have had people pass through here like Mahoney,

                5   Cro---by, Brennan,, DeBakey -- really with very few swan songs;

                6@  but we have had a lot of swan songs from Olson., English --

                    (laughter)    Irv Lewis, Vern Wilson, you know,, wel@realISr-.have

                8   heard  real  so we can see one of the reasons thatthe stake

                9   in our operation isn't all that we would desire.

               10             I really don't have anything else to say on this

                    except I really have gained a lot personall  from the sta f,,

                    they have been wonderful,, and friends among the staff throughout
               12

                    the membership,
               13

                              I have learned a lot about how the government and
               141
               15   BMT works -- or doesn't work.
                              (laughter)
               1(;
               17             DR. PAHL:  Thank you very much, Bland.

                              YoLl were getting me nervous there with your listing o


                    swan songs.
               20             (Laughter)

                              MR. OGDEN:  He is saying there is a difference
               21

                    between us sitting ducks and the swans.
               22
                              (Laughter)

                              DR. PAHL.-  Mr. Baum is our local pundit.  I am glad
               24
                    to see we have a distinguished pundit.
               25

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                                                                                   101

                 1              If we may indulge you in one more short presenta-

                 2   tion, because Dr. Margaret Sloarehas to be over at NIH by

                 3   the tim we will be able to reconvene.

                                I would appreciate very much if she would present t(
                 4

                     you the final result of what  has  been  accomplished  under  the

                 6   section 907 of our Act, and the publication which I see her

                     trying to bear to the table here,

                               Sheland Mr. Robbins have worked diligently over
                 8

                 9   these many, many months to produce a  set  of  volumes  which  we
                ,o   believe is going to be a reference work that will be of great

                     importance to many individuals, many groups around the country.

                               With that, Margaret, will you please tell us what
                12

                     you have been doing.
                 31                                                                    1
                14             DR. SLOANE: We hope it will be useful.

                               This is a progress report on the activities that
                15
                     have been carried  out under section 907, which most of you wl'i.IL
                17   remember started out saying the Surgeon General should establish
                     a list or lists of medical facilities in the country@     staffed

                     and equipped to deliver the latest advances in heart,,    cancer,

                     and stroke,, and kidney disease was later  added,  and  r6sponsi-
                20
                     bility shifted to the Secretary,
                21
                               Under that section of the legislation,, we carried out
                22
                     the various guidelines, contracts which you have heardebolit

                     before, in the field of heart disease, cancer, stroke, and
                24
                     end-stage kidney disease.  And once -vie@had the guidelines,   it
                25

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                                                                                102

                 1  was determined the Joint Commission on Accreditation of Hospitals

                 2 was to carry out the criteria against which lists could pos-

                 3 sibly be constructed.
                 4@          As we went forward under the contract with the Joint

                 5 Commission, it became apparent to establish a list for each

                 6 disease entity might not be in the best interest of the country,

                 7 and that actually since each of the guideline contracts had

                 8 come through with the concept of a stratified system of care

                 9 with every hospital in the country having an appropriate  mis-

               10 I sion to perform in relation to these categorical diseas@

               11  that it would be more appropriate to develop  a  three-levelat

               1.2 least a tiaree-ievei set of criteria in each of the disease ar--a,@.

               13  And that these different levels of hospitals should  be  linked
               14  together in appropriate ways so that  referral would quickly

                   bring a patient to the level of care  which was most appropriate
               15

                   for h-IM.

               17            Therefore, the Joint Commission decided  to  develop

                   sets of criteria in each OP the disease areas which would pro-
               18

                   vide goals for every hospital in the country to  work  towards

               20  in relation to these diseases.

                             Four criteria documents have now been completed.  The
               21
                  lend-stage kidney disease and stroke documents have already       I
               22
                   appeared in the JAi4A in October.
               2'@
                             The Heart disease guidelines.or cri-teria-- I am  sorry!
               24
                   should be in this week's JAMA., and cancer should appear
               25

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                                                                                 103

                 I sometime in December.


                 2            These are considered tentative documents and comment
                 11
                   and criticism is earnestly solicited.

                 4            All comment and criticism and all the discussions

                 5 which mernbers of the various expert committees are holding

                 6 all across the country will be fed back  ]Into  their  considers,

                 7 tion and revised criteria will be  established  sometime  in  the

                 8 spring&

                 9            Now,. if any listing of hospitals were to be developed

                10 it was obvious that we would have to  have  information  on  what

                11 was actually present in hospitals in  the  country,  which  would
                12@ give them the possibility of delivering the highest quality of

                   care for heart disease, cancer,  stroke,  and  end-stage  kidney

                14 diseas64 So the Joint  Commission,  in  addition  to  developing

                15 the criteria statements, sent out questionnaires to every

                   hospital in the country, and I thought I would pass around

                   copies bf"t@ie questionnaires so that you  could  perhaps  take
                1'7

                   them with@@youo because I aca going to ask each of you to  do  s
                18                                                                ome-

                   thing for  us in rele-tion to the questionnaire.

                              The questionnaire was sent out In  September  1972  to
                20

                   every nonpsychiatric hospital in the  United  States  from  six
                21
                2  beds and up.
                2.@           The'response was really tremendously encouraging, and
                  !I would like to take this opportunity  to  express  deep  appre-
                24
                   ciation to the American Yiedical Assocition',  American  Hospital
                25

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                                                                               104

                1  Association, for their great assistance in assuring a good

                2  response to this questtiona,ire.

                3            As it now stands, the returns represent over 92 per-

                4  cent of all the hospital beds in the United States. That Is all

                5  the short-term nonpsychiatric hospital beds.  The  response  in

                6  terms of hospitals is not quite so high$ because the small

                7  hospitals., 6 to 50 beds, which had very few  resources  or  he

                8  treatment of these diseases, did not give ,i very good response.

                9  But we were over 95 percent of hospitals  over 300 beds, and 9"

               10  percent of those over 500 beds, and the response I  think  has

               11  really been remarkably good.
               12            Now, these are voluntary questionnaire responses wit

                   some validation, a large number of telephone checks were
               13 1               0,
                   carried out of hospitals over the  country.  Any  questionable
               14,
               15  data were verified.  But this does not represent a large degreE
                   of site visiting to assure the validity of the data.,

                             Nevertheless, the data have now been  compiled  and,

                   for better or for worse, here they are,  (Indicating)

                             These volumes,v6 might pass these around  too,  Bob,
               20  you can pass them one at a, time, just so you can look at  them
               21  and see what kind of record these represent.
                             It is compiled in the same way that hospital guides,.
               22
                   American Hospital Association has done, and this represents in!
               23
                   these various disease areas and with separate volumes for
               24 1. i
                  Ihospital organization, pathology and radiology, the inforinatio
               25

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                                                                                      ot:;


                  1  that we now have available on hospitals  in  the  United  States.

                  2             I my say we have been deluged, really, with requests

                  3  l'or various cuts of this information and it has been a con-

                  4  siderable problem to us to know just In what formto present

                  5  the data,, tha.t@ 'Isy sumwries of various aspects of the  data,

                  6  so that it could be most helpful.

                  7             I would like to thank Mr. Joe Ot@ down  there,,  for  his

                  8  excellent  assistance in helping us with this  whole  e_,,,ercise.

                  9             We have received questions  of  this  sort-.  How  many

                10   hospitals  are there in the  United  States  which  Provide  renal

                11   dialysis 2LI hours a  day?  How  many  hospitals  are  dolngcpen

                12   heart surgery?  How many are doing coronary bypass surgery?

                     How many operations were done  in  each  of  these  categories  dur-
                13
                14   ing the past  year?  How  raany  hospitals  have  hospital-based
                15   cancer registries?  How many of these are physician directed?,,

                                There is a  great  amoOnt  of  information  which.is'

                1 7  available.

                                iNow, one of the requirements  on  the  Joint  Commission

                     on Accreditation of Hospitals was that  before  the  end  'of  their

                     contract, they should  make  a  redommendation  through  the  Board
                20

                     of Commissioners of the  Joint  Commission  to  the  Department  of
                21

                     HEW as to what should be  done  with  this  information  in  the
                9-2

                     future. And  their  Board  has  recommended  that  th@  kind  of

                     activity be continued with some modificetiods.  They believe it
                24
                25   should be broadened, that it probably should eventually      include

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                                                                                io6

                 1  respiratory disease, arthritis,. dia.betes.

                 2            Actually the questions that we have asked in the

                 3  laboratory field and in rehabilitation and in a number of other

                 4  areas have been sufficiently broad to serve the purposes of the

                 5  other four disease area@ that there is very little additional

                 6  information that would have to be added to obtain data in

                 7  these other areas,

                 8            The American Hospital Association is interested in

                 9  working with the Joint Commission on this,   The American Col-

               10   lege of Surgeons is particularly interested in joining courses
               11   with the Joint Commission. And In addition to renewing this

                    questionnaire which will be done,, will presumably be done with-
               12
                  1 in another year or two, it is proposed that the Joint Commis-
               1.3
               1.4  sion over a voluntary accreditation program,, sothat hospitals
               15   may ask to be inspected by the Joint Commission with the help
                    of specialists in the different disease areas,, and to receive
               1,7  acknowledgement that they fulfill the criteria for a  primary,
               18   secondary or tertiary lev, el hospital "in one of these disease
                    areas, Whether they are to be called primary, seconeary or
               l'o
                    tertiary or A,B,C,D, or whatever, we are not sure yet,, but at
               20

                    any rate to offer a kind of Voluntary accreditation  service
               21
                                                                                o  @r-
                    comparable to that of the American College of Surgeons has  ff
               22

                    ed in the field of cancer.

