I I!illl liii IEI iiiii i@ll@l l@ll lit, -x i- 00 t 7' T IY4.OOVL"R CO-NIP -1@ 6 -,66 I!" 3 DE'PART@T,,"@T Or T-,DITCATIOTL A@ID @17ELPARE P7@"PTI@@IC7 01' AD HOC CO,'@'iStjLTA.\ITS PT-,VIE@'7ITIC, MRDICA.L PROC@P"! APPLICP-TIOTTS Conferenc.e Roorn 11 Parkl.a@@7n Ptiilc9.incT 5(,OO risliers La.ne Rockvill(-, @.4c-;-ryland 202-52 ThursOa-,I, !-4ay 23, 19'74 Panel B conlieneO at 8:40 o'cl-ock, a.ir.. 14r. 'Peterson ChEii.rr,,an, nre.-,iclincr. TI'ATIT'T, (,As licretofore notrO.) C 0 't I T @l, @l T c.; c--.i rT e -.Ian for Orcgon 11) 5 Pr7 Motion for recommendation 204 RerTi.ona,l 'Dlan for ('aliforn-ia 2 0 5 @iotion for recornmen0ation 212 Motion for recororen6ation 232 P,r,-qion,-il Pie(.ical Ill.an for 'DLic-rto Pico Motion For recoTnT,,c--no',ation 23") P,e,crional T'lan for the "oi-intain @)tc7.i-of3 2 4 2 l@ot;-on -rnr rccorr-enOaticn ?19 ',,Ioti.on for rccol,-,rnc-l-,f,,ation r) 14 or !@'@@.-@cal -lan -.For 2 r-,, 0 1) P, A. @lotion for r-,3cor-,-3nOati.-on @ioti-on 'cr 2 5-.7 ','@'.oticn for r@co-rrenrlaticn 2pp@ T.Zcc-ionz,.! @lan i'or 'IeTir Ter@o.-t, 2 ci Motion for recorrendation 29r) f-lotion for re-cori-,cncl.ation 30 5 P..eqional- I-ledical nlp.n for Pcchester, vorl-, 307 Motion --For reccnuien(lation 3ii P.,P-@ional Ili@(lical ',?)-an for @,'7@ishinrTton an6 Alaska 312 I-lotion for recor@renrlation 31@5 I,-!otion for rcc-.oT;.iir-enrlat-'@(.)r) 322 lr@'4 - A C 0 T,'@' T T@7 T (Continued) AFq'ERI-10011 Sr@913IO,'l -I 7 ,"P-(Iical Plan for l@7est(@-rn renn-,Yl.v,-inia 336 P,Ioti.on for r(?cc)rimendation 3 50 Virc@l-i-nia. R(--gional- @4eOical TrocTrar. 355 !,!.Otion for rccorT,-.,en(Ic-Ltion 36 7 .ecormc;nc,e.. Teri-i. c F- I T, I- F- n F o r t' -i e the I,ake-, @.reci 3 r. 9 !notion -f(@-- .-ecor,.--enea.tion 3n2 Motion for )-occTmp-n('.E,-.i-c)n 40r) TrocTra.m for the Peci-n-nal -e. r, i c a'. f'@tate of ila.rvlzinc7L lic)tion 7or reccml-nn@-z;.tic)n H7W Reaicnal kle@ica'L @l.an for tho D-L.-,trict of Columl)ia @25 I'@loticn for rc-,co-nTnen(lation 4 31) I-T-'-r@,,7 Pegional "leeical '?]-an for LoncT Islan@, @,-7e@,7 vork anO @Tassau- Suffol-% Counties 443 @,@otion for recoTmpneation @55 TIPI,T RecTional !,,eO-4.cal !'Ilan for Susauchanna N:al-lev 461 @40tion for recoplj,-en0ation 4 72 7t 1 p R 0 c E E D I A G s iurs [Th(,, B '2-iTicl @.7as called to order at 8 it-0 a.m. !Dy n a. L@. T-leterro,-i, ttic, C'@@a.irman.] PETERSI@)'@i: l@,7e are still missing, a coiinle of peonle. I took some stuff home last ni( is .jlit and this just to! Clive vou an idea of -vihat .@7e did Yesterday. [Indicatinq the blaclcboard,l, on %7hich was inscribed Rec 77und- Overall Item ing in l@s %!Zca % Tar&e+-- Alban-,,- (1) SU.? 3.0 1.066 @100 70 T,Iaine S u-@) 2.9+ 1,600 8 0 12,0 AA S 2.5 700 67 5 C,D Valle@@7 2 . 5 2 30 0 82 61 C-@-I York Aug 1.8 615 77 Ai-ta 1.8 70 70 ,.la,,.7aiit 1,109 Ariz (1) Bi% 1.7 860 64 50 Conn BA Poon 1.6 510 80 22 $8,751 c 80 70 It seemed to me t',Lie realons fell out- into al:)otit four nice cTroups. The first column indicates that sort of overall ratin-r that revie@.,,crs aave "Sun,2rior", ".@bove AveracTe", "Belo%.7 Averaa(--", or "Poor. !4o%.i the second colur,.in is sort of an itemization. You Still -recall that you i@7cre asked to chec'i', "Cood", "Averacje t 2 "Bclo%q Avera,7e" -- and I sort of ,,Yc-,i-cThtc@ that as 11311, "2" and t count in where pcon)-e said there i.,7as insufficient and diciii' basis for judgment. And again, it seems to me those sco res, that itemized kinO of scorin(T is rouqhlNi consistent with the verbal score. And then I indicated i-.71-iat your recommended fundincT levels Caere, in thousands. @.nd the last tN,'70 columns are the percentc-,ige- of that recorn-r.ene,ation vis-a-vi.s the request in the first column; and vis-a-vis the overall target fic-ure or level for that ret73-on. So i,7e do have in,:irled disparities II,ai..ne, -for if ,ou -,.fill recall, theirs i-s onl,;, comiTic in now (1) Connecticu@@ is at the very @ottori of the list. -@@s it ',Ianr@-cned, heir initial request was really quite modest co,-,'Oared to what .je were exnectina. But this is noti'lin,,T authoritative or final, but I thougi-it vou mig',--It be interested in just -,ort of seeing one a,,,r of .--u+-- k@-incT, ho@-i things care out yesterday. It did seem to r,@e the-,7 sort of fell out into four ec,,ual cirou-)s, rather than t,@170 -,mall ones and then the middle -- we don't have a bell shamed @urve ,@ihich I guess is something that educators are ex- treriel,7 interested in. DR. TESCE@-'I: That's because tliev are saving taoney or the nroqram. 187 3 1-71-7E CIIAI@TI.I@TT: Well --yes. Those are- rouc.Th np-rceii,@-aCTC C@ at ti'le 'i.)ottom. You r-cco@tmended about 80 Percent of the requests in the acgreqate, and about 70 percent of the tarQct figures -- on the eicTI-it recTions we looked at yesterday. Well, I'm not sure that we rcallv ira.nt to wait on ,,',ill and Toe. We @.!ere aoin(7 to take up Puerto @,ico first, and' both of those are Puerto Ri-co people. DJ.'. ,-.cCALI,: llo,,.7 about taking @,lest Virginia first? TIIE Well. or otherwise You haven't had your coffee vet, Sister Ann, would you mind if we qo to 17cst Virginia? Otherwise, I was aoina -Lo@ 0 to Oregon. S'-,ic was the orlv o-crson @,7e didn't cret tovasterday 9 -- and, T.,,ell, that wasn't entirely accidental, there was a little collusion with the chairman. It was -part of the ecumenical T-iovei-.c,.nt. [Laualiter. I,,,'h@,7 cbn't we start !..,,i.tli T,,Te s tVir(-inia, then, -@nd let Sister -@.nn drink her coffee -- and ma@7be then bv that tirie Bill Thurman and L-Joe @,7ill be here. if they aren't, they'll have two Y)laci-, marks apiece thevlve alreadv qot one. (Laug'lt(--r.] And on latest Virginia, @7c have Paul Tescl'lan and ,--hari-s and vou Pe .-.cCall oT)le have colluded -- or do vou @@7an,@- to flin 7 acoin? DR. T@SCTIAN: 11@o. I I I vield the floor Author )r. jl,,'cCall, pleasure to my senior colleague; from -Le.@as. 188 A "'HE CIIAI-T-@7'Z: No@.7 if we are going to ,jet into these Senate tvpe protocol, Caere not going to aet fourteen regions done-todav. [Laught@r.) DR. !