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                                                                      1


    McLaughlin    I           DEPARTMENT OF HEALTH, EDUCATIONP AND WELFARE
    CR2219
                  2                        PUBLIC HEALTH SERVICE

                  3                   HEALTH RESOURCES ADMINISTRATION

                  4                        ROCKVILLE, MARYLAND

                  5

                  6
                                         Thirtieth Meeting of the
                  7
                         NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGR MS
                  8

                  9

                10                                     Conference Room G
                                                       PArklawn Building
                11                                     Ed kville, Maryland
                                                         c
                                                       Tuesday, July 17, 1973
                12
                                 The meeting was conven@-4a@,.,9:07 am.,
           p    13
                     Dr# H. B. Pahl, Acting Director, Regional Medical Program
                14
                     Service, presiding.
                15
                     COUNCIL MEMBERS PRESENT:
                16
                17             "IMrs. Audrey M.  Mars
                               @,, Dr. George E. Schreiner
                                'Z,,Mr. Edwin C.  Hiroto
                18
                                 Dr. Paul Haber (for Dr. Marc J. Musser)
                                 Dr. John P. Merrill@
                19
                                 Dr. Alton Ochsrier
                20.              Dr. Alexander M. MdPhedraft
                               17 Mrs.-Mariel S. Morgan
                                 Dr. Ru sell B.  Roth
                21
                              i.( D " Benjamin W. Watkins@'
                                 Ur4 Sewall Oi  Milliken
                22
                     ALSO PRESENT.,
                23
                                 Dr. Robert van  Hoek
                24               Dr. Robert Laur
                                 Mr. Robert Chambliss
                25               Dr. Paul Teschan
                                                                     (cont'd)


                                         2

          ALSO PRESENT (continu6d):

         2      Dr. Harold Marguli6s
                Mrs. Judith Silsbee
         3      Mr. Jerry Gardell
                Mr. VAn NostrAnd
         4      Mr. Kpnneth Baum

         5                       And others

        @6

         7

         8

        10

        12

        13

        14

        15

        16

        17

        18

        19

        20

        21

        22

        23

        24

        25


                                                                                3

                                               C 0 N T B N T S

                 2
                     Agenda  Item                                                 @e
                 3   Call to Order and Opening Remarks                             4

                 4
                     Consideration of Minutes of February 7, 1973 Council       10

                 5
                     Report by Dr. Pahl, Acting Director, RMPS                  11
                 6   Overview of Legislative Chronology                         26

                 7   Overview of Phaseout
                 8              Mrs. Silsbee                                    39
                 9              Mr. Gardell                                     51
                10              Mr. Chambliss                                   60
                11   Presentation by Dr. Paul Teschan for Coordinators          67
                12   Remarks by Dr. Robert J. Laur and Related Discussion       so
                13   'Remarks by Dr. Robert Van Hoek                            144
                14   Consideration of Future Meeting Dates                      140
                15   Resolution re Construction Authority                       15
                16   Resolution Endorsing Adjusted Budg6t Periods and
                17     Approved Support Levels for     S. and Delegating
                       to the Director, RMPS, Limited Authority for
                18     Making Similar Future Adjustments                        159
                19   Discussion of Statement Submitted by Coordinators          17
                                                                                186

                20   Discussion of Development of Criteria and Application
                21   Other Business                                             190

                22

                23

                24

                25


                                                                                 4

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

                  2              DR. PAHL:  The meeting will now come to order-

                  3   1 have been waiting a few minutes because *6 do expect to have

                  4   Dr. Roth here.  Dr. Margulies  although not officially

                  5   connected with the program, is on h  a way, and  I'm  ur  you

                  6   wish to see him,  And we also expect to have Dr. Merrill
                  7   appear a little bit later this morning en route  from  out  of

                  8   town.

                  9              Before getting into our agenda, I  would  like  to
                 1-0  welcome each of you personally and officially  back  to  the

                 11   council ta-ble  4
                                       circumstance which perhaps some  of  us  did

                 12   not expect to  see happen at least during a  portion  of  the

                 13
                      year.
                 14              We  Are very glad to have the opportunity  to  meet
                 15   with you particularly during  *hat I@ am sure is a very  busy
                 16   summer period  for all of us, and we feel 16ttunatO that
                 17   you have b6en@able to arrange your schedules to  be  with  ba.
                                 We have a rather full day, and the staff has

                 19
                      worked Very hard in preparation tot the Council  and so

                 20
                      with your permission, I will move Along and  try  to  indicate
                 21   to you, after we get through some of  the  general  announce-
                 22   ments  whit the plan of the day is and what we hope to

                 23   accomplish.

                 24              We did indicate that we would like  to  have  you

                 25
                      feel free to depart early afternoon, but, of  course,  if  the


                                                                                  5

                  I-   discussion continues on, we would be very pleased to stay

                  2    as long as you feel it is important to our mutual

                  3    understanding of the matters at hand.

                  4              Now first I  would  like  to  welcome  Dr.  Paul
                                     .4      PI
                  5    Hpber, whom I also haven't met but who is sitting in

                  6    for Dr. Musser from the VOterans Administration.  We are

                  7    pleased to have you here, Dr. Haber.

                  8               In terms of out general announcements, in the

                  9    folders under the tab "Agenda Materials"  and  behind  the

                 l@o
                       seating chart there is the usual statement on conflict
                       of interest and the confidentiality of meetings.  1 believe

                 12    tIhese have been with us in each of our Council meetings.

                 13    Thusi it is not important to go over them.  And, Of
                 14    course, all of our Council meetings, including this one, are
                 15    open meetings.

                 16
                 17               Dr. Roth, welcome@back to  the  council  table.
                                  DR, ROTH:  Thank you,

                                  DIR@. PAHL:  I would like to indicate  that  Mr.
                 19    Ogden is unable to attend the,.meetiog this time and sends
                 20
                       his regrets  and  looks forward to working with the staff and

                 21
                       the Council  in  coming months.

                 22               Dr.   Cannon also is unable to attend, although we.
                 23    had a very long conversation by telephone concerning some of

                 24    the matters at hand, and he indicated he would be perhaps

                 25
                       in touch with some of you conveying his thoughts !bout items
                    I


                                                                                 6

                 1   vhich undoubtedly would be coming up for attention, and ve

                 2   vill be glad@to have those comments at the appropriate time.

                 3              I did intend to make some introdbdtiong, but

                 4   perhaps,we vil@,,have@to hold those@3off until the parties

                     appear               n  c
                 5            Bu@ti let me @@i'@di a"te' vhom We do expect to  have

                 6   presenting items, tq,you today, and,, undoubtedly, the  will

                 7   be here later this morning..

                 8              Dr. Robert@Laur vill@be@speakin  vith us some"
                                                                9

                 9   where about 11:30, quarter of 12i  Dr. Laur is the Acting

                10   Administrator of the nev Health Resources Administration

                     and is very active and has been activei of course, in that
                12   capacity in the Rekiohal Medical Programs issues And concerns

                13   over recent months.

                14              And timing couldn't belbottet.  Dr. Robert van Hoek

                l@5
                     Vill be meeting with us for I hope as much as  possible

                16
                     during the course of the meeting and At least after coffee,

                17
                     viil@have a fev remarks to make4  Dr. van Hoek is not only

                18
                     the Program Director of the NiiionAl Center for  Health

                19
                     Services Rosoardh and Development  and hag mot vith  the
                20   Coubdil before and presented items of interest, but also is

                21
                     the Acting Director of the nev Bur6iu of Health Services
                22   Research and Evaluation vhich has been developed iithin this

                23   nev organizationand ve vill be having more to say to yo

                24
                     about that in a tev minutes.

                25
                                We may have some guests from downtown.


                                                                              7
                                     u will also recognize familiar facts around
                               But yo
                 2   the  All. And  of course, the other person I would like to
                        v
                 3   specifically mention is Dr. Paul Teschgh as the Chairman
                 4   of the Coordinators' Natibntl St-eering'Committee and
                 5   Program Director of the Tennessee Mid-$Outh Regional Medical
                 6   Program, who also will have to be departing early but would
                 7   like to have An opportunity to present a few comments to
                 8   you from the Co  dinators"point,of view  and we *ill make
                                   or

                 9   opportunity for that presentation.
                1.0                           e4face" sitting next to Paul
                               And the "strang
                                                     ell (indicating Di.
                     is one that you recognize full W:@
                12   Margulies).  I must say it@feels very strange

                13
                     sitting here and having him sitting there,  (Laughter)
                14              I will have more to say about this as we go@,

                15
                     along.

                16
                                Concerning some housekeeping detailsi some of us

                17
                     will have our first cup of coffee, and some the second cup,

                18
                     about 10-.15.  We had scheduled the lunchtime break at

                19
                     approximately 12:30; buti of course, that is subject to
                20
                     how you feel the day is moving along.

                21
                                And Mrs4 Handal in the yellow outfit will be very
                22   interested in helping you with plane reservations and any

                23
                     changes that you would like to make.
                24              This is an open meeting.  We have members of the@
                25   public who are at the appropriate point in the agenda vtlcome


                                                                                8

                     to make comments and observations,

                 2              If any member of the public does wish to address

                 3   the Council, we would appreciate it if he would identify

                 4   himself or herself as to name, organization, and  the  group

                 5   he represents if other than himself.

                 6              Now, the plan of the day sounds a little

                 7   formal, but, in fact, as you know, we have not met since

                 8   the first week of February, and at least here  in  Rockville

                 9   much has been going on, and we would like to take  this

                l@o  opportunity primarily to bring you up to date as to what

                     hat been happening from our point of view, and  through

                     the Steering Committee chairman we will have what  has  been

                13   happening in the Region al Medical programs from their point

                14   of view.

                15
                                Thus, I will have a somewhat brief report to
                16   give to you, pointing out certain highlights  of  activities

                17
                     that wo have been engaged in and some matters that  we  will
                18   be discussing over the day, and following that there will be
                19   a report by Mr. Lyman Van Nostrand who is the Chief  of
                20   our Planning Branch of the Office of planning and EvaluAtion,
                21   who will give an overview of the rather  complicated  budget
                22   and legislative chronology, which will bring you up  to

                23   date as to where we are and how we got here.

                24              Following this -- and there are items in the agenda
                25   book which will be identified for you by the individual


                                                                                9

                  1  speakers -- we will then have a@presentatioh of the overview
                  2  of the phaseout, and Mr. Chambliss,and Mrs.,Silsbee will
                  3  describe what we did, how we vent about it, what we see the

                  4  impact to have'been.

                  5             Then we will have something concerning the

                  6  financial aspects, which are rather important, and Mr. Girdtll,
                  7  who deserves some kind of medal yet unstrtck by the Government

                  8  for call beyond duty this year, will present to  you  the
                  9  overview of vfiat our financial affairs are.  Mr. Chambliss

                10   will then wind up on a programmatic,note giving you some

                     indication of where the regions are in terms of activities

                     tjat are now going on.
                13              We ate certainly far from on out knees.  We

                14   have been stumbling a bit but I don't believe that we;are
                     beyond repair.  And I believe Mr. Chambliss will indicate
                16   that to you in his report.
                17              We do have today two formal actions that we
                18   would like to have you consider and take action  ono  and
                19   these will be the subjedt of handouts.  They represent

                20
                     delegations of authority which will become cleat to you as
                21   to why we need these delegations of authority in order to
                22   manage our affairs during this still  somewhat  difficult

                23
                     transition period.
                24              Then, if we can accomplish most of this by

                25
                     10:15 to 10:30, we will have presentations by  Dr.  Laur,


                                                                               10

                 I-  Dr. van Hoek, Dro Teschan, and We may have to rearrange the

                 2   order in order to accommodate schedules.

                 3              And then, most importantly, both before and

                 4   after lunch,6r over the lunch period, depending  upon  your

                 5   pleasure, we@@need to discuss very im  rtant issues as
                 6   to vherewe go from here, the kinds  of programmatic
                 7   options which Are under consideration, and some of the
                 8   review process and procedures which,,we are facing and on

                     which we need your guidance and assistance.
                10              So really the first halt of the morning, it
                     you will, is devoted to historical presentations, what

                1-2
                     happened and hov we got here, and then we move  into  where

                13
                     we go from here.
                14              As I say, we sorely need your good advice, coun-

                15   sel and participation in doming months.

                16
                                That is our overall plan for the day, and you

                17
                     will be hearing from a number of our staff members.
                18              Sin6e Dr. Merrill is not here, let us  omit  the

                     consideration of future meeting dates, but I  will  indicate
                20   to you we are looking toward a two-dty Council  meeting  the
                21   la$It Week of N6vdmber after Thanksgiving, but I  believe  it

                22
                     would be better if we held off the actual decision  on  that

                23   until Dr. Merrill is able to arrive.

                24              so if we may turn to a consideration of the
                25   minutes of the last meeting of the Council, February 7th  I


                  I-  would ask the Council if there are any corrections to be

                  2   made in the minutes.  And if not, I will receive a motion

                  3   for approval of the minutes.

                  4              DR, McPHEDRAN:  I move they be approved.

                  5              MRS. MARS:  Second.

                  6              DR, PAHL: It has been  moved  and  seconded  to

                  7   approve the minutes of the February 7th Council meeting.

                  8   All in favor say "aye."

                  9              (Chorus of "ayes.")

                 10              So moved.

                                 I would like now to turn   to my report, which I

                      do intend to make fairly brief.  We   are all on a  little

                 13
                      bit of a time schedule this  morning,  and that  includes  the

                 14
                      chairman, and I will try to  observe  that.
                 ]@5             The most  important and singular  event  which  has
                 16   occurred since we last meet as a Council  and  staff  has,
                 17   of course, been the departure of Dr.  Margulies  from  the
                 18   leadership of the program. And I must  say  again  that  I

                 19
                      find it quite strange to be sitting here with Dr. Margulies

                 20
                      on the sidelines. But I am glad even  with  the  press  of

                 21
                      duties he is able to meet with us today, and I hope he vi

                 22   be able to meet with us in the future,  since  we  again  need

                 23   his outlook, information and guidance.

                 24              1 would like to say that from my point of view
                 25   it often happens -- and I think this is a  case  in  point  --
                    I


                                                                                       12

                   1.  that people tho. ha@ye,served the@@G  vetnment very  well  in  a
                   2   capacity of major   responsibility   for one  reason  or  another,
                   3   through reassignments,  rea  pointment  to  positions  of  major
                                                   p
                   4   responsibilit    seem  to drift off  from  the  program  and  it
                                     yp

                   5   is never quit6 recognized.
                   6                And I would like to take this opportunity I
                   7   think to make it a part of our formal record that we
                   8   note that this is an important event in the life of the
                   9   Regional Medical Programs and that Dr. Margulies served the

                  10
                       program not only  as  the  Acting  Director  from  March  of  1970
                       to December of 1970 but Also, as you know, gave strong
                       leadership as the Director from December of 1970 through

                  13
                       June 17th of 1973.

                  14
                                    There is nothing  magic  about  June  17th  except  I

                  15
                       became the   Acting Director on June 18th, which happens to be
                  16   the  day  the  President  signed  the  one-year  extension  so  I

                  17
                       believe I revitalized the program, not Dr. Margulies.
                  1.8  (Laught6r)
                  19
                                    1  know  Dr.  Margulies  is  generally  uncomfortable

                  20
                       about being  on  the  receiving  end  of  statemetts,  but  again

                  21
                       the staff, because it has been summer and we have beet Very

                  22
                       busy  in  our  own  respective  responsibilities,  have  not  had

                  23
                       occasion    to get together, and I believe this is an

                   4
                       appropriate   point to read  a  statement  into  the  record,  a

                  25
                       brief  statement,  which  perhaps,  I  trust,  expresses  some  of
                     I


                                                                             13
                 1   the feelings that the staff have concerning@Dr. Margulies'

                 2   leadership over these years.
                 3             And so, with your permission, I will read the

                 4   brief statement.
                 5             ffOn behalf of all of the staff of the Regional
                 6   Medical Program Service, both those who are with us this
                 7   morning and those who are absent or who have departed from
                 8   the program, I want to take this opportunity publicly to
                 9   express to you,, Harold, our congratulations and very best
                10   wishes as you assume your new duties as Associate Administrator
                11   for the Office of Planning, Evaluation and Legislation in

                1-2  the Health Resources Administration.
                13              "Mor6 importantly, however, I want particularly
                14   to express our awareness and deep appreciation for your
                15   having set a high standard of excellence in which WO have
                16   taken great pride throughout your several years as the

                17
                     Director of the Program.
                18              "We note here for all to witness, particularly in

                19   these troubled days of our country, the strength you have
                20   afforded to all because of your personal integrity and
                21   your selfless dedication to the highest principles of
                22   public interest And to working in the public interest thoug
                23   at times this has been at personal cost.
                24              "As your staff we have benefited too from your
                25   belief in the worth of each person as an individual and the


                                                                                14

                 1   need to work for the betterment of that person, and nowhere

                 2   is this better exemplified than in your personal and

                 3   official commitment to the principle and program of pro-
                 4   viding equal opportunity both within the Regional Medical
                 5   Program Service and the Regional Medical Programs for a
                 6   persons regardless of race, sex, or other circumstances

                 7   which may compromise such opportunity,

                 8
                               "Haro,,Id,,it has been A rewarding experience for
                 9   each of us to have worked together with you in the Regional

                10
                     Medical Program Service toward a worthwhile goal, improving

                11
                     the health of all of our people. We wish you our best in

                  I  your new endeavors,"

                                (Applause)

                14
                               DR. McPHEDRAN:  Dr. Paul, may I add something

                15
                     to that?
                16             DR. PAHL:  Dr. McPhedran.
                17             DR. McPHEDRAN:  I want to add my thanks, Harold.

                18
                     You have been a great help in our search for ways to

                19
                     insure quality medical care for everyone.  It has been a

                20
                     pleasure for the same reasons given by Herbert Pahl.  I
                21
                     have appreciated your literate speaking and writing, but,
                22   more than that, your friendliness and consideration for
                23   others which informs all of your work.
                '24             1 am pleased to learn that you Will continue in

                25
                     that same kind of effort.


                                                                            15

                              DR* PAHL**  Thank you, Dr. McPhedran.  And I know

                2   I speak for all the members of the Council in having these
                3   statements recorded in the official record of this Council

                4   meeting.

                5              You didn't expect this, I know, and,so you may

                6   now leave for vacation "- or I guess it's tomorrow you leave

                7   for vacation.  (Laughter)
                8             Turning back to our report, which seems a little
                9   less of interest to me right at the moment, but, nonetheless,

                'O  let me pursue the agenda I set for myself.
                               lwould like to indicate, first of all, what is

                    the status of our Council.  Unfortunately, I have to

                13  relate that Dr. Gerhard Meyer has resigned, with his

                14
                    regrets, by letter, most recently, as a result of the press

                15
                    of business, And so I believe this leaves us, Ken, with seven
                16  or eight --
                17             MR, BAUM:  It leaves us I think with seven

                18
                    vacancies.

                19
                               DR. PAHL:  Seven Council Vacancies.  Of course,

                20
                    nominations had been in for the Council this past spring,

                21
                    and all of that was held in abeyance because of the proposed

                22  termination of the program4

                23             So we do hope to have our Council up to full
                @)4 strength in coming months, but I also have to indicate to
                2,5 you that five of those sitting around the table have terms


                                                                                16

                 I  expiring this November@ 30th, and'we will'be most fortunate

                 2  indeed if we can arrange matters to have all of you  with  us

                 3  beyond that point in time, and we will be working toward

                 4  that end with your permission.

                 5             Our Review Committee, as the next topic, no longer

                 6  exists. As you,may know, there is a  general  interest

                 7  within the Government, and certainly within DHEW, to reduce the

                 8  number of advisory groups to the extent that the Government's

                 9  business may still be conducted without undue detriment.

                10
                               In addition to that, with the phaseout of the

                11  program, we had no choice but to have the Review Committee

                12
                    as an established committee submitted to the  Department  for

                13  termination June 30th. And with the  efficiency  which

                14  the Department does sometimes show, these papers  were
                1,5 processed somewhat prior to June 18th, and so we  find
                16  ourselves at this point in time with no Review Committee.
                17             To reestablish a Review Committee represents a
                18  certain lag in time due to procedures one must go through,

                19
                    so as a Council and staff we stand together and alone,

                20
                    and this will have A bearing on some of the matters  that  we

                21
                    discuss this afternoon concerning how we conduct our

                22  affairs over coming months, because our primary responsibility
                23  of course, is to not only support but revitalize the
                24  regions, and we must do this under somewhat strained circum-
                25  stances.


                                                                              17

                                I would like to indicate for those of you who

                 2   are not aware that the chairman of our former Review

                 3   Committee, Dr. Schmidt, is now the Commissioner of Food and

                 4   Drug Administration, so we do have the opportunity to
                 5   pass in the halls and oh the elevator  but we don't see him

                 6   in connection with Regional Medical Programs business.
                 7              Now I@@would like.to turn to a brief review

                 8   of the various organizational changes that have taken
                 9   place since we met.  We have these in your folder, but I would

                10
                     ask you not particularly to turn to them since we have

                11
                     vu-graphs.  But under "Organizational Charts" you will be

                12
                   1 able at your leisure to study what all these new boxes are.
                13 1
                                gut I would like, if I might at this point, to
                14   run through rather quickly for you with vu-graphs these
                15   changes, And we will hope that this shows what the new
                16
                17   structure of the health part of the Department looks like.
                                (Slide)

                18
                                I hope all of you can see this. Can you hear me?

                19
                                The organization of the health agencies is, of

                20
                     course, under the Secretary of HEW, Mr. Caspar Weinberger,
                21
                     and Under Secretary Frank Carlucci.  The Assistant Secretary

                22
                23   for Health is Dr. Charles Edwards.
                                Under Dr. Edwards there is the National Institutes
                24   of Health under Dr. Stone, the Center for Disease Control

                25
                     under Dr. Sencer, Food and Drug Administration under our


                                                                                 18

                 I-   former chairman of the Review Committee, Dr. Schmidt, t e
                 2    Health Services Administration under Mr. Harold Buzzell,
                 3    and the Health Resources Administration,  the  administration

                 4
                      that we are located with, under Dr. Robert Laur w o  will  be

                      addressing us later this morning.
                 6              The Health Services and Mental Health Administra-
                 7    tion under Dr. Verne Wilson, therefore, has been broken
                 8    into three units, the Center for Disease  Control,  the  Healt
                 9    Services Administration, and the Health Resources Administra-

                10
                      tion.
                                  In addition to that, the Bureau of Health Man-

                1-2
                      power Education and certain other activities have been
                13    brought into one or another of these units.

                14
                                  This how constitutes the set of agencies and

                15
                      responsibilities that Dr. Edwards has.
                16                May I have the next vu-graph9

                17                (SlidO)

                18
                                  Now, turning to Dr. Edwards' office,  the  Deputy

                19
                      Assistant Secretary is Dr. Henry Simmons, and, of course,

                20
                      the Executive Offide is under Rupert Moure.

                21
                                  Health Planning and Program Evaluation  is  under
                22    Beverlee Myers, who was with Dr. Wilson in HSMRA.

                23
                                  Program Operations, Lionel Bernstein,

                24
                                  Policy Analysis and Research, Daniel Zwick.
                25                Regional Or.erations, Mr. Kelso.


                                                                               19

                                Administrative Management under John Droke.

                 2              Beverlee Myers, having been in  HSMHA  Andworked

                 3   very closely with RMPS in past years, of course, understands
                 4   the program and I think will be a wonderful liaison to have

                 5   in this new position.

                 6              The next chart, please.

                 7              (Slide)

                 8              Now, turning to the Health Services  Administra-

                 9   tion, the Administrator is Mr. Harold Buzzell, and there
                10   is a Program Planning, Evaluation and Legislation Office

                11   and Administrative Management. But the  programmatic  areas

                     are the Indian Health Service, the Federal Health  Programs

                13   Service, the Bureau of Community Health Services under

                14   Dr. Paul Batalden, and the Bureau of Quality Assurance

                15   under Mike Goran, which includes the PSRO, Utilization
                16   Review  Medical Review, and Independent Professional
                17   Review.
                18              Again, these charts are in your book.   t is a

                19
                     lot of information and new titles.  You can study them at your

                20
                     leisure.
                21              The next chart, please.

                22              (Slide)

                23              We now turn to the organization where we are

                24   located, the Health Resources Administration.  These are
                25   all acting appointments at the moment.  The Acting  d


                                                                                20

                 1   Administrator is Dr. Robert Laur.

                 2              Public Affairs, Mr. Lebow.

                 3              Planning, Evaluation and Legislation, Dr.

                 4   Margulies.

                 5              Administrative Management, Mr. Parks.

                 6              Programitidally, the Administration has been

                 7   constructed along the lines of three major bureaus.  The

                 8   one bureau, the National Center for Health Statistics, under

                 9   Dr. Perrin, has a major responsibility for aggregating

                1.0  all of those kinds of functions in which generalized

                11   information and statistics are sought from various

                     programs.

                13              So it does include the National Center and

                14   also the Bureau of Health Manpower Education's Medical

                15   Intelligence Division -- is that it, Harold? --

                1 6             DR. MARGULIES:  Yes.

                17              DR. PAHL:  -- and other units.  And this also

                18   has the Federal, State, local cooperative health data
                19   system.
                20              The Bureau that we are located in is the Bureau
                21   of Health Services Research and Evaluation under Dr. van

                22   Hoek, and later this morning he will perhaps have a few
                23   words to say about the proposed organization of this.

                24   But it does consist of Dr. van Hoek's current program

                25   responsibility, the National Center for Health Services


                                                                              21

                 11  Research and Development, together with the Emergency

                 2   Medical Services activities of what was USMHA,  and  the

                 3   Regional Medical Program Service.

                 4              I will say more of this in just a moment.

                 5              But to give you the third bureau, it  is  the

                 6   Bureau of Health Resources Development under Dr. Ken Endicott

                 7   of the Bureau of Health Manpower Education and consists

                 8   of the Bureau of Health Manpower Education under Dr.

                 9   Peter Eidhman, Comprehensive Health Planning Service

                10   under Mr. Robert Jahes, and the Health  Care  Facilities

                     Service under Dr. Harald Graning.

                1 2
                   1            All of the bureaus are  currently  organizing

                13   themselves and will be submitting proposed plans of
                   I
                14   organization over the course of the summer, and again Dr.
                15   van Hoek perhaps will be interested in giving you a timetable
                16   for this.
                1.7             I think the point is that we are in the bureau
                18   which includes both the Emergency Medical Service system

                1 9
                     and the R & D activities.
                20              1 made a note for,myself,that it's interesting
                21   to me that within the six-month period --land I hope this
                22   is not a prognosis by any.means     that we have had at the

                23
                     Administrator level of  the agency in which I find at least
                9@4  myself working Drs. Wilson, Sencer,@ Mr. Buzzell, and Dr.
                25   Laur.  And so if sometimes the policies from Washington seem


                                                                              22

                     to be changing and directions move a little differently,
                 2   you will see that this rapid turnover of top management
                 3   undoubtedly is partly responsible, and we continue to

                 4   suffer to a certain extent certainly within the health area

                 5   in the fact that certain key positions are not filled at

                 6   all and certain major positions turn over rather frequently.

                 7              We do not at the moment have a full-time

                 8   permanent Administrator of the Health Resources Administra-
                 9   tion, but this is probably true across Government from w a

                10
                     I can understand, but it does make a difference in how

                11
                     wellwe can act,

                ]@2             Now I would like to turn to the staffing of

                13   our own Regional Medical Program Service --

                14
                                (Slide

                15              -- and indicate to you where we are, where we
                16   were before we engaged in the phaseout process which   i
                17   applied to the Regional Medical Program Service itself, of
                18   course, not just to the Regional Medical Programs.

                19
                                And without trying to make too much of the
                20   numbers, we have looked at the professional people on
                21   board in January --.at January 1 -- and at July 1 and
                22   our clerical and supporting staff January I and July 1 by

                23
                     office.
                24              First of all, the totals.  We did have 234 People

                25   in January.  We are now down to 128 people.


                                                                            23

                               We had 125 professionals.  We are down to 84.

                2              We had  109 supporting personnel, and we are  down

                3    to 44.

                4              This should indicate that we have been going

                5    through the same kind of personnel loss that the Regional

                6    Medical Programs have.

                7              There has been within the Government a RIF, a

                8    reduction in force program, which has a planned program  for

                9    us for a reduced number by September 30 and March 31, so

                10
                     that if the personnel continue to depart -- which we  believe

                11
                     is no longer necessary with the extension of the program  --

                12
                     we would have been down to perhaps 70 people by September

                13
                     30 and 30 people by March 31 and 9 people by the end of  the

                14
                     year.
                15              I would like to take just one moment and  publicly

                I (i
                17   again thank-"  The staff knows full well what has happened
                     here in recent months.  But Mr. Charles Hilsenroth, who

                is
                     has been our Assistant Administrator or Director for the

                19
                     Administrative Management and Services of the Regional

                20
                     Medical Programs, has done an outstanding job.

                21
                                I think only those of you who have worked in  the
                22   public service know how difficult it is sometimes to
                23   rearrange transfers of personnel and to locate  opportunities
                24   for personnel as they move out of a program into other

                25
                     areas, and without question Mr. Hilsenroth, who retired  last


                                                                              24

                     month, has done an outstanding job in relocating our

                 2   personnel, the kind that you see have been lost  from  each

                 3   and every office.

                 4              1 think due recognition of this was made, but

                 5   it should be also a matter of record here.

                 6              Now, the numbers themselves, either in the

                 7   professional category or the clerical category, don't really

                 8   indicate what has happened.  As you know from being with

                 9   many organizations yourselves, it is who leaves, the

                10   timing, and, of course, the morale problem.  And so we

                     find at the moment that we have key people in  each  office

                12   who have left.

                1,3             And it would be somewhat I guess  not  necessary

                14   really for me to indicate to you, but the fact that Dr.

                15   Hinman is sitting over there, the fact that  Dr.  Margulies
                16   is sitting there, the fact that we have people from the
                17   Office of Planning and Evaluation, Systems Management,
                18   this office is leaderless (indicating Office of Communications
                19   and Public Information)--  And we can go down and down.