                              If this is to occur,, it is possible that the  Amerloa@
               24
                    College of Surgeons may turn over its cancer  approvals  programi
                                                                                    i
               25                                                                   i
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                                                                                       107

                  1  to the Joint Commission or the Joint Commission may  subcontract

                  2  with the American College  of  Surgeons  to  do  this  in  the  field

                  3 1of cancer, but this is a model of the sort of thing that  they

                  4  would propose to do.

                  5             We have  had  one  extensive  discussion  with  Dr,  Porter

                  6  field  on  this  subject,  The  Health   Resources   Administration

                  7  and  Health  Services  Administration  have  both  expressed   Interest

                  8  in supporting the initiation of  this  program,.and  at  this  momeni-A

                  9  it seems probable that this will be undertaken.

                 10             I think  it  is  interesting  to  note  that  the  State

                 ii  of Massachusetts  has  come  through  with  a  very  excellent  legis-

                 12  lation for  hospital  programs,  for  cancer  programs  id  14assachu-

                 13  setts   -                                                       d  cu-
                             vihich embody most  of  the  principles  in  the  cancer  o

                 14  raent, cancer criteria document, ,i,nd recommend three Levels  o.'L-@

                     hos pi to, Is @@i i th close linkage in between.

                               @What  I would like to ask from    each of you  is  that  if

                 17  there is  any question you would like to     put to these data,

                                                                   0
                     if-there  is any kind of information you     c u@ld identify that  YoLt

                     think would be helpful to you  or  to  others,  let  us  know  and  we

                     will try  to  prepare  the  information  in  accordance  with  your
                 20

                     requested
                 21

                                Some of the requests  we  have  had  have  been  to  run
                 22

                     the data on a  single  state  basis  and  several  of  the  compre-

                     hensive health planning agencies are using the data       in   this
                 24@
                 25  fashion or plan to.@ We can have special runs for anything        in

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                                                                                                                                 108


                           1    the field of these four diseases and for general hospital


                           2    resources.

                           3                    So we will welcome your requests; if It happens to

                           4    be something that will cost too much money., we might  have  to

                           5    charge for it, but we would welcome your comments, yoLu, criti-

                           6    cisms, ans any suggestions as to ways in which  we  could  make

                           7    this data useful as possible.

                           8                    It is something that  regional  medical  programs  must

                           9    take either the blame or the credit for, and  we  would  like  to

                         10     make it as useful as possible.

                         11                     DR. PAHL:  Thank you very much, Dr. Sloane.

                         12                     I believe Dr. Sloane was a little  overly  modest  in
                         i3     saying the blame or credit, because it is, I am sure,, only'
                         14     credit.        It has been a tremendous cooperative effort a d we
                         15     certainly would like to make available to Council  any  or  all

                                of the volumes that you may care to have.  Some of you may not

                                        to have any.
                         t7
                         18                     If you will indicate to Dr. Sloane whether just
                         1!)    particular volumes or full sets, we will get them to you.  But
                         20     we didn't want to burden you with material unless you would

                                find  it  of  interest and  value  .'Ln havinc,  it.
                         21
                         22                     DR.  SLOANE:   They aife being                xaailed    out    the     thir     ieL,

                                of November  to all  the  regional medical  program  and  to a@
                         2,'.',',

                                broad mailing  List.
                         24
                                                DR.  CANNON:          Council racriabers?
                         25

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                                                                                         109

                   1              DR. SLOANE:    If the Council iaembers wish them,

                   2              DR. PAHL:  Does everyone on Council wish to have

                   3   a full,. set?


                   4              Why don' t we,raail a full set to each of you?

                   5              If you have another rainute  or  two  before  you  ha,ve

                   6   to run, I  wonder if there are any q@ stions or comments by

                   7   Council on this matter?


                   8              It is  something  which  you  have  been  involved  with

                   9   and It is  nice to see the culmination of a complO,@ effort.

                   10             I think a lot of people deserve to be certainly com-

                   11  mended for it.
                   @2             MRS .MORGAN:    Is there any plan for updating these?

                   1              I am sure they change  --  this  was  done  in  1972;  I

                   14  am sure--

                   15             DR. SLOANE-.  As@  I  indicated,  the  Joint  Commission

                       has proposed they undertake the updating of this; whether it :D,,

                   17  dbne@,:'next spring or ne@,t fall,, or j@ust,how soon,  we  are  not


                       s Lire.


                   if)            I thi*it is impossible     to'do this every year.      It

                   20  is too b,'LS an undertaking,

                   21@            MRS  kIORGA N: Could this,   though, be part  of  the  ir

                   2   accreditation of hospitals in updating this?

                   2311           DR. SLOANE:  Yes.  The visiting program which would

                       be undertaken - one  of  the  reasons  it  was  decided  not  to  go
                   24
                       ahead with the establishment of lists at this point is that th@
                   25

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                                                                                  110

                    Steering Committee of this effort felt very strongly that no

                    kind of accreditation should be given to 1-iospital@ no kind
                 2

                 3  of lists should be established unless  there  was  actual  site

                 4  visit by adequately qualified people. And it is that sort cf

                 5  effort that the Jo3'-nt Comission would undertake.

                 6@            They would expect to do the inore housekeeping part oC

                 7  the inspection as part of their regular accreditation visit,

                 8  but they would give"a special kind of visit for a hospital

                 9  that wanted to be accredited as, let's say, a cancer,,or region-

                 10 al cancer center.

                 11            DR. PAHL:  Dr. Roth.

                               DR. ROTH:  I don't know whether it  is  possible  to
                 12

                 3  answer this question, but what did this effort  represent  .'Ln

                    terms of RIVIP expenditures?
                 14
                 15            DR. SLOANE,: The JCH contract has been  about  100  --
                 I  first year was @,)120,000; second year $150,000,  80  that  these
                 17 seven vbluraes plus the criteria documents have represented
                 18 $?-75,, 000.

                               DR. ROTH:  In grants out, or is this total?

                 20            DR. SLO-AITE This was a contract wit[-, joint-- this
                 21 does not include cost of guidelines,, with the  American  College
                 22 of Surgeons, Araerican Heart Association, American Neurological

                    Associ-ation, National Kidney Foundation.
                 2 '3

                               DR. PAHL:  What would that have added to it?
                 24
                               DR. SLOANE: Well, each of those  came  to  about  four
                 25

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                 1   not the kidney one,, that was done really by the National

                 2   Kidney Foundation, and we only paid the travel expenses of the

                 3   experts who came to the meetings really. But  the  other  three

                 4   have been quite ad expense.

                 5             American College of Surgeons was the first one,

                     $350,,000; American Heart Association is a  continuing  activity

                 7   still going on, they are continuing to revise and update,,  and

                 8   I think that would come to about $450,000.  And the American

                 9   Neurological Association about the same,

                10             But these represented an enormous meeting,,  enormous

                11   n@er    of experts, top people in the country meeti.ng,again

                12   and again and again to h,9,mmer but materials, not all of  which

                13   have been published.

                14             The ICHD documents were published serially in the

                15   journal@ circulation and they have now been collected and

                     are about to be published as a single volume.

                               The stroke documents are still coming out In the

                18   journal Stroke, and they will probably be collected into a
                1!1  single volume eventually too.
                20             DR. PAHL;  Well,, thank you very much.
                21             -Are there other questions before Dr. Sloane

                     departs?
                               Thank you again, Margaret, and to all of those on ou@
                231
                     staff who have participated in this.
                24
                               I should say there are a few extra copies of the


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                                                                                 lip

                    questionnaire so if other visitors present today would like to

                 2  have a copy, or others, I am sure they can get a copy from
                 31 Dr. Sloane's office.

                 4            Now I would like to come back to the housekeeping

                 5  detail, which has to do with lunch.

                 6            I am sure we have worked you overly long this mornin@,.$
                                                                                     1
                 7  but we appreciate your indulgence.

                 8            We have not gotten through our public discussion

                 9  session, but I think what we would prefer to do,  if  you  will,

                 10 is to have Council members and the staff who have already been
                 11 identified, those who are working very closely with the regioni   ,
                 12 have lunch in this room  and those so honored may pay Mrs. H,@n@el
                 13 at the door $2.25 and we hope that thesandwiches that have bee

                    ordered and the little side things are cost-effective,
                 14
                 115 let's put it that way. We have to pay  for  room  service.'

                              The other merabers of the staff and visitor.1  we ask

                 -  if you will leave, because this is a  closed  executive  session
                 (7

                    in which we will be discussing matters relating to specific
                 18
                 I!) regions, specific grants.  No formal actions will be taken   in

                    thissession. It is designed to  give  the  Council  members an
                 20


                                                                                   f
                 21@ opportunity to get some first-hand information from our  staf
                    as to activities within regions, so that as we go through today@
                 22
                 2  and tomorrow, you will be better able to understand the status,
                    now, of regions and make we hope better judgments,
                 24
                             We would like to have visitors and the staff who a-re
                 25

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                                                                                     3

                 1 not -oining us for lunch reconvene, oh, I think an hour should
                 2, be plenty of time. Le'-u us reconvene in  open  session  no  later
                 3  than five of tiio;, because we do have a f Lill agenda. -' That
                 4  will give as a full hour. And at that  time  we  hope  to  have  a
                 5  discussion of the kidney program by Mr. Spear and comments

                 6  and discussion by Council,, we have a presentation with some

                 7  actions and considerations by Counci I a,nd presentation by

                 8  Mr., Gardell., and -vie have an overview of matters which will  be

                 9  more meaningful to you, overvieo7 of the  REP's  by  Mr.  Petexson
                io  as we then go into again executive session to discuss specific

                11  grant applications.
                12@l           So with that, if we may reconvene at five of two for
                13  the open session a-nd Council and appropriate staff now adjourn'

                14  for lunch.