@','cCALL: I'm not sure whether I accept the floor under those circumstances. I'm sorrv Bill is not here. I wanted to point out to him that I find another "SuT)erior" region, but that I'r. not one that came in ,.7ith t,,.7o volums of elaborate amplification Y)er Se -- but just the onoosiLe. k quarter inch, non- i bound, non-color, bl.acl@ and.@7'n.Lte aD-Dlication that is one of t'ie simplest, clearest, i,-iost conci--e aT)nlications tiiat I've read and it's siri-c)le for a lot of reasons: One, is the state, itself, and the the-,7 i-iave v developed the nroaram, bulk-- also because this application is 0 a recTuest for support for staff, and onlv tio continuation projects !.ii-th the plan to come in for all of their neT,,7 programs in Julv. And that is clearl,7 as stated here, it is a reaion that came in rather late in terms of the overall 56 that ultiratr--lv -,,,as our peak -- so that tl iev came in, developed their T)roQram based on the neeris of the region, developed theix priorities, stucl!-. with then, haven't had to shift them they have a strong staff and region advisory grouT) leadership and an integrated proaram that has been consistent, right along. 189 t 4 And I have alreadv mentioned that i.tls reallk,, a staff @ge 4A [3roposal, Primarily, -- just t@,ro continuation projects just continued in other funds. I think the feasibility of their accomplishing, in the lirTht of @7hat they say here. vihat they have done in the -past, is excellent and @,7hile there is not a lot of information on 7P,-P relationships -- there is nothing that indicates there is nrobl---ii nO'@7 there, at all.. They are reauestincT, no-,,7, 663,132. The onlv thina I -qould noi.nt out there is that there is a significant indirect @ost in this that has come up before, about 130 some odd -- or 136,663 which -,.ias indirect cost but that is an establi-s'-ieCi 'I--hi@ng that @,70 couldn't do an,ithinq ai-)out at this point in time. 1 merely call it to ,7our attention. 1,@nci I think I'll sto-o there. The @7.,ea4-onal -@@dvisor,7 Groun is a little heav@7 on thc. rofessional T,"e-wershin, but it's t@iere -- I don't think it's a ;erious oroblem. Pciul? DT.Z. r."ESC',I-@l: T,7e have no reason to disagree -.,7it@l an,7- -hing that has been said. It's a pleasure to read a program I --hat has not onlv ',:)een able to carry -- not onl-,), been able to ,accumulate funds currently, and arrange ongoing funding -- lut i,,,hd is able to accumulate funds concurrcntlv in multiples -- .e., -,,7here they @@7ill put in half a million and they @.?ill be igo running about a ti.:o to three million dollar program 5 that @.7hcn P2-IP was going to -)hage out, the Governor and the State Government were ready to take the staff on. It looks as if they are as far along bccominct the follo@,i operation of PIIP as anv rcqion that %.!e have come across. I-.le have kno@-in Charlie, in operation of West Virginia, because it's a mer-loership in the Southeastern CROUT) and @?ye have been a@@.lare of this development in the general direction, un to no@i. ,hev seen to accorqnlish more interaction, and startina of more services and devel-o-oina of manpower, @,Titill fe@ver dollars t-@lian almost any group @.7c,- are aT@iare of. So mv recommendation -- if I can nree-mot the dignit7;, of r,,.y T)rce,eccssor would reco!-.-Lnend f tinO incT as rec:i:tested. I'll second that. THE O.Tz'. Before we opera that u-o as Charlie did indicate, this is a verv, in one sense, a verv modest application a continuation of nroararq staff with fundina -- a sliQht expansion in view there and a cou-)Ie of projects so that it totals @663,000.00 in round nu,@,ers. They do anticipate comina in with a major su_oplerental@ application injulv for $1.2 million. DR. I!c,OALL: But that, added to this, would nut ther,! above the target. 1,7e're recognizing that. But I tl.'Iinl@ we are in a position to let them mal-.e igi the judgment of what 'I--hey do come in with, in their new committee. TFIE CIIAIP@,LV@l: All we knew -- this is one of the reasons -- this is one of ma@,,,be eight or ten, where the initial application is, indeed, restricted to continuation and to program staff -- and all of their new activities will be reflected in the iulv submission. O.N.,, !\Torm, are there anv comments regarding CAP or this matter I recall @,7est Virginia has at least considered, over I the years, some possibility of disassociation from the University but I'm not sure Whether that ever got much bevcnd a sort of @@iR. NOR@-L'V,-i A7-TDE:T-',SO-@4: Anv AgencN.7 Director is a ember. of the LecTal 2%dvisor,,, (,roup, and t,ic@.r did 'recor@-n@-nc3, annroval. of this particular anDlication. @,nd as- I said, it has been nreviouslv anD--oved by the aqencv, since the wor"@ is continuing on schedule. The major thrust of the urocrram we can anticipate in@i@ the next application, will be on the State-@@?ide basis, as opposed to the individual project, or community basis. Now I think it orobablv will be the size that thev will get. DR. TESCTIP,14': They have helped build PAC aaencies in an area. TIIE Tom, do you have anv particular 192 i Virginia? ,it 7 'into this as regards West MR. SIMONDS: Well I think Norm summed it up very well. That's a pretty good state. THE CHAIRMAN: Most of West Virginia is still that way,, I know. We do have a recommendation but are there additional comments,, questions, observations. MR. BARROWS: I would like to ask a question, just as a matter of my own information: What qualities, as you fellows isee it, accounts for this marvelous support on the part of Itheir constituency? DR. McCALL: The usual fact of strong, capable Ileadership involving MR. BARROWS: On the part of the coordinator, or do Ithey have a good RAG too? DR. McCALL: I think it goes on further than that MR. NASH: The coordinator, the utiversityll and the force of the medical society They started off with -- had the RAGs to start with and they haven't had to shift. They have been right on target throughout. MR. BARROWS: The university and the medical isociety &re united -- i.e. -- they both