                20
                                So we have been working against a difficult set
                21   of circumstances and continue to do so. We  Are  trying  to

                22
                23   stabilize and move ahead.  And to the 6xtent that the Agency
                     is reorganized and the Bureau is reorganizing this has
                24   posed or superimposed a set of problems which we continue to
                25   deal with.


                                                                              25

                 1              1 would like to turn to the other topic of  the

                 2  overall picture of our budget.

                 3              (Slide)

                 4              This chart is in the book.  I wontt spend too much

                 5  time on it. The original budget request  for  fiscal  1973

                 6  'Was $131 million.  The amount in the appropriation bills for

                 7  1973, which was vetoed, is $164 million.
                 8              We roughly spent $59 million in 1973, and  Mr.

                 9  Gardell again will receive a commendation because  out  of

                10  that we ended up with a balance of $2,449, which  is  again

                11
                    an unusual circumstance particularly with the ways in which

                12
                    the program has been going recently.

                13              The authorization for fiscal 1974 is $159.6

                14  million, and the continuing resolution under which we

                15  operate at the present time for fiscal 1974--  We might as
                16, well indicate it's either $60 or $81 million, and itts

                17
                    an academic point at this time because of matters which have
                18  moved the whole process somewhat further along.

                19
                                I think that's all we need from the  vu-graph.
                20              Now, I'm taking more time than I should, and  I
                21  know the staff is nervous.  On the other hand, I think

                22  itts important that you realize some of the positions that we

                23  have been in.

                24              1 would like to terminate my portion of this

                25  presentation and then turn it over to Mr. Van  Nostrand  to


                                                                                 26

                 1   go over the budget and legislative  overview  by  saying
                 2   that the WASHINGTON POST today -- they  must  have  been
                 3   psychic -- recognized the position that the Regional Medical
                 4   Programs have been in.  And I'm very happy to say that those
                 5   of you who got up early enough and got  past  the  front
                 6   page and that rather startling series of things may have
                 7   gotten to see on the comic page where Charles Schulz
                 8   finally recognized the Regional Medical Program Service's
                 9   problems and expressed the philosophy perhaps that the

                10
                     staff has had to adopt over recent months.

                11
                                 It's a four-picture comic strip, and Peanuts

                12   is saying,  with his face in his hands, "I used to try to
                13   take each day as it came -- you know, live one day at a

                                                          Itm down to half a day
                14
                     time.  My philosophy has changed.

                15   at a time."  (Laughter)

                16               I'd like to indicate I think wetre out of a half

                17
                     a day at a  time and we're back at least to the one day.
                18   And I think with this Council meeting wetre beginning to
                19   look at weekly, monthly, and possibly even the full fiscal

                20
                     year.

                21
                                 With that I'd like to have Lyman come and address

                22   you oh the  budget And legislative chronology.

                23               MR. VAN NOSTRAND@. As Dr. Pahl has said, you

                24
                     could call  this year almost the fall and rise  of  RMP,

                25   although the novel isntt quite fihi0hed yet.


                                                                              27

                 1              It really started back in 1972, the Presidential
                 2   budget for FY 73.  The figure that was proposed was $130.3
                 3   million.  During the appropriations process, the bills
                 4   that came through were quite a bit higher across the board,

                 5   not only for RMP but for all of HEW.
                 6              In the case of RMP, the figure that they came up

                 7   with was $164.5 million, which was some $34 million over

                 8   the Presldent's budget.

                 9              Because both the HEW appropriation packages were
                10   so high, the President vetoed both of those.

                11
                                This forced us to go into the situation of a
                12   continuing resolution.  The figure that was picked for
                13   this was the lower of the House and the Senate appropriations.

                14
                     Since the House figure was $150 million, that was the
                15   figure that became our sort of current rate.
                16              In January 1973 the President released the FY 74
                17   budget, and this was, of course, where they made the major
                18   decision to propose termination of RMP in FY 74.  At the

                19
                     same time they put in an amended 1973 level budget which
                20   was for the amount of $55.4 million.
                21              When they proposed the termination of RMP, they
                22   gave what they considered a rationale behind this.  They
                23   said that the program had been going for eight years, had
                24   spent about $500 million.  They felt the program had never
                25   really established a clear focus for itself.  It had been


                                                                            28

                 1  part of the time on heart disease, cancer and stroke,
                 2   moved into comprehensive care delivery systems.
                 3             Another problem they found with the program  was
  Is             4   that they felt too much money was being spent on the core
                 5   staffs.  Over the past few years this has averaged about 40
                 6   percent, and there was some problem with this.
                 7             There was some feeling that too many funds had
                 8   been going into training and continuing education, with the
                 9   belief that this kind of thing could have been picked up
               10    by physicians, nurses on their own, on their own salaries,

               11    hospital costs, and so forth.
               12              And there was some dispute too in terms of@.  Had
               13    RMP really gotten the latest advances out into the system?
               14    There was some question about this.  Could It really be

               15    proved?
               16              An additional rationale was that there were  a
               17    number of now health programs that hid come along that
               18    could pick up some of the functions RMP had in the past,

               19
                     The idea was that planning functions could be done by  the
               20    Comprehensive Health Planning agencies, that the Professional
               21    Standards Revi6v Organizations could pick up on the quality
               29,   of care aspects of health care.  NTH was doing more in the
               23    way of heart disease and cancer control programs and  that
               24    they could pick up some of the things that RMP had been

               25    doing.


                                                                               29

                 1              And also that probably another very big piece,

                 2   with the passage of the social security amendments last
                 3   year that included reimbursement for  kidney  disease--  The
  fA             4   idea was that with Medicare paying for kidney disease, a lot
                 5   of the work RMP had been doing In this area probably wouldntt

                 6   have to be continued.

                 7              On March 8th, the first evidence of some

                 8   congressional opposition to this proposal was evidenced
                 9   when Senator Kennedy introduced, with 15 of the 16 members of

                10   the Labor And Public Welfare Committee, a one-year

                11   extension of 12 of the Public Health Service authorities.

                12   This included RMP as well as a number of  others,  including

                13   Hill-Burton  Community Mental Health Centers, R & Do

                14   Health Statistics, Allied Health Training, a whole broad

                15   range of programs.
                16              The level of authorization that they put In there

                17
                     was the same as it had been in the previous  RMP  authoriza-
                18   tion, $250 million.

                19
                                The basic rationale of why they were calling

                20
                     @for aone-yetr extension was that the committee felt they
                21   had not  had enough time to review these programs,  that  the
                22   budget had proposed phaseout in such a quick period of
                23   time they really hadn.1t had time to go over and see what
                24   the strengths and faults of the program were,  what  changes

                25   needed to be made to modify it so it was a little more
                   I


                                                                              30

                 1  productive.
                 2            On March 14th an extension bill was also intro-
                 3  duced in the House, H. R. 5608.  This was Representative
  Is             4  Hastings along with the entire Subcommittee on Public Health

                 5  and Environment.
                 6            The first hearings were March 22nd in the Senate.
                 7  That was a one-day hearing after which the bill was reported
                 8  out.  And a few days later, on March 27th, the Senate
                 9  passed the bill by a vote of 72 to 19.
               10              This was followed with hearings in March, March

               11                                              use. Alo
                    27 through 29,and again on May 8, in the Ho        ng with

               12
                    the Administration testimony, there were also the RMP
               13   coordinators and a panel of RMP  hysicians that were on RAGs
                                                    p
               14   around the country, and they presented evieence that they
               15   thought was contrary to the point of view being expressed
               16   by the Administration.

               17
                               They talked about some of the accomplishments RMP
               18   had had.  They admitted there were some problems in certain
               19   areas, that there could have been more focus on certain
               20   problems, but they thought the overall record was generally
               21   favorable around the country.
               22              On May 15th, H. R. 7806 was substituted for the
               23   first House Version, the idea being to lower the total
               24   authorization levels in there by over a billion dollars
               25   so there would be less reason to cite vetoing it in terms of


                                                                               31

                 1   budget-busting.
                 2               Because of that, the RMP authorization was dropped

                 3   from a level of $250 million to $159 million.
                 4               On May 31, the House passed this bill by a vote

                 5   of 372 to  1.
                 6               On June 5 the Senate decided to drop its original
                 7   version of the bill which had the $250 million for RMP
                 8   and accept  the House version, I think on the assumption that
                 9   it had a better chance of being signed by the President,

                10
                     and that was passed by a vote of 94 to 0.

                11
          -Z                     So, in essence  the bill went to the President
                12   with   really only one vote against it.  It was passed

                13
                     unanimously in the Senate  and 372 to 1 in the House.  And

                14
                     the President signed the bill on June 18th.
                15               In his signing message he said that he realized,
                16   you know--  He acknowledged the opposition they had had to
                17
                     the passage of this but he said he felt if the Congress
                18   had one year to look over these programs and recodify and
                19   consolidate, they might be able to come up with a better

                20
                     package, how to authorize some of the authorities under the
                2 1
                     Public Health Service law.
                22               Once we had the authorization, the next step in

                23
                     this process, of course,, was t,o'@get appropriation, the
                24   actual funds.  There have been both House and Senate he@arings

                25
                     over the last couple of months.


                                                                               32

                 1             The first real action on this was the House
                 2   passage of the FY 1974 appropriation  bill.  That  included
                 3   a figure of $81.935 million for RMP.  The Senate is
  Is             4   still holding hearings on the 1974 appropriation.  If they
                 5   follow their usual form, they will come up with a figure
                 6   higher than that,which leads to the problem again that  if
                 7   the HEW appropriation is too high -- again the House version
                 8   is already a billion over -- will this lead to another
                 9   veto? And so that is something that has to be  looked  out

                10   for down the Pike.
                               At the same time, because the  Senate  had  not
                12   finished its work on the appropriation, it  rdquired  the
                13   signing of a continuing resolution.  This allows us to

                14
                     spend through September 30th, and the rate at which we are

                15
                     allowed to'spend is the lower of the House version or
                16   last yearts continuing resolution.

                17
                              ,@Since last yearts was $150 million and this

                18
                     yearts is $82 million -- the House version for FY  74  is
                19
                     $82 million    our current rate at least for this purpose
                20   is $82 million, at least according to  the  congressional
                21   interpretation.
                22              At the same time, at the end of PY 73, a supple-
                23   mental appropriation bill was passed.  This  is  something
                24   that happens almost every year.  The Executive Branch sends
                25   in all the last-minute items that have seemed to have


                                                                             33

                 1  occurred In the budget, expenses that were not really known

                 2  in advance.
                 3             That budget was sent to the Senate and the House.
                 4  The House added $12 million under Section 304 and Title IX
                 5  of the Public Health Service Act -- which is the RMP
                 6  authorization -- for construction for D. C. Childrents

                 7  Hospital here in D. C.
                 8             At the same time, the Senate both in committee and
                 9  outside, in the floor debate, added the $12 million for
                10  D. C. Childronts, added $4.5 million for construction of

                11
                    a children's center In the northwestern part of the United
                12  States, very probably in the State of WaOhington, and
                13  $500,000 for completion of a hospital up in Vermont which

                14
                    Senator Aiken had added on to the proposal.
                15             So the bill as passed -- and the President signed
                16  it    this was after the negotiations on the Cambodian

                17
                    resolution    includes $17 million that is available until
                @8
                    expended under Section 304,@l, which is the RMP authorization,
                19
                    for construction of these three projects that I have men-

                20
                    tion4d.

                21
                               Dr. Pahl  I guess will be speaking to you later
                22  about those in terms of delegations of authority of how we
                23  are going to handle those.
                24             The only other thing I thought T might mention
                25  quickly In terms of other legislation that is sort of coming


                                                                              34
                 I  along the pike is in terms of the HMO bill.  The Senate
                 2  passed that on May 15th with a total authorization of
                 3  $885 million for three years.  The House Is working on the
                 4  bill,l think this week, H. R. 51. They expect to  have  a
                 5  markup I think this week, which would mean it would be

                 6  reported shortly thereafter.
                 7             That is expected to have much lower authorization
                 8  levels than the Senate version, more in the version of  a

                 9  demonstration grant program.
               10              The other bill that is moving along fairly well
                    is the @rgency Medical Services  bill.  That  passed  the
               12   Senate on May 15th, the House on May 31st.  The conference
               13   report was reported out July 10th, which essentially  put
               14   money into planning, feasibility stud es, establishment and
               15   initial operations, research in emergency medicine, and

               16
                    training grants.  And that was for $185 million for three

               17
                    years.
               18              And the only other thing with that which may
               19   cause some problem is the fact that the eight Public Health
               20   Service Hospitals were added as an amendment to keep these
               21   open, which is being opposed by the Administration.  So
               22   that may or may not cause a problem.  Itts hard to tell at

               23   this point.
               24              A third piece I thought I would mention is the
               25   kidney disease part of the social security amendments of


                                                                                 35

                 1  1972.  The reimbursement, for Medicare, began on July 1,

                 2  1973, and interim regulations on how this was to be worked
                 3  out were put in the FEDERAL REGISTER on June 29th, essentially

                 4  saying that for the time being, until final regulations are
                 5  done, they will continue paying through the normal Medicare
                 6  channels for hospitals that have already been doing such

                 7  kidney operations, dialysis, and so on, and that as the
                 8  program gets going, within six months to a year, they will
                 9  probably have final regulations that set up what the final

                10  procedures are going to be.

                1 1
                                DR. PAHL4.  Thank you very much, Lyman.

                12              We have given you a good bit of information  in

                13
                    both my report and Lymants, and I think we  might  ask  whether
                14  you have any questions or points to make or observations

                15  as a result of these presentations before we move on.

                16              In this connection, I would like to again indicate

                1 7
                    to you that in your agenda books, which I hope  you  will-"
                18  Pardon me.  Dr. Schreiner?

                19
                                DR. SCHREINER: When you  originally  introduced
                20  thisi you mentioned a continuing level of either $60 or
                21 ,$80 millidn,@and I don't.understand where the  $60  million

                22  came "from.

                23              DR. PAHL@. There hits been a debate going on as  to

                24  whether the continuing resolution from the Department's
                25  point of@viev would be at the current operating  level  of  the


                                                                               36

                 1  program or whether the congressional, $82 million House
                 2  allowance, would be the level of the continuing resolution.
                 3             And this has been a matter of great internal

                 4
                    interest within the bureaucracy.  At the moment, as   have
                 5  indicated, this is not of major import because we will be
                 6  taking up this afternoon the actual funding and fiscal situa-
                 7  tion of the program, so that at the moment we are not privi-
                 8  leged to be expending at either of those levels.
                 9             So although it is of still great academic interest,

               10
                    I believe we'll accept the congressional level of $82

               11
                    million as being at least the lover figure which we can
               12   expect from the Congress, and then leave it to OMB and the

               13
                    Department to decide what the funding level of the program

               14
                    may be, looking hopefully, of course, toward full
               15   authorization and release of all the funds that are made
               16   available.

               17
                               But it's an internal kind of consideration of
               18   continuing resolution levels, and the lawyers have had a
               19   wonderful time trying to decide just what the continuing

               20
                    resolution means.
               21               If you read the legislation and the report, you
               22   will also find that the Congress has tried to make very
               23   clear from their point of view what they believe the Ad-
               24   ministration should consider to be the continuing reso ut on

               25   level.


                                                                             37

                 1             Yes, Dr. Haber?
                 2             DR. HABER@.  Previously you mentioned one of the
                 3   criticisms of the Regional Medical Programs was  too  much
                 4   money had been put into core staff.  I don't understand how
                 5   that is a criticism.  Can you elaborate on it?
                 6             DR. PAHL@. Lyman, do you want to, or  shall  I?
                 7             MR. VAN NOSTRAND4* Essentially what  they  were
                 8  saying I think is that some of the activities--  They tended
                 9 to equate core staff with administrative  costs,  which  Is

                10   not necessarily the case.

                11             DR. HABER@.  That's what I mean.
                12             MR. VAN NOSTRAND@*  The idea was the money could
                13   have gone into direct operational projects rather than into
                14   program staff.  I think when the coordinators presented
                15   their testimony they tried to,shdv that the administrative
                16                                                     ut 7, 8
                     'costs at least in their definition amounted to ab6
                17   or 10 percent and that the activities carried ou
                18   @by the program siaff'vtre really as good as the operational
                19   projects in terms of getting something done.

                20
                                So it's really a matter of their view of how you

                21   define what core staff is doing.

                22              DR. PARL@.  It has been looked at as a very
                23   high overhead, when, in fact, it constitutes very important
                24   programmatic activities included in  that  figure.  There
                25   has been a good bit of misunderstanding as to just what that

                   I


                    includes, and we have tried to clarify it.
                 2             1 would itdicate in the agenda books that under
                 3  the various tabs again we have the Xeroxed charts of all

                 4
                    those which have beet  presented to you through the vu-graphs.
                 5  Also there is a more detailed legislative chronology,
                 6  actual excerpts from the congressional hearings and staff
                 7  relative to the RMP program this year, a section on related

                 8  legislation.
                 9             1 believe you will find all of these of value
                10  and interest to read a little bit more at your leisure.
                               If we may turn over to the next item on the
                12  agenda, which Is the overview of the phaseout, we have

                13
                    asked Mrs. Silsbee, Mr. Gardell and Mr. Chambliss to
                14  give to you--  And I would believe perhaps we could accomplish
                15  this in a half hour.  I have eaten up a little too much
                16  time.  But I believe that might be about an appropriate time
                17  to give you a picture of what really has happened from
                18  the period when we last met in terms of administrative
                19
                    actions and where we stand.

                20
                                Just by way of introduction, since you all know
                21  Mrs. Silsbee, I would like to say she ver  graciously has
                                                              y
                22  accepted, and I am pleased to announce to the Codn6il,
                23  appointment as Acting Director of the Division of Operations,
                24  having formerly served as the Deputy Director of that
                25  Division, and, likewise, Mr. Chambliss has graciously


                                                                            39
                 1 accepted to serve as the Acting Deputy Director to me for
                 2 the Regional Medical Program Service, having served as  the
                 3 Director of the Division of Operations.
                 4            And so, you see, it's the domino game of everyone
                 5 moving upward into better jobs, bigger  titles,  greater
                 6 responsibilities. And we are really  pleased  that  they
                 7  take on these responsibilities for us.

                 8             Judy.
                 9             MRS. SILSBEE:  Well, when Council met last time,
                10  we had had the first step in the phaseout, and I believe you

                11
                    had just received copies of the February 1 telegram  which

                12
                    vent to the Regional Medical Programs explaining that  the
                13  phaseout would have to occur and that we would need
                14  applications putting forth their plans.
                15             The telegram stated the criteria which would be
                16  used to review the phaseout plans, stating that during the

                17
                    phaseout only activities that had a  short-term  impact
                18   that we could note would be considered or that had  an

                19
                     opportunity to be picked up from other sources and needed
                20   some additional time in order to accomplish that fact.
                21              We sent the telegram on February 1.  And since
                22    apparently in the Department of HEW no one had ever phased
                23   out a program in any orderly fashion before, we had to
                24   start from scratch.  We had to develop instructions.  We ha
                25   to think of the kind of information that the Regional


                                                                          40

                 1  Medical Programs would need in order to do this in an
                 2  orderly fashion, and, knowing that the Regional Medical
                 3  Programs is an unusual grant program, In that it involves a
  Is             4  number of different organizations, not only the grantee but
                 5  all the affiliates, this was our major consideration.  How
                 6  could we do this in a way that would be helpful to the Regional
                 7  Medical Programs under very stressful conditions?
                 8             So it took us a while.  And I think Jerry Gardell's
                 9  staff does need a hosanna here, because from the grants
               10   management.standpoint they had to develop this materla

                    from scratch.
               12              The instructions went out sometime in the latter
               13   part of February, and the applications were expected back

               14
                    on March 15th.  At the same time we had promised by April

               15
                    15th to give a re @ nse so that they would--  Again looking
               16   at June 30th as a first part of the phaseout  February 14th
               17   the end point, this would give the Regional Medical Programs
               18   time enough to do with all of their various organizations
               19   what they had to do in order to have an orderly phaseout,
               20              Well, we received the applications, and they
               21   came in--  I think it was probably a first in the history of
               22   Regional Medical Programs.  Just about every one of them
               23   made the deadline of March 15th.
               24              And the applications as a whole were very well
               25   organized.  The Regional Medical Programs under tremendous


                                                                               41

                 1   stress of time and decisions did a beautiful job of present-

                 2   ing their plans.
                 3              The applications broke out into various categories.
                 4   There were programs that had decided to essentially phase
                 5   everything out June 30th.  There were those that had done a
                 6   pretty stringent veeding-out job at the regional level and
                 7   were recommending projects based on our  two  criteria  and
                 8   providing the documentation. There  were  those  that  were
                 9   trying to keep the program staff intact, because the
                10   program staffs in certain regions, As  Dr.  Pahl  mentioned

                11
                     earlier, some program staffs, do a series of studies, and
                12   so forth, were the vital part of the program, and they had

                13
                     used small amounts of money for studies, and so forth, in

                14
                     order to make the program go.   And then there  were  those
                15   Regional MedicAl Programs that  wanted to  keep  everything

                1 6
                     @going pretty much..
                17              We had no experience In reviewing phaseout plans,

                18
                     but we did have some understanding of what the Department
                19   expected In terms of phaseout and *by they had allowed
                20
                     this extra time, because there had been one consideration
                21-  of June 30th -- period.  They were interested in allowing
                22   some projects meeting these two criteria to go on.
                23              So that had to be our major cue  in  looking  at
                24   the applications, looking at the projects, to see whether
                25   they met one criterion or another, and then to see if they


                                                                           42

                 I  had the documentation that went along with it, and then  to

                 2  develop the program staff, minimal program staff, that  was

                 3  needed to monitor those projects and phase out the  program.

                 4             The review of the 56 applications was done  under

                 5  very intensive circumstances. We decided very early  on  we

                 6  couldn't do a gradual review as we usually do, with the

                 7  staff looking at it and then coming up and  recommendations

                 8  being made that way, because we were having to do it  and

                 9  make our own ground rules as we went along and then go  back

               10   to staff information.

               11              So aside from a few forays to the emergency

               12   medical clinic on my part and to the hospital on Dr.  Pahl's

               13   part, five of us sat day by day during the day considerin
                                                                              9

               14   these applications, and night by night reading them so we

               15   would be ready for the next day.

               16              Well, about April Ilth we mete able to send  out

               17   the telegrams to the regions stating what they could

               18
                    continue beyond June 30th and a level of support that  we
               19   would allow them.

               20              The telegrams also indicated-- Or we  knew  that

               21   there would be appeals, so there had to be appeal  review

               22   afterwards.  And gradually all these decisions were made,

               23   and we were ready to phase out.

               24              You may be interested in the back of the  book

               25   under "Phaseout" that the majority of the regions were


                                                                            43

                 1  approved to go from June 30th to January or February of
                 2  1974.  About five were approved to phase out June 30th, three

                 3  of which had opted for that.
  Is             4            Of the projects that were approved--  And again
                 5  1 want to emphasize that they had to meet one criterion or the
                 6  other.  Of those projects -- there were about 289 -- of
                 7  the 289, 209 of then were in the regions that were going
                 8  on to January or February of 1974.

                 9             (Slide)
               10             In terms of the types of activities that we now
               11   find ourselves with before the phaseup again, I did an
               12   analysis which could be challenged by practically anyone

               13
                    in terms of the types of projects, and that's in a little

               14
                    vu-graph.  But you can always quarrel about how you are going
               15   to categorize.  But I categorized all of them on the same
               16   basis, which are my definitions.

               17
                               As you can see, the majority of those projects

               18
                    ,that were approved,beyond!were'in the area of

               19
                    categorical diseases, or I threw in there specific groups

               20
                    like the neonatal group, and so forth.  And emergency

               21
                    medical services about 11 percent.  Health manpower, ge era

               22
                    ,which would include our support for the health services edu-
               23   cation activities.  And health manpower, specific, wh c  was
               24   for specific professional groups or for specific types of
               25   training, including categorical diseases.


                                                                              44

                 1             That's all I have.

                 2             DR. PAHL4*  Okay.  Are there any questions that
                 3  you may have concerning this rather brief but I hope
                 4  interesting view of what the staff tried to accomplish in
                 5  a rather short time frame and as fairly as possible'?

                 6             These were professional judgments relative to
                 7  regions and projects, and, of course, the staff stands to be
                 8  criticized and have been criticized, but I would merely
                 9  say that In the circumstances we had to operate, at least
                10  from our point of view, we tried to be as fair and

                11
                    equitable as possible and I think only history will

                12
                    record whether this was in fact as good as v6 tried to make

                13
                    it be.

                14
                               Are there any questions?

                15
                               MRS. MARS:   What happened to the three that were
                16  phased out June 30th?   Are they still continuing?

                17
                               MRS. SILSBEE46  Well, actually, there were five
                18  that were scheduled to be phased out.  But that shows in
                19  relationship to our former rating of A, B and C.

                20
                               MRS. MARS:  Take the five then.

                21             MRS. STLSBEE.I  Of the five, once the legislation

                22  was extended, two of them which seemed to have enough there
                23  to go on requested reconsideration.  They had opted
                24  originally to go out of business on June 30th.  We had no
                25  plan B for them.  We had a plan A only.  So that was the only


                                                                    45
                 thing we could consider.  And the decision was made to
              2  continue those.  They had funds that would allow them to do

              3
  fh          4  it.
                           MRS. MARS@.  This was two of them?
              5            MRS. SILSBEE@.  Two of them.  Three of them have

              6
                 been phased out.
              7            MRS. MARS@.  Completely?

              8            MRS. SILSBgE.i Completely.
              9            MRS. MARS@.  Which ones are they?
             10            MRS. SILSBEE4.  Delaware, Ohio, and Northeast

             11
                  Ohio.

             12
                           MRS. MS   Thank you.

             13
                           M. PAHL   Dr. Roth.

             14
                              ROTHI*  dent know when o
                           DR.@                      r even if it will

             15
                  become appropriate to say more about a document that
             16
                  has been given to me, but this came from the coordinators,
             17
                  and in the first part of it there is a statement that
             18
                  relates to what we have just been talking about on phaseouts
             19
                           Let me ask a question.  This saysthat it is

             20
                  believed that the February issuance of phaseout orders
             2 1
                  with subsequent amended awards to each individual Regional
             22
                  Medical Program was in violation of Public Law 91-515

             23
                  because those orders were never approved by this Council.
             24             Would you care to react to that? And is it of any

             25
                  Significance if itts true?


                                                                             46
                 1             DR. PAHL@O  I -feel like perhaps one of the indi-
                 2   viduals who has been appearing before the Seoate.  That's a
                 3   two-point question. (Laughter)
                 4             Let me answer the second point first.  If true,

                 5   yes, it is significant.
                 6             With regard to the first matter, we do hot concur
                 7   with that position, because as members of the Executiv6
                 8   Branch we feel that we really must follow what is the
                 9   Administration's position, and, therefore, when the President
               10    did not request support for the program for fiscal 1974
                     it seemed to us to be a matter of prudent administration to
               12    alert, which is what that telegram did -- to alert, all

               13
                     Regional Medical Programs of this fact and to ask them to

               14
                     take those kinds of steps which could lead to an orderly
               15    termination and the request, therefore, to submit plans of

               16
                     phaseout.

               17
                               We did not terminate the program with that

               18
                     telegram.  I think this is a point which should be under-
               19
                     stood.  That telegram was considered to be a matter
               20
                     of administrative necessity in view of the fact that

               21
                     no funds were requested for the continuation of the program.
               22              The administrative actions which followed were
               23    considered to be that -- administrative actions on the basis
               24    of  prudent management.

               25
                                The decision to terminate the program, if you


                                                                                 47

                     will, was a collective decision by the Administration.  I'm
                 2   not enough of a lawyer to know in fact whether this  required
                 3   Council approval or not. But we felt it was a  matter  solely

                 4
                     of management and not a question of Council approval,
                 5   because this was not seeking advice about programmatic
                 6   areas or approval of grant funds for the support of activi-
                 7   ties by the regions.
                 8              In confirmation of this point of view,  I  would
                 9   say that as soon as the President signed the extension
                10
                     legislation, which, of course, we had been also looking
                     forward to ourselves daily, the first official act  which  was

                12
                     taken    and I happened to be the one in the chair  at  the
                13   time   was to institute the Council involvement by trying to

                14
                     call this meeting together.

                15
                                So, in fact, we view it as a very desirable

                16
                     feature to have Council involvement in matters of

                17
                     advising on policy and certainly in approving  grant  funds
                18
                     for expenditure by RMPS.  But the termination was vieve
                19
                     as a necessary prudent managerial procedure and not requiring
                20
                     Council.

                21
                                That I think is the viewpoint.  Whether legally

                22
                     this position can be sustained I honestly don't  know,  and

                23
                     we have been so busy trying to be prudent managers,with

                24
                     both our internal staff and our external programs having

                25
                     great difficulties, that we did not wait for a 4-month


                                                                              48

                 1  written opinion from General Counsel, very frankly.
                 2             That is as honest a statement as I can make.  And
                 3  as soon as our program has been extended, we have come back
                 4  -- not reluctantly but quite enthusiastically -- to seek
                 5  your advice as to how to advise us on matters of great
                 6  importance to us, and also, of course, at the appropriate
                 7  time, to approve the expenditure of funds.

                 8
                               DR. ROTH:  Thank you.

                 9
                               MRS. MARS.  Yes,, but now that these three are
               10   actually phased out and there is a continuation, isntt it
                    illegal that they're not to receive funds or are not being
               12   dontinued?  The three that are phased out -- the three
         @o

          p    13
                    programs?

               14
                               DR. PAHL.@  Let me go off the record, please.
               15              (Discussion off the record.)

               16
                               DR. PAHL4.  May we go on the record again?

               17
                               Dr. Schreiner.
               18              DR. SCHREINER@.  Since one of our previous drives

               19
                    was to get Ohio consolidated, I just wondered if it would

               20
                    be appropriate to simply reassign the territory to an
               21   existing, ongoing regional program.  This really punts the
               22   legal question, because you haven't phased out anything.
               23   You9re simply redistricting.  And maybe this is the right

               24   time to think about it.