                15             Thank you.
                               (Whereupon, at 12:55 o'clock  p.m., the meeting

                                     d, to reconvene at 1:55 O'clock, Pomoq the
                t7       was recesse

                               d y
                18        same a


                1!)


                20


                21


                22


                2,3


                24


                25

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                                                                               114

                1                      AFTERNOON SESSION
                21                                                (1:55 p.m.)

                3            DR. PAHL:  Will the meeting come to  orders please.

                4            May we reconvene our afternoon session,

                5            This, again., constitutes an open session of the

                   Council and we have a number of items left before we get to
                6

                -  applications, So I would like to indicate first  of  all,  that

                8  the discussions that you had during the lunch hour are  svbject

                9  to the confidentiality which Council has always observedin

               10  matters relating to specific grants and applications, and  the

                   fore should not be discussed apart from the staff and  Council

               12  members.

                             The present session is ancpen meeting and we  expect

                   to have some public participation as well as continued  presen-
               14

                   tations by our staff. Because Dr. Schreiner must  leave  before
               15

                   too Long,, @I would like to ask Mr. Matt Spear if he would

                   please present to you the status of kidney activities., and
               i7@

                   then have a general discussion by Council concerning any mattert

                   on this point, since it will involve some of the  applications

                   that you will be looking at this afternoon and tomorrow.
               20
               21            Matt.
                             MR. SPEAR: I am not sure what the specific  level  of
               2.-)
                   understanding of this activity Is So with tLpol6gy,for,some

                   repetition of things. I know a lot of you are familiar with,
               24
                   let me start from the year one.
               25

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                                                                                115

                 1           HR-1. which was major legislation in 1972 so  far  as

                 2 the health area was concerned,, finally was enacted on  October

                 3 30th last year into'Public Law 92-603.  Those were principally

                 4 amendments to the Social Security Act,  And within that public

                 5 law was a very short section labeled section 299I, which dealt

                 6 with kidney disease; and to clarify what I am speaking  about.,

                 7 I will give It a name and even though it doesn't show up in print

                 8 anywhere, I am speaking about what has become a  national  end-

                 9 stage renal dialysis program, or as we call it in shorthand.,
               101 ESRD program.

               11            The provisions of 299I are how incorporated in section
               12! 226 of Title II of the Social Security Act,, and under those

                   provis ions . @e nd -s tage .,kid ney d isease patie nti3 - have @ broader covqxl-
               13

               14  age under Social Security, Medicare, than any of the  other

                   classes of citizens.

                             The law now extends coverage to citizens under  65  whc

               17  require end-stage renal dialysis, if they are  currently  covered

                   for Social Security benefits and this coverage extends to
               18
               1!) their spouses and dependents.
               20            By virtue of those patients who  receive  renal,dialysi

                   ot transportation and supported by Medicare payment.% have
               21

                   available to them all the coverage of Medicare., so it Is quite
               2

                   a large thing., very precedent setting in many respects.
               2.1

                             Work on implementing 2991 began even  before  enactment
               24
                  -of the law by members of the Bureau of Health Insurance in
               25

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                                                                              i  16

                1  Battimoreo coming down to RMPS, and discussing with us a  n  um-
                2   ber of aspects,, and those conversations accelerated in succeed
                3 1 ing months.  And Ithink at best one can only state the activity
                4   suffered the fait of many things in these trying days;  it  had
                5   several false starts and we hope now we are on the final lap

                6   of the race,
                7            The law was effective, the coverage of end-stage
                8   renal dialysis was effective July 1. 1973, and by that time
                9   the program should have been ready to be implemented, but i
                10  wasn't, And so to get the wheels  rolling  interim  regulations
                11 Iwere published on June 29th, and the Interim regulations estab-
                12,1 lished an interim period to begin on July 1. 1973,, and to  ex-
                    tend to some unnamed date., which is labeled when the permanent

                14 1program is promulgated.
                15            So we are working with Interim regulations  In an in-
                1(; terim period to provide Medicare payments support forli,ronal
                -17 dialysis and transplan  care,
                18            The interim regulations did several things.  It
                J!) in effect put a moratorium on the development of capability to
                20  provide care. It did so by saying anyone  in  the  busineiss.of
                    providing renal dialysis or transportation on or before
                21
                2;-) June 30., 1973., would be reimbursed for the services they were
                    providing at that time,
                21
                              The level of services they were providing at that
                24
                25  time.

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                                1     be  considered  temporary  until  the  permanent  program  is  mounted.
                                2                        And  the  reasons  for  that  I  think are  best explained

                                3     further  back  on  pages  2  and  3  in  which  it  is  said,  well,

                                4     for  instance,  in  the  second  paragraph  it  says  with  regard  to

                                5     transplantation,,  there  are  six  criteria  provided  which are

                                6     expected  to be  contained  or  required  under  the  permanent  pro-
                                7     gram,  And at the bottom of page 2 are the criteria of which
                                8     the dialysis facilities ate expected to have to adhere to in
                                9     some  respect.
                              10                         These provisions place a condition on the use of

                                    RMPS funds.  And the condition is this, that if those funds are

                              12      being employed             I in any way to expand someone Is services who

                                      was already in the business on June 1, or if they are to be

                                      em toyed in the development of care capability where it is not,
                              14          p
                                      now at a stage to be covered for Medicare reimbursement, those
                              15

                                      institutions,,  regardless  of  the  source  of  the  funds  with,which

                                      they,are trying to effect these changes  must have that

                                      interim'ap
                                                       -.proval in order to go ahead,

                                                         We need to be sure that investments are not being

                                      made     in    areas where there may be a refusal or a disallowance
                              2011
                                      to@@-@Derfdrm the service that is intended to be carried out.
                              21
                                                         The onus for getting that approval falls upon the
                              22      performing institution.
                              23 11
                                                         Now
                                                                  when these regulations -- even before these regll-
                              24 l'
                                      rations were             printed, the interim regulations, the Bureau of
                              25
      HOOVER REPORTING  CO.  INC@     Health Insurance had queried all of the institutions of                                                       their
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                                                                                 119

                     record regarding their intent to participate under the program,
                     And most have responded with a "yea*fl
                 2

                 3             There were also responses as a result  of  that  query
                 4   from those who wished to expand their program as defined in tiLe
                 5   interim regulations andoertainly many of them who were not  yet;
                 6   in business who wanted to start new  facilities,  new  capabilitIes
                 7            All of those people are still waiting  for  an  answer.
                     Hopefully they will have their answer about January,, end of
                 9   January or early February.
               10             What is happening now is that the requirementsas
               11    they are listed within the interim regulations require  for  any-
                                                                                    I
                     one to make a judgment regarding a request for an exception  isl
               12
                     going to require a fair amount of information from these pro-
               131
               14    viders as to just what it Is they want to do,, and what it is
               15    they want to do fits in with what is going on already,
               i(i   And the difficulty has been in pulling together-in,,a package
               3-7   which encompasses or incorporates an application  for  exception
                     some expansion of the criteria with regard to exactly what do

                     we mean,, directions as to how you fill out this application,
                     and certain other forms and documents that go along to help
               20
               21    explain what is happening.
                             Everything is ready to go  except  the  application  for
               22
                     exception and as with many of these kinds of documents

                              (Laughter)
               24
                             -- some other people want to approve them and we
               25
   HOOVER REPORTING  CO,  IN. think we have those approvals in hand,, but we are right at   the
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                                                                                  120

                 1   brink of that. I hope within ten days  to  two  weeks  that
                 2   whole package, application form and all  of  the  associated
                 3   documents,, will be out In the hands of those people who need

                 4   exception request applications.

                 5              I thin@ Dr. Pahl, I should stop right there.  That,,

                 6   essentially,, is what it is and where we are.
                                I would certainly field the questions as best I can.

                 8              DR. PAHL:  Thank you.

                 9              Dr, Cannon.
                10              DR. CANNON:  When you say that an institution that

                11   has a dialysis program wants to expand into a transplant pro
                12,  gram, are you saying it is incumbent upon this organization tc
                13   give its approval for this expansion so it can,be paid by

                14   Medicare?

                15              MR. SPEAR:  No.  I am simply saying--

                                DR* CANNON:  Somebody has to.
                17              MR. SPFAR:  That RMP that Is about to provide the
                18   funding for that needs to be aware I think that the institu-

                I!)  tion should have an approval in hand,
                20              DR. CANNON::  But you don't know who will  give@ ttAt.@l

                21              MRS. MORGAN:  Who gives that approvals
                                MR, SPFAR: That institution should  raake  an  aplica@'
                22                                                             p

                2'@'i tion for exception.
                24              The approval will be a decision by a body   pulled
                25   together by the Bureau of Quality Assurance and will    be--

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                                                                              121

                             DR. CANNON:  Separate from this organization?

                2            MR. SPEAR:  Yes.  The authority for the interim regu-
                3   lations,, implementation of the interim regulations is a joint
                4   responsibility of the Bureau of Health Insurance and Bureau  of
                5   Qaulity Assurance, and there are work groups within each compo-
                6   nents working together topull this together.
                7            The facility will be requested to submit t-he
                8   application in triplicate Time is passing and  everyone  is  in

                    a hurr  on this,
                9        y
               101           One copy will go to CHPB agencies.  At the same time,
               11   copy should go to the CHPA agency, And  at  the  same  time,,  copy
               12   goes Into the Bureau of Health Insurance regional office,,
               13   which is one of the ten HEW regional offices.  That regional

                    coordination will be from the BHI regional o
               14                                               ffice.
                             The CHP agencies are permitted 30 days in order to
               15
                    do their review and they are to review on the basis cf need
               -i7  for that service,, aid to give their recommendations  to  BHI,  who
                    will collate the documents and review plus their own,, and

                    when CHP states the regional review will be a combination

                    of regional advice and BHI people that will come into the
               20
                    Bureau here.,and the plan  is  here there will be representation
               21
                 i  of the BQA and BHI people and a majority of outside professional
               22
                    people who will sit in judgment on these applications.
               2@3
                             DR. PAHL:  Dr. Merrill.
               24
                             DR. MERRILL:  Does this apply to an outfit which  has@'
               25

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                   1  been functioning for several years  and which wants to ex-

                   2  pand?

