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Montana Stale Library



3 0864 1004 9692 9




MONTANA
COMPUNENSIVB
NiALTN PUNNING



STATE DOCUMENTS



Second Class Postage Paid
at Helena, Montana 59601



HiWS



5J0 Logon Ave. - Helena, Montana 59601 - Phone 449-3121



Volume 5, Number 2 — January - February, 1974



CHP Staff Aids in Utah



^1 T



b' Agency Assessment



state CHP Administrator Robert
Johnson; Warren Brass, Coordina-
tor for Areawide Affairs; and Levi
Taft, Director North Central Mon-
tana Health Planning Council, spent
the week of November 26-30 in Salt
Lake City conducting an agency
assessment of the Great Salt Lake
Health Planning Council, a two-
county areawide organization rep-
resenting some 486,000 people.

Staff personnel were part of
a six member assessment team
that brought experience in area-
wide, state, regional and federal
health planning to the Salt Lake
City agency.

Under a program instituted by
the Comprehensive Health Planning
Service of the Health Resources
Administration HEW, all state and
areawide CHP organizations in the
country must undergo an assess-
ment by June 30, 1974. The pro-



gram has been designed as a con-
structive plan to assist the agencies
in their effectiveness in key func-
tional areas as a means of strength-
ening CHP agencies across the
country. The assessment program
is specifically formulated to help
agencies in identifying operational
problems and to assist in dealing
with these problems.

Johnson, Brass and Taft attended
a training seminar in Vancouver,
Washington, earlier last fall in pre-
paration for the assessment pro-
cess. Respectively specializing in
the areas of "agency management,"
"public issue involvement and com-
munity participation and educa-
tion" and "project review." John-
son, Brass and Taft met with
and interviewed approximately 60
individuals who had been active
in the CHP programs or who had
been affected by decisions made by




Taking a break from their assessment duties are Levi Taft, Director of the NC
Bob Johnson, CHP Administrator; and Warren Brass, Coordinator for Areawide Afl



the Great Salt Lake Health Plan-
ning Council program.

Other members of the team as-
sessed the Council in terms of
health plan development and im-
plementation, studies, planning co-
ordination and data management.

Commenting on the Salt Lake
City trip. Administrator Johnson
stated, "The assessment process as
a whole is a very equitable and
beneficial experience; for both the
agency being evaluated and for the
people doing the evaluation. In that
we're not judging the agencies in
terms of good or bad performance,
they receive the full benefit of an
objective observation which at-
tempts to identify strengths as well
as weaknesses. It's a peer-group
review in which everyone concern-
ed learns something about maxi-
mizing the agency contribution to
the areawide health planning
goals."

"It also puts us in a good posi-
tion because we now know more
about what the assessment process
is all about, and we know what to
expect when our own agency un-
dergoes assessment next spring,"
added Warren Brass.

Areawides Begin
Health Plans

Areawide health planning or-
ganizations are just beginning to
realize the size of the chunk they
have bitten off for themselves as
they begin work on their individual
areawide comprehensive health
plans.

Under the contract agreement
reached last July, the areawide or-
ganizations agreed to develop a
". . . comprehensive plan for health
at the areawide level using narra-
NTANA STATE LlBR-*rS)Ytinued on page 2

930 East Lyndaie Avenue

Helena, Montana 59601



Areaw'ide Health Plans —

— continued from page 1
tive explanation and including
normative comparisons and rank
ordered lists of health priorities."
With the first draft of the plan due
for submission to the State CHP
Office by January 31, areawide
staffs are busy compiling data ac-
cumulated via the nominal group
sessions and through statistical in-
formation provided by the State
Agency.

Having assumed the responsibili-
ty for outlining the alternative im-
plementation approaches which
will have been taken, or might be
taken, in order to meet the health
needs identified as health priorities,
the areawides will have taken on
a complex health planning task.
Areawide directors and boards are
being aided in their efforts to a
limited extent by state staff assist-
ance in the form of working meet-
ings. State CHP personnel are at-
tempting to provide as much as-
sistance and direction as is needed
and time permits.

Once the first draft of the area-
wide plan is submitted to the State
Office, it will be reviewed and sub-
mitted to the areawide organiza-
tion in rough draft form for com-
ment by February 1. The second
and final draft will be resubmitted
to the State CHP Office bv May 1,
1974, for inclusion within the State
Plan for Health.