agree. Now, I didn't say the relationship was good between the medical society and lithe university, but both units support the RMP. PORTING CO, INC. 320 t@lassachusetts Avenue, tq.1. Wasfiingtof,@, D@C. 20092 193 DR. TESCHAN: There's a very important phrase about ihalf of one line in the application that says that, in working with the medical societies in the health delivery area, they have restricted their activities to their legislative franchise. And then the thing goes on. Well, anybody who reads English in the context that ,we have all experienced it, will know exactly what they mean. That says that Charley's been very careful as a non-MD, he's been very careful and he's working with full understanding with the People who might otherwise take umbrage. MR. NASH: That's right. THE CHAIRMAN: I think I've observed something this isn't just West Virginia -- it does seem to me that in those states which have, perhaps less in the way of health ,resources, institutionally and otherwise (and Maine falls into that category certainly) and during the phaseout period, they seem a little more, for whatever reasons, anxious to preserve .what little they've got, including the RMP, than some states ,Lhere there is almost an embarrassment of riches, in one sense. I don't know that that's an axiom, but I have that mpression that in places like Maine and West Virginia, they I eem to be, or to have been willing -- and I think they have i@ad good programs there, to try and preserve the RMP with I ilotate and other fuhds, moreso than had it .-joeen Michigan or H PORTING CO, INC. 320 flissachusetts Avenue, N.'-.. Wa@.ing!on, D.C. 26002 194 Illinois, necessari.ly. DR. McCALL: But I think also, in addition to that i t lthe good leadership, good program a lot of needs relative to', the resources. THE CHAIP14AN: Yes. DR. McCALL: But also, a rather homogenous noncomplext reaion, too. You know there has been a lot of competing institutions land people, so that they were able from the beginning to focus it, and then have not only the need to recognize their function' but they were productive in it -- and therefore, you can rally when the legislation gets shot out from under you. People ;come in and say: This is a worth while thing, and MR. NASH: There's a motion. THE CHAI@4AN: Yes, there is a motion, but are there any other questions or conunents? If not, we have a motion to recommend approval of the amount requested, $663,000.00 which has been seconded. I call for the question. [Approval of the amount requested was put to vote and carried unanimously.] ii PORTING CO, INC. 320 @Aass3chusetts Avenue, N.',. Wastlinzto,,i. D.C. 2@jOO2 195 wt 10 THE CHAIP-m@N: O.K., again we are still short Bill Thurman. He's got three black marks now -- but he can afford it,' he's a dean of a medical school and he's got enough major insecurities without worrying about black marks from the Chairman. [Laughter.] I wonder, Sister Ann, since Bill isn't here, if we could again improvise, and ask you to review Oregon? This is a region where we only do have a single reviewer, Sister Ann, since Dr. James is not here. SISTER ANN: There is a staff person here. THE CHAIRMAN: Yes, there is a staff person here, Dick Russell, and he's just coming up here. OREGON SISTER ANN: Oregon is presently at the $767,000. level and they are asking for $1.2 million. They are bringing in three new activities, and a total of eight projects, and they plan to come in, in the July review for a project at the cost of $200,000. The program, from what I can read, and I questioned a few people who were there on a site visit, and apparently it has been a good program over the years. From the material that is presented in the book I was able to identify a strong program leadership, with staff, with t he regional group, that has a good review process and 1apparently it functions adequately. PORT(NG CO, INC. 320 Mlssachusetts Avenue, Washington, D.C. 20002 19b The Regional Advisory Board select projects and 1 assign priorities, and they do this through three standing committees, by which this is accomplished. It was interesting to me that the coordinator of the': program is really in control of three projects with a total of $360,000. You might want to comment on this, this is rather interesting -- it kind of indicates the style of leader-' ship in this'program. MR. RUSSELL: Yes. SISTER ANN: There are eight professional staff and', there are three vacancies that they hope will be filled. Credentials could indicate that the staff is well qualified. Their job descriptions are well written, and if they operate within that framework, they should be able to do a good job. In the past, they have had adequate technical review,@ problem analysis, and documentation of need and technical soundness. They have also addressed themselves to efficiency and containment of costs and this would appear to be on an ongoing basis. The project, submitted in two ongoing projects (approved but unfunded projects due to phaseout directions) and the new activities not reviewed by the Board -- the methodology for achieving the goals listed on page 42 of the project and I won't read it if the methodology is H PORTING CO, INC. 320 Massachtisett@. Aveiue, N.',. 'Nashir,gton, D.C. 20002 198 wt 12 'Ifollowed, it's very adequate. ished The three priorities are ones that were establ !by the Federal Government the availability and accessibility. and improvement of following, and containment of reduction of costs -- it would appear that they would be able to carry out the projects in the allotted period of time. And the CHP relationslts appear to be good although as I looked at the letters and concurrence on the last project, I noticed that there was no return on about 50 percent of them, which kind of conflicted Vth some of the other impressions that I got. And those are the main things that I picked up. THE CHAIRMAN: I think Sister Ann was the only reviewer, but I think perhaps you will want to elaborate on this MR. RUSSELL: Well, let me respond to Sister Ann's questions, because I think they are very pertinent questions. The one that you didn't quite understand the 50 percent return -- was this of letters? SISTER ANN: Yes, that's right. MR. RUSSELL: 0. K. This is a matter of procedure as part of the Oregon structure. They have a CHP subcommittee and all the project applications come through that subcommittee so they do have input there. HOO EPORTING CO, INC. 320 Massachusetts Avenue, N.