                   3             MR. SPEAR:  Wants to what?

                   4             DR. NERRILL:  Wants to expand?

                   5             MR. SPEAR:  Yes.  An expansion would need the

                      interim--


                   7             DR. MRRILL:  Any increase?

                   8             MR. SPEAR: Yes.

                   9             DR. MERRILL:  As I understand,, in addition       to what

                 10   you said,, you also need certificate of need from the        State

                 11   Board of Public Health; is that corredt!

                                 MR. SPEAR.-  Yes.  We would really be      asking for any
                   2,

                 13   kind of licensed certification, approval, that        is in operation
                 14   In that -locality, -We would like to have it documented as all

                 15'  clearances having been made.

                                 DR. PAHL:  Dr. Schreiner.

                 1 7             DR. SCHREIMR:  Do you recall how many s a es requize

                      certifica,t6s?


                                 MR.  SMAR:  I don' t reca 11.

                 20              DR. ROTH:  About 23?

                                 MR. MILLMN:  Twenty-two I believe,
                 21
                   2             MR, SPEAR:  That is more than I thought,  But there
                 2!1   iis qQite a variety.
                    I
                    i            DR. PAHL:  Is there other discussion on this matter
                 24 II                                                                        I
                      or related points?
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                                                                                123

                1             We are sending the Interim regulations to all  of  the

                2   RNF,8, As we go through the applications,, there will  be  point
                31  brought up for your consideration and in those instances,,  we

                4   will be reading to you a form,,short paragraph that will go  to

                5   the coordinators alerting them to the fact that the  ae  iv  y

                6   in question would need Interim Approval,, and RMP funds therefore

                7   should not be spent until such approval  iscbtained,  And  Mrs.

                8   Silsbee,, I believe, will read you the proposed paragraph as  we

                9
                    get Into the applications,

               10             Thank you very much, Matt.

               11
                              Now we have been able over the lunch hour  to  loc6t6

               12   Mr. Robert Landman,, of the Office of General  Counsel,  While

               13   some of you were discussing grant matters,, we were  discussing

               14   with him our opportunities for arranging Council  meetings  As

               15   may be needed,, but without at this point specifying an  6xact

               I(;  date.


               t7             It turns out after much discussion that  probably  the

               18   best avenue for:vB to take at this point In time is to set  Cou

               1!)  cil dates for January,, February and March.

               20             (Laughter)

               21             And then cancel.

               22             This shorteirouits much legal jargon,, which I am  sur

               2,'@'i -- and Mr, Landman can interpret better than I can.  But it
               24 ;I seems the safest r6ate to establish early to mid-January,

               .5   midfebruary and mid-March meetings., and then we are   certain

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                                                                               124

                I   that we can proceed,  Whereas, other avenues may be subject

                2   to cancellation by other parties in the Administration.

                3             So if we might look at the calendar, I do  that  now

                4   while all of you are here, if we might look at the calendar

                5   which is in your agenda folder and is that teriffic government

                6   calendar, I would have to leave to you what dates might be

                7   appropriate.

                8             Mr, Landman advises that possibly early January would

                9   be a suitable time in view of what he knows to be the current

               10   status of thinking, lawsuits and so forth,  He can't guarantee

               11   us obviously since the matter isn't completely under his

               12@  control,

                              I would suggest you look at the second week  of  Jan
               13

                    uary, or failing that, the third week of January,, and again
               14

                    not knowing exactly what business will be before us,, I  would

                    hope that a one-daymeeting would be sufficient.  If  you  care

                    to set two days., we can always cancel the second day if,@:it

                    doesrit turn out to be neede(% orin fact, we can cancel the entire
               18

                    meeting if the time selected is inappropriate.

                              MR,% MARS:  Monday the 15th of,January?
               20

                              DR. PAHL:  Monday the 14th and Tuesday the 15th'?
               21
                              Are those ones that are open to Council?

                              Are Tuesday-W6dnesday, 15 and 16,, as satisfactory as,
               2'3

                    Monday and Tuesday?
               24

                              DR. S C HRE INER
               25                             It is better for me.

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                                                                             125

                1            DR. PAHL:  It is better for you.

                2            MRS. MORGAN:  It doesn't make any difference.

                3            DR. PAHL:  All rights let's set January 15th and i6th.,

                4  Tuesday and Wednesday', as a meeting of the Council,, and perhaps

                5  we might now look at February and again I am not sure what tim

                6  is appropriate.  Agtin, the budget message will be going to the

                7  Congress the end of January,, so perhaps again mid-February might

                8  be sufficient to know what the Administration's legislative

                9  package is.

               10            MRS. MCRGAN:  When does the holiday for Washington's

               11  Birthday fall on?

                             DR4 PAHL:  The eighteenth.
               12
               113           Did someone want to suggest?  Do you like the 12th
               14  and 13th?

                             MRS. MORGRN:  Fine with me,
               15

                             MRS. MARS:  That's all right.

               17            DR. PAHL:  The 12th and 13th of February,

                             I think we have probably tired you out.  We have
               18

                   never had such quick consensus on Council dates.

                             DR. ROTH:  You have finally reached a matter of
               20
               21  concern on which I have no opinion,
                             (Laughter)

                             DR. PAHL: Let's try one more,  See how our batting i
               2,1
               24i           MRS. MORGAN:  We might as well try for the 12th and
                   13th of March.
               25

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                                                                                  12- 6-


                 I             DR, PAHL: We are missing  the  exact  Ides  of  Marcho

                 2  if we select the 12th and 13th  --  does  that  sound  reasonable?

                 3             MS. MARS:  That Is all right.

                 4             DR* PAHL:  Teusday and Wednesdayo 12th and 13th,

                 5             All right,, the dates we have scheduled., then,, are

                    January 15th and 16th, February 12th and i3th,, and    March I  th

                    and 13th.

                 8             I am certain we won't have to meet  on  each  of  those

                 9  occasions  and we certainly will take  into  account  your  schedules

                10  and our workloads., both,, and we will try to arrange matters

                    so that we meet when we have really something we can accom-
                11

                    plish and  hopefully those dates will  come  close  to,the  decisions
                12i
                    cn'which we will have to act,
                13
                14             @Now.. I would like to turn to a presentation  by  Mr.

                    @@Gardell some matters which must come to    ur  attention  rela-
                15                                             YO
                    tiVe to  the management of our affairs) and  I  ask  that  yoQ.tistEn
                10'

                    closely because we are going to ask you to accept certain revi-.
                 7

                    sions of existing policy which.. again,, we believe to be in
                1 8
                    the best interests of the RMP's and the good management of the


                    programme
                20
                21             Jerry, will you please make the presentation,
                               Mrs. Handel,, will you please hand out  the  'materials
                2

                   Ito Council.
                2!))
                               Please don't  read these as they are handed  to  you., but
                24
                    listen to Mr. Gardell,,  if you will,, and he will call  to  your
                2 5

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                                                                                  12,

                 1   attention what the important features are.

                 2             MR.GARDELL:  Anybody can make this presentation,,

                 3   but I just happen to be the one who was involved in part of

                 4   the writeup of ito so if you will bear with me,, I  will  try  to

                 5   go through it.

                               I think that what we are proposing to do here Is

                 7   kind of a companion piece to the resolutions that you discussed

                 8   this morning, and the situation As it  presently  exists  as  far

                     as the support of the RMP's is concerned,
                 9

                10             We have been runnings as you well know,, with some  oJ'

                     our grant awards in excess of two years of support in one
                11

                12   budget period.
                13             We have in a sense disregarded the  budget  as  submit4

                     ted originally, because of the phaseout  activities  we  have  ha
                14
                     to go through. Then we  have  reinstituted  the  program  because

                     of the extension of the legislation for one  year,  and  we  feel
                'L7  that in All of this, plus the development of our allocation
                     mode which we,have developed for ease of getting  the  funds  out

                     there as quickly as possible, the termination of the review

                20   committee the lack of a review of  applications  as  we  previous
                     ly did on an anniversary basis.  The fact that we have only
                21,
                     oreyear of support instead of three or five years of legis-    i
                22
                     lative support4 which means that we are looking at our applica-,
                2 @'3
                     tions on a one-year basis instead of three years.
                24
                              What I am really leading up to is the fact that it
                25

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                                                                                                                                     128

                            1     turns     out     that     we     really     havenltbeen     applying     all     of     the      pro-
                            2     cess  involved  in  triennium versus  the anniversary or  nontri
                            3     enni=     applications.,     and     therefore     we      felt      along      with      the      re-
                            4     sponsibilities  that  the Director has  through  the  policies  estab-
                            5     lished by the Council,  that we should be  considering all of our
                            6     regions at  this  point  in  time  on  the  same basis  for the  rema  n-
                            7     der of  the  period  of  our support.,  whatever  that might be.
                            8     Whether,it be  through June  30th  or  12/31                             apparently at
                            9     the moment we are  talking about  12/3'1/-74,
                         10                       So    what    we    propose    to    do    is    take    what    is     passed     out
                         11       now..  Revise  it  slightly,  have  those  common items.
                         12!,                     I think this  is  probably the best  thing to do at
                         13       this  particular  time,  because many                     of  the  items which we
                         14       previously distinguished between  the  two sets  of  ra                                 ngs
                         15       or categories we are  no  longer applying.
                                                  Secondly,     or     I     should     say     there      are      several other
                         17       considerations,,      and      that      is      thEt      the      triennial      review      respon-
                         is       sibility     has     been     watered     down     for     we     are     no      longer      applying
                                  the    rating     system,     we     no     longer     have     a     review     comittee     as     I
                         20       mentioned,      and      to      some      extent      the      responsibilities       under       the
                                  triennial     have     been     watered      down      as      I      mentioned      also.,   0
                         21
                                  in   view   of   all    of    this,    we    felt    if    you    take    a    look    at this
                         22
                                  white     document,     I     think     we      have      pretty      well      explained In       the
                         2 ',3
                                  second  paragraph what  is  intended  to do here.
                         24
                                                  We    would     life     to     supersede     number     17S,     which     is     the
                         25

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                                                                                                                                129

                           1    green -- and we gave  it  to you,  here  you are  -- you have

                           2    got  the governing  principles as  they were  change   on  the  front
                             1
                           311  and  the  covering document  is  in back,  and explains what we
                             I
                           4    propose  to do.