Citizens' Advocate
Office Open

Montana residents with ques-
tions, complaints and requests for
information about state govern-
ment will be glad to learn that the
Citizens' Advocate Office in room
237 of the State Capitol Building
is open for business.

By writing, dropping by the of-
fice in person, or simply calling
their toll-free number (800-332-
2272), citizens may contact the
citizens' advocate, Kent Kleinkopf,
or his assistant, Kathy McGowan,
for assistance when they find them-
selves lost and confused in the
maze of bureaus, departments, divi-
sions, boards and councils that is
state government.

In operation since last July, the
— continued on page 11

PAGE TWO



EHC Voids

FY 14 Work Program



In an attempt to aline the En-
vironmental Health Committee of
the CHP Advisory Council more
closely to the environmental health
planning role of Comprehensive
Health Planning, the EHC moved
on a unanimous vote at its Novem-
ber meeting to void its FY'74 Work
Program.

The Environmental Committee
has been suffering a variety of ill-
nesses in the recent past, evidenced
by low member interest and sparce
attendance at its meetings.

Dave Turner, recently assigned
staff assistant to the Committee,
spent the early part of last summer
conducting a critique of the EHC
and made a rather critical report
to the Committee at the September
meeting. Since that report, the
Committee members, under the
leadership of Chairman Don Piz-
zini, Great Falls, have expended a
great deal of their time re-examin-
ing the Committee and its role in
environmental planning and par-
ticularly as it related to CHP.

Several times during the past few
months there seemed to be a con-



sensus that the Committee might
in fact have been a supernumerary
in the environmental scene of Mon-
tana. However, a "pep talk" by Dr.
John S. Anderson, Director, De-
partment of Health and Environ-
mental Sciences, and the continued
deep-felt concern on the part of
individual committee members led
to the Committee's attempt to dis-
cern a viable role in environmental
health planning.

It was finally at the November
meeting, during an address by
State CHP Administrator Bob John-
son, that the Committee struck
upon the notion of becoming in-
volved in the writing of the En-
vironmental Component of the
State Plan for Health.

So contrary to previous sugges-
tions that "maybe we ought to let
the Committee just die its natural
death," the Environmental Health
Committee is alive and well. As
one Committee member remarked
at the conclusion of the last meet-
ing, "and I thought that the En-
vironmental Committee was dead!"



Sauttt Cctttral Aro€ttvi€le Haitis
Annu€il Meeting



The South Central Regional
Health Planning Council, Inc. held
its annual meeting in Billings on
November 8. Following status re-
ports by the Areawide Alcoholism
Plan Steering Committee, the
Health Training Network Task
Force, the Review and Comment
Committee and Executive Director
James Toner, the SCRHPC Board
took affirmative action on propos-
als relating to membership, role
functions, and responsibilities for
the agency.

This being the annual meeting,
the South Central Areawide held
its yearly election with the follow-
ing results being reported.

Officers: Miriam Sample, Presi-
dent; John Manley, Vice-President;



Colvin Agnew, M.D., Vice-Presi-
dent; Kenneth Jacobson, Treasurer;
Beatrice Kaasch, R.N., Secretary.

Executive Committee: Miriam
Sample; John Manley; Colvin Ag-
new, M.D.; Kenneth Jacobson; Bea
Kaasch, R.N.; Ralph Gildroy; Gene-
vieve Dyche; Art Lamey; Carol
Juneau.

New/Continuing Board Mem-
bers: Genevieve Dyche (cont.);
Doleen Lind, R.N. (new); Manuella
Mesteth, R.N. (new); Roger Han-
son (new); Alma Johnson (new);
Ralph Gildroy (new); Robert
Holmes (cont.); Gary Bounous
(new); Ken Jacobson (new); Carol
Juneau (new); Warren Bowman,
M.D. (new).



EDITORIAL



The Coming of PSRO's



By DAVE TURNER



Health Planning Assistant, CHP



Much like a continuously quar-
reling husband and wife who have
known for some time that "old
Uncle Harry" is coming to live
with them, health care providers
and consumers are still having
their doubts about the scheduled
arrival of Professional Standards
Review Organizations (PSRO's) .

Consumer advocates complain
that Public Law 92-603 which es-
tablishes PSRO's, requires con-
sumer input only on a statewide
PSRO Council, which is only re-
quired when three or more PSRO's
are formed in a single state. With
the small number of physicians in
Montana, just over 800, there
would probably not be more than
two PSRO's formed and no require-
ment for a state council. This, they
say, sets the fox to guarding tlie
chicken coop.