               25              DR. PAHL@.  I believe we will be considering


                                                                                    49

                  1   territorial questions at some point.
                  2               At this point it is fair to say, and for the record
                  3   it should be stated, that RMPS  did,  in  fact,  phase  out  the

                  4   three Regional Medical Programs, so at this point that

                  5   action has been taken.

                  6               I believe, Bob, perhaps  you  might  care  to  comment,

                  7   if it was you who  had  that  conversation,  or--  Who  had  the

                  8   conversation concerning the activities from Northeast

                  9   Ohio  in  perhaps  reforming--  Mrs.  Kettle?  Mrs.  Kettle,  would

                 10
                      you  6i@6  to  make a statement, please?

                                  MRS. KETTLE4.  As far as I know

                 12               DR. PA#LI. Would you  care  to  use  the  microphone

                 13
                      so   everyone can hear?

                 14
                                  MRS. KETTLE-4  The acting coordinator who

                 15
                      stepped in  to administer  the  phaseout  procedures  of  Northeast
                 16   Ohio met with  the chairman of the Regional Advisory Group

                 17
                      for Northeast  Ohio, and they called  a  joint  meeting  of  the
                 18   board of trustees.  Northeast Ohio had a corporation as a

                 19
                      grantee.
                 20               And they met with the  board  of  trustees  last  night
                 21   1 believe  to see about  courting  Mr.  Milliken,  Mr.  Cashman,

                 22   and called for assistance in tracking down some Ohio

                 23   Columbus -- people so that they could just discuss and

                 24   explore coalition.

                 25
                                  DR. PAHL:  Thank you.


                                                                               50

                 1             1 would indicate that in terminating these three

                 2  regions the staff officially and the coordinators officially
                 3  indicated that both groups would be interested in providing

                 4  as much assistance to these regions as may be desired in

                 5  reforming, but at this point the Council does have 53

                 6  programs existing and not the 56.

                 7             Mr. Milliken, would you care to comment  on  any-

                 8  thing that you may know of?

                 9             MR. MILLIKEN@O This is all news to  me.  This  is

               10   the first time I have heard about it.

               11              DR. PAHL' Well, we're all trying  to  get  caught

               12
                    up.

               13              MR. MILLIKEN:   I'm sorry.

               14              DR. PAHLio  Dr. Teschan, do you want to speak

               15   for the coordinators in this?

               16              DR. TESCHAN.  No, everything has been said

               17
                    exactly as we understand it.
               18              MR. CRAMBLISS.I  Imight call to memory of Council
               19   that the Northwest Ohio Regional Medical Program did set

               20
                    a precedent in Ohio.  If you recall, that region at the time
               21   was one of the, shall we say, weaker regions, and it was

               22   merged into the Ohio RMP.

               23              So we have had some history of this kind in

               24   Ohio; and this Action that has been taken does not preclude

               25   them from reapplying.


                                                                            51

                1              DR. PAHL@.  All right.  If we may move on, with
                2   your indulgence -- I know blood sugar levels may be a little
                3   low -- but if we can just get through a few more minutes I

                4   believe it would be helpful to finish this part of the
                5   presentations with Mr. Gardell at this point giving you
                6   what our fiscal activities have been and then Mr. Chambliss
                7   just winding up.  Then we could break for coffee, delaying
                8   the actions we were considering taking until a little bit

                9   later.
               10              At this point I would like to welcome Dr. Merrill

               11
                    to the Council, who made a s  cial effort to be here from
                                                Pe

               12
                    out of town.  Thank you, John, for making the effort.

               13              And then we will again have to rearrange our

               14
                    agenda in order to accommodate,Dr. Teschants
                    presentation before he has to depart at 11@030.

               16
                               So perhaps we will just take a few minutes longer
               17   than we had originally proposed for the meeting, but I
               18   think it will be better if we can continue the present report.

               19
                               Jerry.
               20              MR. GARDELL@.  Thank you.
               21              As you can tell, we have had some fun this year.
               22              And I might thank my predecessors here in their
               23   presentations because they have helped considerably to lay
               24   the groundwork for the presentation I am going to make,
               25   which is very brief, but to try to show you that we tried


                                                                               52

                 I   to stay within our legal limits, if you will call it
                 2   legal, as far as the amounts of money are concerned, both
                 3   from the standpoint of the Council levels, our funding
                 4   levels, and the amount of money available to us.
                 5             If you will excuse me, I will read from a

                 6
                     script prepared for me -- and I was the writer -- that hits
                 7   all the highlights.  And I don't want to miss any of them.
                 8   So I hope you will understand what we had to do.
                 9            @We were prepared initially in 1973 to fund 56

                10
                     regions on a 12-mouth basis, as usual, using a projection
                     of at least $96.6 million.  And, therefore, after the June
                12   NAC meeting, we funded 17 grants for one year with a Septem-
         r@j
                13   her 1 start date.

                14
                               However, our allocation of approximately
                15   $52 million for grants under the continuing resolution
                16   caused us to announce on December 29, 1972 that we would

                17
                     fund the additional 18 regions coming up with a January 1

                18
                     date for six months only, in line with the NAC levels,

                19
                     at annualized funding levels, but with the understanding

                20
                     that the second half of the budget period would be made

                21
                     at a later date when additional funds were made available

                22   to us.
                23              This was based on the assumption, of course,
                24   that the appropriation act would be passed with an alloda-

                25
                     tlon near our projection or maybe even better than that.


                                                                             53
                 1             Finally, when the President's budget was sub-
                 2  mitted and did not include any funds for RMPS in 1974 and our
                 3  1974 allocation remained the samej we informed the
                 4  RMPs on February 1 that no grant awards would be made
                 5  beyond June 30, 1973 except that we would provide for phaseout
                 6  purposes but not to extend beyond 2/15/74.
                 7             The 17 September awards in accordance with  this
                 8  decision were reduced by,tvd months, because they  normally
                 9  would have ended August 31.1  And the May I awards which

                10
                    should have be6h,made for 12 months were then  extended  or

                11
                    just two months.

                12
                               So an aside here is that what we are now

                13  faced with is a possibility of one budget period  involving

                14
                    three separate fiscal years, so you can see we are going
                15  to have some problems in reconciliation as well as just
                16  plain making the funds available.

                17
                               Budgets for all the programs were to be
                18  negotiated in line with the criteria contained  in  the

                19
                    February 1 telegram which Mrs. Silsbee mentioned to you.

                20
                               Then the phaseout plans A and B were reviewed as
                21  indicated by her and the programs were funded with
                22  ending dates at that point ranging from June  30,  1973
                23  through 2/14/74 depending upon a  realistic  assessment
                24  of the staffing needs to complete the approved projects and
                25  activities as reviewed and provided RMPs in  our  April


                                                                             54

                 1  telegram.
                 2            A balance of approximately $6.9 million remained
                 3  from this process which could not be made available at that
                 4  time to the regions because of the phaseout decision.
                 5            Now, this is a combination of what our
                 6  normal operation is of offsetting against unexpended balances
                 7  that the regions report to us-, so that is how we came
                 8  up with the $6.9 million, which was in line with our

                 9  projection of our lapse anyway.

               10
                               On June 27th, after the legislation was extended

               11
                    on the 18th, the phaseout restrictions were lifted and
               12   discretionary funding authority was reinstated to the

               13
                    regions but with the understanding that they would hot receive

               14
                    additional funds at that time.

               15
                               On July Ilth, however, after the continuing
               16   resolution was signed, authority was granted to us to
               17   negotiate budgets with each RMP for funds from fiscal 1974
               18   continuing resolution that would be necessary to maintain
               19   the program's viability, providing for adequate staff
               20   and activities at a level not to exceed three times the
               21   avera e monthly expenditure rate for the period April 1
                         g
               22   through June 30 to be made available for the succeeding
               23   period July I through September 30, 1973 out of fiscal 1974

               24   money.
               25               It also permitted us to distribute the remaining


                                                                             55

                 1  $6.9 million out of 1973 money but not to be used
                 2  until approved by us.  And that was because the mission as
                 3  yet had not been defined and we wanted to make sure
                 4  that that money would be used hopefully In line with the

                 5  mission.

                 6             This distribution was accomplished by prorating on

                 7  a monthly basis the program staff costs for each region as

                 8  of 12/31/72,vhich we thought was a good operating point,

                 9  for a six-months period ending 12/31/73, but offset again  y

               10   the funds presently available to the regions for the

               11
                    program needs for that same period.
               12              This process resulted in, as was mentioned by

               13   Dr. Pahl  a balance of $2,449 of the funds

               14
                    available to us for grants in fiscal year 1973.
               15              We are presently reviewing the requested funding
               16   needs of programs for the period 7/1 through 9/30/73,  and

               17
                    we will amend the current awards as the requests are

               18
                    approved.

               19
                               'Now, currently, the continuing RMPs have ending dates

               20
                    as follows, and this is because we had to distribute the
               21   $6.9 million and give them additional time to use it,  but
               22   that date is negotiable.
               23              We have one program ending on November 30,  and

               24   that happens to be Florida.  And the only reason is it
               25   didn't get any additional of the $6.9 million, so, therefore,
                  I


                                                                             56

                 1  we will extend it through 12/31 so that everybody is at least

                 2 up to 12/31/73.

                 3             Nov, they have asked for An extension  without

                 4 additional funds, so they have enough at least  to  remain

                 5 viable.

                 6             We have 21 ending on 12/31, four ending on I  1,

                 7 and 27 of then go through 2/14/74.

                 8             So these figures do change from the ones  that

                 9 were mentioned previously, but that was prior to the time

               10  that we have amended awards.

                               Depending upon decisions regarding the  coming

               12  review process which we are going to be facing, it may be

               13  necessary to extend further these programs that have a

                   termination date of 12/31/73 to assure their continued
               14

               15  support until we can make them an award for 12  months  or
               16  whatever period of time is decided out of fiscal 1974 funds.

               17
                               It may also be necessary to provide certain
               18  programs additional funds beyond 9/30 to maintain their
               19  viability provided for through the use of the first
               20  quarter's allocation.  In other words, some of them really
               21  are taken through 9/30 with additional funds.

               22              Nov, if that is not enough to take them through

               23  12/31 until we can reach them with a 1/1 beginning date for

               24  a new budget period, we will have to extend them again.

               25              It should be clearly understood by all of you that


                                                                                  57

                  1  in these changes to the existing grants we have always

                  2  utilized the NAC levels of record  annualized,  and  the

                  3  annualized funding levels, so we have not exceeded both.  In

                  4  to instance have we exceeded the NAC levels and we do not

                  5  antlclp;tte that we will between now and the next review

                  6
                     cycle, and  I think that is extremely important because it was

                  7  hard to do  in our machinations to keep abreast  of  the

                  8  amount of funds available to us.

                  9              So that is the story of what we  have  done.   I

                10
                     have tried  to do it in a nutshell for you.  Now, if you have

                11
                     any questions --

                12               DR. PAHL@.  This is a very technical presentation,

                13   and perhaps the major thing you have gotten out of it is

                14
                     how complicated a set of procedures we have had to go through

                15
                     in order to account for budget  periods,  ending  dates,
                16   fiscal 1972 funds, fiscal 1973 funds, fiscal 1074 funds,
                17   continuing resolution, balance out of 1973, phaseout periods.
                18               And one reason for having Mr. Gardell present it to

                19
                     you was, first of all, you should have the information,
                20
                     which I'm sure you couldntt  absorb.  Secondly,  it  should  be

                21
                     a matter of public record for one point in  time  what  It  was
                22   that we did do.
                23               And, thirdly, again I think it  does  indicate  the
                24   high level of professional activity which has gone on
                25   internally  in trying to accommodate both the congressional


                                                                              58

                 1  intent and the Administration's position.  And I believe

                 2  1 can speak for Dr. Teschan's group of 53 but formerly  56

                 3  coordinators who have repeatedly given public commendation

                 4  to Mr. Gardell and his grants management group  throughout

                 5  this most difficult period.

                 6             So we are ready to entertain questions on any

                 7  matter, but it is a matter of record what we did try to

                 8  accomplish.

                 9             Mr. Milliken.

               10              MR. MILLIKENie What were the two programs  that

               11          instatod?
                    were re

               12
                               DR. PAHL:  The two programs that had been scheduled

               13   for June 30th phaseout and were reinstated were North

               14   Dakota and Puerto Rico, and there is a written record as to

               15   why these actions were taken, and we will be glad at  some
               16   point to mention that to you.

               17
                               But both were on the basis of very valid
               18   reasons and merits of the case.

               19
                               Are there any questions?

               20
                               We will be talking a little bit more after coffee
               21   about this $6.9 million balance in fiscal 1974 funds.  1

               22   wouldn't be unduly concerned about all of the kind of
               23   problems we have been involved with.  It is very technical,
               24   very complicated.  But we at this point end up with all
               25   regions being assured of funding for a sufficient period of


                                                                            59

                 1  time that we can accommodate the legislative  requirement

                 2  Of Council approvals, at the same time accommodating  the

                 3  Department's position of still trying to determine what

                 4  the direction of the program should be, and this represents

                 5  a complicated set of actions going on simultaneously.

                 6             Dr. Roth.

                 7             DR. ROTH.@  I don't know whether this is a fair

                 8  question, but it would seem to me personally in trying to

                 9  adjust to the situation I would like some kind of a  notion

               1 0
                    about..,WhAt happens.

                               You have got a one-year extension.  Should one
               12   be malting two gets of alternate plans, an orderly  phaseout

               13
                    presuming that there is no further extension or

               14
                    revitalization of the program, or do you simply have to wait

               15
                    for what is going on downtown in the Rogers Subcommittee,
               16   for example, of considering ways of putting this together with
               17   other programs for extensions?
               18              DR. PAHL.@ Well, that is part of the heart  of
               19   what we should be talking about today, and with your
               20   permission I would like to defer it and put it in a  larger
               21   context after we have had an opportunity to get you  some
               22   coffee and ourselves impart a little bit more Information to

               23   you.
               24              We need advice from you not just today but  in

               25


                                                                            60

                    coming months about this matter4 But it  is  an  importan

                 2
                    topic for today's conversation, so I would like to  defer  it

                 3  with your permission.
                 4             Jerky, thank you very much.  And, of course, we
                 5  will be ready to answer any kinds of questions you  may  have
                 6  over the bourse of the day on this, but we did want  to  give
                 7  you a picture of the convolutions which we have had to go
                 8  through in order to maintain this period of activity  in  the

                 9  program.

               10
                               And now, as the last brief  presentation,  Mr.

               11
          -Z,       Chambliss does wish to end up not on a fiscal note

               12
                    but to toll you what our overview is concerning the
               13   programmatic activities of the regions today.

               14
                               Bob.

               15
                               MR. CHAMBLTSS:  I would like to end on a program-
               16   matic note. As we  worked  tovArds'th6  impbhdingphasedut  of

               17
                    RMPS, the Director sought to pull out certain specific
               18   project activities for support beyond the  June  30  1973
               19
                    deadline, and these projects fell into three specific areas.

               20
                               First, projects in the area  of  hypertension.
               21              Second, those in the area of  health  services

               22   educational activities.

               23              And, last, those in the area of EMS, or
               24   emergency medical service systems.
               25              In the area of hypertension, RMPS had under


                                                                             61

                    support about eight projects totaling approximately
                 2  $1 million, and these were selected out for continued support

                 3
                    as far as they could go depending on the determined phaseout

                 4
                    date of an individual Regional Medical Program.
                 5            Also in the area of health education activities,
                 6  as you recall  this is the area, health education type
                                11
                 7  activity, supported by Regional Medical Programs that took
                 8  off on the initiative as set forth in the Carnegie Report.
                 9  As Mrs. Silsbee pointed out in her expression to you, we

                 10
                    are supporting about 11 percent of all the projects that

                 11
                    were identified for continuation in the area of health
                 12 education activities.

                 13
                              And in this health education activity area
                 14 the staff has endeavored to visit all of these projects
                 15 that had high potential for viability.
                 16            If you recall, about $6.8 million was awarded to

                 17
                    the regions for this type of activities, and these activities
                 18
                    vent on in 27 Regional Medical Programs.  About 38 of these
                 19
                    projects vent for developmental or operational activities,
                 20
                    and about 41 of these projects were for the support of

                 21
                    feasibility studies or planning studies.
                 22            Now, as we began to contemplate the phaseout, we
                 2,3 felt that there was a need to site visit each of the
                 24 identified projects to assess their progress, to update our
                 25 knowledge on them, to see what t  e of evaluation was being
                                                    yp


                                                                             62
                 1  conducted, and to determine if possible their potentialities
                 2  for continued support perhaps from some other source of

                 3  support in HEW.
                 4            Now, to date, out of 15 RMPs that were identified
                 5  where site visits should be made, we have conducted 11 of
                 6  those site visits by members of the staff, and there are
                 7  four of those site visits to RMPs yet remaining to be con-

                 8  ducted.
                 9            We have set up a task force of Regional Medical

                 10
                    Program staff, and this has been augmented by representatives
                 11 from the Bureau of Health Manpower.  They have been
                 12 augmented also by representatives from the

                 13
                    Veterans Administration and also from the regional offices,

                 14
                    and representation has also come from the Secretaryts office,
                 15 to see how these projects were moving along.
                 16            'We think that this perhaps has been one of the
                 17 most worthwhile areas of support that RUP has engaged in.

                 18
                    These independent, community-based consortias have proven
                 19 to have started a new type of activity at the local level
                 20 bringing together educators, providers, health institutions,
                 21 and consumers, all sitting around the table to discuss
                 22 health manpower needs at the local level.
                 23            As one of the site visitors has reported, one
                 24 person at one of the RMPs indicated that this is the type
                 25 of activity that should have been engaged in at the local


                                                                            63

                 1  level 30 years ago, to bring this coalition of people to-
                 2  gether to discuss manpower needs of a specific location.
                 3            Then in the area of emergency medical services,

                 4  funds were awarded to the RMPs out of 1972 supplemental
                 5  funds in the amount of $8.6 million.  These funds went to
                 6  28 separate RMPs for the support of 34 emergency medical

                 7  services planning and operational projects.
                 8            Now, these projects ranged in dollar amounts from
                 9  $16,000 up through.over $1 million, the highest being $1.7
               10   million. However, the majority of these projects ranged
                    in amount from $25,000 through $100,000, and there were
               12   three that exceeded the $1 million level, Wisconsin, Tri-

               13   state, and Havaii.
               14             Here again a task force was established of RMPS
               15   staff members.  This staff has been augmented by staff from thLb
               16   National Center for @lth Services Research and Develop-

               17
                    ment headed by Dr. van Hoek, and there has been Joint
               18   planning effort toinvolve their staff in going to some of the
               19   larger and more critical EMS activity projects, and they
               20   have done so.
               21             Out of a total of 28 RMPS, 20 site visits have been

               22   made. There are only three remaining to be done at the
               23   moment. And the objective of these visits has been to again
               24   update bur knowledge, to assess the project being made to
               25   determine whether the plan for a given project was being


                                                                             64

                1                                            tion, to assess
                    carried out in accordance with the applica
                2   th                           d emergency medical activities
                     e development going on ardun
                3   sponsored by RMPS, and to see if there were involved in the
                4                              evaluation component where
                    ongoing program activity an
                5   some assessment could be made as to the productivity, the
                6   viability and the strength of a given M project.
                7             Of course, these projects touched on communica-
                8   tions, planning, transportation, public education, training,
                9   equipment, and the development of local EMS councils.
               10             We feel around this activity there has been a
               11   significant developmental activity to improve emergency medi-
               12   tal services and to develop a high sense of awareness of
               13   the need for concerted planning and systems development for
               14   the care of the emergency patient at the local level.

               15
                               I might say one thing that came to my attention

               16   about a visit I think you would like to know.  Tn the
               17   Alabama Regional Medical Program an award of about $150,000
               18   was made.  There was to be training for a total of 1,200
               19   people, trainees, in the program.  With that amount of money

               20
                    they have trained in excess of 1,400 people.,'
               21              At one of the hospitals where a training program

               22   had been conducted and completed during the hurricane
               23   season, ten days after the training project was completed
               24   that community was hit with a tornado.  There were 47 victims
               25   brought to the hospital wherein the training program had


                                                                              65

                 1  been conducted just ten days prior thereto, many with
                 2  very serious traumatic injuries.  The staff was
                 3  alert and ready to perform under stress, catastrophic
                 4  circumstances.  The patients were treated.  Triages were
                 5  set up.  The emergency medical plan, involving the health
                 6  department, the police department, the fire department,  and
                 7  all other emergency activities, was brought into play,  and,
                 8  as was pointed out, it was a great demonstration of the worth-
                 9  whileness of this type of activity.
               10              Here again we thought you would like to know

                    that just as a matter of information.
               12              if I may summarize then by shifting over to
               13   another set of activities that is ongoing in the RMPS,

               14
                    we thought you would like to know that of the 53 RMPS, all
               15   have coordinators.  However, there are ten acting coordi-

               16
                    nators on duty now.  Three of those coordinators you

               17
                    already know were acting, but the new acting coordinators

               18
                    are Mr. Edward Morrissey in Connecticut, Dr. Francisco in

               19
                    Northern New England, Dr."Harrison Owens in  Nassau-Suffolk,

               20
                    Dr. Stephen Langfeld in Greater Delaware Valley, Mr. Chad
               21   Combs in Susquehanna Valley, J. L. Robertson in Alabama,
               22   and Mr. T, R. Newman in Ohio Valley.
               23              This gives you some indication of  the  viability
               24   of the R@ , that they are still engaged in holding on to

               25
                    their leadership and recruiting leadership for  the  support


                                                                             66

                 1  and continuation of the RMPS.

                 2             Time is short, and let me say if there are

                 3  any questions I will be glad to answer them for you.

                 4             DR. PAHL.@  Thank you, Bob.  And I apologize,

                 5  because I think it was my exuberance this morning which

                 6  perhaps shortened your time.  And since I have been in the
                 7  same position, I apologize and appreciate your  summarizing.

                 8             1 think we have had quite a bit of material,  and

                 9  with your indulgence T think it would be perhaps well if
               10   we broke here for coffee.

                               Dr. Teschan has repeatedly Indicated to me he

               12   has to leave at lli$30.  I think it is very important  that
               13   you have his presentation before he departs because he  does

               14
                    represent the other coordinators and itts important you
               15   hear from them through him.

               16
                               So if we could break for coffee now and reconvene
               17   at no later than ten after--  And please bring your

               18
                    coffee back with you, but get a stretch, and then we  will

               19
                    have time I think--  Paul, will that be sufficient?

               20                               -
                               DR. TESCHAN:  11:05 would be better.
               21              DR. PAHL'.  Make it 11.0-05, if you can, please.
               22              (whereupon, a recess was taken.)
               23              DR. PAHL@. May we sit down at the table,  please,
               24   and come to order?
               25              Without taking further time from Dr.  Teschan's


                                                                               67

                 I  presentation, I would like to say that we are very pleased

                 2  to have him here because what we have been presenting to you
                 3  so far, of course, is the RMPST view of what has happened,
                 4  why it has happened, and where we now stand, and it Is most
                 5  important that you have directly, firsthand, the view from
                 6  not only a coordinator of one of the programs but
                 7  the spokesman for all of the coordinators of the RMPS.

                 8             Paul.

                 9             M. T.ESCHAN@O  Thank you, Dr. Pahl.

               10              First of all, I think itts important that you
                    understand that we of the coordinators and the members of the
               12   regional Advisory groups are enormously appreciative of Herb
               13   Pahl and Jerry Gardell and the staff's activities in
               14   support of the RMP.  The facts are 53 of the 56 programs
               15   have come through this very difficult time.
               16              1 feel that the degree of discouragement,

               17
                    the erosion of morale and the damage which has been done in
               18   the regions would have been far greater if we hadn't had
               19
                    the kind of steadfast support and the kind of very

               20
                    careful attention to our individual problems which  this staff
               21   has continued to give in spite of all their problems In
               22   dealing with the shifting administrative pressures that
               23   you have had just a little glimpse of here.
               24              So ltd like to say I fully agree with the
               25   comments that have been made today, and we are fully in


                                                                                68

                 1   accord with the idea that what procedures the  staff  has

                 2   undertaken, with the possible exception  of  convening  this

                 3   Council once more in the area of March and the awards

                 4   with that possible exception -- we  are  fully  appreciative

                 5   that, given their situation and their direction, they have
                 6   proceeded as best they could, and we appreciate it.
                 7              Novo I think the important message, quickly, that

                 8   1 would like to-- There are  several  important  messages  I

                 9   would like to communicate to you, and I  much  appreicate
                10   this opportunity to do so.

                11
                                The first point, and the overriding point I
                12   think, is that RMPs are still under attack within the
                13   Administration, in  our  view.  The  coordinators  consensus

                14
                     is that the evidence is clear that the phaseout has not, in
                15   effect, been rescinded, that the practical operating

                16
                     circumstances of the programs are not compatible with what
                17   has been called here revitalization.  It's not the case.

                18
                                And, therefore, I want you to  understand  the

                19
                     way it looks in the area where we operate.  For example,

                20
                     what has come by a rescinding of phaseout restrictions is that

                21
                     within the phaseout order we now cab rebudget between
                22   continuing projects and staff. Well;  that  still  spells
                23   phaseout.
                24              And in view of the one-quatter authdrizat ons

                25
                                                      it follows that recruitse0t
                     which you have also heard about,


                                                                              69

                 1  is out of the question.

                 2             Commitments of any substantive or  significant

                 3  scope are also out of the question.

                 4             1 have also determined this morning that

                 5  the reduction in force program imposed upon RMPS is still in

                 6  effect.

                 7             We understand through our various communications

                 8  that the Secretary still maintains precisely the attitude

                 9  that he had when we last met together on February 7th.

               10              Nov. the particular point I think we should get

               11   into more specific detail on has to do with the  telegram

               12   from this,office on July 5.  In that telegram there was

               13   a notification that negotiations would be underway for

               14   a level of support to assure viability through the  first

               15   quarter.  Well, eve yone knows through five years or more
               16   of experience with this program that the RMPs do not
               17   operate on a quarterly basis, that the intent of the law is a
               18   one-year extension. The intent of the  authorization  and
               19   appropriations is a one-year extension.
               20              Therefore, a quarterly allocation and authoriza-

               21   tion are in contravention of the Intent of the law, and this

               22   is the way the coordinators see it.

               23              Now, you understand, and I want to reiterate
               24   here, I am stating a viewpoint from the way we see it.  This
               25   is in no way to be interpreted as a criticism of Dr. Pahl

                  I


                                                                           70

                1  or the situation in which the RMPS staff must operate.

                2   1 am not holding them responsible for what I am seeing,

                3   but I am leading into what I propose and offer to you
                4   for your consideration as to action or position which this

                5   Council might wish to take.
                6             The second element of the telegram of July 5th is
                7   that the RWS has been authorized to utilize $6.9 million of
                8   unexpended PY 1973 funds but that no expenditure may be
                9   made until the Department announces the mission of the
               10   Regional Medical Programs Service for the rest of 1974.
               11             Again let's recognize that the Congress extended

               12   RMP.  It did not write a new law.  It did not create a

               13   new situation At all.  This Council has approved an
               14   authorized mission statement under which all RMPs are
               15   operated.  There is at this point no Countil-apprdved or
               16   Council-authorized change in the mission.

               17
                               Classically, the RMP has generated the mission
               18   statement from this Council and not from higher up in the
               19   Department.
               20              So our view is that we have a mission and that
               21   there is no basis for a further mission statement at this
               22   time under the intent of an extension of the law.  And
               23   certainly, therefore, the idea that then the $6.9 million
               24   may not be expended until there is this new mission statement
               25   is an additional obstacle, obstruction.  That is, in effect,


                                                                              71

                 1  the money does not flow in spite of the intent or the
                 2  language saying that we now can obligate it from RMPS.  In
                 3  fact, the money does not flow. It has another  contingency
                 4  which we see to be virtually illegal in view of the extension
                 5  concept which the Congress intended.
                 6             There is another element in this July 5  telegram

                 7  that says that proposed RMP activities, presumably  reviewed
                 8  at intervals, will need to meet review criteria to be
                 9  established -- another sense of obstruction and delay and

               10
                                                      e
                    interference with the purpose of th Congress to  extend  the

               11
                    programs.
               12              And the RMP coordinators are somewhat exercised

               13
                    as you might understand on those points.

               14
                               DR. PAHL.@  Paul, if I may just interrupt for a
               15   moment, we have included these telegrams in your  folder.  1
               16
                    dontt think you have to turn to them right now, but we cab

               17
                    consider them after Dr. Teschan has to depart.

               18
                               It's the last set of yellow sheets under the  ta)

               19
                    called "Phaseout," which is the third tab from the back.  And
               20
                    the last yellow sheet is that July 5 telegram Dr. Teschan
               21
                    has been referring to.  We can take that up at greater
               22   length following his presentation.
               23
                               DR. TESCHAN:  The point of this discussion is
               24   really not the detail of the telegram@as:sudh but the
               25
                    significance of it aslits effect is, felt in the regions


                                                                            72

                 1  where the action is supposed to take place.

                 2             1 think the overall issue that I am indicating is

                 3  that the intent of the Department is to continue the phaseout

                 4  of RMP, to place obstacles in its way and essentially to
                 5  proceed despite the fact that the congressional support as you
                 6  have ju0t seen and the Presiddntts signature exist.
                 7             Now, our feeling here is that the Council needs
                 8  to take a stand, and a stand has been prepared as an offering
                 9  for your consideration.  Dr. Roth has already referred to it.
                10  And it reads like this in the draft that we would offer for

                11  your considerations.
                12             "The National Advisory Council on Regional
                13  Medical Programs believes the February issuance of phaseout
                14  orders with subsequent amended awards to each individual
                15  RMP was in violation of Public Law 91-515  because  those
                16  orders and awards were never approved by this Council.
                17  Therefore, the Council hereby recommends to RMPS  that  all
                18  previously issued phaseout orders be rescinded immediately."
                19             We would also offer for your  consideration  the
                20  possibility of your recommending that the awards
                21  actually made under what has been called phaseout be retro-
                22  spectively legalized    that is, approved by  the  Council.
                23             Nov, all we mean in connection with  Dr.  Rothts
                24  previous question on this point is that the  language  in
                25  section 964(a) simply indicates that awards are  made  as


                                                                                73

                 1 standard procedure by the Secretary  on  recommendation  of
                 2   this Council.  The so-called phaseout awards and these inter-
                 3   vening awards now have not been so processed.  But I
                 4   think the Council could undertake that at this point.