                                                It     is     intended     to     clarify     further     the      authority      of

                           6    individual      RMP's      under       the       decentralized       method       of       operation

                                instituted     by     RNIS     sometime     ago      particularly      in      view      of      re-

                           8    cent     changes     to     available     funds     and      periods      of      grant      support.

                           9                    Two policies  relating to decentralized  operation
                         10     have been       issued,already,      These       are       the       RNPS       review       process
                         11     requirements and standards,, which specify the standards  to
                         121    which     the     local     RNP     review     process     must     conform,     and     the     re-
                             :1 view      responsibilities      under       the       triennial       review       system       which  1
                         13  1
                             1  among other things  delineates  the@scope. of  the Council approval,
                         14
                                                The     attached      policy      modifie6      the      application      of      the
                         15

                                policy      contained      in      the      triennial      document      and      outlines      con-

                                ditions  under which  RNPS approval                    of    local RMP funding decisions

                                is  or is  not required.
                         j@ 8
                                               This was,  as         we say in our          next      paragraph,       this       is
                         if)
                             1 assumin   that we do get                your acceptance.  If we do,  then we WiLli
                         20  1            9
                                follow  the  process  required  to get a change@made  to this
                         21
                                NID.
                         22
                                               We     feel     this     would     be     most      appropriate      to      continue

                                applying our allocation mod6  for  the  rest of the year,, whether                                       t
                         24  1
                         25     b6$41,236 or$76 million out  of$81,9 million.
     HOOVER REPORTING CO, INC.                 We    ought    to    be    able    to     proceed     in     this     fashion,     and
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                                                                                                                                                               130
                                     1    certainly advising  the  Council  as  we  go  alongs  since we  are
                                     2    setting  up  tentative  meetings.    So  all  of  this  can  be  brought
                                     3    to  your  attention.
                                     4                      But  we  don't  think  in  view  of  the  fact  we  have
                                     5    ceased  applying  some  of  our  processeso  that  we  should  continue
                                          to  distinguish between  an  anniversary and  a  triennial  applica-

                                          tion.
                                                             I think  It was  also  pointed  out  to  you  this  niorn  ng
                                          by Dr.  Pahl  that  we  Intend  to make  certain  that  those  who
                                     9
                                          have  not  been  certified  in  the  review  process  or  who  still
                                     10
                                     11   havemnagement  problems  in  the  eyes  of  RMPS  will  be  corrected
                                          to  the  best  of  our  abilities  between  now  and  sometime  in March.
                                     12,
                                          This  is  basically what  it  does.
                                     131
                                                             Nov.  really  the  only                    change  in  here  is  in                    section  3
                                     14
                                          of  the  NID,  and  it  really  takes                           what  was  basically                    the  trienn  a
                                     15
                                          areas  of        responsibility  and  makes  It  applicable  to,all  of  the
                                          RMP's,,,  assuming  there  are  no  conditions                                   placed  on  the  awards
                                     17
                                          by  us,

                                                             By  us.,  I  mean  the  body  here*

                                                           @.,DR.  PAHL:    Thank  you,  Jerry,
                                     20
                                                             We  apologize  for  handing  you  so  much material
                                     21
                                          you    haven't  had  a  chance  to  see.  We  hope  that  because  you  have
                                     22
                                          lbeeh  Involved  in  these  policies  earlier,  that  they won't  be
                                          IlcompleteLy          new  to  you.    However,  it  is  not  essential  that  you
                                     24
                                          take  action  this  minute  and  we  are  having  an  open  session
                                     2

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                                                                             131

                1 tomorrow morning and I would suggest, Jerry, that  what  we  do

                2  is, again, Indicate to you the essential feature o    is  re-

                3  vised statement and then ask for action tomorrow morning after

                4  you have had a chance to review them and see whether in   c

                   you endorse this.

                6            In summry., we are abolishing the line between  tri-

                   ennial and anniversary type regions because in fact it  makes

                8  no sense any more with the kind of policies and  procedures

                   which we have had to engage in over the preceding months  and

               10  which we are still engaged in,, and what we will do is focus
               11  our energy on providing technical assistance In  certifying
               12, that the local review process is approved at the national level
               1.3 and also management assessment visits to give that type  of

                   assistance also to the regions, So we see no reason,  just  as
               14
               11  we have abolished the A,B,C rating system and the actual
                   criteria, and so forth,, we feel that it is artificial tD continue
               17  to have this triennial and anniversary status.

                             We are treating all 53 regions alike in many respee S,

                   but we aretrying to work with each of the 53 on an  individual

                   basis to the extent that our staff permits.
               20
               21            So you may either decide to take action now and mere l@y
               22  accept this amendment to the existing policy, or if you  care
                   look at these materials and tomorrow morning take action.

                             MRS. MARS: I don't see any reason we  can't  take
               24
                   action right now.
               25

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                                                                                    132

                  1            The only thing that we might put in there would be

                  2  some statement of fact that this could be reverted back to a

                  3  triennial and anniversary status if RMP,-,-it to@be.1continuecl  in

                  4  the future, or something to that effect,

                  5            DR. PAHL:  We might incorporate that in the transmit-.

                     tal letter.

                  7            MRS. MARS:  Right.

                  8            DR. PAHL-,  That would  be our interest and intention

                  9   certainly.

                10             M. MARS:  Otherwise I move It be accepted.

                11             MRS. MORGAN: On number 2 here# 'research,,.@--  or  other

                12! activity involving the use of human subJects, that is a pretty
                131  broad statement there,

                14             MR. GARDELL:  That is Public    Health    Service,po.icy.

                               DR. PAHL-* That  involves  a  little  bit  of  everything

                     as you know,

                               (Laughter)
                37

                               Dr. Hirot6.

                               DR. HIROTO:  Second.

                               DR. PAHL:   It has been moved and seconded to      accept
                20

                21   the proposed statement,

                               Is there any further discussion by Council?
                22

                               If not, all in favor say  aye,

                               (Chorus of "ayes.
                24
                               DR. PAHL.-  All opposed?
                25

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                                                                                        133
                  1              (No response)
                  21             DR. PAHL:  It has been approved by Council.

                  3              MS,-MARS:  Don't forget to put something in,

                  4              MR, GARDELL:  Transmittal.

                  5              DR. PAHL:  Yes.. there will be a statement in the

                      letter or  transmittal memorandum relative     to the future

                  7   interest of the program in reestablishing      that distinction.

                                 NRS. ARS:  Right.
                  8

                                 DR. PAHL4.  Thank you very much; Jerry,
                                 Again  as a small matter, item of business,.     let
                 10                                                                   me
                 11 call to your  attention  in  the  agenda  folder.,on  the  back  cover,,
                 121 we have the minutes from the last meeting,, and I would hope that
                 13  perhaps between now and tomorrow morning there would be an
                     opportunity for you to see if there is@ anything you wish to
                 14
                 15  alter or modify, delete or acld.,and we    will  take  action  at  that

                     time on the minutes,

                                 I would like now to move   to  our presentation by Mr.
                  7
                     Peterson,, who has  been  charged  with  the 'responsibility of tryirv
                                                                                           '7
                     to present to you in very brief      fashion a current status and
                    !overview of the RMP'S.  And following'th'is presentation, we wil
                 20
                     then  open  the  meeting  to  discussion  or comments  by   non   Council
                 21
                     members, and specifically I    know    there are one -or two individuals
                 22
                     who do  wish  to  address  the  Council  and make a statement.
                 2,'i
                                So with that                   YO
                                               Pete., would     u please-- there is a
                 24
                     handout you have?
                 25

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                                                                                                         134

                      1                 MR* PETERSON:   Yes.   Ken is handing it out.

                      2                 Bland reminded me., brevity is  like being the

                      3   principal     character In the last act of a -@--play.   The audieneB

                      4   has been sitting there for six hourso they have gone out for

                      5   lunch,, but most Westerners wish they would get on with it and

                      6   get over with it,

                                        What  we  have   are   some   data   that   I   hope   might   provide

                          some insight and feeling as to the current status of the RNF'S,

                          their   viability,,   to   use   that   much   overused   word,    and    stability#
                      9

                    10    Some of these are summarized in the handout and I will try

                          and briefly,, Bland,, summarize that,
                    11

                                        Before I do so, though   let me make a couple of
                    12!