Providers argue that consumer
input in the review of professional
activity is out of place, since lay-
men are not competent judges of
professional practices. They also
point out that economy and quality
care in the medical field are often
just not compatible.

And so goes the debate, back and
forth, and back and forth. Claude
E. Welch. M.D., in a recent article
in the NEW ENGLAND JOURNAL
OF MEDICINE, has written the
most objective analysis of the
PSRO approach that we have seen.
The article, entitled "PSRO's —
Problems and Prospect," cites sev-
eral areas of concern that health
care professionals are going to have
to face and resolve if PSRO's are
to function as expected.

Welch expects establishment of
service norms to be difficult, since
they must vary among different
types of health facilities which
have "variable lists of diagnostic
and therapeutic procedures deemed
acceptable for inclusion." In Mon-
tana, outcomes of the Legislative
Council /Department of Health and



Environmental Sciences study of
public health service will likely
bear heavily on norms of health
care.

Hardware costs in terms of com-
puters and data banks, and operat-
ing costs can be expected to be
high. "Medical practitioners are in
a particularly vulnerable Dosition
since the great bulk of available
hardware and expertise is in the
Imnds of the Social Security Ad-
ministration or third-party car-
riers," according to Dr. Welch. He
estimates the total cost of the sys-
tem of PSRO's "... from a few
hundred million dollars yearly to
about a billion. A report made by
Michigan Blue Shield . . . estimates
the maximum budget of a single
PSRO would be $330,000 yearly."

Finally, Dr. Welch questions
wl^ether the PSRO system will be
able to maintain confidentiality or
withstand political pressures and
rivalries. "Petty jealousies could
react to the detriment of all," he
warns, "medical statesmanship will
be essential."

And the consumer advocates are
also suspicious. A report issued by
the Washington-based Health Re-
search Group in conjunction with
the National Urban Coalition Con-
sumer Health Project says the job
of a PSRO is to establish, after
consultation with its member doc-
tors, standards of care, or norms,
for the treatment of different ill-
nesses handled by local doctors.
Once these norms are agreed upon,
the PSRO can then begin its screen-
ing process of claims for payment.
"In other words, the PSRO will
then compare the type of medical
care shown in the Medicare and
Medicaid claims submitted by local
doctors with the norms established
by the PSRO. If the claims show
unnecessary service they may be
denied payment by the PSRO panel
for that medical specialty."



"Denials probably will be rare,
however, since rotating panels of
PSRO members will conduct the
review. Thus a doctor who has dif-
ficulty getting a claim approved
by his peers will later be in a posi-
tion to review their work when his
turn comes to sit on the panel.
This will result in typical medical
society backscratching.

"Consumers are completely ex-
cluded from any involvement in
local PSRO's just as they are ex-
cluded from participating in local
medical societies. It will still be
virtually impossible for the public
to know whether a doctor practices
poor medicine. In fact, consumers
can only get information on a local
doctor when he is actually sus-
pended from receiving Medicare
and Medicaid (reimbursement)
altogether."

But not all the news about
PSRO's IS bad. A number of major
benefits should be provided by a
working PSRO system. According
to Dr. Welch, perhaps a 20% re
duction in costs of hospitalization
could be achieved — something
that should make consumers quite
happy. "Physicians will of neces-
sity become cost conscious," he
says, "a feature that at present is
woefully lacking . . . sooner or
later they will become involved in
risk-sharing with the health under-
writers."

PSRO s may also give physicians
something to cheer about. In addi-
tion to providing "an enormous
stimulant to medical education,"
Dr. Welch says, "The PSRO's for
the first time would begin to create
a single system that is quite in
contrast with present disorganized
methods.



VIEWS AND COMMENTS ON CHP NEWS WELCOMED. ADDRESS: LETTERS
TO THE EDITOR, CHP NEWS, COGSWELL BLDG., HELENA 59601.



Montana Comprehensive Health
Planning News is published bi-month-
ly in January, March, May, July, Sep-
tember, and November by:

Comprehensive Health Planning
Division of Montana Department of

Health and Environmental

Sciences
510 Logan
Helena, Montana 59601



PAGE THREE



CHP's Vista's
On the Job

Four of the five areawide com-
prehensive health planning organi-
zations have received a much-
needed shot in the manpower arm
with the addition of VISTA Volun-
teers to their staff.