                 5            "Public Law 93-45 continues RMP for one year, or
                 6   until June 30, 1974.  The lawts substantive language remains
                 7   the same.  This Council has approved the mission statement
                 8   for RMP that is consistent with the provisio s of the presen
                 9   law.  The Council regards this mission statement as still
                10   valid and any subsequent mission statement at  this  time
                11   is unnecessary and inappropriate.'  Likewise,  previously
                12   adopted policies of this Council shall remain  in  effect
                13   until altered or revoked by this Council.

                14              '4The Council hereby authorizes RMPS to  issue
                15        d awards up  to the existing 1973 approved level of
                     amende
                16   each Regional Medical Program, and that these amended
                17   awards be made to all RMPs for the entire 1974 fiscal

                18
                     year as soon as money becomes available.  Future awards to
                19   the regions should not be made for less than one year al-
                20   though supplemental awards for the remaining months in this
                21   fiscal year may be made after  appropriate  consideration
                22   by this Council.  All interim awards which have heretofore
                23   been made for maintenance of program staffs are hereby

                24   approved."
                25              And that is the issue I indicated.


                                                                               74

                                "Finally, the Council reconfirms its faith

                 2   and confidence in the concept of RMP and urges the Department

                 3
                     to reconsider its position relative to RMP."

                 4              And Ttll leave this copy with Herb if he finds it

                 5
                     useful.

                 6              I think the issue could  be  summarized  further

                 7   this way.  The RMPs today are the remaining long-shot
                 8   chance of a cooperative enterprise between the 'Federal Govern-
                 9   ment and private providers and private  enterprise  in  the
                10   health care field. There is really no  other  way  by  which

                11
                     the panoply of the bureaus and agencies which  you  saw  in
                12   the organization statement and charts  can  see  their  effect
                13   actually occurring in the towns and  cities  and  neighbor-

                14
                     hoods and crossroads unless there is an in-place mechanism.
                15   There is no other competitor for an  in-place  mechanism  to

                16
                     get it to happen.

                17
                                Assuming for a moment, therefore,  that  if  it  is
                18   intended that there will be effects in EMS,  that  there  be
                i9
                     effects in inequality  assurance  area,  etc.,  these  effects

                20
                     will occur because they happen in  localities,  not  because

                21
                     they happen only at the bureau level.
                22              We see also, as Mr. Van Nostrand has
                23   clearly pointed out to us today, an erosion of RMP's
                24   mission by the Administration assigning  to  new  bureaus  and
                25   new agencies the kinds of activities which have been RMP


                                                                             75

                 1  prerogatives and responsibilities up to now.  However, that

                 2  is a fraudulent position, because you won't get it to happen
                 3  by the establishment of a new bureau on an organization

                 4  chart or filling additional offices with additional

                 5  personnel in Parklawn Building.  I'm sorry.
                 6             Therefore, our presentation to the Assistant

                 7  Secretaryts office has been that RMP be recognized as  the
                 8  local in-place organization for the implementation of  the

                 9  whole variety of Federal health initiatives which need
               10   local application.  We in the RMPs could very easily see

               11
                    these bureaus that you have just seen as the resources  on

               12   which we call to implement these things.

               13              You will see I think shortly some further comment

               14
                    that the regional offices, the ten of them of HEW, are
               15   supposed to have this type of activity and role.  Our
               16   feeling is that in our area, for instance, in Tennessee,

               17
                    that the regional office in Atlanta is as remote to the

               18
                    hills And valleys that we ate familiar with and work in

               19
                    as would be a bureau in Washington.

               20
                               So I think the critical issue here is that we stil

               21
                    have a fighting chance, an uphill fighting chance, to
               22   establish and to develo  public and private partnership
                                           p

               23   in the' effect -- that is  in getting the activities to
               24   happen In the communities of the,tegion if RMP is so
               25   recognized by the Department, the Administration, and by this


                                                                            76

                 1  Council.
                 2            We believe that there are, secondly,  four  areas

                 3  of mission which the RMPs are able to do:
                 4             First of all, we do believe we have a role in
                 5  quality assurance and would cooperate with the bureau  with
                 6  that name in implementation activities.
                 7             Secondly, we believe that we have a track record
                 8  in the proved utilization of manpower and a track record
                 9  in developing the colmunity-based area health education

               10
                    consortia.  We are able to do that and should be mandated

               11
                    to continue it.
               12              Thirdly, we have obviously demonstrated

               13
                    capability, as Mr. Chambliss has indicated, in improving

               14
                    primary care services, including EM.  We should be
               15   mandated to do that from the EMS office.
               16              We have five years' established experience in

               17
                    regionalizing specialized services and the HEW should be
               18   using RMP for that purpose in their communities rather

               19
                    than in each of these instances eroding the RMP's energies
               20   and contribution by separate bureaucratic mechanisms
               21   for these localized fragmentary initiatives in  the  health

               22   care field.
               23              Now I would like to go off the record  for  just

               24   a moment.

               25
                                (Discussion off the record.)


                                                                              77

                 I             DR. PAHL@O  Thank you, Paul.  I know you are
                 2  dashing for an airplane.  Is there any point that--  Dr.

                 3  Merrill?
                 4             DR. MERRILL@.  I'd like to ask Paul a question.
                 5  Is it  your opinion that the vehicle through which an
                 6  expression of opinion by this Council should be made is a
                 7  resolution written out and transmitted to the Secretary?

                 8             DR. TESCHAN:  I do believe so.
                 9             M. MERRILL"   I'm not convinced that action would

               10   be  greatly effective.
               11              ]OR. TTSCHAN@* Youlrd asking that at two levels,
               12   John.  My answer to that is, yes, a resolution that is
               13   resolute and clearout  and unequivocal may have no immediate,
               14   direct effect In moving affairs, but it doesn't detract
               15   from its value, because the National Advisory Council
               16   will be on record.  It will raise a standard around which

               17
                    others can rally.  And essentially this is a very important
               18   area if private and voluntary participation is to enter the
               19   health field and continue in the health field.

               20
                               So don't underrate the significance of your
               21   action.

               22              M. PAHL.  Thank you very much, Paul.

               23               1 am afraid that because of the need to return
               24   to the Southern Coordinators' meeting Paul will not be able
               25   to be with us this afternoon during the discussion. We have


                                                                            78

                 I  assured him that we will get to him what does  transpire.

                 2             Before we move on, I would like to say as the

                 3  acting director of the program that we do endorse the
                 4  statement that Dr. Teschan Just made.  That is, we do believe

                 5  that th is Council should play a very real role in the
                 6  policies and activities of the program.  And the reason we are
                 7  meeting today in July is to tot only bring you up to date but
                 8  to look to you for that kind of advice and formal advice to
                 9  the Department, the Secretary, the Assistant Secretary for
               10   Health, the Administrator of Health Resources Administration,

               11
                    and myself as to your interests and concerns.
               12              And so I would like to fully support Dr. Teschan

               13
                    in this plea for very strong Council involvement regardless

               14   of what position that may be on your part.

               15
                               Nov. with that, I would like to say  one  more
               16   thing and then perhaps open it for discussion.

               17
                               One of the things we were not able to do this
               18   morning was to distribute prior to the coffee  break  our
               1.9  one proposed Council resolution which at  least  includes
               20   one part of that which Dr. Teschan distributed.  And, Yen,
               21   if you will distribute that.
               22              1 am not asking for action on this at the moment,
               23   but I think you will be considering the proposal that Dr.
               24   Teschan made, and you will see in the proposed resolution

               25   that we have drafted for you, if you will, the need to


                                                                                 79

                 1   endorse actions which we have  taken  particularly  as  regards

                 2   the adjustment of budget period and the proration of funding

                 3   levels and Council ceiling support  levels  of  regions  that

                 4   Mr. Gardell was telling you  about,  technical  aspects  which

                 5   we had to engage in in order to keep the programs Alive

                 6   and which we may still have to engage  in  during  the  coming

                 7   months.

                 8               So I'd like to have you read  that  and  consider

                 I   that   @ther with  Dr.  Teschants  more  inclusive  proposal.

                10               DR. McPHEDRAN.i  Dr. Pahl, --

                11
                                 DR. PAHL:  Dr. McPhedran.

                12               DR. McPMO)RAN@.  -- I wanted to ask a question

                13   about this  telegram, that is, the telegram  that  Dr.  Teschan

                14
                     read,   which is the last yellow thing in the phaseout section

                15
                     of the agenda, particularly about  this  matter  of  stipula-
                16   tions that no expenditure be made therefrom until the

                17
                     Department announces the mission of the Regional Medical
                18   Programs Service for the remainder of  fiscal  year  1974  and
                19
                     that proposed RMP activities meet review criteria to be

                20
                     established.

                21
                                @'You must have had some reason for putting that in.
                22   1 must say I would 'agree with  Dr.  Teschants  interpretation
                23   of that, and I wondered why this was put  into  the  te  egram.

                24
                     Why were those stipulations made?

                25
                                 DR. PAHL@O  These stipulations, although the


                                                                              so
                 I  wording is ours, were put in the telegram on the basis of
                 2  requirements which came out of the Department.
                 3             Nov, let me amplify that a little bit. I  think
                 4  1 would like to go off the record for a moment, please.
                 5             (Discussion off the record.)

                 6             DR. PAHL.@  Before continuing the discussion,

                 7  because I am not quite certain what Dr. Laurts schedu e
                 8  might be, having just come from downtown and as Acting
                 9  Administrator of Health Resources Administration undoubtedly
               10   having to leave shortly to do other things, and being

               11   fully aware and involved
                                             in all of the activities I have

               12   just indicated to you plus others which I have hot been
               13   privy to, 1 think if you will permit we might  hold  Council
               14   discussion and take advantage of the fact that he can be
               15   with us and ask him to either address any question  that  he
               16   may care to or respond to some questions from you.

               17
                               And in this connection I would like to welcome
               18   you, Bob, to our Council and ask you to take as much time
               19   as you might have to reflect on matters either of
               20   organizational or RMPS variety, the latter being, of course,
               21   the preference.

               22              DR. LAUR@.  Thank you, Dr. Pahl.

               23              These Are times where rim not so sure it pays to

               24   "stop and reflect.
               25               1 would like to do a couple of things if I  may.


                                                                            81

                 1            First of all, express greetings to you from Dr.

                 2  Edwards.  He and I were just now at a meeting with Secretary
                 3  Weinberger on some other matters, and Dr. Edwards had hoped
                 4  to be able to come out here and visit with you during this
                 5  meeting.  He still has that hope but I think it is diminish-
                 6  ing as the day goes along and other events intrude on his

                 7  calendar.
                 8            But he did want me to convey his greetings to

                 9  you.
               10              Secondly, of course, to convey my own.  This
               11   Council has not only served our predecessor organization,
               12   HSMHA, exceptionally well over the years, but your willing-
               13   ness to come in now under short notice and with so many
               14   uncertainties I find very gratifying, and we are most

               15   appreciative of your willingness to help.
               16              1 guess I'd like to keep the remarks short

               17
                    for two reasons. One is this spot on these agendas always
               18   provides an interesting time for the staff, especially
               19   now where there is a new person, not new to the organization
               20   but new to the day-to-day workings of RMP. I'm sure the
               21   staff always wonders, "What will that damn fool say next and

               22   get us in trouble over."
               23              So, you know, itts an interesting little tense

               24   time for them when these sessions occur.
               25              And from the point of view of the Council it
                  I


                                                                            82

                 1                 rough another 20 minutes of inanities
                    means sitting tb

                 2  from an Administration official who isntt very much
                 3  involved in 'the process and it's a little difficult to endure.
                 4             So I thought for both of those reasons r

                 5  wouldntt say much.  (Laughter)

                 6             But r would like to respond as best r can to any
                 7  questions you might have or observations you have about
                 8  this rather difficult situation we all find ourselves in.

                 9             And I would only make one observation that may or

               10   may not help you understand the kind of direction that

               11
                    we will be trying to provide RMP in the new Health ReOources

               12
                    Administration.

               13              rt seems to me that the first question was

               14   the question that motivated this Council originally,
               15   that motivates theIpeople who work in Regional Medical Progrant
               16   around the country, and that motivates the staff, and

               17          0
                    that is.  What will be best for patients in the country?
               18   What can be done to make the greatest contribution to the
               19   improvement of health of people?

               20
                               And if we start with that concern, other consideta-
               21   tions I think begin to fall into perspective as to whether an
               22   organizational arrangement is or is not very critical to
               23   improving the care of patients or the health of people.
               24              Well, I only offer that as an observation which

               25   1 think motivates the staff, which I know has motivated th s


                                                                               83

                 1  Council, and its predecessor members.  And I would always
                 2  like to keep that as one of our fundamental concerns as we

                 3  plov ahead.
                 4            Even with that noble motivation, we will have
                 5  difficulty doing the right thing.  Therd is no question but
                 6  what in the weeks and months ahead we are going to make
                 7  some mistakes in the Health Resources Administration as
                 8  we try to administer these programs.  I will probably
                 9  make more than anybody else, first because I probably am
               10   better at it, and also because of my naivete in some of these

               11
                    areas.

               12              It seems to me that the only contribution

               13    might be able to make is that we would like to have our
               14   mistakes called to our attention as rapidly as you discover

               15   we are making them, and on that basis urge you to
               16   be in touch with myself and with Dr. Pahl and the staff of RMP.

               17
                               I simply do not believe in advisory councils who
               18   don't contribute.  This Council has certainly not had that
               19   reputation.  It has been an outstanding one.  And even in
               20   the situation we are  nIov in I vouldllike very much to have it

               21
                    be a functioning Council that you believe is important
               22   and you believe is making a contribution to HEW's efforts.
               23              So I want to say as we struggle through the next

               24
                    period please lot me know if you think that will make any
               25   difference, if that will be helpful to something, how we


                                                                                84

                  1   could do things better, and remain in touch with Dr. Pahl

                  2   and the staff.
                  3             Well,  enough of a preamble.  If  anyone  has  ques-

                  4   tions or observations  ltd welcome them.
                  5             MRS. MARSO@  Do you see any real future for RMP

                  6   beyond this year?
                  7              DR. LAUR@.  Okay.  That is certainly a very good

                  8   questions, Mrs. Mars.
                  9                                          ring Dr. Roth
                                 DR. PAHL@  I held off ansve
                10    until you came because I wanted also to hear the answer.

                11
                                 DR. LAUR@*  You were all waiting to hear the

                12    answer.  (Laughter)
                13               MRS. MARS4.  Right.  You realize this is a very
                14    frustrating experience for everyone concerned, particularly
                15    the Council members,.
                16               DR. LAURI.  I'd like first of all to ask if

                17
                      someone would kind of keep track of me and not let
                18    me respond too long. I could go on  at  some  length  on  that
                19    question.
                20               ltd say two things.  There is absolutely a future

                21
                      for the kind of fundamental activities that RMP has been

                22
                      addressing its6lf Ito across the country.  By that I mean the

                23
                      Involvement at the local operating level of the key
                24    participants in the provision of care in  a  way  that  causes
                25    them to make things  happen that would  not  otherwise  happen


                                                                           85

                 1  or would not happen as rapidly.

                 2             Now, that is a long, sort of abstract statement,

                 3  but I believe at the local level or regional level, if you

                 4  vill,,in assembling resources to improve the delivery  of

                 5  care to patients, Regional Medical Programs have  een  an

                 6  effective instrument at least in some instances and  that

                 7  there is no substitute for the kind of involvement that

                 8  those effective instances have demonstrated.
                 9             Now, whether it continues as Regional  Medical

               10
                    Programs    in capital letters    federally funded by HEW,
                    and so on, that I think is yet t6 be answered.  There  is
               12   @uite a ways t     gone as to what the Department's position

               13
                    is going to be, what the Congrdss' position is going to  e,
               14   what your recommendations to us will be.  All of that lies

               15
                    before us.
               16              1 simply cannot myself envision a world, given

               17
                    the kind of health care problems we have and the  limited
               18   resources with which we have to work, where we would ignore

               19
                    the kind of activity to which the RMPs have been addressing

               20
                    themselves.  That would astound me if that were the case.

               21
                               I will hazard on the record a personal observa-

               22   tion about the specifics of RMP in the sense that it is the
               23   challenge to the Health Resources Administration, the
               24   staff and the Council right now in the next several short
               25   months to come up with a proposal to the Administration
                  I


                                                                          86

                 1  which will be accepted which will foster the kind of activity

                 2  1 have already alluded to.

                 3             Now, I haven't sensed personally -- and my

                 4  involvement in RMP is fairly recent, fairly superficial

                 5  but I havenft sensed an outright opposition on the part of the

                 6  Administration to the concept of Regional Medical Programs.
                 7  The concern has been one over has the concept (a) been mal-

                 8  addressed, you know.  Have we si!%ply gone at-a good  dea

                 9  in an ineffectivtz- vmLv?  a have we devoted more
               10   resources to the concept than the concept merits?  You know,

                                          int in time?
                    at least  at

               12              It has been those kind of concerns that I think

               13   were addressed.  And I would have to say also that

               14   those concerns were raised at a time in which it was
               15   absolutely necessary to make very substantial cutbacks in
               16   the Federal budget.
               17              In other words, questions that otherwise might

               18
                    have been not so deeply and poignantly actures@vere

               19
                    addressed under those budget-cutting circumstances.
               20              Whether those circumstances are still with
               21   us or not I think other people have to determine besides
               22   myself.  They certainly haven't totally gone away.  And
               23   that will condition how much we can aspire to with RMP.

               24              But I believe the Health Resources Administra-

               25   tion--  I e@ct--  I wouldn't even be interested in working


                                                                             87
                 1  in HRA riaht now if I didn't think we were going to come up
                 2                               tuation of RMP-type activities.
                    with some
                 3              MRS. MARS4.  But not as RMP as such?
                 4              M. LAUR@. I don't know about RMP as such.  I  think!
                                                                                   i

                 5  that  has  to be thought  through.
                 6              Given--  How can I put this and not sound unkind'?
                 7  1 was about to say given the barnacles which RMP has
                 8    accumulated  and that's not a very kind way to put  it
                 9  but there are a lot of associations with RMP right ww,  and
                10  some of those may be impediments to doing what we can   to
                11  improve the health care of people, you know.
                12              RMP in my estimation--  I had a very satisfactory  1
                13  relationship with it. It doesn't have  barnacles  from  my

                14
                    point of view.  Itts something that I mou@,ldntt mind

                15
                    continuing AO, y U"knowl capital  letters, Regional Medical

                16
                    Programs.  But I think we have to  weigh that as to whether

                17
                    those words are the right words.

                18
                                The first question is@. What is the  activity, what1

                19
                    is the function that can'be addressed,  and what is the

                20
                    Federal role in  that  function?

                21
                                Then if it ought  to be called RMP, we'll call it

                22
                    RMP   think.

                23              DR. PAHL@*  Dr. Merrill?

                24              DR. MERRILLI.  No.

                25                           i
                                M. McPHEDRAN.  I have some things to say About


                                                                                88

                 I   that.

                 2               You know, the Council wasn't mute on February 7th.

                 3   At least I  wasntt.  I had something to say at the time.

                 4   This Is in  response to something that Dr. Teschan said in

                 5   his  remarks.

                 6               1think that I thought at the time that it was

                 7   too bad to  see the whole thing apparently being discontinued

                 8   at that time, and I said at the time     I can't remember
                 9   exactly how it was said     that it was done out of ignorance
                10   more than out of wisdom.  And I still feel that that's SO.

                11
                                 And I think the ignorance, for example, is

                12   reflected in this statement in the telegram that I referred

                13   to    that no expenditure be made until the Department

                14   announces  the  mission   for example    when this was  done
                15   as part  of  continuing resolution.  There was a mission and     i

                16
                     there were review criteria that had been established, and

                17
                     this could have been put in the telegram.

                18
                                 Obviously, Dr. Pahl put it in because someone

                19
                     else told him  that  he should.  But it couldntt have been put

                20
                     in by anybody who knew how the thing had been operating.

                2 1
                                 So that I think that it seems to me that the

                22
                     actions that were taken were takdn,in blissful      or perhaps

                23   not so blissful     ignorance and not in wisdom.

                24
                                 It doesn't seem to me to@have been a  sensibly

                25   planned kind of activity.


                                                                           89

                  1            1 really find myself, as I have reflected on the
                  2   suggested statement prepared by the coordinators, pretty
                  3   much in support of what the coordinators.have felt about

                  4   this.

                  5
                               I think that it's surprising in the site visits I
                  6   have made to find the number of Regi,@onal Medical Programs thati

                  7
                      did as good ajob as they did.  I thought it was

                  8
                      surprising to find as good staff work from RMP as there was.

                  9
                               This is a new kind of activity for me.  I never
                  0   knew anything about it before 1970, so r learned everything
                      about it right here and on the site visits.
                  12            And I know that the barnacles are there, but it

                  13
                      seems to me that what is implicit in your suggestion,

           @,j
                  14
                      Dr. Laur, that there might be some other vehicle to carry
                  15  on this mission is that the RMPs in the various regions

                  16
                      would probably be disassembled.  And some of them are really

                  17
                      very good.  They are not all, but some of them are really
                  18
                      very good.
                  19            And it would be just a shame and a pity to do that,

                  20
                      I think, just as it would be a shame and a pity to take away
                  21
                      their        e
                           activiti s in quality assurance and manpower need
                  22  assessment and their activities in improvement of primary

                  23  care and EMS.
                  24             1 agree with Dr. Tes6han that the more of those
                  25  things that are taken away, the less effective will be the


                                                                              90

                  I  Regional Medical Programs.
                  2             1 think that it  would be far better to go back,
                  3   if we could go back, to where we were eight or ten months
                  4   ago and try to scrape some of the barnacles off, as probably
                  5   will be possible with some of the phaseouts that have been
                  6   done.  It may be easier to get some of the barnacles off
                  7   and go on with the organizations that were good and pursue
                  8   the policies of this office before, which were in the main
                  9   selection for funding of programs that were good and were
                10    satisfactory, if there were hard times not to make across-
                11    the-board cuts.  This is a policy of the previous Director
                12    which I concurred with and I think everybody on the Council

                13    did as  well.
                14               1 think it would  be really  a shame to take apart
                15    these various regional organizations-,   Some of them me could

                16
                      do without, but many  of  them ate really very good.
                17               And I cannot   help but believe that the  direction

                18
                      for the phaseout, as I said  before,  was done by people who
                19    really did not know what they were   talking about.
                20               DR. LATJR@.  I don't know how to respond to tha

                21    If I say I totally agree, I have got a problem on one
                22    hand.  It seems to me we are saying the same thing, which
                23    is there is a useful activity there.  If it ought to remain
                24    as Regional Medical Program, then let's try and do that.
                25    If it ought to be strengthened or if there ought to be some


                                                                                  91

                  I  changes made in certain aspectsp letts decide as best me
                  2   can what those changes are and see if we can get them

                  3   accepted.
                  4             But this group probably more than--     I'm  sorry.
                  5   Does this microphone bother somebodyls eardrums?  If we've
                  6   got cardiologists or somebody in the room who are so care-
                  7   fully attuned to listening to little thumps and noises, this

                  8   probably drives-&em crazy.

                  9             This Council perhaps mote than any group we
                10    could assemble does understand, I think, the very real
                11    world we now face as we move ahead with the kind of program
                12    you have described, Dr. McPhedran, and thatts that some
                13    very important and very well intentioned Administration
                14    officials have decided,  under  the  circumstances  decisions
                15    were made in, about what the future  of  RMP  should  be.  If

                16
                      we are to ask them to change their minds,   I think we are
                17    going to have to apptoachn it in a way  which  they

                18
                      will find persuasive.  And, you  know, I think that's the Jo
                19    we have in front of us.
                20    -          I don't@ think they are about to  be steamrollered.

                21    1don't think they're about to suddenly decide
                22    that the anal sia they vent  through,  on  whatever basis, is
                                   y
                23    suddenly wrong and they  wish they hadn't  done  it and so they

                24
                      are going to do  everything  differently.  I  don't believe that

                25    is going to happen.
                    I                                                                  I


                                                                             92

                                I do believe that we have not found a way
                                                                         moo
                 2  personal opinion -- to express what it is that Regional
                 3  Medical Programs do in a *ay that          ot Intimately

                 4  involved in the activity can understand.

                 5              Time after time after@timeo even among knowledge-

                 6
                    able health professionals, I have found it necessary to

                 7  take a half an hour to articulate what it seems to me

                 8  was the real function of an RMP as opposed to the kind of

                 9  transitory projects with which an RMP might be engaged at

                10  that  moment.

                11              And if you have to do that with knowledgeable
                12  physicians and hospital administrators and health officials,
                13  then it isnft surprising to me that economists or budget

                14  officials in the Federal Government or Congr6ssmen might have

                15
                    some difficulty with the whole concept.

                16
                                So we have a challenge I think as a staff to

                17
                    find ways to articulate that, and that's in part, Mrs.   Mars,
                18  what I meant earlier about maybe a new word will be required,

                19
                                MRS. MARS:  Yes.

                20
                                DR. LAUR.@    just to express the same activity.

                21
                                DR. PAHL@6 Dr. Merrill.

                22              DR. MERRILL$.  This bears a little bit on the

                23
                    question I  asked Dr. Teschan, because, although I dontt have

                24
                    it in front of me, it seemed to me his statement was really

                25  kind of affirmation of the status quo.  I'm not sure how


                                                                            93

                 I  effective that is in the present climate of opinion.
                 2                                  rceful and effective
                    And I wonder if perhaps a more fo
                 3  instrument emanating from this body might not be a
                 4  revision perhaps embodying things such as no across-the-board
                 5  cuts, but paring specific barnacles, i  you will, and some
                 6  positive suggestions to which the Administration might be more
                 7  receptive than simply strong affirmation of the status quo.

                 8

                 9             DR. ROTHO@  I'd like to ask a couple of I think

                10  related things.
                11             We referred to this, telegrato@with the implication

                12
                    at any rate that there shall be a new mission statement.  Do
                13  we have anything po6king on the stove in terms of staff
                14  suggestions for a revised mission statement?

                15
                               And is it c6ntdmplated,-- we mentioned the possi-
                16  bility of a November meeting -- that it would be debated
                17  and discussed by then?  Is there any chance we'd get a
                18  new mission if we vent that route before the expiration  f

                19
                    the present extensions

                20
                               DR. PAHL.@ No, not really.  Somehow the

                21
                    discussions got into mission statement when actually what

                22
                    the Department currently is doing is attempting to make a
                23  determination as to what programmatic option or options

                24
                    it wishes to pursue with the program over the coming year.
                25             Now, there have been a number of suggestions


                          r@A It to R
                                                                           94

                    made to the Secretary as to the kinds of activities
                 2  which the regions can profitably engage in for this  one-year

                 3                                            r and
                  lperiod, and at his request an  options  pape
                    subsequent revisions have been transmitted internally.   nd

                 5
                    lfm-sorry. Because they remain internal, we are not  able  to

                 6
                    distribute them to you. But it is not doing a  disservice  to
                 7  that position I believe to state very clearly that all of
                 8  the options in this internal communication are statements  of
                 9  Activities which the regions have been doing and are

                10
                    very familiar and comfortable v
                               For example, quality assurance activities.
                12  Strengthening CHP programs, particularly the (b) agencies

                13
                    Ems.  Hypertension.  Kidney activities.  And the community-

                14  based area health consortia.
                15             When you hear this, you wonder vbat is different
                16  than what we have been doing.  And the point is nothing
                17  that I know of that is under active consideration by the-
                18
                    Department is different than what ve'holve;been doing.
                19
                    The difference, therefore, is that perhaps one or several of

                20
                    these activities *ill either be specifically excluded

                21
                    from this yearts set of functions or perha-p-s---all o?'them will
                22  still be considered permissible by the Department.
                23             So it is not the  Department  or RMPS   separating
                24  ourselves for the moment -- are  trying  to devise a different
                25  mission statement.  It is that the Department feels that


                                                                         . i
                                                                        95

               I with the  one -year extension and working in good faith with
               2  the congressional intent there is a need during this one-year
               3   transition period which begs the question of transition
               4                                                iod the
                   to what -- but during this one-year transition per
               5                 'Program s should be active in activities
                   Regional Medica
               6                              uate the RMPs as 'RMPS, yet
                   which themselves do not perpet
               7         lengthen administration in Federal health programs
               8   or health priorities and perhaps provide a bridge into a
               9   new state of affairs after the one-year extension is

              10   terminated.

                                                        that we have been
                            And so the kind of activities

              12
                   asked to suggest for the Department's consideration are tiose
              13   1 have mentioned. We believe that there can be useful work
              14   done in the areas of emergency medical services, hyper-

              15
                   tension control programs, end-stage kidney disease activi-
              16   ties, CHP strengthening, and activity of health planning
              17   agencies and certain manpower development and utilization
              18   programs and quality assurance programs.

              19
                             And we are awaiting a determination by the

              20
                   Department, which we had hoped to have for you by today
              21   but unfortunately we don't,.which then places the Department'

              22
                   stamp on what should be the set of activities for t s one-

              23   year period.

              24
                             But I see there is nothing here that is really I
              25   a new mission. It is a set of determinations on activities.


                                                                                  96

                   1  And in that framework the first  of  the  two  steps  in  the

                   2  telegram  was  incorporated.  Namely,  we  are  awaiting  the
                   3  Department's determination for programmatic direction either

                   4  to use the $6.9 million which hn-@                         in the
                   5  fiscal 1973 balance or   @@ 4"di-CaLto to thp rf%Lyions- v at    7r

                   6  should be their set of activitip-st ti-tilizinLy  fiscal,1974

                   7  funds, which as yet are going  to  be  at  an  unknown  level

                   8  and will be determined following the selection of opt ons.