                          caveats,
                      3i@
                       1
                    14                  Obviously   what   Ve   have   given   you   here   is   selective   a d
                    115   limited,@     In   part   it   is   compromise   of   what   was   readily   availa-
                    1(;   !Dle and comparable., what could be easily compiled and counted.
                         '@And 1 am always aware that what you can count is not always
                    17
                         @,@,the mist Oignificant@thlng in a situation.
                    18

                                        So that attitudes,, outlooks,, morale, which are not
                       1-@readi@l-v susceptible to quantification.. are not spoken to.
                    20

                                     ',,Similarly,,   the   figures   especially   to    the    extent    they
                    21

                          are overall figures, totals, averages, et cetera, ate likely

                          or I
                               n some cases may be misleading,   I think you Vill get a
                    2'3 11
                          little better feel of that as you get into the individual
                    24 1
                          applications,   Indeed,, there are striking variations among
                    25

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                                                                              135


                 1  regions.
                 2           The data Itself is essentially as it has been re-
                 I
                 31 ported to us in the RMP'S. either in current applications
                    which you have before you or in prior applications, which
                 4
                 51 was incorporated into our own management information sys em
                 6  And I would also note there may indeed be some small discrep-
                 7  anci6s or errors In the data as a result of last minute changes,
                 8           I came in on Monday morning@.. having taken Friday
                 9  off, to find@some of the data I had looked at late  W6dnesday
               10   afternoon had had some minor changes in.it.  I can only

                    apologize for that.
               11
               1211          Oneo with respect to the RMP coordinators,  I  think
               13   this group,, most people who have had anything to do with RMP
               14   over time recognize that they have been an all-important  and

                    critical element in RW.
               15
                             As of this point in time,, we have 35 coordinators vhc
                    are,the same people that were there over a year ago. Most  of
               1.7
               18   these are longtimers,  So that roughly two-thirds of the coor-
                    dihators are the same who have been associated with their indii

                    vidual region for many years.
               20
                             There are 18 new coordinators, some of them new sinc
               21
                    a year ago, some more recently.  There has been a fairly.sig-
               22
                    nificant turnover since July, about ten coordinators followed
               2 t3
               24   through on plans and did Indeed leave,  So that  here are new
               2 5  coordinators in 18 regionsfrom a year ago, three or four

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                                                                                                                                 136

                           1     coordinators are still on an acting basis,, that is  indicated

                           2     in the attachment A. Five are now part-time  people  and  again

                           3     that is Indicated.  The extent of the time which they are

                           4     spending with the  program.

                           5                     As  far as  the  program staffs  themselves are  concerned,,

                                 and    this     again     I     think     has     been     another     important     strength     of

                                 the    RMP     and     basis     for     much     of     their     effectiveness     and     activity

                           8     we    do    see    if    one    looks    at    attachment    A-1.    that    from     a     level
                           9     of roughly 1500 full-t me equivalents In the 56  RMP  program

                           10    staffs    of    a    year    ago,    there     was     a     noticeable     drop     beginning     in
                           11    the    middle    of     this     year     with     the     announced--     well,,     before     the
                           1211  middle     of     this     year,     but     with     the     announced      phaseout      of@the

                                 program and  then  the actual  approval of phaseout  planst  a
                           13

                                                                            We  probabl              or     the     region      prob-1
                           14    drop of about  50 percent.                                  y
                           15    ably reached  the  lowest strength some-time  in                         August      and      Sep-
                                 tember.  Bit, even         now,, we are,.      talking      about something  like

                           -     700-Plus     people     actually     onboard     in     the      53      regions,      Based      on
                           (7
                           18    the     application     submissions     we      have      in      hand,      however,      sugges-

                                 tions    there    will     be     some     additions     to     those     staffs     and     prob-

                                 ably    reaching    90(4    or    I    know    some     of     the     data     the     coordinators
                           20
                           21    have    given    me,,    perhaps     as     many     as,L.,000.     So     there     would     be

                                 some  recouping by early next year.


                                                                                                                                 u
                             t                   The  size  of core sta fg,              as    I    said.,    have    een    abo    t
                           2.")
                                 half., and      that  is  reflected  in the             average, average  to-@:14.
                           24
                                                 More  important,  I think              the  range      of     staff     has     been
                           25

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                                                                                        137

                  1   considerably  reduced  and  compressed.  Whereas.,  in  about  a  year

                  2   ago there werecnly three regions with 10-1/2 program staffs,

                  3   there are ncw  26.  And  whereas  a  year  ago  there  were  something

                  4   like 26 regions that had over 25 program@staff,, that is down tD

                  5   about 5 now.  And there are none now.,.not even California

                  6   in excess of 50 program staff.

                  7              I have included on that table  A-I,,  I  won't  take  up

                  8   any time of yours with the recitation, a breakdown of the

                  9   professional staff  by  one,  the  functional  areas  in  which  they

                 10   are  operating  such  as  program  development,  research   evalua-

                 11   tion, planning, and also by their discipline or professional

                 12!  background,, physicians,, nurses., and the like,

                 13              I have also included., because you may    want  to   uti
                                                                                        Liz

                 14   it in  your-other  activities  as  a  B-2  attachment,  listing  by
                 15   region of  the staff as reported to us on board now., broken dowi
                      by'professional and clerical,,and what they anticipate In theNO7

                 17   of additional people.

                               :.&@nother area of activity which we tried to take a quick

                      look at  feeling it may possibly be  one  indicator  of  continvad
                 1!)

                      inte,rest,.'and support of those individual providers and the
                 20
                 21   others,, And the  groups  and  organizations  they  represent  in  the
                      program,, relates to  the  activity  of  RMP  advisory  review  and
                 2.)

                      othercommittees during  the  past  year  and  some  of  that  data  s
                 23
                      summarized briefly again in attachment C., handed out to you.
                 24
                                 I think it  is  perhaps  significant  that  we  find  that
                 25

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                                                                                            138

                   1   of the 60,0 committees, other than RAGs themselvesponly 10

                   2   percent have become dormant in the last year.  That is, they

                   3   haven't  met  at  least  once,  The  remining  have   had   an   average

                   4   of four meetings.

                   5               We  find  certain  kinds  of  committees,  such  as   execu-

                   6   tive committees, most regions have such,, have been far more

                       active.  An average of six meetings during the year of           those

                       committees,
                   8

                   9               In addition, we find that the technical review c         omm

                  10   tees and Pah4ils,, there seems to have been consid6rabl       6 act
                                                                                           iv:Lt

                  11   on their part as well during the past year,
                  12!              I can't isolate that all in terms of,the last two
                  13   months versus six months ago.  But it does suggest that not

                       only  in  terms  of  coordinators  and  program  staff,,  but  that
                  14

                       considerable assemblage of individuals who are contributing

                       to the program on a voluntary basis, many important and influ-

                       ential-people
                  17                  , that there is still a high level      of activity

                       ref leated by those people.

                                   The tast  two  items  I  briefly  want  to  touch  upon

                       relate more to the proposed activities as reflected in the
                  20

                       applications, attachment D provides an overview, an overview
                  21
                       of how the current applications, the 53 you will be consid-
                  2!)
                       ering,,,,break down  in  the  option  areas  that  were   indicated
                  2,'l
                       earlier inthe meeting.
                  24
                                   One  sees  that  strengthening  local   planning   does
                  25

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                                                                                  139

                 1 account for a larger the largest  single  Part  of  the  money,

                 2  with quality assurance, EM activity accounting for 50 percent

                 3  of the activity.

                 4             Smaller amounts, percentages at least have been pro-

                 5  posed for programmin  in  kidney  and@hypertension  with  some
                                          9

                 6  additional.. there  are certain multicategorical activities,

                               I do  think, in view of the  discussion  this  morning,

                 8  that perhaps  it  would notbe inappropriate to  make  an  aside

                 9  or two. I think the RW Is as well as  the  RNPS  staff  over  the

                10  years,, as Russ Roth and others described it, have been sub-
                11  ject over the years to a certain amount  of  drift  with  respect

                 2! to what it was we were up to,  I  think  everyone  has  become

                    sensitive to and perhaps adept at fitting things into the guid
                13

                14  lines which are momentarily in vogue,

                               I don't say that in a dishonest nature, because I
                15
                1(; think something such as quality assurance -- there are any num--
                -   b6r of activities which could just as well have been labeled
                 7
                18  cancer or heart, but since that is the way they want things

                    categorized this time, they appear thetway,

                               Similarly, strengthening local plannin  activities
                20                                                    9
                21  I was part of the very -- very much of  a  draftsman  as  opposed

                    to decision maker although as Harold pointed out, there are nol
                22
                    longer decisions being madeo only understandings reached, in

                  1 workingon the option area six months  ago,  you  know.  We  some-
                24
                    how found room based on a dependent prepositional clause
                25

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                                                                                                                      140

                         1    for something called a HAPS.

                         2                  I would not be surprised to find agreat  deal  of  RNP

                         3    manpower activities Interpreted and squeezed into strengthening

                         4    local assurance or local planning efforts,

                         5                  I simply say that because I think labels can be mis-

                         6    leading and people who have to work -- people who have to work

                         7    with labels., whether John Sparkman or myself,, you know, we

                              make do with@what we@can@i6 terms of those labels, and I
                         8

                         9    think it Is Important that the Council as it  l,ooks@At  individ

                       10     ual applications, that it recognizes that.

                       11                   The other attachment that is Included was simply

                       12     intended to give yo some idea of the kind of active working

                              relationships that RNP still has with other agencies                              groups,
                       13

                              and organizations.. and           this is done essentially In terms of
                       14

                              who is going to be sponsoring or conducting  the  activity  that

                              they proposed.

                                            Now, it is true, as you have a chance  to  look  later
                       i 7

                              at E, we ha         included more than operational projects,@ We
                       18

                           @have,include,d      where      possiblepwhere      they      were       separately       iden-

                       20     tifiab,le,,Idiscreet planning or Feasibility studies; that almost

                              a third of the activities  proposed,, at  least in terms  of the
                       21

                              total number as opposed to dollar value would  be undertaken
                       22
                          11  by staff.      But if one excludes  those kinds of activities,, we
                       2.'3

                              find  that    many of the samefactors have been involved  in
                       24
                       2511   RNP from a     working    point    of    view    are    still     there.     The     medical

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                                                                                                                                                        141

                                      schools and centers are still the single largest group of

                                2     projects sponsors.
                                 I                        I thinks although I didn't have a chance to make such
                                3

                                4     comparisons# that more activity Is proposed,to be carried out

                                5     by CHP agencies thigl,time than it perhaps has been in the past,

                                      something a little less than 10 percent.
                                6

                                                          But here again I think one does see a working
                                7                                                    .9

                                      within a set of options., guidelines,, call them what you like.