@. Washington. D.C. 20002 199 3 And in the applications for Oregon, I think it was only nine of those did not respond formally. But the CHP relationships are SISTER ANN: Yes, that is verv good. MR. RUSSELL: Now in terms of the staff, they do show two professional vacancies. Now those vacancies have been filled. They, you know, knowing that it is sometimes difficult to recruit just on short time, they are using interns from the Ten WICHIE program -- The Western States Commission for Higher Education. And these young men are on board. SISTER ANN: I think there were five they were going to bring in -- is that right? MR. RUSSELL: Well there were only two vacancies on page 53 SISTER ANN: Yes, but five interns were going to be hired into those vacancies. MR. RUSSELL: No, I think there were only two as I understood it, and those two are filled. Now the three projects which Sister Ann referred to which show the coordinator as project director -- which, I believe would be a CHP priority as 1, if I remember correctly. The other is an emergency medical service consulta- tion. Yet he is not project director, per se it's that 40 EPORTING CO, INC. 320 Massachusett,, Avefiue, ti.' .@'ithese funds are controlled through the Program Staff budget Viashington, D.C. 20002 200 Advisor and all of that money will be subject to Regional y 4 Board review, and approval. You are right, the Regional Advisory Board is aware of them -- I sat with them for their four-hour meeting to look at the applications, and they have been very much involved, and it has been a very strong program. DR. TESCEPQ: How many of the new activities are going to be processed through, or managed by the University of Oregon? Just in round numbers -- one out of ten, or ten out of ten or -- there are a number of these projects who will be managed through the University. MR. RUSSELL: Very few,, if I remember. DR. TESCH@L: W@ll, when I seO-. the list here look, it looks as if they were managed somewhere else. "A hundred thousand dollars to CHP priority" was the title, and I was interested in what it was. SISTER ANN: But that, then, is when it was under [Dr. Rhineschmidt] and that -is under staff $900,000 and then there's another $150,000 somewhere it's total $360,000 under his direction, so he keeps it in the program,himse. DR. TESCHAN: What do they plan to do with that? Can you tell from that? SISTER ANN: No, I can't tell from the application, but apparently the staff-is going to address itself to the H PORTING CO, C. 320 Vasq,,husetts Aven-----, N.'-,. DC 2ilOO2 201 management of it, but I would think that CHP is going to be 5 involved in the planning, and I think the various agencies in the @area. are going to be involved in providing the services. MR. RUSSELL: What', this is -- this is, you know, in keeping with the emphasis being placed on the particular relationship DR. TESCHAN: That signal, I got. I wanted to know the content -- I can read this myself. MR. RUSSELL: And they have a number of.activities that now are in the developmental stage. These will come in as prO3ects -- go through the advisory group interview, and then will be approved and awarded to individual CHP agencies. DR. TESCHAN: I gather the decision is exactly what the content would be -- it's open ended. They wanted to get some staff resource to move in that direction and to have it earmarked for committee for that purpose, to get the signal to you all and to the rest of us on that. [Reads from the document.] what they are saying, you see, the law is that they have to do this and most CAPs or many, would say: This lin our experience has not been ready because they didn't have the basis to make the judgment. SISTER ANN: I got the impression that the majority ,of the funds for these programs, tha"L-. it's really kind of a ,Ithrust into the future as well beginning in the present, and H PORTING CO, INC. 320 Massachusetts Avenue, N., Washington, D,C. 20002 202 it really would be very difficult to kind of link these programs 6 together in the kind of a model that their Federal Government t time. talks about at the presen Is that right? Does that reflect MR. RUSSELL:- Yes. THE CHAIP14AN: Paul, with respect to the University of Oregon and the Medical School, I recently, on a flight, was I sitting next to somebody from the University of '.Oregon', and I had the -- apparently, you know Oregon is a "different" state you see in many respects. They are trying to keep people out, and they led the way in gas rationing -- but also, its University is one that they are at the end of the line in feeding at the Government trough They get less money in terms of Fe era grants percentage-wise, than any other medical school in the country. And the Dental School won't even accept percapitation grants that, you know, is almost unheard of. So it isn't surprising in one sense that despite the fact that the University is a grantee here, that very many P14P activities now, or in my recollection in the past, has been university-sponsored. DR. TESCIIAN: You really must have a first rate coordinator out there too. MR. RUSSELL: Not too long ago there was a management assessment this was by a management program -- and the best @4 PORTING CO, INC. 320 Via@chusetts Aveiue, N.,,, @Vashingtof@, D.C. 2@@)002 203 wt 17 I can remember, the only recommendation was that the grantee ought to buy some curtains for the RMP Office. MR. SIMONDS: Well, that's a little exaggeration. [Laughter.] DR. HEUSTIS: Well, while you folks feel sorry for the university, I know that they are getting $163,000.00 in indirect costs MR. RUSSELL: I didn't say I was feeling sorry Lor it, Al. THE CHAIRMAN: I seldom have bled for a university. SISTER ANN: But you know, for a university grantee, they get the lowest amount. DR. TESCHAN: What's their rate? SISTER ANN: Oh, 1 think it goes up to 60 percent in some cases DR. TESCHAN: And how low MR. RUSSELL: 40 percent for salaries and wages. THE CHAIRMAN: Well, this is an application for, again, in round numbers $1.2 million. They have estimated that they will be in with a very small supplemental, roughly $200,000.00 in the July request but this is their major request. The total of those would bet again, almost their target level figure of 102 percent by our calculation. 