                   9
                                  And, of,course, this is@@@of  great  interest  to

                   10
                      the Coun6il and your roles and prerogatives in the program,

                                  DR. ROTH* This gets  to  the  second  part  of  my

                   12
                      question, because I  have heard  of  all  these  figures  from

                   13
                      $6.9 million, $60 million, $82 million, on up, $159 million,
                   14 and so on.  Being  relatively  naive  about  these  things,  I

                   15
                      know that  there  was  this  administrative  phaseout  decree

                   16
                      and It was then said that if Congress wanted to pull

                   17
                      together an extension law there would be some question as

                   18
                      to whether they could get it passed.

                   19
                                  Well, they did under the   circumstances.  It was

                   20
                      then postulated that it might be vetoed.  It was not.
                   21 But it is still unanswered in my mind.  There is one      further
                   22 stop to funds, and  that  is  impoundment  or  simple  failure

                   23
                      to   release.

                   24
                                  Now, is this essentially what we don't know the         I

                   25
                      answer to  as y.6t,',whether we are really talking about money


                                                                                97

                 1  in hand that you can fund the program with?
                 2              DR. PAHL.@  I think you are perfectly correct i
                 3  your observation that there is from our point of
  Is             4  view as a service an unknown figure, and that is   what  funds

                 5  will actually be made available to US.
                 6              To try to clarify the figures, because  it  is
                 7  difficult,  the House has recommended through  the  appropria-
                 8  tion process a figure of $81.9 million.  Since we do not
                 9  have a full appropriation, we are on a continuing resolu-

                10  tion. Under that continuing  resolution  we  certainly,  under

                11  any objective view of that, would be permitted  to  go  as
                12  high as the current operating level, which roughly is $60

                13  million.  It was, Jerry, $58

                14              MR. GARDELL@*  $55 million this year.

                15              DR. PAHL4.  $55 million this year.  But the

                16  Department  has by administrative action  determined  that

                17
                    it is in the best interests of the program to state initially

                18  at this point in time only that all programs, all 53

                19
                    programs, will'be given sufficient funds under the continuing
                20  resolution, 1974 resolution, to make  Isure that they
                21  remain viable through the first quarter of  the  fiscal  year,

                22  through September 30th, and we  are  actively  negotiating
                23  now through Mr.Gardellts staff with each  region  to  make

                24  sure there are sufficient funds that 53 programs will not

                25  only be in existence but will have some complement of


                                                                               98
                 I  professional and supporting staff, space, equipment,  and  so  i
                 2  forth, through the period Sept6mbei 30th.
                 3             What we haven't been able to give to  the  regions

                 4  is a clear statement as to what kinds of activities they

                 5
                    should be engaged in at this point in time or

                 6
                    what they will be permitted to do or should be
                 7  encouraged to do with either the monies that we just
                 8  distributed at the end of 1973 or any additional  funds  that
                 9  come to them through 1974.  And that is the status of
                10  affairs with respect to the Department's looking at these

                    options.
                12             1 hope that clarifies it.

                13
                               DR. ROTH.@  r promise to stop with this one.  I

                14
                    given those answers, is it an essentially correct over-
                15  simplification of the status of this Council     We have
                16  got a few options. We could go the route which  is  at  least
                17  started with the resolution that staff has circulated  to  us
                18  which says, "We thank you for and approve, retroactively

                19
                    okay, the way you have adapted to a difficult situation."
                20
                    And we could append to this, since we don't know how much
                21  money we are talking about, how much we are going to get,
                22  that we ought to go along on this basis and trust  our  staff
                23  to do the very best they can with the money available for
                24  the best kinds of projects.  Thatts one option.

                25
                               The other option is to go in, in rather starry-eyed


                                                                                99

                    fashion, with the resolution put in by the coordinators
                 2  which directs the way money should be spent  that  we  arentt

                 3  even sure we're going to have,

                 4              Or we could I presume as a Council go over

                 5  the whole batch of 53  rograms and pick c

                 6
                    thought were good  and we would m* e the  recommendation  for
                 7  where the money ought@to  go4  And that seems totally

                 8
                    i         1 in the time  frame.

                 9              But is this about the options up to  the  Council?

                10
                                DR. PAHL@*  Yes.  I think I perhaps would--  I
                    find myself in a difficult position.  The  Council  under  the
                12  authorizing legislation has been established  to  advise  the
                13  Secretary on policy for the program, so it seems to me

                14
                    perfectly appropriate, at least with my experience with

                15
                    councils, for this Council to take whatever  kind  of  formal

                16
                    action it wishes,  and it could be in the form of a resolution

                17
                    or statement or discussion as to what it views  either  to  be

                18
                    concerns or support of the Administration's current

                19
                    position.

                20
                                We have not been able to bring to you     and that

                21
                    may be an administrative failing     but we have  not been

                22
                    able to bring to you the rapid changes  which  have  occurred,

                23
                    and thus you have not been brought into position in which
                24  in fact you could advise us or the Administration about
                25  program directions.  Today you do hear what the status   of


                                                                               100

                 I   af f airs is.

                 2             To my knowledge,  the determination has not yet
                 3   been made by the Secretary, although Dr. Laur may be able

                 4   to comment on that, as to what the Department would

                 5   1. P- .0,@@e the programs do this

                                I think it is most appropriate, therefore, th@

                     kind of statement that you would wish to make to me as

                 8   the Acting Director, to Dr. Laur or certainly to Dr. Edwards
                 9   or Mr. Weinberger and which we would transmit to the

                10
                     appropriate office -- to make whatever statement you  feel

                11
                     is appropriate in exercising your prerogative under  the   I"
                12   and advising us on programmatic directions, options,
                     emphases, priorities that you may see or endorsing your

                     orevious positions.

                15
                                And that's something that',we te I    And I think Dri
                                                                e

                16
                     Teschan was indicating before that a position  by the Council

                17
                     perhaps would be of.gkeat assistance to  the Secretary.

                18
                     After all, the Secretary and officials below him are that
                19   much further removed from the actual program operation
                20   and direction that perhaps they would value very  highly  the
                21   advice of this Council.

                22
                                In addition to that,  I believe that the  question

                23
                     Of the actions taken through the  phaseout period and the
                24   legality of those actions we have attempted to answer,
                25   and I think thatvs a point which I have to leave to the


                                     liicn IPS(if 0               t: " vwp
                                     @ co "tr 6i                 4p so ri
                    Council to decide how it best wishes to handle it.

                 2
                              I would like to make one more statement, and that
                 3  is that in the resolution   and if you have not really
                 4  had time to look at this, and again I am not asking for
                 5  action at this point -- the resolution which we proposed

                 6
                    for your consideration merely would endorse a very limited
                 7  set of administrative actions that ve.have taken.  Namely,

                 8
                    the adjustment of budget periods and the adjustment  of
                 9  funding levels on a prorated basis and the adjustment

                 10
                    of the Council-recommenaed levels on a prorated basis, which

                 11
                    had to be taken in order to carry out what we knew to be
                 12 your intent and the Administration's intent and the

                 13
                    congressional intent, and that is to meet the tests  of
                 14 viability for all of the regions over this period.
                 15           The resolution that we have proposed for you does

                 16
                    not in any way state -- very clearly does not in any way

                 17
                    state that the Council has approved those  professional
                 18 judgments concerning either the phaseout of  individual
                 19
                    RMPs or anything concerning the decisions made relative to
                 20
                    which projects, contracts, etc., could or could not  be
                 21
                    continued.

                 22
                               We are in this resolution asking for that ettdorse- i
                 23 ment only of what had to be done in a technical fashion
                 24 in order to Arrive at a continuity of the program through
                 25 the phaseout period and as we go into the fiscal  year.


                                                                                102

                                So I do want to make that clear, and we as a

                     staff  bear the responsibility for the professional judgments

                  3  which  were made throughout this phaseout period of the
  fA              4  Individual Regional Medical Programs and the activities

                  5 ',lloved  to 00 nn      n       programs.

                  6             That is more than you asked   for, Dr. Roth, but

                  7  does this help you in your options for   the Council?
                  8             And perhaps Dr. Laur or Dr.   van Hoek,  from  whom

                  9  we haven't heard, might care to comment,   because  they  do
                10   sit in on some of  the meetings that r am  not privy to and

                11   they may be able to shed some light on this.

                12              DR. VAN HOEK:  Well,  to  respond  specifically  to

                13   Dr. Roth's question, it  seems to me that there are two
                14   parts to the question.   One is,the  question  of  retroactive
                15   actions, retroactive approval or endorsement of actions

                16   that were taken. The other is  what  happens  from  today  on.

                17
                                And what  happens from today on again is two

                1 8
                     parts.  One is the  immediate question of what do we  tell
                19   the regions in terms of priorities or program  activities
                20   that they can carry on during this fiscal year, whether thatts
                21   at the use of $6.9 million or some higher figure, and the
                22   other part being how can the Council working with the
                23   staff develop program statements, justifications for  the

                24
                     continuance of the activities beyond this fiscal year
                25   in other words, participate in the development of options for


                                    IV       He                             103

                    legislative proposals.  Whether that is a continuation of
                 2  an RMP   in capital letters -- or whether that Is some
                 3  other substantive program with a different process should be
                 4  examined.
                 5            No*, that is not an immediate question.  That can
                 6  be done over the next several months. ]3ut I think it  is

                 7  tied in with the shorter-range issue, because the point--  And

                 8
                    as usual telegrams always use the wrong words and give us more

                 9
                    problems than we anticipated.  But the term mission" I
               10   meant to mean the fact that within the existing mission of

               11
                    RMP, through the continuing resolution, that we would

               12
                    identify priorities or specific activities that could  be

               13
                    carried out over this next fiscal year which would be  of

               14
                    an important nature but would not lead to commitments which

               15
                    would conflict with either legislative proposals or budgetary

               16
                    proposals that would be foEt@VA-inir rivis  tbg
                                                                      several

               17
                    months.

               18
                               And so, therefore, that Is really the question.

               19
                    We are really Involved in two processes.  One is a
               20
                    legislative process where, despite the continuing resolution,

               21
                    there is nothing on the books that carries it beyond June 30,

               22
                    1974.  And then there is the appropriation process which,
               23   despite the continuing resolution, means the funding level may,
               24   be anywhere from zero to total authorization, depending on

               25
                    what we propose to the Department and to OMB.


                                                                               104

                 1             And I really think it's our  initiative,  as  we
                 2  have done with the options, once the Secretary suggests
                 3  support of  certain approaches     and we would  like  your
                 4   advice on that    it's up to the Department and us then to go
                 5   to OMB and justify the release of the funds to  carry  out

                 6   that activity.

                 7              DRO PAHL@O  Dr. Schreiner.
                 8               DR. SCMEINER@.  I like that analysis.  But what
                 9   bothers me is I have this cartoonist vision of a construction
                10   elevator that's been stopped with the motors running on the

                11
                     89th floor pending study to see whether there is enough

                12
                     energy to go higher, and the banker sais, "Well, while we re
                13   studying this we're going to cut off the electricity."

                14
                                And itts just innocent, but I think it's incredible
                15   that this can be a serious proposal or that this Council can

                16
                     foster standing still for three months.
                17              Nov,, there are certain basic activities in the
                18   perpetuation of a local resource at the  very, very minimum.
                19
                     The electric bill, the salary of the coordinator and the
                20   secretary to the coordinator are very, very minimum.

                21
                                Nov, it seems to me completely incredible    to
                22   say that youtre going to have people who are losing

                23
                     coordinators and losing secretaries hot having the authority
                24   to contract for a year to hire somebody for a year to

                25
                     keep this activity going.


                                                                               105

                 1             You simply cannot--  I don't   hink  it's  viable

                 2  to say you are going to go  out and recruit  somebody  for
                 3   a three-month period.  And that's where the rub comes.

                 4   The rub doesn't co  @in in your stud ing the t'hings.   The
                                      ,me                y

                 5
                     rub doesn't come in in  your vanting,to prune off the  barnacles'.
                 6   The rUL-comes in that the method of going about  it  is  to me
                 7   a totally inoperable, totalll U!nfeasible -- and so lacking

                 8
                     in insight that I don't see how anyone can believe it.
                 9              Because you end up September 1 with  one  of  two

                10
                     possibilities. You cut the program here,  in  which  case

                11
                     you have wasted three months of funds, or you  say  we're
                12   really going to continue It to the end of  the  continuing

                13
                     resolution, in which case you have lost a quarter of

                14
                     momentum and you have again wasted three months, so   that
                15   there is only one activity that can hap  n.  That  is,  you
                                                             Pe

                16
                     are going to waste a quarter's budget in the  whole  thing,
                17              And it seems to me that I agree with  Russ,  or
                     John, that a resolution is going to get  us  anywhere  but
                19   wonder if we can't at least ask for a workshop or  a  meeting  or

                20
                     something concrete to get that three-month business out of
                21   the way, because it seems to me that is just so Untenable,
                22   given all the circumstances, that I just cantt see how as a

                23
                     Council-- At least I couldn't personally  endorse  that  as

                24   a method of operation.
                25   -                                                               I
                                DR. PAHL.I  I think, Dr. Merrill, were you  trying  t@


                                                                           106

                    get a comment in?

                 2
                               DR. MERRILL@. I wanted to point out what I  was
                 3  saying consists of two parts, one of which George talked
                 4  about, which is the immediate one.  But the other one is
                 5  long-range clout other than simply endorsement of the  status

                 6
                    quo.

                 7
                               This is perhaps something we can talk about this

                 8
                    afternoon.  But a lot of specific suggestions have been

                 9
                    made in the last hour which if put into the form of a resolu-
               10   tion would give it some teeth rather than, "Just let's

               11
                    get on with what we're doing."  That certainly is the
               12   immediate part, but there is something I think which would
               13   make RMP durable for a good many years,  ot iui--t three
               14   months  which we might be able to entertain this afternoon
                         lip
               15
                    in specific points, a number of which have been made  in  the
               16   last hour.

               17
                               DR. PAHLI.  Mr. Milliken.

               18
                               MR. MILLIKENI.  I'd like to ask Mr.  Gardell  if

               19
                    there is any information in the past or any way to find  out

               20
                    in the future that this quarterly funding thing is any

               21
                    different than in the past -- that is, circumstances  of  not
               22                  but resolution funding -- or if this  is  a

               23
                    deliberate intent manufactured for this special situation.    i

               24
                               MR. GARDELLI. We have never extended  any  program
               25   in the beginning of a fiscal year for a quarterly  period  of


                                                                             107

                    time, so this is the first time we have done that.
                 2             Normally, your continuing resolution gives you

                 3
                    enough money to be able to get on with the business and to
                 4  make your first set of awards for the I?-month period,
                 5  assuming you are going to function on a 12-month period, which

                 6
                    is exactly what I said in my presentation.

                 7             MR. MILLIKEN@.  Then it's quarterly?

                 8
                               MR. GARDELL@.  No, it's not necessarily quarterly.

                 9             MR. MILLIKEN.  Are there any other parts of

                10
                    Government where this has been done b6fore?

                11
                               MR. GARDELL.'  There are some programs that fund
                12  on a quarterly basis, but I'm not aware of any of a categorica

                13
                    nature.

                14             DR. PAHL.I  Mrs. Silsbee has a comment.

                15
                               MRS. SILSBEE.@  In answer to your question, Mr.

                16
                    Milliken, I have not been privy to any of the discussions,
                17  but I think perhaps itts an understanding of a grant process

                18
                    that may be lacking.

                19
                               1 having made my entire career in trying to

                20
                    develop review procedures that are in line with the under-

                2 1
                    standing of the reviewing groups and the staff, it has
                22  been difficult,' and one of the things behind the resolut on

                23
                    we have there is,  as you know, we developed a triennial
                24  system where regions  were looked at and you as Council

                25
                    approved some for three years, and then we had an understandi  g


                                                                              108

                     of how the review would be accomplished in year 2 and year 3.
                 2             At the same time you as Council frequently did not
                 3   recommend triennial funding.  You recommended anniversary

                 4
                     funding.
                 5             Well, at this point in time, going back and
                 6   looking at the review record, we have 13 regions that

                 7
                     are in an anniversary situation, and as of this moment six of
                 8   those really in terms of our understanding should be looked

                 9   at by the Council.

                10
                               Nov, we're trying to work all of this

                11
                     around because we don't have an application for you

                12
                     to look at.  We have got to get this back into some kind
                13   of working arrangement between the Council and the staff.

                14
                     We don't know what to tell the regions to apply for.  We are
                15   in a bind.  And in a sense that resolution, which may be-

                16
                     improperly worded, was to try to get you to let us

                17
                     extend until such time as a region can come in with an

                18
                     application.

                19
                                MRS. MMS.I  Dr. Pahl,

                20
                                DR. PAHL@.  Mrs. Mars.

                21
                                MRS. MARS:  -- is there enough program staff left
                22   in the majority of the RMPs to be able to carry on effective-
                23   ly any major activity7
                24              DR. PAHLI.  Yes.  We have made a survey on that.
                25   Mr. Chambliss may wish to respond in more detail.  But the
                                                                                   I


                                                                             109

                    answer is yes. In the majority of the  regions  that  is

                 2
                    true.

                 3             MR. CRAMBLISS@#  Yes, there has been a survey,

                 4  and there is a minimum of staff on board in each of the RMPS,

                 5  including the coordinators and their secretaries.

                 6             MRS. MARS.@  That isntt what I asked.  I said is

                 7
                    there enough program staff left to carry on major activity?

                 8  Not just coordinator and minimum staff.  In  the  actual

                 9  programming part of the staff.

                10
                               MR. CHAMBLISSO@  My impression is that there is

                11
                    a minimum of staff that could

                12             MRS. MARS*@  Could effectively carry out major

                13  activities?

          @j    14             MR. CRAMBLISS.I  Yes.  Also our survey has shown
                15  that"the regional advisory groups are essentiall  intact
                                                                     y

                16
                    and will be ready to respond once they have more knowledge as   i

                17
                    to what the real missions of the RMPs will be.
                18             DR. PAHL.@  Mr. Hiroto.

                19
                               MR. HIROTOO. I have a couple of  questions  I        i

                20
                    think that have some legal implications.

                21
                               Your definition of the Cqoncills  role  would

                22  indicate to me that if it is merely advisory  then  this

                23  resolution is not necessary for staff, for RMP here, to do

                24
                    what they have done, and so I wonderiif the enabling legisla-

                25
                    tion had a little more meat to it than the fact that the


                                                                            110

                    Council was merely advisory in nature.

                 2
                               DR. PAHL: The Counbillis advisory in nature
                 3  relative to the policies, program directions, and so forth.

                 4  It has a very real function in recommending to the
                 5  Secretary approval for expenditures of grant funds, and,

                 6
                    in fact, the Program Service may not expend grant funds withou
                 7  the specific recommendation for approval by this Council.

                 8
                               So it has a very well defined role in the

                 9
                    approval for expenditure of grant funds -- not contract,  but

                10
                    grant  funds   and is advisory in terms of program

                11
                    policies.

                12
                               And it was in the program policy area  that  the
                13  resolution would be advisory.

                14
                               But I believe it is fair to say that  all  Govern-

                15
                    ment officials take very seriously statements  by  advisory

                16
                    councils relative to such policy matters.  And my own

                17
                    personal opinion is it would be very helpful to know   what
                18
                    the Council may feel about these important matters.

                19
                               When it comes to grant funds, the purpose  of  our

                20
                    resolution    and what Mrs. Silsbee was trying to  allude  to

                21
                    and I don't want to come back to our resolution all the
                22  time because It's not really in conflict with what Dr.

                23
                    Teschan.said     is that it is giving to us your  post-action
                24  endorsement of that which we had to do and providing us
                25                 on of authority in a very limited  fashion  to


                     continue between Council meetings to do that which actually
                 2               s ar  if regions are to remain viable, which is

                 3   everyone's intent.

                 4              And again I think that it Is important to

                 5
                     separate then the fiscal actions which@ve have  had  to  take

                 6   and the authority which we really need from you to take

                 7   those actions when me don*t have applications or have

                 8   ceiling levels which are meaningful for  regions until   such

                 9   time as we can get back into concert with the recommendations,

                10   which we expedt we will be able to do by fall.

                                We are trying to put the brakes on phaseout,

                12
                     stabilize, and move forward -- with  serious  question  marks

                13   in this area.  But we have certain legal obligations

                1A
                            e recognize, one of  then being that the sta-

                     not have the authority to continue to  support regions and fund

                     them without approval from this Council.
                17              On the other h                   rmlic-atinns to
                18   bring to you and no way  to advise you and no review conmitteei
                .9   to recommend ceiling Igavala  fivniiincr  m,
                ML
                20@             So this is an interim procedure   of delegating to
                21
                     us necessary administrative authority.  That is what our

                22   resolution is intended to do.

                23
                                This does not encompass all, of  course,  that  is

                24   in the coordinators' resolution, which is br

                25
                                Dr. Haber?


                                                       a lb  Am   4v '
                                                       nfit>CO               112
                I              DR. RABER.@  I must say I am extremely sympathetic

                2   to the position of the staff in this, because there is a
                3   basic kind of schizophrenia involved here.  On  the  one
                4   hand', as an effective bureaucrat, there is an  apparent
                5   mandate from the Administration which one must take
                6   seriously. On the other hand, there is, as  all  of  you know
                7   who are purveyors of health care and interested  in  the
                8   delivery system     I think Dr. Laur mentioned it    the
                9   concern as to what happens to the people out in the  regions.

                10  One would want to continue certain promising kinds of

                1 1 activities.

                12              It seems to me that some historical perspective
                13  might be useful here, and I'd like to ask the question of
                14  you or Dr. van Hoek or Dr.  Laur.  That is, part of the
                15  problem, it seems to me, is due to an evolution  of  the
                16  mission. The Regional Medibal Programs  started  out  to
                17  do something somewhat different from what now or laterally
                18  appears to be the mission.

                19
                                If one could address that  that as heart, cancer

                20
                    and stroke centers some good was accomplished, much good
                21  was accomplished in the dissemination of  this kind of

                22
                    expertise throughout the system, if@'that could be developed,
                23  then I think one might have a clue to what your_ immediate

                24  posture might be for the ensuing 12 months.
                25              Because then again it seems to me that out of the


                                                                                    113

                     array of options you chose, one could say, "All right.  Tile
                  2  part of the mission that is available to us for this
                  3  year is changing.  Yet over the course of time RMP has

                  4
                     done these following things all under the rubric of
                  5  disseminating effective health care."
                  6              And what I'd like to ask is could a case be

                  7
                     made that the heart,   cancer and stroke centers concept     was

                  8
                     indeed helped by the   RMPs and that the mission evolved    into
                  9  something else which   you were not  able  to  complete  because
                  10
                     the program was caught in mid-flight?

                  11
                                 DR. PAHL'*  Dr. Laur may wish to address the

                  12
                     point, because I believe some of the recent meetings      he has

                  13
                     had entailed those very considerations.

                  14
                                Dr. Laur.

                  15
                                DR. LAUR:  riii try to respond first to that
                  16
                     question and then make an observation.  To my knowledge,
                  17 the case cannot be made  that  heart,  stroke  and  cancer  centersi
                  18
                     tendered that kind of a positive service.  Now, if the             i
                  19
                     Council can make that case or if the staff can,     you know,
                  20
                     that would be certainly a starting point.
                  21
                                My impression  has  been  that  there  was  considetablei
                  22
                     disagreement around the country especially at the local

                  23
                     level as to whether those ideas were, in fact,    the best

                  24
                     way to disseminate improved health care to the    people.
                  25            Nov, I would welcome comment from staff oh      that.


                                                                                  114

                 I   But that sort of goes back to the original notion of

                 2   Dr. DeBakey and the Commission  and  what  finally  became

                 3   law and that finally happened in practice, and I am only

                 4   trying to read the tea leaves at the bottom  of  the  cup  now

                 5   that we have all@had a  deep  draught@from,it  which  says

                 6   to me that since it didn't happen that  way  in  the  real

                 7   world there was probably something   faulty with the  idea  in

                 8   at least many parts of America.

                 9               Now, T would like to have my own understanding

                10   broadened if that is not the case.

                11               DR. BA13ER*-  Well, I am not sure I can make the

                12   answer, but t am sure there are people who can make the

                13   answer that the dissemination of techniques  in  care  of  the

          @j    14   coronary patient and the education of a great variety of
         C@7    15   allied health professional people was in some definite measure   I

                16
                     attributable to the deployment  of  the  Regional  Medical

                17
                     Programs, and maybe the same thing is true in cancer,    less
                18   so possibly, but certainly in stroke.

                19
                                 I think if that case could be made,  or  At  least

                20
                     if the issue could be raised enough so that people could not
                21   definitely negate it, I think that would give you a clue

                22   as to what the situation might be, what the     sition   might
                                                                    PO

                23   be.

                24               DR. LAUR.@ I wonder if I  could  take a slightly

                25   different cut at the same question  by  saying  Ido not believe


                                                                            115
                    that this Council or this staff or the people whom you suffer

                 2
                    under as administrators of HRA right now can make that
                 3  case within the time available to make any difference. That

                 4
                    goes back to Dr. Merrill's long-range question of!  Is that
                 5  the way we ought to go in@the future?
                 6            But I thought Dr. Schreiner's question was much
                 7  more short-run, which vas@.  Somebody made what to him
                 8  doesnft look like themost intelligent decision, which was
                 9  to fund up to Se tember 30th the core support of RMP so
                                    p

               10
                    that they would be around to do some good mission for the

               11
                    remainder of this year while the long-run fat6'gets
               12   settled in Congress and in the Administration.

               13
                               Now, it seems to me he had a very specific idea

               14
                    in mind, which was.  "Dummies, don't try to do it that way

               15
                    because it wontt work.  At least assure core support through

               16
                    the year."

               17
                               That*s a quite different level of decision and

               18
                    recommendation to us than, "Go back to'the centers idea as
               19
                    to the way to get work done.

               20
                               DR.,HABM.@  No, no, permit me.  I was trying to s-a4

               21
                    if one could say the mission had been evolving, that part

               22
                    of it could be accomplished, then you have a line on what   ul

               23
                    are to do for the next year.

               24
                               Dr. Pahl read for us a list of seven or eight

               25
                    different options.  Real case could be made that the accom-


                                                                             116

                    plishment could be furthered during the course of the year.
                 2              1 would agree with Dr. Schreinerts analysis.  ltd
                 3  say dontt lose a quarter of the time.  But you could do a

                 4
                    great deal towards, say, hypertension  control  demonstrably

                 5  in the course of the year, or kidney programs, or

                 6
                                DR. LAUR@*  Pbrhaps I read much more into your

                 7  observation than I was entitled to.  Every one of the

                 8  options which we have developed and suggested to the
                 9  Secretary, the ones you heard, are ones we deliberately

                10
                    picked on the ground that we thought RMPs were superbly  equipped

                    to make a major contribution in the time available.
                12              Tn other words, we wouldntt have suggested  them
                13  had we not  thought they were appropriate to the mission  of

                14
                    RMP and to  the health needs of the country and that we

                15
                    had a reasonable chance of getting the money to do those

                16
                    Jobs with.

                17
                                We tried to be quite selective in what we

                18
                    recommended.

                19
                                1was extending your thought to say what we ought

                20
                    to now be doing in the coming year is to establish regional

                21
                    centers for hypertension, which left me less  than  enthusi-
                22  astic.

                23              DR. HABER@O  If the mission is changing, the
                24  agglomeration of these could be subtended on the mission,

                25
                    which would require the  cbntinuation,of RMPS.


                                                                            117

                 1             DR. PAHL.@  Dr. Ochsner.

                 2             DR. OCHSNER@* I mould like to speak to the  ques-

                 3  tion of the centers. It seems to me the idea  originated  by
                 4  the DeBakey Committee was the centers, but I think they

                 5  failed miserably in establishing what we have in mind  in

                 6  the RMP,  And to go back, they did fail I believe, and

                 7  thatts the reason why this mechanism was set up.

                 8             Nov, whether this is the right one or not--   But

                 9  I don't believe that they did a good job in  hypertension

               10   and cancer and stroke. They were given a time to  do  it,

               11   and they didn't.

               12              DR. LAUR*. From this or other groups I  think,

               13   Dr. Ochsner, your observation is quite important in the

               14   sense that Dr. van Hoek at the end of the table now

               15   serves as the Director of the Bureau of Health Services

               16   Researdh and Evaluation, and it seems to me after years of

               17
                    exploration we have at least uncovered an important question

               18
                    that ought to be studied by the Federal Government, which is

               19
                    how do you go about accomplishing iins like that?

               20
                               At least we ought to be doing some research on

               21
                    it if not actually moving forward with an action  program  if

               22   we think we have the answers.

               23              But what I am trying to separate out today  in

               24   the remaining hours of your time is:  Can you give us

               25   advice,which we may or may not follow but I assure you we


                                                                                118

                  I  will welcome, on@. Given the  circumstances  right  now,  what

                  2  would be the intelligent thing to do, the most useful thing

                  3  to do?

                  4              And you suggested some already.

                  5              1 think we in turn will have to say'.  Now,, under

                  6  the constraints with which we have to work, with the

                  7  Secretary's office, with the legislative situation,   with the

                  8  Congress, some things can be envisioned and others     cannot.

                  9              What the staff I think is looking for are two

                10   kinds of help from you.

                11
                                 One is let's put the past behind us,  kind of seal

                12
                     it now and be done with  that, and give us the kind of

                13   guidance you are willing to give us to govern our future
                14   actions, recognizing that we will have  to  take  some  action

                15
                     before we can get together again and discuss it thoroughly.

                16
                     That is, in the interests of getting on with the job of

                17
                     RMPS, some funding decisions will have to be made between
                18   now and September.  The sooner the better in our estimation.
                19   And we need some guidance from you on how to do that and
                20   leave you feeling comfortable with our Actions.
                21               1 guess I would add one other point  in defense

                22
                     of the September 30 date, since I was inTat least some of

                23   the   discussionIs.  There were really two major concerns.