                                9     If there are any questions, I would try to answer them., but
                              10      I feel I have already violated Bland's excellent admonition,,
                              11      brevity,

                                                          DR. PAHL: Mr. Ogden,
                              12
                              13                          MR. OGDEN: One request, your collator seems to
                              14      have given, at least to me and I notice Sewell Milliken,
                              1;5     duplicate  of A-2  instead  of B-2.    I suggest  perhaps  they
                              I       could be picked Lp and corrected.

                                                          MR,  PETERSON:    I will  try  to  rectify  that  before  the
                              17

                                      day  --
                              18
                              1!)                         MR,, OGDEN:    I  think  probably  thev are allseparated
                              20      a nd  ha ve      the  same  prob Lem.
                                                          DR.  PAHL-,    Thank  you,  Pete,
                              21
                                                          Are  there  any other  coments                          on  this  presentation
                              22
                                      and  analysis?
                              23
                                                          All    right..  if  not..  thank you again,  Pete,
                              24
                                                          At   this  point  in  the  meeting,,  we  would  like  to have
                              25

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                                                                              142

                   members of the public make any presentations that they care

                2  to. And in so doing,, I would ask each person  identify  himself
                3  and the organization he represents.

                4
                             We have a microphone at the other end of the table a-4

                5  we would ask you to please use this,

                6            Before identifying$ since I know Dr. Sparkman

                7  wishes to make a statement and we would like to have him  do  so

                8  in just a moment.. I would like to indicate  that one of Dr.

                9  Sparkman's duties is to serve as chairman cf the  Steering  Com-

               10  mittee of the Coordinators.. and he took over the reins fo@llow-

               11  ing the resignation of Dr. Paul Duchene,,, this being a very

               12. real and significant loss for all of,us,  I  believe Dr. Sparicnvtn

               13  would like to speak to you In several capacities,, but I will

               14  let him speak for himself, and then I will be very glad to

               15  identify anyone else, or call upon  anyone else@ who may wish

               i(i to make a public statement.

                                 SI
               17            Dr   parkman.

               18            DR, SPARDMN:  Thank you,

               19            I appreciate the opportunity  to meet  with you here

               20  to represent the coordinators and I  have  thoroughly enjoyed the

               2i@ meeting,  I have a couple of comments I could make  about  that,

               22            I would flesh out some of the numbers,Pete gave you I)y

               2t3 saying from my personal observation among my coordinators who

               24  met last time;on a  national basis mid-October,,  that there is

               25  I think a surprising degree  of optimism among  them, and I

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                                                                               I  Li


                1   find the same thing, my contactoas I can have iboand completely

                2   relative to regional advisory groups,, the attitude of constitu-

                3  encies of RNY staffs and programs.
  ,O            4             Overall I am favorably impressed, I am sure some
   0            5   of the programs may have problems, I know that you all have yoLr
                6   own applications which you are going to be reviewing -- 1

                7   would point out that these applications were put  together  in

                8   relatively short term with short staff and addressed to

                9   five new options., options which at  hat  ime we regarded pre  y

               10   much as restrictions, not just as guidelines.  And  this  pro-

               11   vided some difficulties.

               12.            I am confident that given a reasonable degree of

               13   funding,, with removal of restrictions that RNP's will again

               14   around the country prove to be effective programs

                              Relative to my meeting with you  I would like to
               15

                    make clear to you that my fellow coordinators look to the

               17   National Advisory Council as a vital part of  the  program.  I

               18   thi,nk;you know that,,"but I want to mke it clear that you under-

                    stand that.

               20             They see you as making important policy redommehda-

                    tions and approving projects and in other ways helping to
               21
               22   guide the program,

                              They are grateful for your leadership and they, like
               2@3
               24   I,Iam concerned that Your numbers have diminished and that the
               25   Secretary has not taken the time or whatever it is to replace

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                                                                                  144


                 1  them,

                 2            All of the regions have submitted candidates to

                 3  Dr. Pahl for new members on your Council,  I note from the
   0             4  Washington-Alaska Regions we have submitted three excellent
   0             5  candidates.
                 6            I see no reason for the delay in making appointments

                 7  to fill out the members of your group,, particularly  now  that

                 8  you will be losing five more.

                 9            It is obvious that whatever strength and per oxmance

               10   RMP has had in the last six years is due in no  large  part  to

               11   the leadership you people have provided,

               12             I was struck this morning by the disparity In the

               13   views that some of you have relative to what we should be

               14   doing.  I don't think this is necessarily bad.  But  I  am  con-

               15   scious of the fact also that since  the  Administration  reeom-

                    mended phasing out RMP, you have not had  much  opportunity  to

               17   meet and you have thought that perhaps the  program  was  dead,

               18             Nevertheless, it seems to me that It  should  be  re-

                    called to you that in your meeting of May  19710  you  approved

                    a mission statement which had been carefully  prepared  by  RNFS
               20

               21.  in collaboration with a lot of people, and I  consider  that  a

               92   good statement which modified somewhat the  earlier  mission  of

                    RMP, in that it dealt with availability,, accessibility and
               23
               24   quality,  But It also I think subsumed the categorical activit7

                    some of you indicated you felt still to be important,
               25

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                                                                                145

                 1            I think it seems to me that this group, at some

                 2  point., should have opportunity to review that as well as a

                 3  direction statement paper which the coordinators, in a task

                 4  force, prepared within the last two months$ in order we get

                 5  to the Congress and Administration our views as to what we

                 6  think RMPS.


                 7            I don't knows Herbo whether the  direction  statement

                 8  which we prepared was submitted to the National Advisory

                 9  Council.. but I think it should be.

               10             DR. PAHL:  No, we have not.

               11             DR. SPARKMAN:  It seems to me, here we axe as

                    coordinator, very much concerned,,working hard to develop  what
               12

               13   we think is the'role of RNP.  You are separately doing this,,

                    RNP staff.,Administr atidn, Dr. van Hbek, and others also
               14

                    doing this.
               15

                              I would welcome the opportunit  of having some of than
                                                            y
               17   coordinators e)e@lress to you, for example, what they see is the

                    way RMP ought to'go and get your response to this.
               18

                              It seems to me this would be very  important.  And  I

                    am struck with the fact so far we have very little of this
               20


               2,1,
               22            At this point when legislation is  in the mill, in
               23   Congress, and at which time the Administration is  also  in  the
                    process of developing such new programs  I was pleased with
               24                                          q
                    what I think I heard this morning; namely  that the
               25

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                                                                               146

                 1  restrictive language relative to the options is to be removed

                 2  and that these are simply options,, not restrictions.

                 3            I hope that your Council will go on record as  making

                 4  this clear.  I would like to hear it a little clearer than I

                 5  heard it I guess from Dr, Endicott this morning.

                 6            I would also like to hear it clear and on  the  record

                 7  the fact that programs may be extended beyond June 30th  as  far

                 8  as RNIF spending is concerned.

                 9            I don't know whether Is presumptions of me, but it

                 10 seems to me Council ought to go on record to this effect if

                 11 you think it is appropriate.

                 12,          The coordinators look to you for this kind  of  action

                 13 and lacking it, they Are disturbed.

                 14           The matter@of the release of impounded funds,, I

                 ir) would like Dr. Reinschmidt to speak very briefly to the

                 1(; National Association of RMP, just to tell you where  it  stands.

                 17           The task force of coordinators In recent past has

                 18 also developed a statement of different kinds of alternative

                 I!) organization arrangements under@which RMP might continue  If  in

                 20 fact It Is to be merged with CHP and with Hiii-Burton.  After

                 21, considerable discussion we agreed this should not be distrib-

                 9-2 uted,, but should be held pending the appearance of some  legis-

                 2@3 lation at which time we hope to be in A position to  respond  to

                 24 that.

                              I think many of you know we happen to have several
                 25

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                                                                                  147

                 1   coordinators particularly close to the legislative scene and

                 2   valued enough by the legislators that they are called for

                 3   consultation and advice as to development  of  legislation,,  whicli

                 4   I think is very, very good.

                 5             Since we had some question that RMPS was going to

                 6   be able to develop the ongoing kind of Information about RMP

                 7   perhaps, at our last meeting and  after  development  of  a  program

                 8   by task force,, we will be in a position to provide on-going

                 9   information under what is  called  a  public  accountability  system

                10   as to the n=bers of people who have been benefitted by RFY,

                11   and number of people that will have been train6d,

                12,            I think I will tie it up with that., just indicate
                13   againi.itg., appreciate for the opportunity of meeting with you  anl

                14   if there are questions that I               I wi It be happy to,
                                                    can answer,,

                15             If you  Lver thought about the coordinators and

                1(;  the way the programs are going on, I would be happy to hear thes(

                17   and carry them back to my coordinator colleagues.

                18             DR. PAHL:  ThAnk you very much, Dr.   Sparkmam

                1!)            Are there questions or comments by ()ounc:Ll?

                20             We will make available to the Council any of those

                21   materials which the coordinators would like to       we in  a  sense

                22   were observing your confidentialityx not knowing fully the
                2t3, purposes for which you were developing it, So we have no prob
                24   lem in directing these  materials  more  widelg  perhaps  we  should
                25   have distributed them more widely,  Apology is in order.  We

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                                                                               4


                   will make them available.