0 40op RTING CO, INC. 320 MassachusettsAvenue, N.1,@I Washin;,fton, D.C. 20002 204 wt 18 Any other questions, or any other comments? Sister Ann? SISTER ANN: I recommend that they get the amount i@.that they are asking br $1.2 million. Their target is just 102 percent. I believe in rewarding good programs. DR. HESS: Was that a motion? SISTER ANN: Yes. DR. HESS: I'll second it. THE CHAIP24AN: We have a motion and a second, to approve, or recommending the funding at the level requested, $1.2 million. Is there any further discussion, comments, questions? In that case, the question. DR. HESS: Let's vote. [The motion was properly put to vote and carried unanimously.] H PORTING CO, INC. 320 Mawchus@tts Avepue, Washi,i@ion. D.C. 20002 205 THE CHAIRMAN: Again, unanimous we're just continuing the complacency of yesterday afternoon. DR. HEUSTIS: I think the Chairman should find a better word than "complacency." THE CHAIRMAN: Everything, in the eyes of the beholder, Al. Well, we are still missing Bill Thurman, so we re going to continue to extemporize. DR. HEUSTIS: If they ever subpoena these tapes, I would just hate to have anybody think we were complacent. THE CHAIRMAN: Well I don't think they will find very many explicatives, or, on my part, many "inaudible" portions. As long as we are on the West Coast, and if John and Al feel up to it, we might want to take one tenth of our MP, namely, -California, which in terms of population, past funding, has roughly come out that way. Al, do you want to lead off? Or John? Again, I don't know DR. HIRSCHBOECK: No, Al does. [Laughter.] DR. HEUSTIS: You see, I have a voice problem, this morning. CALIFORNIA DR. HEUSTIS: Well, California is submitting two applications for this year, and the one that you have before you .4 PORTING CO,!4.C. 320 Ma@chu etts Aven,-,, N @E. 'Alast,in2ton, Dsc. 20002 206 11 is for approximately $8.3 million, of which about $1.6 million is for the program staff. And they would estimate that with the July application they would come to $14 million and you can note, if you care to:@ look on your white sheet that the RMP are prorated figures at $12.5 -- so there are approximately $1.5 million ahead of what they were advised to do. They served the area of California with two regional offices, both of them (note) located near major airports, one in the northern part of the state and one in the southern part of the state. The Regional Advisory Group has established siy@-goals, and six program elements, and they will implement these. The goals are to be implemented through six programs, and they have assigned a percentage of funds, and have determined their priorities in this way to each of the riajbr goals. The percentages are the largest, they held manpower at some 25 percent and the least is 4 percent -- with others ranging in between. The RAG is strong, stable, and very interested and this is judged by the attendance which has a very well- known committee structure. In addition to the Executive Board, there are three standing committees on program development, one on program lireview and one on evaluation -- and then they have what I like,' Ho*(P'ORTING Co, INC. 320 f,,iassachusetts Ave,.iue, N.',. Oiastiipgton, D.C. 20002 207 and the program element committees in each of the areas their charge is to develop programs and to monitor programs. Here, again, it seems to me that real guiddnce is provided to people that would request money, in what the money should be requested for. It came through strong and clear to me that the P14P Central Staff plays an extremely important role in actually coming up with the projects and trying to define what our RMP role ought to be in each of the general areas -- and trying to define what kind of applications they ought to address themselves to, and they actually have pretty well defined criterias for the program development and provide actual guidance and request preparation I don't know whether they actually write the requests or not, that wasn't stated. It was stated that the nine RMP Area Committees that formerly existed, had been phased out and that the program elements committees had replaced these, and that the they were well satisfied with the fact that the volunteers were now doing -- at least I got the impression from the work, that they were now doing a better job than the goo job they previously thought that the staff had been doing. The final budget, as requested, has been approved by the RAG, and first of all, apparently in the process the reports of the Program Area Committees goes to an Executive. PORTING CO, INC. '1120 Viassachusetts Aven,i,,. @Yashington, D.C. 20002 2o8 n of the Board, and the Executive Board recommends a divisio 2 funds among the Program Arzas -- and then the RAG makes the decision as far as the -- within that context, with regard to the applications. I think they have a really well defined review and approval process, which is adequately described and interestingly -- and before I reviewed this, I didn't know that this was exclusive. They used technical experts,, apparently from outside the region -- but the technical experts work under the supervision of the Review Committee. The one matter that I felt was defective, and yet I am extremely understanding, because California is a pretty I complex state -- and other large states have been having similar problems -- and that is: First of all, who speaks for CHP? And how do they effectively communicate what they think, to