                24   They weren't exactly compatible but that governed that

                25
                     process.


                                                                              119

                 I             One of them  was the view by some of  the  officials

                 2 in the  Administration  that they' were right all along
                 3  about RMP, that basically it was not fulfilling a
                 4  worthwhile enough mission to deserve funding and it  ought  to
                 5  be phased out.  You might come back with a new approach
                 6  that was okay    but RMP was essentially a failure and it

                 7  ought to be phased out.
                 8             So that concept is governing some of the

                 9  kind of decisions that were made.  They didn't wish to

               10
                    reverse that decision so they were trying to come up with

               11
                            satisfying the intent of the Congress with the
                    ways of
               12   extension legislation without reversing that  basic  decision.

               13
                               Nov, that's real. It's there.  And  the  staff  has

               14
                    to  struggle with that.

               15
                               On the other hand, there was another dimension which
               16   said, "In reality we want to come up with a useful
               17   mission for RMP.  We cantt do it overnight.  So let's at
               18   least get enough money out there to sustain them" -- and

               19
                    here's where they may have made an error in judgement as
               20   to what it takes to sustain -- "at least let's get  the  money
               21   out immediately so no RMP will be in dire straits while we
               22   get all this straightened out," in the  factual  circumstances
               23   which are that most of the RMPs were carrying out  activities

               24   into February.
               25              You know, December and February were the times  in


                                                                                  1201

                     which under the phaseout plan they were continuing on into

                 2
                     those dates.

                 3              So I think their perception was that not very many
                 4   people are in dire straits right now and that to avoid
                 5   a hasty decision that seems to commit the Administration to

                 6
                     continuation of RMPs full blast, we'll have this time-

                 7
                     limited one.

                 8
                                But we picked a time      we  meaning this is how
                 9   the conversation went    a time  was picked which provided
                10   what they thought was ample opportunity to come up with an

                11
                     ongoing funding level and a set of HEW expectations of RMP.
                12              DR. SCHRETNER@.  This is precisely where I find
                13   the problem, because if the assessment is  that  this  was

                14
                     a polite gesture by Congress and there  is no real intent to

                15
                     go beyond a year., then to@have full funding of  the  non-
                16
                     programmatic portions is really a waste  of the taxpayers
                17
                     money.
                18
                                MR. HIROTO@O  I think so too.

                19
                                DR. SCHREINER.;  If  youtre talking about allowing

                20
                     somebody to recruit a  coordinator  so that he  can  extend

                21
                     the existing programs,  then  somebody has got to be able to
                22   recruit a coordinator on the basis that he is going to be
                23   here for a year.
                24              As I read this telegram, you  know,  there  are
                25   vacancies all over the country, but you can't recruit anybody


                 I  for more than three months, but he is  supposed  to  then

                 2  arrange for the extension of programs beyond      at  least

                 3  from February to June at the very, very least  if  you  are

                 4  going to meet the intent of Congress.

                 5              And so here you are recruiting a guy, you know,

                 6  and saying  he is going to have a job for three months, but

                 7  his real task is to be sure this program  is  running  well

                 8  June 30,  1974.

                 9
                                And I find that  administratively  untenable. You

                10
                    either have to  decide certain parts of it  are  going.to

                11
                    be extended for  the full year of the extension  so  that
                12  you can carry out the intent  of  Congress, or you are going

                13
                    to say that the whole thing  is  impossible and is  a  gesture,

                14
                    and then you ought to cut it down.

                15
                                What TI'm saying is there are three  possibili-

                16
                    ties.  Of the three, it seems to me the one you have

                17
                    chosen is the least tenable of  the  three.

                18
                                DR. PAHL'$ Before continuing this  most  important

                19
                    discussion -- because this is why we wanted  you  to  assemble on

                20
                    the 17th of July@-- Itd like to come back to some practi-

                21
                    calities.

                22
                                We are very concerned that  we have as much dis-

                23
                    cussion and advice from yoult@dday as@ve can possibly derive.

                24  1 had indicated earlier that  we hoped  to be  completed  by
                25  2 o'clock
                                and some of you may have  made your plans  on  that


                                                                           122
                 I  basis.  I should have realized, of course, that, having
                 2  lived with all of these parameters these many months   We
                 3  thought we could perhaps summarize them more rapidly than
                 4 we did', and if we took too long we apologize for that.
                 5 but we felt we had to give you a flavor and a background set
                 6 of data so that you can go into the considerations of the

                 7 future a little bit better prepared.

                 8            So what I would like to ask is what kind of

                 9 schedule we may look to with you for the rest of the day.
               10  If you can stay somewhat longer than 2 o'clock, for example,
               11  we could profitably continue this discussion perhaps to
               12  1 o'clock or so and break for lunch in the cafeteria, during   I
               13  which time you could discuss some of these matters which
               14  1 dontt think we have gotten quite enough to the point that
               15  you feel prepared to propose a position of the Council,

               16  and then reconvene.

               17             But it we do break for lunch, it is going to be

               18  relatively short after we do reconvene, and it may not
               19  provide that kind of opportunity for further discussion
               20  that both you and we would like.

               21
                              So, as a simple question, is it possible for you to,]
               22  stay beyond the 2 o'clock period or do you not wish to
               23  break for lunch and vetll try to guide our own conversations

               24  here and the other material which I have to present to you
               25  which is part of this discussion and which I'd like  o  0


                                                                              123

                   before we broke for lunch? And I'd like to be  guided  by

                 2
                   what your schedules are.
                 3             DR. MCPHEDRAN@* How far behind are we in your

                 4 proposed agenda?
                 5             DR. pAHL.; I would suspect if we could continue to
                 6 3 otclock we would have the kind of opportunity that at

                 7
                   least I think staff would appreciate havingg but I don't  know

                 8 what that does to your schedules.

                 9             mRS. MARS.;  Three is all right.

                 10
                               MRS. MORGAN*.  I have a 5 o'clock.

                 11
                               DR. RarH.; 4.@30.

                 12
                               Dlt. OCHSNER@.  I have to leave at 1 o'clock.

                 13
                                                              at 2'30.
                               MR. MILLRKEN:  I have to leave

                 14
                               DR. PAHLI  Why don't we try to stay as much

                 15
                    through    but terminate definitely,at three.

                 16
                               Let me ini6ct one or two things here which  I

                 17
                    believe should come into the conversation at this  point and
                 18
                    try to recap    not "recap" but give you what I consider to
                 19
                    be some important elements which perhaps have gotten lost  in
                 20
                    all of this general discussion.
                 21            That Is  where do we stand now and what is the

                 22
                    staff thinking about in trying to react to all of  this?
                 23 Because I think this should be part of your  lunch-table
                 24 conversation and afternoon thoughts.

                 25
                               Facts* We now have 53 Regional Medic  1  Programs, I
                                                                    a


                                                                          124

                    all of them guaranteed to be viable through the first quarter
                 2  of the fiscal year, with a clear intent of the Department  I

                 3  believe to try to make determinations which will  permit

                 4  all 53 to continue throughout the fiscal year with  some
                 5  kind of profitable activity along the set of options that  I

                 6  have indicated.

                 7             My best information at this point is

                 8
                    that there would be a series of options supported by the

                 9  Department, and, thus, regions would not be confined  to

               10
                    doing this or that but that there would be some  electivity.

               11
                    The decision has not yet been made.

               12
                               MR. MILLIKEN:  Is there readily available by staff

               13
                    a  breakdown of this sort of thing now, regional program by

               14
                    program?

               15
                               M* PAHL:  A set of what now?

               16
                               MR. miLLrKEN.  Identification of existing projects
               17   that

               18
                               M. PAHL@.  Yes, we have, although not for you today!

               19
                    but wel,db have knowledge on each program as  to  what  activi-

               20
                    ties are being continued and, of course, can  derive  the

               21
                    latest information Op that. So we can get  for  you  where  we
               22   stand, but we are not prepared to do that today because of
               23   -he time considerations.

               24
                               MR. MILLIKEN:  I understand.

               25              DR. PAHL@$ However, the set of  activities  in  any


                                                                              12  5
                I    one region now going on have already been funded through  the
                2    phaseout awards that were made.  In addition to those
                3    activities, in some regions there are no activities going
                4    on. They have just discontinued. They  have  just  terminated
                5    their last activity.  In most regions there are a handful
                6    of activities going on, and in some regions there are quite a i

                7    few activities going on.
                8              Most regions have more than a minimal complement
                9    of staff, but it varies dramatically from region to region.
                10             Next, $6.9 million has been distributed to

                11
                     the regions at the end of this fiscal year which at
                12   the moment they are not permitted to use pending instructions
         @j
                13   from the Department as to purposes for which they may be
                14   used.  And within those purposes certain criteria must be

                15
                     met.

                16
                                1 want to address myself to that in a moment,

                17
                     because that is the second part of the telegram we

                18
                     haven't talked about which you should be aware

                19
                     of and which we have given much thought to.

                20
                                Thirdly, we are operating under a continuing       i
                21   resolution, and it is my understanding that as soon as the
                22   Department makes a determination as to what the regions
                23   may do, we will then develop a spending plan and submit this
                24   through the Department to the Office of Management and
                25   Budget requesting those funds which would be  appropriate  to


                                                                                  126
                  1   the options decided upon by the Department.
                  2               So I do not know what  the  spending  level  is  for
                  3   fiscal 1974. It  will  not  probably  be  greater  than  $81.9
                  4   million, and It probably will be not less than $30 or $40

                  5
                      million.

                  6
                                  This is the result of many conferences and

                  7
                      inferences,  but we do  not  know.  I  donft  believe  the

                  8
                      determination has been made since the options haven't yet

                  9
                      been selected.
                 10               Now, the options  that  are  under  considerat  on
                      are all those kinds  of  things  which  the  Regional  Medical

                 12
                      Programs have been  doing.  There  are  no  surprises  to  the

                 13
                      Council, and there  are  no  surprises  to  the  coordinators

                 14
                      or to the community groups.  Thus,    it is a question of

                 15
                      making    decision,  not starting off  in a new direction   for

                 16
                      any given Regional   Medical Program.

                 17
                                  Now,   let Mfi turn for a moment; to  that  second

                 18
                      stipulation in  the  telegram,   because it is important that you@
                 19
                      understand the  thinkin   at  least   that staff has given
                                              9

                 20
                      to that cryptic phrase   which  says,  "Regional   Medical

                 21
                      Programs Service has   been   authorized to utilize the  balance

                 22
                      of FY  1973  funds  (approximately  $6.9 million) with  the

                 23
                      stipulations that no expenditure be    made therefrom    until

                 24
                      the  Department  announces  the  mission of  the  Regional

                 25
                      Medical Programs Service for  the  remainder  of  PY  1974  and"


                                                                              127

                    now the second stipulation    "that proposed RMP  activities

                 2  meet review criteria to be established."

                 3             What this really says is that the Department  has

                 4  indicated that in expending either the $6.9 million

                 5
                    balance from fiscal 1973 -- which has already been

                 6  distributed in individual awards to the 53 regions  but

                 7  they are not allowed to spend it    or in permitting

                 8  expenditures from the fiscal 1974 funds yet to be  made

                 9  available to the regions, not only will those funds have  to
               10   be spent in certain programmatic areas now under consideration

                    by the,Department, but within those areas the actual
               12   projects which are funded and activities which are engaged in

               13
                    must meet certain review criteria which at this point in time

               14   are not developed.
               15              So we have an obligation placed upon us by the
               16   Department to develop reasonable criteria of a  general
               17   nature !or those programmatic areas which are approved by
               18   the Department and to have these criteria be applied by  the

               19
                    local Regional Medi6al Program in consideration of  the
               20   activities they would like to engage in with either the

               21
                    balance of 1973 funds or the 1974 funds and to have a review
               22   process involving you, the Council, and me, the staff, which
               23   would certify that the projects are in fact meeting the
               24   criteria.
               25              And since telegrams cost money, we didn't write


                                                                          128

                    all that.  We just thought vie would put that all down on

                 2
                    July 5.  And since July 5 vie have been trying to
                 3  determine how as a staff we might accommodate these

                 4
                    various constraints or, if you will, requirements.

                 5
                               In a sense, we are returning from program-,re*iew

                 6
                    which you are familiar with with the triennial application    i

                 7
                    to a modified project review.

                 8
                              Nov,  I would like to give you the thinking of

                 9
                    staff because it does involve both advice from you and

               10
                    hopefully your participation with us over coming

               11
                    months, and the best way I can phrase this I think is to
               12   reflect back upon how we managed the earmarks on the emergency
               13   medical services funds and also on the community-b
                                                                      ased

               14
                    ANECs where we involved Council in the development of

               15
                    criteria and the subsequent review of these and yet

               16
               17   had a type of project review back here at the national level,
                    not depending solely on the review process at the local
               18
                    level.

               19
                               What we would propose is in accordance with the

               20
                    Departmentts interest in not waiting until the end of
               21
                    September before regions can get moving, but to provide

               22
                    that kind of framework which will permit regions to move
               23   ahead as quickl  as the Department decision can be made known
                                   y
               24   to regions.

               25
                               What We have considered is the following, and I


                                                                            129

                    would appreciate it if staff would react or add to what I
                 2  am about to say because I do want to make it as clear as
                 3  possible so that we can either get your endorsement  or

                 4
                    advice as to how to proceed otherwise.  And I do mean that.

                 5
                               We have given much thought but I am sure there are

                 6
                    other ways of doing this.
                 7             We do expect aDepartmental decision on these
                 8  various options within a very short period of  time.  I
                 9  indicated to you we had hoped to have that decision today,

               10
                    which means v6 may have it this week or  next  week.  I

               11
                    believe we are that close, because I Understand that the
               12   Assistant 8ecretary'8 office is in a position to make its

               13
                    recomwndations'to the'SecretAry!s office, whore the final

               14
                                    made, so that we hope for a decision very
                    decision will be

               15
                    quickly
               16
                               Once this decision is known, the  only  thing

               17
                    holding up the regions from,  therefore,  utilizing  the $6.9
               18
                    million that is already out there  and  from  developinga

               19
                    spending plan for 1974 is the fact that  we  donft  have
               20   these criteria which the Department  believes  we  should
               21
                    develop and apply against the specific projects to be funded
               22   within the constraints or possibilities provided by the
               23   Department.
               24              So in developing criteria, what we propose to do is
               25   to ask the Council if they will with staff and with selected


                                                                                 130

                  1                                                        vities,
                     coordinators who are closest to these kinds of acti
                  2  be they hypertension control programs, EMS programs,
                  3  quality of care and assurance programs, or what have   you,
                  4  to participate with us in the development of these
                  5  criteria by forming yourselves or with our guidance into
                  6  Small subcommittees of two or three Council members who
                  7  could meet possibly in the very first part of September    to
                  8  approve a general set of criteria for the programmatic
                  9  areas determined by the Department, and to then make
                10   these criteria immediately known to the regions, the
                     regions then having the opportunity to immediately provide to
                12   as those applications for projects in those areas which,
                13   since the criteria are now known to both the region and
                14   the Council, would be a  simple  certification  process  here

                15
                     to indicate that these Or @jecto  can"be  approved,  approval

                16
                     sent to the regions,  and the regions immediately then

                17
                     engage in the kind   f staff hirings And initiation of   pro-

                18
                     jects or staff  service   that are requested.

                19
                                 We believe that  the actual criteria could be

                20
                     developed  very  quickly  over early August and we would hope

                21
                     that in  the  early  September meeting we would make it t littlell
                22   bit  more  clear.  The  actual applications for specific
                23   projects to  be  funded  could come in from the regions.
                24               So this  would  be very much like the EMS and the

                25
                     health services education activity program that we bad


                 1 about a year ago.

                 2             This would get regions started  immediately  with

                 3  the funds that have been made available.

                 4             Now, we would believe that if  this process

                 5  were one which you believed would be effective and in  which

                 6  you would participate, we would have to ask that there be

                 7 an understanding by the Council  that  these  subcommittees

                 8  had delegated to them the authority of the full Council  for

                 9  making the decisions for the actual award of  grant  funds

                10  either out of the $6.9 million or the 1974 funds  for  these

                    specific activities without bringing them back to  a  full

                12  Council meeting.

                13             Again we are working within a time constraint, but

                14  this would get the regions moving in a very definite

                15  programmatic direction.

                16
                               It adds an additional layer of  review  which

                17
                    perhaps everyone would not wish to engage in  but  which seems

                18
                    to be the appropriate method for proceeding  right  now.
                19             We are open to other suggestions as to  how  to

                20
                    proceed effectively.
                21             We do'belleve that It is  not  poIssIible to  rate

                22  in any numerical way the projects that may come  in.  I  may

                23
                    be very mistaken about this. But,6ettainly  some  kind  of

                24  ranking in priority order will@be required because  we  will

                25  have to pay on some graded scale, again in  accordance  with


                                                                              132

                 I  what may be indicated by the Department to be preferences

                 2  or even certain levels of funding for certain directions.

                 3             Nov, that is a modified project review for the

                 4  immediate future which is merely designed to get the

                 5
                    regions moving faster than waiting until September 30th,

                 6
                    and we believe, therefore, this could all be done over
                 7  August-by perhaps one meeting on criteria and one

                 8
                    meeting in September of the individual  committees,  sub-

                 9  committees, of the Council with staff to review the

               10
                    specific projects that came in.

               11
                               The tote important thing, of course, is to
               12   look at the regions as a whole over the fiscal  year  and

               13
                    the future of this in the longer term, so what I have just

               14
                    proposed is a short-term expedient arrangement to help us all
               15   got back into some kind of functioning within the regions.
               16
               17              The longer-term considerations of each region and the
                    program as a whole would be presented at a November Council
               18
                    meeting where we would have two days, if  your  schedules

               19
                    permit, to look at all of the regions collectively and
               20   individuall and these longer-term  considerations  as  to
                               y

               21
                    what happens beyond June 30th and the kinds of things which v
               22   neither have time for now nor are as clear to us as they
               23   should be, and over the course of the coming weeks and a few

               24
                    months r believe we will have a better appreciation for what
               25   the stands of both the Congress may be and the Administration.


                                                                               133

                 1             Now, I just wanted to mention this to you because
                 2  as a staff we are under an obligation to the Department
                 3  which is, of course, my problem to somehow release
                 4  those funds already made available to the region and
                 5  those funds which can be made avalable to the reg ons  provided@
                 6  we have criteria and provided projects can be developed

                 7  which meet such criteria.
                 8             Now, the kinds  of criteria that I am talking
                 9  about are broad in nature, general in nature, and generally
                10  revolve around the idea that whatever project would be
                II- submitted would be one which would have an impact in a   real
                12  way in a community over this one-year period.

                                                        m the Department in any
                13             There  is no coercion fro

                14                                              a certain line
                    sense of the   word to design criteria along

                15
                    or to make   things impossible either here or within the
                16  regions.  The idea Is to use what funds  are made

                17
                    available out of  the 1973 funds or the 1974 funds to

                18
                    accomplish something in a relatively visible

                19
                    way within the communities over the one-year period but
                20  not to start those kinds of activities which would if initiates
                21  have to be continued by an RMP as an RMP in order to make an

                22  impact in the region.
                23              Because, gain, we are probably talking about the
                24  continuation of the program in some  new  form,  or  alternatively
                25  an actual termination, And this from my point of view here       I


                                                                              134

                    has not been finally determined. But the intentions  as  I
                 2  best perceive them are to continue the program in a modified
                 3
                    form, the structure of which is at least for me ill-
                    defined but which by November Council meeting may well have

                 5
                    much greater opportunity for discussion and useful input
                 6
                    from you.

                 7
                               If it turns out, of course, that it is
                 8                                                                1
                    possible before that time, we most certainly would want your
                 9
                    advice. But it is not too helpful today to  speculate  too

               10
                    lengthily I believe on what happens after next June 30th
               11
                    except perhaps to indicate an overall concern or point  of
               12
                    view by the Council.

               13
                               Now, again, that is rather technical, but we have

               14
                    very severe administrative constraints, and we not only
               15
                    need your advice as to how to proceed over the next 60
               16
               17   days but we from our point of view--  With this recommendatio
                    to you, it would involve your actual participation with
               18
                    staff and with selected coordinators towhee
                                                               Pi

               19
                    the criteria very quickly and get your approval and then to
               20
                    have possibly a September meeting with the  subcommittees,
               21
                    a subcommittee Iprobably established fok'@,d'ach option, a
               22
                    subcommittee for the strengthening of health planning agenc es
               23
                    in the co   nity and a subcommittee maybe for the EMS
                             ?mu

               24
                    activity, who could be given the authority by this full
               25
                    Council today to act oh behalf of the full Council and thus


                                                                             135

                     to start the regions moving ahead very positively with what

                2
                     funds are available.
                3              1 hope I haven't muddied the waters.  All of
                4    that is contained in those few words of the stipulation

                5    No. 2.

                6
                               Dr. Roth.
                7              DR. ROTH@. Well, ltd like to react to that.  As
                8    I look around; I guess I'm the only-one that was on the
                9    Council back in the days when we were reaching a decision,
                10   which may have been an ill-advised decision, but we

                11
                     always had the dilemma with limited dollars do you put
                12   them into places with a demonstrated capacity to use them
                13   to put on a good program or do you look at the areas which
                14   are backward, deprived, who probably need the kind of stimu-

                15
                     lus that RMP thought it was pre ared to give without
                                                   p

                16
                     putting on such sophisticated programs?

                17
                               Ouk decision was that indeed we weren't going

                18
                     to deprive the backward, underprivileged areas in

                19
                     order to pour more money into Boston and Philadelphia and

                20
                     places where there was all this capacity.

                21
                               Now, that may have been a wrong decision at the

                22
                     time, and it certainly is a luxury that we cantt afford if
                23   we believe that the RMP philosophy is right, that the
                24   catalytic role of RMP has demonstrated a capacity to do good

                25
                     in areas, and if we would like in the time available to us    I


                                                                               136

                  1  and with the funds available to make  RMP  as  visible  as

                  2                                              hat it v
                     possible, build its credibility and hope t          ill
                  3  attract further funds and congressional and departmental

                  4  support, it seems to me that this is important, because what
                  5  has high visibility may be a very rudimentary program in

                  6
                     rural Mississippi and what has  value  in  Philadelphia  or

                  7
                     Boston or metropolitan Washington  may  be  something  very

                  8
                     different.

                  9
                                And I would think that committees would have a

                10
                     terribly hard time looking at 53  regions  and  coming  out

                     with hard and fist criteria of these sorts.

                12
                                It tends to suggest  to me  that there  may  be

                13   an awful lot ot'vheel-spinning  involved  in  this  simply in

                14
                     order to involve Council  in  a  relatively  nonmeaningful way.

                15
                                If we are officiating at the demise of a
                16   program, you go one way.  If we are struggling to save it,
                17
                     you go another.
                18              And  I believe that the RMP staff as I have

                19
                     observed them in my connection with the program want    RMP to

                20
                     survive and believe in it. I  have  been  on  enough  site
                21   visits with them and enough  Council  meetings  with  them to

                22   know that I think they want it to work.

                23              And with the limited number of dollars it seems

                24
                     to me that the only practical thing  in  this  short  time

                25
                     period is for the Council to  charge  staff  with  picking out,


                                                                               7

                 I  in the areas which appeal to me that you have listed--  I
                 2  mean EMS has high visibility,  AHEC support may have high
                 3  visibility. 'These kind of things.  And  with  the  money

                 4
                    you have got available and  geographic  distribution  the best
                 5  you can, try to put on a final  flare of fireworks,  if that's

                 6                              can't be spectacular  enoug
                    what it is,'and see i-f,you                           h with
                 7  it that Congress and the Department  and the Administration

                 8
                    will want to continue the program.
                 9              ltd be willing to consider putting faith in a

                10
                    staff that  we have been working with long enough.

                11
                                It's sort of like we have been saying  in the
                12  regions. You build a good core and  then  you  depend  on

                13
                    core to exercise its-judgment on how the available funds

                14
                    should be used.  We never redly lot them do that, but there
                15  is the opportunity to do that with this central core staff.
                16              DR. PAHL@.  Well, thank you.
                17              Ate there other expressions by Council?

                18
                                We will be breaking for lunch in a  moment.

                19
                                Dr. Schreiner?

                20
                                DR. SCHREINER@. I always feel guilty mentioning

                21
                    kidney and hope somebody else will.  But I notice it was

                22
                    left out.
                23              DR. PAHL@.  We had our coffee break.  (Laughter)
                24              DR. SCHREINER.@  I think if people are going to

                25
                    talk about  strengths of the program, even though that came


                                                                                138

                  I  in very much later than the  original  heart,  cancer,  stroke
                  2  routine, we have got a real  talking  point  in  focusing
                  3  against H. R. 1 where we are going  to  spend  $250  million

                  4  next year in implementation.

                  5              Where would this be if there  weren't  a  State-

                  6  wide program in Wisconsin, for example?  Where would this be      1

                  7  if there weren't a State-vide program in Arkansas?

                  8              And these were things that were set up   by RMP,

                  9  and I  haven't  ev.en,beard,them mentioned once, but they  are

                10
                     very, very  practical points.

                11
                                 And I think that ve,obviously  ought  to  continue
                12   during this year while we   are'intetdig  ating with a     9

                13
                     pay program--  There'ts no  danger we ate going  to  have

                14
                     to take over the cost of   the patient dare,  because  it  is

                15
                     already taken over.  We ought to work on methods for

                16
                     better distribution, better  techniques  for  coordination  of

                17
                     programs develop tertiary care  centers,  all  these  kind  of
                18
                     things.
                19               Because our focus is right there in a way that
                20
                     is going to interdigitate with the spending of big dollars.
                21               DR. PAHL*@ I thank you for  calling  my  attention
                22   to really a very major oversight, because in trying to
                23   keep all these points in mind I did fail to say that one of
                24   the key options is the kidney option,  It's right here in the

                25
                     paper,  so you will have to accept the  veracity  of  the


                                                                            139

                I   statement.
                2             DR. HABER.I You did mention it.

                3             MRS. MARSI.  You did.
                4             DR. PAHL.I it must have been in passing. Let me
                5   emphasize it most certainly here.
                6             Nov, if we might, since we have until 3 o'clock,
                                                    uld like to use this as
                7   entertain with you whether you vo
                                                     nsider some of these
                8   a point to break for lunch and co
                9   matters--  Let me tell you what we see to be at least two
               10   necessary items, or three necessary items, of business,
               11   all of which I hope are relatively short.
               12              one, our own proposed resolution to you, or some
               13   variation thereof, is necessary to give us that kind of
               14   administrative legality to continue on in the next two
               15   months.  This is apart from the development of these criteria
               16   and the application of the criteria.  But adjusting budget

               17
                    periods  and so forth.

               18
                               The second thing is there is a resolution we

               19
                    have to hand out to you deal n  with the construction
                                                  9
               20   funds which way back in the early morning were mentioned by
               21   Mr. Van Nostrand, and again for us to conduct the Government'
               22   business in an expeditious way over the next period until
               23   we meet.  We will have to take a few minutes and tell you
               24   what that is and ask you if you will approve the resolu-
               25   tion we are proposing or some variation thereof or else


                                                                              140

                 1  we are always going to be answering the telephone to the
                 2   Congress. But we have to get into  that.
                 3              The third thing is while most of you are still

                 4
                     here we would like to have a two-day meeting for November
                 5   set, although we may have to either adjust that one way or

                 6   the other depending on circumstances.

                 7              We believe it would be helpful, and if we
                 8   may just get that first point out of the way because  people
                 9   may have to leave as we go through the day, I believe
                10   there was a calendar provided to you and we'd like to have
                11   you look at the month of November.
                12              Staff has determined--  Is the 27th a holiday?

                13
                                MR. BAUM: Yes, Thanksgiving is the 27th  in  red.

                14
                                MRS* MORGAN:  The 22nd is Thanksgiving.

                15
                                DR. PAHL.I Does anyone know for the purpose of

                16
                     Government business what

                17
                                DR'. ROTH@.  It is Rosh Hashanah.  No, I'm sorry.
                18   I'm corrected.  That's September,?,7tli,,

                19
                20              MR. PETERSON.  According to the Esso calendar
                     the 22nd is Thanksgiving.

                21
                                DR. PAHL$I  What we'd like to have you do is look
                22   at the week of the 26th  the last week of November, and see
                23   if we can select a two-day period which is such that
                24   most of you tan attend, hopefully all of you but most of

                25
                     you can attend, and at which time we would not  only  review


                                                                              141

                     what had happened, of course, between now and then but look
                 2   at all of these longer-term questions and bring to you the

                 3
                     Departmehtls position, the Congressional position, and so

                 4
                     forth.

                 5                                                        ould be
                                The reason for that is by  that time  we  w
                 6   able to anticipate formal applications from each region

                 7
                     for the total fiscal 1974 funding and you would be
                 8   acting on those applications for the entire fiscal   year,
                 9   not this piecemeal trying to use the $6.9  million,  but

                10
                     if, for example, we are given $40, $45,   $50 million for fiscal',
                     1974, the request for the total fiscal  1974 picture from each

                12
                     region would be in an application which   had been reviewed by

                13
                     staff with recommendations to you and that would be part

                14
                     of the business of the Council,  together  with  these

                15
                     longer-term considerations.

                16
                                And there would  be staff papers for you and

                17
                     positions that we would hope to give you from the Cohgr6ssion@'I
                18
                     al and Administration point of view.
                19              DR. ROTH@*  Just a question.  Are the five of us

                20
                     whose terms expire still alive for this meeting?

                21
                                 DR. PAHL**  Youtre alive through November 30th,

                22
                     and it is our hope,  of course, with your personal interest
                23   and permission, that we will be permitted to extend all terms,
                24   and we are looking into the niceties of advisory committee

                25   regulations and requirements.


                                                                             142

                 1             But we would propose to the Department that it
                 2  is important for us to have the continuity of your  partici-
                 3  pation, so although the terms do expire November 30th,  that
                 4  meeting would be legal, and beyond that we have to get

                 5
                    special action from the Department.