                2             DR. CANNON: I think someone should say  Council  has

                3  been aware of the difficulties brought upon the coordinators iti

                4
                   continual shift of emphasis$ and we recognize you as a bunch of

                5  Mexican jumping beans which have successfully jumped  in the ril"ht

                   direction most of the time,

                              DR. SPARKMAN:  Thank you, Dr, Cannon,

                8             DR, PAHL:  Dr, Merrill.

                9             DR, NERRILL-. Would it be appropriate for Council to

               10  act on Dr. Sparkman's suggestionothat we view these categories

               11  as options, not restrictions, officially9

               12             DPPAHL:  Yes, Indeed, it w,ouldl.be most appropriate.

               13             DR. NERRILL:  I so move.

               14             MRS. MORCAN:  Second.

               15             DR. PAHL:  It @ been moved   and seconded to  accept

               iti the options and priorities as being  that  and@not-restrictions

               17  which they have heretofore been,


               18             Is there further discussions

               11)            If not., all in favor please say flaye.11

               20             (Chorus of "ayes,

                              DR, PAHL-  Opposed?
               21@

                              (N   sponse.)
               22              o re


               23             DR. PAHL:  It is accepted,

               24             Dr. Reinschmidt.. I know, wished to make a statement.

               25             Chuck., would you please identify yourself.

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                                                                                 149

                 1             DR. REINSCHMIDT:  I am Chuck Reinschmidtp of

                 2  the Coordinators Medical Program.

                 3             I really didn't wish to make a statement.  I am

                 4
                    strictly pinch-hitting.

                 5             (laughter)

                 6             I'm pinch-hitting for Dr. Ingall.

                 7             I think it is most unfortunate he is not here with

                 8  you  today., because he is the president of the National Agae-

                 9  ciation   of RMP's and is certainly well aware than I of most

               10   of the activities going on,

               11              However, for your Information, the National Associa-

               12,  tion of Regional Medical Programs Is a nonprofit corporation

               13   formed to provide ard to promote information and education aboLit

               14   the purposes of regional medical programs,  Membership :Ls open

               15   to interested individuals.

                               This organization shoUld be able to promote the

               17   purposes of RNP by means which might not otherwise be

               18   appropriate or possible,

                               Ithink you are all aware of certain recent events

               20   that this  would apply to.

               21              (Laughter)

               92              1 think this has been mentioned earlier today about

               23   some   cfthe action that is going on in the.courts at the moment,

               24   This action has been brought with the request that it be a clai,,s

               25   action by two of the regional medical programsand the National

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                                                                                       150

                  1   Association of RNP.


                  2              I am not sure that I can answer any questions, but

                  3  Dr, Sparkman and I will try if you have any.

                  4              DR. SPARIWN:  May I mke one more commnt?

                  5              DP. PAHL:   Yes,

                  6@             DR. SPARKMAN:  The coordinators recognize Dr. Fahl has

                  7  had a most  difficult  if  not  impossible  task  during  this  time,

                  8  Dr.    Cannon mentioned our problems,  I think his have been even

                  9  worse,    Aid they took the opportunity at our meeting in Chicago

                10   in  mid-October  to  express  unanimously  their  approval  and  sup-

                11   port of his leadership, and of the help of his staff, which

                12,  has dwindled but has been very effective in helping us.

                13               DR. PAHL:  Thank you.

                14               Mrs. M rs,

                15               NRS. MARS:   One thing I have been dying to    ask,#  who

                i(i  is paying   for this lawsuit the coordinators are bringing?

                17               DR. PAHL:  Dr. Reinschmidt.

                                 DR  REINSCHM:EDT:  This is a nonprofit corporation
                18

                1!)  and contributions and membership which is open to anyone who

                20.  cares to make such forms of support,

                21               NES. MARS:  Is each coordinator    paying  into  it  then

                22   out of his own funds?

                                 DR. REINSCHMIDT:  Anybody.  Otu of any personal fund.,
                23

                     Anybody who would like to donate,
                24

                                 It is not restricted to program coordinators or
                25
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                 1 anyone else,  Any member of the public who so wished.

                 2 Also there are the two programs which themselves have entered

                 3 into this action,

                 4           M. PAHL:    I would like to note for the record I

                 5 ha  n't contributed any.

                 6            (Laughter)

                 7           Is there further discussion by Council?

                 8           Dr. Watkins,

                 9           DR. WATKINS:  I would like to note,, with your strong

               io  powerful input,, what massive approach have you made to the press,

               ii  not now but over the years?

               12            This'might"seem like hindsight, but I just@wonder

               13  how much@have you really put into It in term of publicity?

                   To let pe
                           ,p le knov--@consumers,, not providers -- doctors
               14

               15  know,, I don't even know if they do,, butL:.'.- consumers don't know.

                             DR.@SPARKMA,N:  We have all talked about our low pro-

               17  file.  I am sure that;our programs are effective,, if we do thenL

               18. under low%@ profile without making much of a fuss@,about the

                   fact RNF is doing it,

               20            When one has to work with three or four different

               21  organizations and get them to work together$ It works much more

               22  effectively If you do this, you know,  You hope it will work

               2t3 and if it does, fine, And if it does, they may not be very

               24  grateful  it  has  happened,
               25            Nevertheless,,  your  point  is  a good  one.    You can

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                                                                                  152

                 1  carry on effective programs this way, but when it comes to

                 2  the end of the year and Congress looks at what  you  are  doing,,

                 3  until you have mde some visibility, the word Dr. Roth used

                 4  repeatedly'- you icnow.. you are apt not to be continued*

                 5             I think we have clone reasonably well as far  as  pub-


                 6  lid information.

                 I             I have had mixed feelings about it; trying not to

                 8  overdo it,, but calling attention in our local newspapers and

                 9  other places to things that we think are of benefit to  a@@,.par-

                10  ticular community,

                11             I don't know,, maybe some of the res  o  you have

                12,  used the fact it hasn't been adequate@or perhaps.it has been

                13  overdone,

                14             DR. WATKINS:  The reason I  'have'@asked',@sozm of the

                15  Congressmen I have approached are not   even'aware,,of the exciting

                    programs youhave had,  I wonder if you have   done,a good enough

                17  job on that end of it?

                18             You might be too conservative,  that is what I am

                    really saying,

                20             DR, SPARKMN:   I think probably  you are  right,

                               Did this pass critical nine months      I think we hav-,
                21@

                2   done a little better,

                               I think Board members or others have often been in
                2e3

                    contact with Congressmen,  I must say I have been pleased
                24

                    simply to tell them what we are doing# find their@interests,,
                25

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                 1  and indicate thatthey are approving and supportive of what

                 2  goes on,

                 3            DR, WATKINS:  Thank you.

                 4            DR* PAHL:  Are there other points in connection with

                 5  Dr. Sparkman or Dr. Reinsc@dt's statement?

                 6            DR. FO'YE:  Would it be helpful if the Council went

                 7  on record as strongly endorsing the position,, tentative posi

                 8  tiono that grant awards or that awards are for a 12-month period

                 9  starting in Januaryo ending in December?

               10             MR. OGDEN-.  Wasn't that done in the last--

               11             MRS.MARS:  Yes, I think so.

               12             DR. PAHL: I think we have the sense of the Council

               13   in the discussion this morning and we do appreicate that sup-

                    port.
               i4

               15             We invite other members of the public or anyone pres-

               1(;  ent to make comments or add to sane of the discussion'that

               17   was held earlier.

               18             DR, SPARKMAN:  As I look at the action of your last

               1!)  Council# I am not sure it was done.

               20             Council in discussing the proposal endorsed the

               21   actions taken by RMPS during the phaseout period and recom-

               2';) mended use of funds during the full year.

                              That doesn't seem to me the same thing that the
               23

               24   doctor just@recommended or I think is important beyond

                    June  30th.
               25

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                                                                               154

                 1            I personally think it would be very helpful if that

                 2  were on the record.

                 3            DR, PAHL:  Perhaps I misinterpreted.

                 4            I felt the sense of the discussion this morning

                 5  constituted endorsement by the Council.  Perhaps it would be

                 6  well to have it explicitly stated If in fact you-,would like tc

                 7  make a formal resolution relative to the continuation of

                 8  RMPIS through December 31,, 1974, as discussed by Dr. Endicott

                 9  and Dr, Margulies,

               10             DR. SPARKMAN:  I believe this was referring to the

                    time til June 30, 1974*

               12             DR. PAHL:  That was at the July meeting,

                              'Dr. Fore has moved.
               13

                              DR. WATKINS
                                            Second.
               14

                              DR. PAHL:  And Dr. Watkins sedonded, the discussion
               15

                    of this morningo which would endorse the Departmeht,6 present

                    position that the RMP's be permitted to expend funds through
               17

                    December 31, 1974.

                              Is there further discussion?

               20             If not, all in favor say "aye."
               21             (Chorus of flayes.11)

                              DR. PAHL:  Opoosed?
               22
               23             (No :res Pons e.
               24             DR. PAHL-,, The "ayes" have it.
               25             Well,, I think this comes at a very appropriate

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                                                                                  155

                 I   time, because it is three o'clock,, and I understand there is

                 2   a little bit of coffee left. I  ask  perhaps  Council  members

                 3   be given the privilege since they ate  bearing  through  this,

                 4   And we will have,, let us say,, a ten-minute break for  coffee

                 5   and then we will reconvene in executive session to start

                 6   the consideration of specific grant applications,

                 7             So I ask at this time that all those who are not

                 8   specifically involved with the grant applications please

                 9   leave,, and the open session will reconvene  tomorrow  morning

                10   at nine o'clock,

                11             (Whereupon, at 5:10 o'clocko O,m,, the Council went

                12.       into executive@session, to reconvene in open session at
                13        9:00 ol.clock, a.m., Tuesday, November 27., 1973.)

                14


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