R.MP? I gathered that RMP bas, what I would consider an "arms length" relationship with CHP and that RMP was extremely strong, relatively, and CHP was relatively extremely weak and there was no described CHP development or input into the preparation of requests prior to the RAG action, except for the legal review and comment -- and that seemed as though Ilat minimal, CHP ought to in some way formally be consulted lilabout what they thought their needs and priorities were. H PORTING CO, 14C. 320 li'ia@@chusetts Avert---,,, N.',. V4ashino,ton, D.C, 2 0002 209 Of course, the whole problem may be that they don't have any need for priorities that have as yet been developed but that is rather reading between the lines rather than reading what's there. DR. TESCHAN: Well, they have had seven years time to acquire DR. HEUSTIS: The staff is well seasoned and exper- ienced, although substantially cut. They used to have approximately 50 percent of the total awards that went to staff and it's now down to 12 percent. The past results that I found, seemed to be impressive both with regard to the numbers trained and, I guess I have to interpret some of these figures, I'm not quite certain how meaningful some of this is, as far as the meaningfulness. We talked about new medical power resources created or "new medical people power resources created" and the number wasn't really very impressive. I think it was a little better than 2,000. But the access to care -- it seemed as though the two major provider systems that had been started and now were expanding with other funds -- they have given attention to urban Indians, and they have done some work with the California Council of Free Clinics all helping the under- liprivileged. fi@00'iER REPORTING CO. INC@ 320 Niasqc husetts Averi,@, N.F-, 210 The record of continuations, the projects without i ing They said that out of 76 ongo was impressive. 24 RMp funds, projects, Or a total of 81 projects that had terminated since @i July, 1960 -- 70 percent had continued with other funding sources. it said that following the RMP In the first yearr . usly been funded discontinuance the projects that had previo ot a total of RMP funds, in the amount of I over three ears f y ear of going along with other $7 million -in the first y with $4.5 million to continue what funds the people came up ressive on. I thought that that was rather an imp was going iaure. ed by all kinds of moneyl The continuations support including voluntary funds, university funds, hospital fundst State Governmental funds In the proposed program, they are trying to set up of what they call "Health Services, Educational a network Adtivities" to cover the entire state -- d yet some 14 of these formed ten of them are incorporated and four are rove the quality developing -- and these are supposed to imp of health care for coordinated state-wide system for health, manpower, training utilization and health education. And again, it mentioned that over a hundred colleges and 120 hospitals(seemed low) and clinics were involved in this with some 200 people on the boards of 211 ot directors of these organizations. In high bloodpressure control programs, they have a state-wide plan, and I thought it was interesting that of the 36 applications that had been received, the project said that sixteen were selected for funding. Then I think the others were, of course, pretty much there. Again, as I indicated before, the thing that probably bothers me the most, and yet probably shouldn't bother me too 'much, knowing what the facts of life are -- are the relationships between CHP and the Regional Medical Program. THE CHAITNIAN: Oh, I think Staff may have something to contribute to that -- we spent four days in California DR. HEUSTIS: It is very difficult for a person with just the information we have, to evaluate the real meanina- fulness of the CHP comments -- whether they are just bemoaning the fact that they haven't been recognized and want to say some things, or whether they really have a beef and maybe the staff could be helpful there. But before we get to that, as far as my assessment was concerned, I have rated on the Review Sheet, all of the items from -- on the first page, program leadership, program staff, the RAG and the performance and objectives in the ilgood" to "excellent" category. H POP@TING CO, INC. 320 flasn[ilisetts Avenue, Olashir,gtoti, D.C. 20002 wt 26 On the second page, I had to break down the three items in the proposal, thinking that they were congruent and that they were addressed to areas of emphasis, and because I didn't know about the CHP input of plans, and because there were criticisms, I rated that down to "Above Average." And then on CHP relationships, I thought these were very -- I couldn't make the determination, and if I had to vote I would have to vote that these were certainly "Poor." But the column that I checked was the "Insufficient Data" and then the overall assessment of the program was "Above AVerage." And the recommendation was made that as far as the funding level, that we ought to know more about CHP. And t en I should say after that that we need to have staff comments. THE CHAIIU4AN: Well, thank you. You have raised the matter of CHP. Perhaps I would comment on that before we ask John, and then Rebecca can complement some other things, as relates to California region. Relationships with CHP there, are uneven, but even CHP relationships one to another, are uneven. Let me explain that: There are twelve B agencies in California and I think the relationship of the California RIAP, with most of the medium-moderate sized ones (Fresno and the northern counties, Empire Valley, which is Sacramento) we met with, during the H PORTING Co, IN 320 Massachusetts Aventi-@, N.