                 6
                               We would always be trying to act with filling

                 7  some vacancies with people knowledgeable about RMP program

                 8
                    so we  could have as effec,tuve,'fuil complement of the Council
                 9  as possible.  That is a lot to be done in that period.

               10
                               DR. ROTH*@  Then I would propose Monday and  uesday,@

                    the 26th and 27th.

               12              MRS. MMS@.  Fine.

               13
                               DR. PAHL@. How does that fit with other  people's

               14
                    calendars?

               15
                               Fine.  All right.  The schedule then is for
               16   November 26 and 27, Monday and Tuesday, and, of course, we

               17
                    will be in a position I hope to be much more logical about

               18
                    the proceedings than perhaps today.

               19
                               Let us break for lunch, and if we could reconvene

               20
                    perhaps at 2 otclock
               21              MRS. MARS4.  letts make it before that.

               22
                               DR. PAHL@*  letts try to make it quarter of 2.

               23
                    If you have indigestion, it's a result of Council action.
               24   (Laughter)

               25
                               So letts try to make it back by quarter of 2 and


                                                                               143

                 1  hopefully discussion takes place so that we can get our
                 2  business out of the way along the lines we have been talking

                 3  about.

                 4
                               (whereupon, at l@.12 p.n., the luncheon recess

                 5
                    was taken.)

                 6

                 7

                 8

                 9

                10

                12

                13

                14

                15

                16

                17

                18

                19

                20

                21

                22

                23

                24

                25


                                                                           144

                 1                           AFTERNOON SESSRON
                 2                                                        1:50 P.M[

                 3             DR. PAHL:  Mrs. Mars" informs us that it's five

                 4  minutes past our lunch hour self-imposed limit.  So  with

                 5  that liberty that I have just taken, perhaps we can recon-

                 6  vene.  We have approximately an hour and ten minutes.

                 7             In thinking about how we may best utilize  our

                 8  time and also feeling that it's important before you take

                 9  your final actions that Dr. van Hoek have a few  minutes

               10   to present some matters which he believes you should

               11   consider before taking whatever actions you believe  are

               12   appropriate, I'd like to have Dr. van Hoek present his

               13   thoughts to you first.

               14              Then, following that, I think we should  deal

               15   in a businesslike way with at least the resolutions  that

               16   are in hand and then take up whatever additional  points you

               17   feel are necessary.

               18              So, with that, Bob, would you like to address the

               19
                    Council?

               20
                               DR. VAN HOEK:  I just wanted to briefly give you

               21
                    some thoughts based on my experience over the last several

               22   years, most recently being involved in both the

               23   reorganization task forces And some of the legislative issues

               24   that we have been faced with.    think they serve as a frame

               25   of reference for you to consider both in terms of looking at


                                                                              145

                 I  some of the options that might be considered and how RMP could'[

                 2  impact on those or implement those options As well as any

                 3  ideas that you might have for the future of the  program.

                 4             There Are several issues that we are currently

                 5  faced with.  As you know, RMP was only one of 12 programs

                 6  which were to be allowed to expire this fiscal year and which

                 7  received a one-year extension.  Furthermore, along with

                 8  that extension,' most if no
                                              t ill the health manpower

                 9  legislation which HEW currently administers is  scheduled

               10   to expire on June 30, 1974.

                               So what we are working on over the next several

               12   months in essence is the development of health legislation

               13   for virtually everything that we are doing in terms of

               14   health manpower and the delivery of health services

               15   aside from the financing programs, Medicare and Medicaid.

               16
                               Secondly, as Medicare continues to be expanded
  0            17
                    and Medicaid continues to be evaluated, there are the ques-

               18   tions of restructuring those programs, if not looking  at
               19   the various options of national health insurance.

               20
                               The reorganization is tied in with that, in that

               21
                    the basic concept behind the reorganization was in essence

               22   to bring together the various programs or functions  that

               23   are carried out in the health agencies which in many cases

               24   have been separated into separate programs because of the

               25   legislative base and the appropriations structure, and the


                                                                            146

                 1  reorganization was predicated specifically on the basis

                 2  of pulling together similar functions and leading probably,

                 3  undoubtedly, to significant revision of legislation and

                 4  appropriation structures over the next fiscal  year.

                 5             Now, walking you through a process  which we in

                 6  essence did in part of our reorganization work, if you

                 7  take a look at some of the functions which are  carried

                 8  out and you look at various programs, the question is asked:

                 9  What was the basis for that program functioning as a

               10   separate entity? And you then have two  issues,  two

               11   primary issues.

               12              One is program content.  In other words, should

               13   the Federal Government be carrying out this  program

               14   activity or are there significant gaps in which  the

               15   Federal Government should be involved?

               16              And then, secondly, if the Federal Government

               17   should be involved, what is the process by which that

               18
                    function or program should be carried out9

               19
                               So you are really facing two issues with RMP.
               20              Now, let me point out two separate things.   In

               21   the reorganization, on the flip chart here, I have
               22   diagrammed part of the health agency structure, with the

               23   Assistant Secretary for Health having an Office of Policy

               24   Analysis and Research. This was the office  that  Scott
               25   Fleming headed until he left In June, now headed by Dan Zwick.


                                                                              147

                               And then HRA in which RMP is located, as well

                 2  as the National Center for Health Services R &  D,  considered

                 3
                    to be the principal agency for carrying out  studies,  evalua-

                    tion, analyses, data collection, and supporting developmental

                 5  activities in the delivery of health services. It  is  the

                 6
                    principal R & D agency aside from  Biomedical Research, which

                 7
                    is NIH, and because of that responsibility it has the
                 8  primary resources to assist the Office of Policy  Analysis

                 9  and Research which has the responsibility for  the  Assistant

               10
                    Secretary and for the Secretary of carrying out analyses

               11
                    and the development of health policy in HEW.
               12              So that shows you the importance of  the  location

               13
                    of the RMP program, the RMP staff, as well  as other  activi-

               14
                    ties in HRA.

               15
                               Now, if you look at the blackboard, what  I  have

               16
                    done is just quickly sketched -- and this is just  in  essence

               17
                    a rough example of some of the program content, some

               18
                    examples of program content or functions which have  been

               19
                    identified both in looking at the organization of HRA  and

               20
                    other programs in the health agencies and also looking  at it
               21   from the standpoint of where those activities  are  currently

               22
                    carried out.

               23              Now, some of the priorities that  were  discussed
               24   this morning for RMP and which are considered  high  priority

               25
                    in the Department and in the country as a whole  are  listed


                                                                                148

                     there:

                 2
                                 Ouality assessment.

                 3
                                 Standard setting.

                 4               Health statistics.

                 5               Planning and resource allocation.

                 6               Ail of these fufictions@have been identified  as

                 7   key functions that need to be performed and   in which the

                 8   Federal Government has some part to play,  whether  just  by

                 9   subsidizing community activities or actually conducting

                10
                     some of these in a more direct fashion.

                                 I have not completed the second column,  but  if

                12   you take those functions And look at the way HSMHA and

                13
                     other agencies were operating and the way we were structured,

                14
                     virtually every one of the programs in  HSMHA,  for  instance,
                15   was carrying out that function in one form  or  another,  with

                16
                     very little coordination, very little joint planning or joint

                17
                     funding. And it was driving HEW,  the  communities  at  large,
                18   and the regional offices, who were trying to  link  some  of
                19   these resource and research activities with the service

                20
                     delivery program, to despair in terms of trying to find    out
                21   what was going on and *hat information was coming out of all

                22   these activities.

                23               And I can duplicate that for every one of those

                24   functions.

                25               In addition, you can also duplicate it in terms


                                                                              149

                    of legislation.

                 2
                               The question should be asked then in terms  of

                 3
                    column 3: What is currently on the books  which  provides

                    the legislative authority and the funds to carry out those

                 5  functions either in a primary responsibility and then,

                 6
                    similarly, secondary responsibilities?'

                 7
                               For instance, quality assessment.  The primary

                 8
                    implementation in the Nation is going to be,through PS
                 9  But there are a series of other activities related to PSROs

               10   which need to be carried out in terms of research and evalua-

                    tion of the effectiveness of PSRO, the development and

               12   evaluation of criteria, methods  the techniques of
               13   quality assessment, and so forth, which are based at  the
               14   moment primarily in HRA.

               15
                               But here again in terms of quality  assessment
               16   in PSRO you can identify more than five agencies which have

               17
                    in one way or another had some involvement in the early
               18   stages of the PSRO development.  And so on through.
               19
                               The question then can be raised:  Are there

               20
                    program functions or content which are not being met

               21
                    through any existing legislation or any existing programs

               22
                    which should be carried out?  And whether that is carried

               23   out in HRA or RMP is one question.

               24
                               Second, if there are gaps that need to be filled,
               25   is a program like RMP the most appropriate route to go?


                                                                               150
                 1              In other words, what is the content of the program?i  I
                 2  And then what is the process by which you implement it?  Is
                 3
                    there a need for the Federal  Government  to  subsidize

                 4
                    community organizations to carry out the functions that
                 5  have been carried out by RMP in the past or to carry out some

                 6
                    new function in the future?
                 7             My own reaction  in some cases has been that RMP

                 8
                    has been used more in addition to a number of the

                 9
                    standard functions -- has been used to a great extent in
                 10 those special initiatives.  That is, at some point in time
                 11
                    the model cities was a big initiative, so RMPs got

                 12
                    involved in model cities. Then there were  HMOs  two  years

                 13
                    ago, and EMS one year ago, and so forth.

                 14
                               And it relates to Paul Haber's question earlier

                 15
                    about the changing mission and priorities'that have

                 16
                    occurred over the period of time.

                 17
                               And I would like to throw out just  one  problem

                    that I have identified as the Director of  NCHSR&D  looking
                 19
                    both at quality assessment and the problems  of  health
                 20
                    services delivery.  And I think there is a major gap  that
                 21
                    is not being addressed by any of the health agencies  at the

                 22
                    present time.
                 23           And'thitt is methods for studying medical care
                 24 effectiveness.  And by that I mean medical care effectiveness
                 25 in the Archie Cochran-British sense of the word and In terms


                                                                              151

                   of evaluating the effectiveness of medical care in an

                2
                   actual practice setting rather'than,in  the  research  setting

                3
                   where many of the treatment modalities  are being  tested  and

                4
                   evaluated at the present time and again that would link

                5  logical,
                           y PSRO, Biomedical Research, and some  of  the  things

                6
                   fbr'which RMPs were originally established.

                7              So I just wanted to bring out some of those
                8  thoughts that have come up among the staff, and it's not

                9
                   just limited to RMP, but I think it's particularly pertinent

               10
                   to RMP since we are in process of looking at both what if

               11
                   should do this year and what the nature of the program might
               12  be in the future.

               13
                               DR. PAHL**  Ts there any discussion on the points?

               14
                   These are some of the broader considerations that I think

               15
                   are well to have in a way classified for us, because we

               16
                   will be dealing with them both in the immediate future

               1.7
                   but more importantly in the longer-term considerations.

               18
                               1 don't know whether you have comments now

               19
                   or over the course of the afternoon or--  Dr. Laur, do you

               20
                   have any comments?

               21
                               DR. LATJR:  No.

               22              DR. PAHL'*  Well, if not, I would again  thank  you

               23
                   and suggest that there are  two or three Items of business

               24
                   which perhaps we can address.

               25
                               And because one of them is brand new  and  doesn't


                 I  get into the resolutions from the coordinators and ourselves,
                 2  1 would like first to treat the construction authority

                 3  resolution, because it is an isolated point.
                 4             Ken, would you distribute our proposed resolution

                 5  to the Council?

                 6             And if you will bear with me whil,e  try to
                 7  just go through this very briefly  as Mr. Van Nostrand
                 8  indicated this morning, there has been through the legislative
                 9  process a sum of $17,million authorized for the construction

               10   of specified facilities.
               11              Although You don@t have to turn to your book,

               12   under the tab marked "Quotes" -- in which there is a summary
         @j
          7-   13   of excerpts from the legislative activities that have
               14   taken place on the next to the last page -- at the bottom
               15   there is a section which deals with the construction
               16   authority, and perhaps I should just read it to you.  This
               17         erpted from the Second Supplemental Appropriations
                    is exc

               18
                    Act, Public Law 93-50, July 1, 1973.

               19
                               "Health Services Planning and Development - For

               20
                    an additional amount for tHealth services planning and
               21   development', for carrying out, to the extent not otherwise
               22   provided, section 304 and title IX of the Public Health
               23   Service Act, $17,000,000, to remain available until expended."
               24              That mears that $17 million has been made available
               25   in no-year money, so it is not a question of whether the


                                                                              153

                 I  money will be spent or has to be spent in this  fiscal  year.

                 2  It is just a question of how effectively we can discharge

                 3  the obligation for funding the facilities which were further

                 4  identified as follows@.

                 5
                               In the Senate Report No. 93-160 and also  in  the

                 6  floor debate It was indicated that these funds are  for  the

                 7  following items:-

                 8             First, $12 million to permit completion of

                 9  the new Children's Hospital National Medical Center in Washing

               10   ton, D. C.

               11
                               Secondly, $4.5 million to meet the  initial  needs

               12   for a childrents medical center serving  the  Northwestern

               13
                    regions of the United States.

               14              And, thirdly, $500,000 to complete  a  hospital     I

               15   in northern Vermont, the North Country Hospital and

               16
                    Health Center at Newport, Vermont, by  providing  additional

               17
                    grants for hospital construction.
               18              Now, in the press of activities, I will  have  to

               19
                    admit that we have not been able to devote quite  as  much

               20
                    time to this particular part of the end-of-the-year
               21   legislative activities as we would have liked to,  and  there

               22   is some question at least in staff's mind as to  what  our

               23   authorized level of expenditure for construction  within  the

               24   Regional Medical Program Service can be, since  under  the

               25   authorizing legislation we are permitted to spend  in  one


                                                                              154

                                                                                a-
                 I  fiscal year no more than $5 million. Yet here in the legisl
                 2  tion we have a total of $17 million for these three facili-

                 3  ties.
                 4            This poses a kind of problem which T have not been
                 5  able to resolve prior to the Council meeting, and rather

                 6                                            ps try to
                    than face it directly T felt I would perha
                 7  come to you with a resolution which is an innocuous
                 8  one but will let us proceed once we are able to resolve the
                 9  legal issue, which perhaps is very simple but which is
               10   at least in my mind at this point a little confusing.

               11
                               The second matter Is that it Is quite clear

               12
                    that the funds have been given under section 304 And
               13   title TX, and two of the three facilities clearly are within
               14   the Regional Medical Program Service responsibility,
               15   and those are the North Country Hospital, Newport, Vermont

               16
                    and the Children's Orthopedic Hospital in Seattle, Washington.!

               17
                               What again is not clear, because several authori-

               18
                    ties have been cited in the legislation, is just which

               19
                    program element in the Health Resources Administration

               20
                    is responsible for building or assisting to build

               21
                    the Childrents Hospital in 'Washington, D. C.

               22
                               Consequently, in view of the somewhat uncertain
               23   state of affairs from this end of the table relative to
               24   this legislation, and hot having had the opportunity to

               25
                    obtain legal opinion on this, we have developed what I think


                                                                                  155

                  1  is an appropriate resolution for you to consider and
                  2  hopefully act upon favorably, which I would like to    read for
                  3  the record,  And if action is appropriate on it, it      would
                  4  permit us to conduct the business in accordance with
                  5  whatever is determined by counsel   of the Department  to be our
                  6  legal responsibilities and possibilities.
                  7              So the resolution that've have   provided  to  you

                  8  states:
                  9              "WHEREAS the Congress has appropriated $17 million,'!
                10   to be available  until  expended,  intended  for  construction
                11   of facilities identified as follows in the Congressional

                12   reports:
                13               "Childrens Hospital, Washington, D. C.
                14               "North Country Hospital, Newport,   Vermont
                15               ItChildrens Orthopedic Hospital,   Seattle,  Wash.
                16               I'and WHEREAS the construction of   such facilities
                17   would contribute to the  purposes  of  Title  IX  through  the

                18
                      strengthening of primary  care,  enhancing  the  quality  and
                      capacity of facilities, strengthening linkages between

                20
                      primary and specialized care,
                21                                                authorized the
                                  t'and WHEREAS the Congress has
                22    allocation of said funds under Title IX    and other authori-
                23    ties of the Public Health Service Act,
                24                "and WHEREAS the RMP legislation authorizes up
                25    to $5 million per year for new construction,


                                                                          156

                 1             "the National Advisory Council on Regional

                 2  Medical Programs, recognizing the clear intent of Congress
                 3  that construction of the above facilities be assisted,
                 4  delegates to the Director, Regional Medical Programs Service,
                 5  the authority to award funds up to the full legal limit under
                 6  Title IX for that construction determined to be appropriate"--

                 7             And I believe the wor             should be

                 8
                    included, Mr. Baum.

                 9             MR. BAUM.@  Yes.

               10              DR. PAHL@.  Following "appropriate," please insert

               11
                    the word "Provided."

               12
                               "1.  appropriate application is made therefor; and

               13
                               '2.  the applications, plans and specifications
               14   meet all HEW and local requirements applicable to the types
          u
         c@7   15   of facilities to be constructed.
               16              "The Council, further, strongly urges that funds t@

               17   be awarded for construction of said facilities shall be in

               18
                    addition to, and not part of, the total allocation for

               19
                    support of RMPs in Fiscal Year 1974."
               20              Again, the purpose of asking you to ta

               21
                    favorable action on this draft resolution is to provide
               22   to the staff the authority to proceed within the legal
               23   limits of expenditure for those facilities which are
               24   determined to be appropriate@for construction under RuMmPr

               25
                    authority as@qui@kly as possible rather  than to delay longer


                                                                              157

                    since it would not be in the best  interests of the communities

                 2
                    In some cases the construction  Already being underway and

                 3  the funds being no-year funds,  there is no need to delay

                 4  unnecessarily since the funds  in fact will be spent

                 5  as soon as all of the requirements can be met.

                 6
                               Now, I am sorry that I do not have  identified

                 7
                    for you, therefore, the exact funds that we will  spend  this

                 8  year, since it's up to legal determination, and I do not

                 9  have the knowledge at this point as to whether the RMP

                10
                    program is responsible for Childrenvs  Hospital,  Washington,
                11  D. C., and  of course, we will discharge whatever the
                12  Department determines to be our responsibility in accordance
                13  with congressional intent.

                14
                               MRS. MARS4. I move we accept the resolution-,  Mr.

                15
                    Chairman.

                16
                               MRS. MORGAN:  Second.

                17
                               DR. SCHREINER:  Question.
                18             DR. PAHL.I  It has been moved and seconded to
                19  accept the resolution.  Dr. Schreiner?
                20                           i
                               M. SCHREINER.  I don't know whether it's in order
                21  but I would like to propose that a slight amendment be

                22
                    made -- that is, that the word                     e  removed
                23  and that the word "agrees" be substituted.

                24             MRS. MARS'.  Where?

                25
                               DR. SCHR91NER:  Last paragraph.


                                                                            158

                               MR. MILLIKEN:  Second.

                 2             DR. ROTH@.  Is there Any possible relationship
                 3  or parallelism between this and the $15 million of our

                 4  money they stole for HMOs?

                 5             DR. PAHL:  There is construction authority in

                 6
                    the authorizing legislation for RMP, $5 million per year.

                 7  This has been exercised I believe only once, and that had

                 8
                    to do with the Seattle

                 9             MRS. MARS.'  The Hutchinson

               10
                               DR. PAHL.I  The Fred Hutchinson Cancer Center.

                               So, to answer your question directly, I believe
               12   there is only the palest of coincidences which may appear on

               13
                    the surface.  This is a perfectly appropriate expenditure

               14
                    at least up to the $5 million for projects.

               15
                               The identification of these projects, of course,

               16
                    came through the legislative process.  So it is not quite
               17   in the sense of having an open competition for these
               18   funds.  And the question, therefore, is not making
               19
                    these available for competition but to assist in the con-

               20
                    truction of these specific facilities.

               21
                               I don@t believe there is any relationship between
               22   the HMO funding of last year and these specific requirements.
               23              DR. VAN HOEK4.  There was an attempt to put the
               24   $12 million in the 304 authority last year and it fell out

               25
                    because of continuing resolution-appropriation problems, but


                                                                                159
                  I  they did submit an application for funding as a research
                  2  facility and that application was disapproved.
                  3              MRS. MARS*@  I accept Dr. Schreinerts amendment.
                  4              DR. PAHL@O  The proposed amendment to the
                  5  resolution, which has been moved for approval and seconded,
                  6  is that the phrase "strongly urges" in the last paragraph be
                  7  replaced by the --
                  8                       6  The word "agrees."
                                 MRS. MARSI
                  9              DR. PAHL@. -- word "agrees."  Is there further

                10
                     discussion  on this by the Council?
                11                                                Ah
                                 MR. MILLIKEN4.  Question.

                12
                                 DR. PAHL@. If not, all in favor of the amended
                13          ion  please say " aye.
                     resolut

                14
                                 (Chorus of "ayes.

                15
                                 Opposed?

                16
                                 (NO response.)

                17
                                 It is so ordered.
                                 By the way, we, of course,  will inform you at an
                19
                     appropriate time what the resolution   of these legal issues
                20
                     is and what funding is proposed from   the Regional Medidal
                21
                     Programs.

                22
                                 I would like to turn now to the resolution

                23
                     vhich,we proposed for your consideration, and without
                24   attempting to in any way lessen or bypass the resolution
                25
                     introduced by Dr. Teschan for the coordinators, I would like


                                                                             160

                 1  to treat this particular resolution  separately,  because
                 2  it does something a little different and it's more limited.
                 3             And since we have had a chance to look  at  it
                 4  again, let me say very clearly that the intent is to both
                 5  approve A. limited set of administrative actions taken  by
                 6  us, limited to the adjustment of budget periods, the
                 7  proration, the forward proration, of funding levels   and
                 8  of Council-approved levels for regions, as  actions  which
                 9  we had to take in order to accommodate the intent  of  the
               10   Congress and the intent of the Administration  until  such
               11   time as we could have a Council meeting,  and,  secondly, to

               12   delegate to us in this limited fashion     that is,

               13
                    adjustment of budget periods and funding  level and Council-
               14   approved level on a proration basis  --  so that we  merely
               15   prorate those levels over  whatever  period of time is

               16
                    necessary and whatever sums  are  necessary in the near :future
               17   as necessary until again as a Council we can meet to look

               18                                 and Act on them in the way in
                    at applications from regions

               19
                    which we are accustomed.

               20              And at this time that would appear to be the two-
               21   day meeting in November, although if that proves to be
               22   unnecessarily far in the future with respect to how things
               23   go, we may have to be in touch with you and see if we can

               24   construct an earlier Council meeting.
               25              We are still trying our best to predict how events


                                                                                 161

                 1  will f low.

                 2             Mr. Milliken.

                 3             MR. MILLIKEN*@ Are you  ready@for a question?  Go

                 4  ahead if youtre not@.

                 5             DR. PAHL:-  Yes, but I think I will have to read

                 6  this into the record so we make sure it  is there, with your

                 7  permission.

                 8             MRS. MARS@.  May I just ask  are you saying that

                 9  unless we pass such a resolution your hands are more or

                 10 less tied?  Is that the

                 11            DR. PAHL*#  Yes, itts staff's best impression

                 12 that we Are skirting Administrative flexibility here.  We

                 13 know we have a Presidential extension of a bill.  We know   the

                 14 Council must approve the awarding of grant funds.  And

                 15 we are not quite certain about our schedule of Council

                 16
                    meetings and what actually will be necessary until

                 17
                    we meet again.

                 18
                               So we are asking you to give us that authority
                 19 of the kind we have already exercised in this limited

                 20
                    wa  to permit us to conduct the business until such time
                     y

                 21
                    as we have applications and a bona fide review and recommended'

                 22 tions from the Council in terms of new applications.

                 23            DR. MERRILL@.  Doesn't approval of this resolution

                 24 mean we are in essence approving the-quartetly funding

                 25 principle as outlined in your telegram?


                                                                           162
                1              DP,. PAHLI.  No, it really isn't related to the

                2   quarterly funding as such.
                3              1 think what we are basically saying is that
                4   the quarterly funding  which is a departmental--  By the way,
                5   ltd like to strike that.  That carries an implication which

                6   1 think is not really true.
                               All regions are now guaranteed viabil t  i@@h
                         irst quarter, but I believe the Department's clear
                    intent is not to fund the program on a quarterly basis.
                                    ion merely lets us, depending upon the

                                                           flay Deco

               12   available before we meet again, move ahead to both adjust
               13   Council-approved levels and funding levels in order to
               14   expend funds in the way in which we mentioned before we
               15   may have a full Council meeting and full applications from

               1 6
                    the regions.

               17              The problem really has to do with the  fact

               18
                    that regions don't have applications waiting on  their

               19
                    desks to send to us because we yet don't know what  to tell

               20
                    them to construct in the way of program areas and  the

               21
                    criteria that I have mentioned.

               22              And yet we may have a continuation of fisca
               23   1974 continuing resolution funds made available to  us which,
               24   if we have this authority, we can help regions move ahead
               25   functionally without actually having a Council meeting and


                                                                                163
                 I   incomplete a                      and we can't see having
                                pplications for you

                 2
                     real applications much before perhaps October for staff

                 3
                     review and analysis to present to you in November.

                 4
                                So this is not really in any way to be   interpreted
                 5   or related to a quarterly funding principle.  The   staff
                 6   did not construct it that way.  It isn't viewed that

                 7
                     way, and it won't be implemented that way.  And we could

                 8
                     reconstruct it in some fashion if that is the interpretation.

                 9   But they are separate issues.

                10
                                DR. MERRILLI.  I think this statement that you have   1
                     just made, read into the record, will solve the problem.

                12              DR. PAHLio  Okay.

                13
                                DR. SCHREINER@.  But, Herb  as a matter of fact,

                14
                     no RMP that has a vacancy  for a coordinator can hire a man

                15
                     on a year's contract even  though they have congressional

                16
                     authority to do that.

                17
                                DR. PAHLI.  The technicalities are complicated.       i

                18
                     What we have said to  the Department is that we  will  guarantee!,

                19
                     the viability of the  regions through the first quarter,

                20
                     and by viability I have indicated to Dr. Laur and Dr.

                2 1
                     van Hoek he must accept our professional judgment as    to
                22   what viability means, and if there is not now a coordinator
                23   present, then a region 'Without a coordinator still as of
                24   September 3pth would not be considered viable from a
                25   prudent managers point of view.


                                                                               164

                               And so actually although there is  still  the

                 2
                    schizophrenia and the technical complications,  in  fact as a

                 3
                    staff we are negotiating with regions to  have  them  hire

                 4
                    staff, to retain their current staff,  and  the  necessary

                 5
                    supporting staff and space and equipment.
                 6             So that if it is the desire of  the  region  to

                 7
                    hire a coordinator, from our point of view that constitutes
                 8  a reasonable definition of viability to permit that.
                 9             The question more is whether you can hire   a man
                    on the basis of the kind of telegram language that
                    we have had to send out.  So it's not that we are restricting
               12   the region by not allowing them to hire people.  It is that
               13   the communications which have gone out dontt make it very

               14
                    reasonable for responsible people to want to take on this

               15
                    until there is some greater sense of stabilization from

               16
                    Washington.

               17
                                And, of course, we are very hopeful very quickly

               18
                    of giving that stabilization. And  such  things  as  the
               19   resolution that we are considering here  would  help  us
               20
                    implement such a situation.
               21               DR. SCHREINERI.  We're not trying to give you a

               22
                    hard time,  because we really appreciate
               23               DR. PAHLO@  I know you do.

               24
                                DR. SCHREINER@. -- your  situation.  Oh  the
               25   other hand, I would have great  difficulty,  because  if I *ere


                                                                            165

                 I  on record voting for that, someone could pick up that paper
                 2  and say, "What are you beefing about?  You okayed it."
                 3             And it seems to me that it would strengthen your

                 4
                    hand maybe if we got specific, if we feel strongly enough,
                 5  or at least I would feel if I felt strongly enough on that

                 6
                    point, to make that as a specific exception, so that there

                 7  is a clear record.

                 8             But I'm afraid that, you know, when this

                 9  gets translated in the newspapers it's going to mean t  a
               10   the Council is all in favor of this.

               11
                               DR. PAHL@.  Well, I think we could certainly

               12   and we would be certainly pleased to have incorporated into
               13   this document or into another resolution the clear sense of

               14
                    the Council that it does not endorse any principle  other

               15
                    than full year funding.

               16
                               Perhaps, Bob, you might like to  comment.  I'm

               17
                    not sure, because it is a lot of material I have presented

               18
                    on a complicated topic--  Perhaps it would be--  If you had
               19   a point to make
               20
                               MR. CHAM13LISS:  We do feel, Dr. Schreiner, that

               21
                    this resolution will keep the RMPs alive until such  time

               22   as

               23              DR. SCHREINERI*  I understand.

               24              MR. CRAMBLISS@.  -- there is adequate release of
               25   the constraints of the telegram and adequate release of


                                                                              166

                     f unds.

                 2
                                To answer specifically Mrs. Mars'  question,  I

                 3
                     would say, yes, this does tie out hands unless we  do  have

                 4
                     this kind of authority.
                 5              DR. SCHREINIM.'  We appreciate all that.
                 6              DR. PAHL@.  It's the quarterly funding --

                 7
                                DR. SCHREINER'.  How many unfilled positions for
                 8   permanent coordinators  are  there?  Seven?

                 9
                                MR. CHAMBLISS4. We have no  unfilled  positions.

                10
                     We do have, as I reported earlier, ten acting coordinators.

                11
                     Three of those have been acting for in extend6d  period  of
                12   time, which has been brought to your attention prior to

                13
                     today.  There are seven new acting coordinators.

                14
                                DR. SCIMBINER: Has any one of  those  signed  a

                15
                     year"s contrast?
                1 6
                17              MR. CHAMBLISSI.  Fortunately, they come from the
                   I professional staff in the main, and that problem  has  not
                18
                   i been a very acute one. They are members of  the  staff  who
                1 91
                     have been promoted to the coordinator     the acting
                20
                     coordinator    slots.