In October a State CHP-spon-
sored VISTA project was approved
and eight volunteers assigned.
Four of the volunteers were re-
cruited from the national pool and
the remainder were locally recruit-
ed and are serving in their own
communities. Patricia Ulman, su-
pervisor for the project, has tried
to assign one nationally recruited
volunteer and one locally recruited
volunteer to each areawide organi-
zation, thereby striking a balance
of experience and perspective.

The stated goal of the project is
to " . . . increase low-income and
minority participation at both the
local and state level in health plan-
ning matters." The specific intent
is to provide additional manpower.

Since their assignment in Octo-
ber, the volunteers have been in-
volved in "outreach" work for the
nominal group sessions that have
been conducted around the state.
Once these meetings have been
completed, the volunteers will be
engaged in conducting follow-up
work that will have been generated
by the original nominal group
meetings.

Although organizational work
will be the vodunteers' principle
task, they will also be free to be-
come involved in other health-re-
lated projects. Currently, the
volunteers assigned to the South-
western Areawide CHP are work-
ing with the Helena Indian Alliance
to establish a free health clinic. In
the Missoula area, one volunteer is
working with the City-County
Health Department - sponsored
well-child clinic.

The Volunteers In Service To
America are proving to be an in-
valuable aid to CHP in maintain-
ing a sensitivity to the needs of
low-income and poverty people.
"Their input will probably not be
fully realized until long after they
will have completed their year of
service," remarked Supervisor
Ulman.



Nahn Goes West

Taking the advice of Horace
Greeley, Edward Mahn, former
health planner with the South-
western Areawide Health Planning
Council, has headed west to fill the
board-created vacancy as the di-
rector of the Missoula-based North-




Edward Mahn, new Executive Director of

the Northwestern Montana Areawide

Health Planning Council.

western Montana Areawide Health
Planning Council.

A Michigan native, Mahn has
worked for the Southwestern Area-
wide organization as a health plan-
ner specializing in facilities review.
He was also instrumental in the
publication of the Montana County
Profiles, a statistical analysis of
Montana's population, employ-
ment, education, housing and eth-
nic characteristics, which State
CHP recently published.

Along with the continuing
facility review function, the new



director will assume major respon-
sibility for the development of the
areawide health plan for the seven
counties of northwest Montana.

Ed is a graduate of Grand Val-
ley State College, Allendale, Michi-
gan, and has lived in Montana since
being stationed in Havre with the
Air Force.

CHP's Ll+tle Red
Book Now Available

Described as "one successful ap-
proach to community health care,"
Comprehensive Health Planning
has just released a little red, eight-
page booklet that should be a great
aid to Montana communities as
they begin to investigate alterna-
tives to their health manpower
needs.

Depicting the all too familiar
story of a small rural community
isolated from physician and medi-
cal facility care, the booklet des-
cribes how three Montana commu-
nities working together solved their
mutual problem through use of the
Nurse Practitioner approach.

The booklet, entitled "Introduc-
ing a Community Nurse Practition-
er," provides a brief history of
how the various communities went
about establishing the Seeley Lake-
Ovando-Swan Lake (S.O.S.) Proj-
ect, along with examples of duties
and responsibilities of typical nurse
practitioners.

The publication also provides
answers to some frequently asked
questions about the nurse practi-
tioner approach.

The booklet is available by
simply writing the Division of
Comprehensive Health Planning,
Cogswell Building, Helena 59601.



EHC Elects Chairperson



The Environment Health Com-
mittee at its November 13 meeting
elected Mrs. Martha Anne Dow as
its new chairperson.

Former Chairman Don Pizzini,
who has held the post since No-
vember, 1972, was forced to re-
sign due to other time commit-
ments relating to his duties as
county sanitarian of Cascade
County.

Mrs. Dow, a recent appointee
to the State CHP Advisory
Council and Havre resident, brings



a wealth of environmental inter-
est and knowledge to the chair. An
active member of the EHC with a
lengthy history of involvement in
environmental matters, Mrs. Dow
is currently employed by Kemdata
Laboratory, Havre, where she
works in chemical data processing.
Martha Anne is a graduate of Mon-
tana State University and holds a
masters degree in microbiology.
She was a former instructor of
microbiology at Northern Montana
College in Havre.