@'. Washington, D.C. 20002 213 course of our four-day visit, Rebecca and Sandy and I, met i'with six B Agency Directors and the A Agency Director. The relationships -- I would describe those agencies as Fair to Excellent." Much of this has been as a result of the Health Service Educational activities where the State is blanketed ,by those which have been sponsored by the California Rmp again, the development has been somewhat uneven, but in many instances, one finds that these health service educational activities, most of which are now incorporated as private noh- profit groups, are in a very real sense, the health planning arm, or at least an important adjunct of the local CHP agency. Relationship, on the other hand, with the three major CHPs in terms of population areas @- Bay Area, Los Angeles, and Sani)iego -- are arms length to "awful." MRS. SADIN: Well, LA was all right THE CHAIRMAN: Well, yes, LA -- at least the word we got was that LA wasn't doing anything, so that they weren't igetting into anybody's way. But some of that is a matter of personalities, I think. We found, for example, that in the Bay Area, the Director of the C8P (and that's sort of a federated CHP, as ilthere are nine counties, and each of them with one exce tion p I believe)-- DR. HEUSTIS: Yes, but it seemed to me that in PORTING CO, INC. 320 thssacht!setts avenue, N.[. Olashing@on, D.C. 20002 214 wt 28 addition to the B Areas, that every county had its own CHP, and to kind of sort out the comments it became very domplicated. THE CHAIRMAN: Well, the Bay area.is an interesting CHP -- certainly the most vocal, outspoken, bidder, director we ran into, that was Don Ardell in the Bay area. He was having problems with his eight County Directors, and they sort of meet apart from him. Correspondingly, those B A;jencies, and perhaps the, B Agencies in general, but certainly the larger ones -- I'm not sure it's constructive, I think there was some destructive tension going on presently between the A Agency and the area wide agencies out there. I think the RMP has, on the wh!ie, pretty good relationships with the A Agency. Now part of that may be the fact that the A Agency is, comparatively speaking, poor so that it has been getting some money from the State EMS Office, or from the RMP, to do some of the things @hat it really hasn't been able to get State funds or State positions for. But the picture is a mixed one, but certainly based on our site visit, Rebecca has thrust in front of me here both our report to Dr. Paul and our feedback letter to Paul Ward -- while we did have some recommendations about their IIOOVER REPORTING CO, INC. 320 M.,ssachtisetts Avenue, N.' . W;ithi.qotnn I) C 2OF102 215 relationships, I think there are more that have to do with 9 details, that they really ought to do a better job in insuring that the letter, as well as the spirit of the law is followed. If for no other reasons, the defensive purposes. They were kind of sloppy in logging in things, and showing that they -- you know -- somebody wants to get you over a barrel But we felt that on balance, that the requirements for CHP reviewing comment were largely being met in substance as well as technically. We did, also, have a chance to witness at the RAG meeting we attended, that there are several CHP representatives on there -- one from the State CHP and the area-wide agencies have a California Conference of CHPs -- it's kind of their "trade union" and they have a representative on the RAG and at the RAG meeting we attended an alternate member was sitting the fellow from San Diego -- and they certainly, not only spoke out, and they had some objections, but the RAG took them under advisement to the extent that they deferred -- they were going to look into the matter and either accept them in whole or ignore them -- and I think, you know, that even that slight ation suggested to us that in the RAG councils they demonstr have the ability to make themselves heard. So it's kind of an uneven picture, Al, I don't m PORTING CO, INC. 320 Massachusetts A@4enue, N.[. V@as'ninzton, D.C. 20002 216 at least from what we've DR. HEUSTIS: From what you have said previously what comes up with what I get out of the thing -- I had written down a summary of the comments that had been made, and that was marked in red -- and I admitted that the ones that I thought were important, and I had imported negative comments from six of the twelve areas at least what I thought were impor- tant negative comments of the six MR. BARROWS: I don't think we can charge them with the responsibility for resolving these intramural conflicts within the CHP. THE CHAIRMAN: Oh. no. MR. BARROWS: But we can grade them on their effort to relate to CHP -- and would you regard that effort (and this should be a positive one) as "Good" "Average" "Weak?" THE CHAIRMAN: I would have to ask for Rebecca to comment too. My judgement, I guess, would be "Atrerage" to "Good." I think there are some situations where my impressiot is that California RMP feels that it has walked the last mile. For example, when the Area Offices are abolished, that was a kind of a structured cross-over situation., When lthey abolished all their area offices and with them the area advisory committees, and came up with the Program Element Committees as a substitute -- there became a number of vacancies PORTING CO, INC. 320 MassachuseLts Avenue, N,E. '@lashinptoil, D.C. 200f.,2 217 on various B Agencies you know our slots targeted for the PDAP, we found in the Bay Area that an issue of longstanding Director wants an RMP person, but he wants the B Agency a consumer. But it just so happens that in that part of California Paul has only got some providers on his RAG, and you know, I think there is a real personality kind of conflict. But I think on the whole -- and one of the suggestions we have in our feedback letter, was that they should consider 'II the possibility of havin a fairly senior staff,person as kind 9 of a liaison with the Conference of the Aqencies -- they have met with them, and again, this is not a monochromatic picture at all DR. HEUSTIS: Have we any kind of a written agreement that has been either tried, or achieved, as to what each of them have thought they were supposed to be doing and what their responsibilities were DR. TESCHAN: The answer to that is: Yes, as I recall. Now whether it