                2 1
                                MRS. MARS: Why don't you just Add  a  few  words
                22   in here in this last paragraph as you'd like it.

                23
                                DR. SCHREINER@.  Thatts what I think would
                24   strengthen you.
                25
                                DR. PAHL:  Yes,  we would appreciate having that


                                                                            167

                    made explicit, because it is the intent to divorce this

                 2  from any support of a quarterly funding principle.

                 3             MRS. MARS@*  The only thing I don't like about

                 4  it is this part here where it says "endorses the specified
                 5  administrative actions taken to date."  We never had a chance

                 6  to endorse them.  We were simply told what was going to

                 7  happen.

                 8             So we have to accept what has been done, so

                 9  there is no question about that.

                10             MR. CHAMBLISS.@  Well, it can be an ehdorsemen

                11
                    with retroactivity, Mrs. Mars.

                12
                               DR. PAHL:  The position is a difficult one

                               MRS. MARS@6  I know you can, but

                14
                               DR. PAHL: -- that we have placed  you  in.  And

                15  what we basically are asking is endorsement with understand-
                16  ing of the constraints, and, of course, thatts been  clear
                17  all morning.

                18
                               Put the other way, if you do not endorse  these

                19
                    actions, since it is a matter of history one cantt undo

                20
                    the actions, and T prefer to adopt the point of view 1

                21
                    think that Dr. Teschan tried to convey to us, and that is if

                22
                    we can kind of close a door on the past, because it

                23  has been difficult on all parties concerned, and move

                24  ahead--  And we feel this would help clear the way both
                25  psychologically as well as in any legal and program  sense


                                                                           168
                    that would give us a better basis for moving ahead.
                 2             But it is placing the Council in a most awkward

                 3  position.
                4t             DR. MERRILL:  Could one amend this paragraph (4),
             tl  5
              m,'W  article (4), so that it reads at the end of the second line
                          the clear un    -uancing that funding of programs be

                    undertaken on an annual basis"

                                                 suredly, yes.

                 9             Would the Council accept that amended version?

                1 0 That would be most supportive of our position.

                               MRS. MARS.@  And with a cleat understanding,

                1 2
                    Dr. Merrill, that

                               DR. MERRILL@.  That the programs be funded on an

                    annual basis.
                14

                15             DR. ROTH@4  I second that.

                16             DR. PAHL@.  The-suggestion has been.made and
                17  seconded to amend the section (4) of the draft resolution
                18  with the words added "with the clear understanding that
                19  programs be funded on an annual basis," that phrase being
                20  inserted at the end of the second line.

                2 1
                               DR. MERRILLI* @And in place of the third line.

                22             DR. PAHL@.  Yes, and elimination of the third  ine.

                23             MR. 13AUM:  Herb, do you want to read the whole

                ?@4 thing into the record?

                25             DR. PAHLI.  All right.  Let me ask you, Dr.


                                                                          169

                    Merrill, to insert your exact wording, but let me read the
                 2  entire first part so we have it for the record, if I might.
                 3  I think it's an important resolution.

                 4            This would be Council resolution endorsing
                 5  adjusted bud et periods and approved support levels for RMPs
                               9
                 6  and delegating to the Director, RMPS, limited authority for
                 7  making similar future adjustments.
                 8             ti(l)  WHEREAS@.  the President in his budget
                 9  message to the Congress of January 29, 1973, did not request
               10   any further support for RMPs for 1974, thus necessitating
                    that a planned phasing out of both the RMPS and the RMPs be

               12
                             d for the orderly termination of the program, and
                    institute
                               11(2)  WHEREAS:  in implementing this phaseout

               14
                    process the RMPS found it necessary to adjust selectively
               15   the budget periods of the RMPs and to prorate both their
                    funding and Council-approved ceiling support levels, and
               17
                               "(3)  WHEREAS.@  on June 18, 1973, in accordance

               18
                    with the strongly expressed intent of the Congress, the
               19
                    President extended the program for one year, then" --
               20
                               Section 4.  And now, Dr. Merrill, may we have your

               21
                             section?
               22              DR-.  ERRILL-  "(4)  BE IT RESOLVED that t
               23   National Advisory Council accepts And endorses the
               24   specified administrative actions taken to date and, with
               25
                     he clear understanding that the programs would be


                                                                            170

                    on an annual basis, delegates to the Director, RMPS," etc.
                               DR. PAHL*  All tight.         delegates to the
                    Director, RMPS, authority to act in similar fashion
                    as he deems necessary until such time as the Council can
                    review applications from RMPs and determine new support
                    levels for the individual regions."

                               MRS. MARS:  That's good.

                               DR. PAHL@.  It has been moved and seconded to
                    accept this amended resolution.  Is there further discussion

                               MRS. MARS:  Question.
                               DR. PAHL4.  If not, all in favor please say itaye.11

                1.2
                               (Chorus of "ayes.")

                               Opposed?

                14
                               (No response.)

                15             It is so moved.

                16
                17             Nov, the third matter is one that is on the
                    broader issue and involves I believe the Councilts

                18
                    recommendations -- to accept the resolution or the statement

                19
                    which has been prepared by the Steering Committee for

                20
                    consideration by the Council or to amend It in any way it
                21  deems advisable or to take any other such actions as you
                22  feel is appropriate under the circumstances.
                23             And may I remind you that before we broke for
                24  lunch there was a suggestion made which perhaps could

                25
                    either be included in a formal resolution or perhaps discusse@


                                                                            171

                    a little further by the Council, so that there is no mis-
                    understanding as to whether staff will have delegated to it
                 3  the authority by the Council for the development of
                 4  criteria and the use of these criteria to award funds
                 5  either from the fiscal 1973 balance or from fiscal 1974
                 6  continuing resolution funds for the support of specific
                 7  regional activities in accordance with whatever program areas
                 8  are designated by the Secretary for this fiscal year,

                 9
                               MRS. MARS:  How important is it that cancer,
                '10 stroke and heart be brought into -- and kidney -- be brought

                    into this criteria?

                1,2
                               DR. PAHL.@  How important?

                               Let me remove the first non obstacle.  The

                14
                    kidney is involved.  This is a very clearly specified
                15  program area which we have every reason to believe will be
                i(iIsympathetically viewed by the Secretary.
                t7
                               There is a hypertension control program option

                18
                    specifically proposed.

                19
                               There is nothing specifically in the cancer or

                20
                    stroke categories, although these could be appropriately

                21
                    included and would be appropriately included in such things
                22  as the quality of medical care and the manpower development
                23  and utilization categories.

                24
                               MRS. MARS:  Because I'm sure you will recall the

                25  directive that was given to us that we must turn back towards


                                                                             172

                 1  more emphasis on heart, stroke and cancer, and I'm
                 2  wondering whether this viould influence Congress at all  in
                 3  their thinking and perhaps in furthering and continuing

                 4  the Regional Medical Program if such emphasis were directed

                 5  at this time.
                 6             DR. PABL@. Well, this might be a point  of  view

                 7  which the Council may wish to include in a statement
                 8  which could be forwarded to the Department and may  have  a

                 9  bearing.  I'm afraid the state of affairs

                10             MRS. MARS.@  Do you know what the thinking of

                11  the Department is in this?

                12             DR. PAHL.'  Well, at the moment I think we

                i,3 feel as staff that we could accommodate all of these

                14  activities within the broad options that I  have  identified

                '15 for you, although the cancer field is hot singled  out,  nor
                16  is stroke, as a separate area of  activity.  At-this  point

                17  the opportunity for further input into the Setretaryts

                18  office is limited because of the time that we  are  working.

                19             So the only thing that could be done is  to  have

                20  an expression of the Councilts interest and to  the  extent
                21  possible have this expression of interest implemented within

                22  the options selected by the Secretary and with the

                23  Secretary's approval.

                ?@4            MRS. MARS4.  I was solely thinking of how this

                25  would influence Congress when this came up next year for


                                                                               173
                   Irefunding possibly or for reconsideration of continuation of
                 2
                     the  program.
                 3             DR. PAHL;.  I honestly dontt know, because

                 4
                     there are the two points of view that the  Regional  Medical

                 5
                     Programs has in fact done well by broadening beyond the
                 6
                     initial categorical disease orientation. At  the  same  time

                 7
                     there is a very real interest on the part of individuals and

                 8
                     groups to emphasize these areas and less some of  the  other
                 9
                     developments which have occurred in recent years.

                10
                                 And I'm not sure I can really speak for how

                            s would really view this, because it's too many
                     Congres
                     people speaking for Congress and I don't have that sense.
                                 MRS. MARS; From whence came the  directive  that

                14
                     we were given by Dr. Stone, if it wasntt Congress, so to
                15
                     speak, or was it Dr. Wilson?  Where did that
                16
                17   come from?  We were given a very strong directive.
                                 DR. PAHL:  Off the record, please.

                18
                                 (Discussion off the reco d.
                19
                                 DR. PAHL@6  On the record.

                20
                                 DII. VAN HOEK4.  I think itts fair to point out

                21
                     that the options that we have discussed and presented to

                22
                     Dr. Edwards and presumably are going to the Secretary,

                23
                     although they speak of hypertension and renal disease, are
                 4
                     very specific, targeted activities.
                25

                                 The renal disease option is Specifically


                                                                              174

                    geared to RMN assisting in the implementation of the

                                                      der Medicare of
                    H. R. I provisions, the support un
                 3  renal dialysis and transplantation, and hypertension area
                 4  is specifically targeted not to a broad national program
                 5  of hypertension And hypertension centers but to supplement
                 6  the National Heart Institute's program in consumer education,
                 7  professional education and screening and to assist in
                 8  organizing community resources to do  hypertension  screening

                 9  and treatment.

                10             DR. PAEL@  On balance, and being subject to review

                11
                    of the transcri t, I would have to say it Is my best
                                   p

                12  impression that'-the Departmentts posture at this moment
                13  @is to include in this yearts activities, and as a strong
                14  consideration for any continued program,  certainly  emphasis

                15  on those categorical disease areas which were the
                    initial development of the program in the legislation, but
                .17 not by any means to restrict the programs,  Regional  Medical
                18  Programs, or the mission, to those activities, but,  rather,,
                19  to have them a part of broader areas of activity such as
                20  we have been following over the past perhaps two  years  now.
                21             And yet I dontt think I tan honestly say what the

                22  Department's final position will be.
                23             We will certainly take into account administrative-
                @-4 ly and also bring to the attention of others whatever the
                25  Councills position on this might be.  Because this is adv ce.

                    I


                                                                            175

                    It is a transition year.  And certainly it does bear on
                 2  vhat the Department and the Congress may think the future

                 3  of this program could be.
                 4            So not only now but as we go into other Council
                 5  meetings and through the year I believe these points of view
                 6  should be discussed and positions or recommendations made.
                 7            DR. McPHEDRAN.i  Dr. Pahl, I just wanted to ask
                 8  something about these things that Dr. van -,oek pu  up on
                 9  the board.  I'm really asking is it thought that a Federal
                10  agency in order to be viable should undertake one or so of
                    these functions?  I mean in the reorganization plan?
                               And my further ques ion is@.  Isn't it likely that
                    there are going to be some kinds of activities that will

                14  have to include all of those?
                15             For example, any intelligent medical care plan
                i(@ would have to include everything on that side (indicating).
                17  So that a Regional Medical Program would have to do a
                18  of those things really in order to be a Regional Medical

                19
                    Program.  And would not they have to have an agency here

                20
                    and again I don't know about that -- but an agency from whom
                21  they would get direction in this and who would be their

                22  resource here?
                23             1 mean is it conceivable that a regional agency
                24  that was designed to foster cooperative arrangements between
                25  local health agencies and voluntary cooperative physicians,

                  I                                                               I


                                                                            176

                    and so forth-r-  Would not that agency have to have

                 2  some kind of single central agency like RMPS?

                 3             I mean if you didn't call it RMPS, wouldn't you

                 4  have to have that by another name in order to make  the

                 5  concept of an RMP dealing with all of those things on a
                 6  regional level--  Wouldn't you have to have it?  Or could
                 7  you call it something elOe?  Or what -- just in your thinking
                 8  about reorganization?

                 9             1 don't think that anybody here    maybe I haven't

                10  understood it    but I don't think anybody here has quarreled

                    seriously with the idea that there is a place for  some
                12  kind of regional    maybe State would be bettor -- but we

                    have all in the past said that maybe the State health agencies

                1 4
                    never could do it properly and that was the reason  for
                15  starting Regional Medical Programs in the first place --
                16  but that there was real reason for them to get together
                17  to help coordinate these activities.
                @18            And I don't see how those regional  agencies

                1 9
                    could ever be expected to do it unless they had

                20
                    some central Federal agency like RMPS to deal with.

                2 1
                               1 dofilt really pretend to understand these
                22  things very well, but if you would explain t at to me
                23  lfd like to know what your thoughts are.

                24             DR. VAN HOEK@*  Well, under previous health agency
                25  organizations, and particularly under the current proposed


                                                                            177
                 1  ones, you can identify a primary responsible agency or
                 2  organization which deals with each one of those functions.
                 3  They may be doing that effectively or not, to varying

                 4  degrees.  And they may have varying degrees of

                 5  Federal funds to carry out that activity.

                 6             What you're really asking is how at the

                 7  community level do you integrate the technical resources

                 8  that come from both Federal agencies and from local

                 9  agencies and how do you integrate the resources in
                10  the community to do an effective Job of planning and
                11  operating a delivery system?
                12             And the question can be asked@*  What is that

                13  process in the regions?  Is that a Regional Medical Program?

                14  Is that a State health authority?  Is it, you know, just

                @15 in essence the laissez faire economic market system?
                16             And I think that is one of the problems we
                17  are facing right now, why RMP is being looked at, why
                18  other legislation is being examined so closely, in that it
                19  really deals with a political and social issue in which 1
                20  don't think, you know, there is a clear direction for the
                21  country as a whole or even at the community level for any

                22  particular community.

                23             In some areas they are moving toward, you know,

                24  State authorities, and so forth, but they are primarily

                25  focusing on cost control through certificate of need


                                                                          178

                    legislation and rate-setting rather than the overall
                2   integration of health services and resources.

                3
                              DR. McPHEDRAN@.  Well "Ml am persuaded by Dr
                4   Merrill and Dr. Roth that we ought to have, rather than the
                5   statement suggested by the coordinators, a statement from
                6  this Council that would give at least some new ideas of ours
                7   abou"bp fungtion of Regional Medical Pr@rams
                8              And I also don't think that I can imagine how--
                9   At least I couldntt write one in ten minutes.  I don't
               10   think I could write one in ten hours probably.  But I
               11   wanted to have a chance to think about this.  And I
               12   guess I want to clear up in,my own mind some of these
               13   questions about this particular point.
               14              You see, I really think that the idea of the
               15   Regional Medical Programs, at least where they vote well
               16   functioning, the few I could think of -- I could name them
               17   but I won't -- I think the really good ones took

               18
                    into consideration many of those different things.
               19              And had they had to deal with that many, as many
               20   functions as they worked on, had they had to deal with that
               21   many separate agencies here, you know, to get support
               22   funds or to get advice, or so forth, I think that they would
               23   have been less effective than they were, much loss effective

               24   I suspect.
               25              And so that I think that having a Regional Medical


                                                                              179

                 I  Program Service that was really well done, as we  have
                 2  said today -- we weren't just kidding about that,-
                 3  it was well run on the whole; they got good staff support  --

                 4  then I think this enabled them to do a great deal of
                 5  what they did or it facilitated that a lot.
                 6            @@What it would have been like without that I

                 7  don't know.  Goodness knows.

                 8             But I think that just as in proper  medical
                 9  care you have to take all those things in consideration --
                10  I mean if youtre any good at all you do all of them or many
                11  of them -- so would you in the Regional Medical Programs
                12  where you are trying to foster voluntary  arrangements
                13  between the doctors and hospitals and nursing homes.  I

                14
                    think all those things would have to be--  And the medical
                15  schools, goodness knows. All those things  would  have
                16  to be taken into consideration.
                17             So that I don't think that from what I know  about
                18  State health authorities--  I dontt think that without

                19
                    being completely done over they could manage that,
                20             But I think in the places where it was well

                21
                    done that the Regional Medical Programs at least did

                22  that part, and they were the only agencies, it seems to me,

                23  that did it.  And that's why my special plea is for them.

                24             Now, I know that didn't work out everywhere, but

                25  that certainly is the way I feel about it. I think  that  the
                  I


                                                                            180

                1    mechanism ought to be preserved for that region and the

                2    hull should be cleaned in places where itts needed, or
                3    scrapped if necessary in some places perhaps.

                4               DR. PAHL@. Thank you, Dr. McPhedran.  I  think

                5    that is a very eloquent statement about what the
                6    Regional Medical Programs and Program Service has been all
                7    about, and I don't think certainly we could have  phrased

                8    it as well.

                9               Is there discussion?

                10              Time is moving along, and I know your schedules

                11   won't permit you to stay much longer, so we would
                12   appreciate having whatever kind of thoughts you feel  are
                13   important.

                14              Dr. Schreiner.

                15
                                DR. SCHREINER:  Yes.  I think it's very
                16   important when representing this program to the
                17   Secretary's office that you point out that duplication per
                18   se is not necessarily immoral or unethical or evil if there
                19   is an appropriate rearrangement.
                20              Now, you know, everything is fine if you're
                21   going into a pure State situation.  But where you go to
                22   the four corners of Utah or 16 counties around Syracuse,,
                23   and so forth,--  And a lot of this program's slow start
                24   came because it took us a couple of years sometimes to
                25   accumulate the statistics.  Not that they verentt duplicative,
                   I


                                                                             181

                    you know.  They are there in Utah.  They are there in
                2   Arizona.  They are there in the New Mexico Health Department.
                3   They are there in the Bureau of Indian Affairs.  But nobody
   is           4   is going to put them together for that natural
                5   region except a local entity which looks at it through those

                6   eyes.
                7              So what is really important is not what is going

                8   on with rural New York State or urban New York  State  but

                9   for those 16 counties what is important is  that  somebody
                10  pull together those "duplicate" statistics  and  rearrange them

                11  in a way that makes some regional sense.
                12             And this is really what RMP is about.  And what

                13  'makes it difficult to express is because you can sit back
                14  and look at any one of those yellow sheets we used to have
                15  and say, "Oh, yes, this piece is there, and this piece
                16  is there, and this piece is there," you  know.  There  are
                17  the eggs, but there's no omelet unless somebody puts it
                18  together.
                19             DR. PAHL.I  Well, thank you.  We perhaps will be
                20  calling on you more and more to help us express this in ways
                21  which will be meaningful to the Administration and the

                22  Congress.
                23             Before we move along too much further, is

                24  there a consensus by the Council relative to our rather
                25  limited field of view at the moment that in the development


                                                                            182

                 1  of criteria, which is a departmental requirement, that  you

                 2  delegate to the staff -- and, of course, we will keep you

                 3  fully informed -- the development and application of

                 4  these and the authority to award funds on the basis of

                 5  staff review of applications which meet these requirements,

                 6  at least until such time as full applications from  regions

                 7  can be bro   t to you for review and action?

                 8             Now, please understand we are not  requesting

                 9  this authority of you.  This was my understanding of

               10   Dr. Roth's statement as to how perhaps we could move

               11   ahead.  But I would caution you to understand at this

               12   point that if criteria are developed we would do so in

               13   conjunction with coordinators and individuals who are  very

               14   familiar with the program areas under consideration  and
               15   perhaps would be bringing these at least to your  attention

               16   for comment before sending them out to the regions,

               17   because it is a very important step that would be taken.

               18              Because the criteria that would be developed and

               19   employed would govern not only the utilization of the
               20   $6.9 million from 1973 but would be the same kinds of
               21   criteria which would have to govern the use of  whate@er
               22   spendin@ amount is allowed us !or the entire FY 1974, which
               23   could be five, six, seven times that $6.9 million,
                                                                         mm
               24   depending on what spending plan is approved by the Department.
               25              So we would feel comfortable at least in contacting
                  I


                                                                             183

                    those members who would have most interest and

                2   ability to comment upon the specific criteria selected
                3   even if we didntt formally call you together  because  we
                                                                 9

                4   do not intend to try to have long hiatuses of no information

                5   and then spend most of the day trying to catch you up  on

                6   matters.

                7              But I do want to understand what your  feeling

                8   is as to whether we are to proceed with your delegation

                9   of authority to make awards and inform you of our

               10   actions or whether you wish to at least at the time  that

               11
                    applications of specific projects may have to be reviewed,
               12   approved and funded by staff that you would  like to be
               13   in on this specific activity in the form of  subcommittees as

               14   we had announced earlL3ier-

               15
                               Itts a very important point for staff
               16   because we dontt want to get back into the ptocess'whe'rel,".@ve
               17   are through expediency bypassing you without, of  course,
               18   your full knowledge and endorsement to be bypassed.
               19              MRS. MARS@.  I think we should certainly permit

               20   staff to make the awards as necessary.  Certainly it's

               21
                    our vote of confidence in you, and surely your knowledge is
               22   such that it would be far greater than ours could possibly

               23   be.

               24                   think that some of the criteria though
                               I do

               25   that it should be based on the fact that the programs that
                  I


                                                                             184
                   are accepted for funding are those which certainly
                2  will do the greatest good in the shortest time, and also
                3  with the thought behind them that they will be programs
                4  that can be so effective and so essential to a community
                5  that a community will be willing to pick them up  and go
                6  on          m, or some other organization such as the

                7   State itself continue with them.
                8              1 think that probably would be one of the
                9   bases of the criteria that I would suggest.
                10             DR. PARL@. Thank you.  That is a very important
                11  kind of consideration which we too had felt would be the
                12  type of criteria that we would wish to develop.

                13             Dr. Roth.
                14             DR. ROTH@. Herb, does it throw any said in the
                15  gears to include in that -- I agree with everything Mrs.

                16
                    Mars has said    but would it in any way vitiate the intent
                17  to add the words, "It shall be the intent of this Council
                18  to authorize staff to proceed consistent with the
                19  existing mission statements achieved by the Council"?
                20              The coordinators have asked for this, and I tend
                21   to agree that we have worried this mission concept maybe
                22   unduly, and it may have been an unfortunate word in the
                23   telegram, but wouldn't that clarify thinLra?
                24              DR. PAHL:  Yes, I believe there is nothing
                25   that is being discussed within the Department or the


                                                                            185
                1   Service which detracts from the mission statement which the
                2   Council endorsed for the program some time back.  And what
                3   we have been talking about is a set of programmatic
                4   activities within that broad mission statement.
                5             And from what I have tried to indicate to you as
                6   well as I can, it is my belief that the Department will,
                7   in fact, provide the regions with the opportunity to
                8   engage in activities of the kinds that we are all familiar
                9   and comfortable with within that broad mission statement
               10   that we still are living by and which the coordinators wish
               11   us to live by and which you have just indicated should be

               12   our reference point.
               13              So I think the record can show that we are
               14   working within that mission statement for this fisca  year,
               15   and during the course of this year we all will be,concerned
               16   with the longek-term directions and organizational structur
               17   and processes.
               18              DR. ROTHI*  If the staff would appropriately

               19
                    word a statement which

               20              MRS. MARS;. Right.
               21              DR. ROTH4&    would clearly say that the
               22   Council authorizes staff to proceed consistent with the
               23   existing mission statement and according to criteria
               24   properly and appropriately adjusted to the regional
               25   Situations in order to achieve greatest visibility and


                                              QT                              186
                     project the program in the best possible light, I  would  so

                2
                     move.

                3              MRS. MARS.@  I'll s

                4              DR. PAHL.  All right.  It has been moved and
                5    seconded for staff to develop this statement. And  may  1,
                6    because I believe this is an important step by  the  Council

                7    and one that we will feel most comfortable with if we
                8    can make sure that our words do  reflect  accurately--  If
                9    we could perhaps take the statement which we  develop  and
                10   come back--  And let me just suggest that we do this by

                11   telephone.  We are doing a lot of things in order to move
                12   ahead.  But v6 can have this as a matter of record
                13   that you as a Council individually will approve or  we  will
                14   so see to it that our words do in fact convey this  for  the

                15
                     record, because we are working within departmental and

                16
                     congressional intents, and at times the  cross-currents  are
                17   difficult, and we would like to make sure that we have
                18   that. But we know how to act and proceed and  will  be  in

                19   touch with you.
                20              DR. MERRILL#I Are we talking about  a  separate

                21   statement now simply for your purposes?  This has

                22   nothing to do with the coordinators?
                23              DR. PAHL,.; No, vetre talking about a  separate

                24   statement for our purposes.  We will develop it and get

                25   your


                                                                                187

                 1                            Because
                                DR. MERRILL:          there is a second paragraph
                 2   to which I object in what is in the coordinators state-

                 3   ment which sounds vaguely like that.
                 4              DR. PAHL@.  The coordinators' statement is open

                 5   for whatever action the Council wishes.  It can be
                 6   accepted as a reflection of the coordinators' interest and
                 7   concern or it can be acted upon in any way in whole or in
                 8   part I'm sure, and that is a matter for you following Dr.

                 9   Teschan's discussion.
                10              MRS. MARS:  Well, I think really we can table It

                11   for the moment.

                12              MRS. MORGAN@.  I move that we table this to our

                13   next Council meeting.

                14              DR. PAHL.@  All right.  It has

                                MRS. MARS:  And let them perhaps come back with

                16   a revised statement or something,  I dontt think this is

                17
                     acceptable.
                18              DR. PAHL@.  Staff will inform Dr. Teschan that

                19   the Council has received this statement, has tabled
                20   it for consideration at the next meeting of the Council,

                21   and that we will advise them that should they care to

                22   revise and resubmit it --

                23              DR. MERRILL@.  Could we also give them some

                24   direction in how we think it ought to be revised?

                25              DR. PAHL.'  Yes indeed.


                                                                           188

                 1            DR. mERRiLL.@  Because I think these first
                 2  two paragraphs are really, as I said several times, kind
                 3  of a slap on the wrist and a blow for the status quo
                 4  and would be totally unacceptable to any administrator after
                 5  a long, hard day.  And if one could stress positive
                 6  aspects of what we intend to do rather than these negative

                 7  ones
                 8             DR. PAHL@*  Well, we Vill take the full record of

                 9  the Council

               10
                               DR. MERRILL:  I think in the discussion we have
               11   had here there are all the points I would like to make.

               12   They can be pulled out.
               13              DR. PAHL@4  That will be done and we will
               14   transmit as full information as possible to Dr. Teschan.
               15              MRS. MORGAN@.  Don't you feel in these criter a

               16   that we have said for staff to come up with where t  re
               17   is input      Council in establishing it this will be
               18   something than Muld also alleviate a lot of the problems
               19   here?

               20              DR. PAHL@*  Yes, it would.

               21              As we just close
               22              MR. BAUM.@  Before you close, I have something 1
               23   would like to clarify for the record.  As one who has
               24   to write the official record, let me see if I have this

               25   straight.
                  I


                                                                             189

                 1             The proposed resolution presented by Dr. Teschan
                 2   this morning is tabled for further consideration next
                 3   time with certain advice to be delivered as to where the
                 4   wording can be strengthened.  In the meantime I gather that
                 5   we have a--  I don't know whether itts a motion or
                 6   we voted on it or just what by Dr. Roth that we as
                 7   staff develop a statement which would reflect those things
                 8   which were put on the table by Mrs. Mars, Dr. McPhedran,
                 9   Dr. Roth, and others in the afternoon discussion indicating
                10   the general intent of the Council with respect to the

                11   delegations that were ap
                                             .proved and that we check t
                12   wording out with you by phone or some other communication
                13   before we write it into the minutes of the meeting.  Is

                14   that correct!
                15               MRS. MARS:  It was seconded but I don't think we

                16   voted on  it.
                17               MR. BAUM@6  Do we need a vote on that?

                18
                                 DR. PAHL:  Well, to make it official, all
                19   in approval of that description of our action please say

                20    aye.
                21               (Chorus of "ayes.")

                22               Opposed?
                23               (No response.)

                24               Itts carried.
                25               DR. RURH@.  My thought was if -We@hitd to go


                                                                             190
                1   retroactively and approve something that we hadn't
                2   approved before, I would rather give you approval now.
                3             DR. PAHLO@  All right.  Okay.  Well, we appreciate

                4   that vote of confidence.
                5             Before we adJourn -- 30 seconds -- one, I would
                6   like to indicate to you the CHP Council has not only an
                7   interest in but the requirement for a liaison member from
                8   our Council, and Dr. Watkins has been our selection, and
                9   he has very graciously consented to represent this Council
               10   on the Comprehensive Health Planning Council.  I believe
               11   that first meeting is in September, but we will be
               12   getting information to you.  And at Council meetings
               13   we would look forward to having reports from you about the

               14   activities of that service.

               15              Also I again have been remiss in noting our
               16   pleasure at an event that you all are very well aware of.
               17   That is, Dr. Roth's presidency of the American Medical
               18   Association.  And I'm afraid my own limited set of problems

               19   made me overlook that announcement earlier today.

               20              Is there any other business?

               21              (NO response.)

               22              Almost all of our public members have left,

               23   but if there is any public participation this is the last

               24   closing moment that one has.

               25               (No response.)


                                                                           191

                1              If not, I would like to thank all of you  for

                2   a very long day and for trying to absorb a

                3   tremendous amount of detailed technical material, for your

                4   understanding , both personally and officially, in your

                5   capacity as Council members, and to say that from this point

                6   on we really do look forward to keeping you informed, and

                7   we have set up arrangements to do that, so that we  will

                8   not try to burden you with things but to keep you abreast of

                9   high points as we go through still a somewhat complicated

               10   year concerning the technical matters internally but giving

               11   you points of view from the Administration, the

               12   reorganization, the congressional intent, and, of course,

               13   our activities relative to the regions.

               14              And again thank you for a very  understanding

               15   Council and full day.

               16              The meeting stands adjourned.

               17              (Whereupono at 3:-07 p.m., the meeting was

               18   adjourned.)

               19

               20

               21

               22

               23

               24

               25