PAGE FOUR



Hill-Burton

'Tree Care'

Clarified

Almost three decades ago the
Congress enacted the Hospital Sur-
vey and Construction Act, popu-
larly known as the Hill-Burton Act,
to increase the availability of hos-
pital services in the United States.
A major portion of that act ad-
dressed itself to the problem of
lack of available health care ser-
vices to the indigent.

Under the provisions of the act
each hospital facility receiving fed-
eral assistance for new construc-
tion, alteration, modernization of
existing facilities or new additions
was required to agree to provide "a
reasonable volume of services to
persons unable to pay therefor."

Some 26 years after the law's
passage, and only after seven law
suits were instituted and several
court orders directing compliance
were ordered, the Department of
Health, Education and Welfare
finally began implementing the
regulations requiring the 3800 hos-
pital grantees and the 50 state
agencies administering Hill-Burton
funds to see to it that the poor re-
ceived some hospital services to
which they were entitled and so
desperately needed.

Even so, change is slow to oc-
cur. Jeffrey B. Schwartz, an attor-
ney with the National Health Law
Program (NHLP) states, "The
inertia of the past has an overrid-
ing effect and hospital and state
agencies are still not providing the
required free services and below
cost services to the poor. Such non-
compliance is illegal; it should and
must be stopped."

Commenting on the law suits
against Hill-Burton hospitals and
state agencies for failure to carry
out their responsibilities, Schwartz
says that hospitals use a variety of
subterfuges to hide their non-com-
pliance. "Claiming that bad debts
are free service to the poor is one
such subterfuge. Others are count-
ing services provided in prior years
(including so-called Medicaid loss-
es), failure to make prior determi-
nations, and refusing to serve some
poor patients free as part of a mix
—continued on page 12



WAMI May Ease
Manpower Shortage



As the people of small commu-
nities and rural areas can tell you,
the old addage of "them that has
is them that gets" was never more
true than when you go out in
search of a resident physician.

Historically speaking, Montana's
physician shortage has always been
a function of maldistribution, not
numbers. Today, that problem still
exists; those areas that have physi-
cians are the areas that continue
to attract even more.

Presently, the state's ratio is
approximately one physician for
1000 people; not too bad when one
compares it to the national aver-
age of 1.5 physicians for 1000 peo-
ple. However, 46% of Montana's
population lives in rural areas,
while 85% of her physicians live
in urban centers. Twenty-two of
Montana's 56 counties have over
1000 people per physician, and 16
counties have over 2000. Six coun-
ties have no physician in residence.
Big Horn County has a ratio of one
M.D. for 10,000 people, while Mis-
soula, Lewis & Clark and Yellow-
stone counties have less than 650
people per physician; a ratio that
is more than adequate for good
health care.

This maldistribution problem
has many roots. One factor is the
lack of a medical school in Mon-
tana. Prospective students are
forced to go out of state and with
the increased legislative pressure



on most state-supported medical
schools to drastically limit the num-
ber of positions available to out-
of-state students, Montana resi-
dents are often refused admission
because state applicants are given
priority in open slots. With appli-
cations running three to one for
the limited openings, Montana stu-
dents have a slim chance of getting
into the medical schools.

There is little possibility of Mon-
tana constructing its own medical
school. The American Association
of Medical Colleges estimates the
cost of building a facility capable
of enrolling 54 students in the $60
to $100 million range, far beyond
the capabilities of a rural state like
Montana.

The lack of a medical school also
adds to the maldistribution prob-
lem in that few doctors are willing
to practice medicine so far from
major medical facilities and re-
sources. Montana's isolation makes
continuing education for the physi-
cian a big problem. In addition, re-
cent studies have shown that most
doctors tend to set up practice
where they received their clinical
training. No such clinical training
facilities have ever been establish-
ed in Montana.

Adding to the problems of the
small community is the question
of how to keep a physician once
his services have been secured.
Several gimicks have been tried by
^-continued on page 6




^SvW^



"With appUcatioos running three to one for the limited openings, Montana stadents
have a slim chance of getting into the medical schools."

PAGE FIVE



WAMI -

— continued from page 5
various communities to retain resi-
dent physicians but in the end it is
a function of how well the M.D. is
attuned to the people of the com-
munity and their culture that is
rural Montana.

In 1971 the University of Wash-
ington began an experimental pro-


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