is current or not is more to the point, but I recall that there was circulated to the coordinators some two to three years ago -- and this was the first example of a written memorandum of agreement as to what RMP and CHP roles were going to be and how each would interact with them. I'm quite sure Paul Ward was .11 PORTING CO, INC. 320 @viassachtjsetts Avenue, N.' . YVashin-6ton, D.C. 20002 218 SCHAN: DR. TE I thought it was a marvel. As a 2 matter of fact, when we got around to signing a statement in Tennessee, we used that as one of the bases of ours. But I think it's uneven tli,= MRS. SADIN: relationships are Uneven. The only suggestion I could think of and we discussed this -- I think we need a Rabbinical Council you know, you 1 just need it, to mediate. I'm awfully sorry, Sister Ann. [Laughter.] You know, in the old days, they didn't need lawyers both parties just went to the local Rabbi, and I kind of thought that's what they needed. [Laughter.] They are doing, you know, the legal part of it and getting the review in comments and submitting the things, etc, etc, etc, but it's a relationship thing that's the problem, in some areas. They are now logging in, as you can see in their applications, all of the comments that are sent out and all 76 projects DR. HEUSTIS: 76? MRS. SADIN: Well 75 -- hot that's a lot of projects for review and comment -- and they just sent me another whole batch from the LA -- and this is all just LA CHP [Displaying a dossier.] DR. HEUSTIS: That came in late. H PORTINGCO,INC. 32OMa@cnusettsAveriue,N.r@. Washington, D.C. 20002 219 MRS. SADIN: Yes, that came in late. [Laughter.j 33 So it is -- you know, one of the things we suggested and this is the letter sent back to Paul Ward -- and one of the' things that we suggested is that they have a senior staff person as liaison, to spend more time and pay more attention to that problem. DR. HEUSTIS: Well I am satisfied from what I have heard, that I would change my recommendation from "Insufficient' Data" to at least a "Satisfactory" relationship. THE CHAIRMAN: Correct.me, Rebecca -- but most of the program elements committee do have a CHP representative on them. This is really their program development thrusti Now DR. HEUSTIS: Yes, it is pretty good. THE CHAIRMAN: Well, I wonder if we want to hold withhold other staff comments, and let John as a second reviewer, take a look at California -- we have spent an awful lot of time with CHP but given the fact that they are probably 110 percent of the CHP in California, also. At least, in terms of family, I wouldn't think that was far off. DR. HIRSCHBOECK: Well, I won't repeat the comments which Al made because I think they hit the target right along the linc in most instances. I am troubled in one way that in reading this over, I didn't see what really happened when the areas were dissolved" H PORTifiG CO, INC. 320 M3S&lchusetts Av@nue, N.[. in;i,zfiinutnn fJC 2tlOD2 i I 220 34 and they were put into two. Is CHP, again, is it moving into the area-wise approach here that existed with@ the regional setup? I think that because of this, maybe this is one of the reasons for some of the problems that they are encounter- ing there in relating to the CHPS. The other point that bothered me is this enormous project that Dr. White is in charge of -- it's how many millions? Altogether, I guess he's asking for a state-wide consortium of colleges and universities and hospitals and this enormous arrangement seems to me reall y going too far. At the practical level, I don't know how they are going to work this out, but if this is the way to go in California, maybe it should be allowed, but I have my druthers about that enormous approach to dealing with area- wide health education aspects. MR. BARROWS: Resolving that at Berkeley DR. HIRSCHBOECK: I guess so. [Laughs.] I have made several visits, site visits, to other agencies in the California region, and there is one for the California RMP and one in their Review Team consulting visits, and the thing that impresses me out there is that things are HOOVER REPORTING CO, INC. 32o Massachusetts Avenue, Vj.%,zf.iratnn 221 so different in different parts of the State that to try to 'WIN resolve a problem on a state-wide basis becomes extremely difficult and this is recognized initially by their setting up a CAP region. And now that this has gone, I am uncomfortable. It's like setting up a Regional Medical Program for a whole nation, and doing it in one as a sub-set of another nation. I don't think DR. McCALL: That is difficult to do. We tried it. [Laughter.] DR. HIRSCHBOECK: So that my overall evaluation is: Sure, the leadership is good. The problems are difficult. The program and staff is good. The Regional Advisory Group I might differ a little with Al on all these he has perhaps read it in a little different way. I had the feeling at least that the Regional Advisory Group- was@ not really involved in the actual process of evaluation as much as other IU4Ps are. In other words, they take the word of others very readily, without being, themselves, directly involved. Now I may be all wrong on that but I sort of sensed that a PORTING CO, INC. 320 Massachusetts A,;enue, N.@. Washir,gton, D.C. 20002 222 6 Past performance and accomplishments ... objectives and priorities -- I think these are well defined. Feasibility -- here, again, the whole idea of true regionalization on a state-wide basis, I think, is Very difficult. In general, I would say "Average" or "Good." "AV3rage" would be my overall evaluation. MR. BARROWS: Let me ask a question: One of the things -- California, as you both pointed out, is not only vast, but extremely complex. One of the very unique com lexities is the strength p of the foundation movement. Now nobody has commented on how this program relates to the practices of the community which happens to be an unfortunate bias of mine -- have they been relating to these foundations at all? This is including the interplay between DR. HIRSCHBOECK: Well some of their projects are involved in the quality insurance. DR. HEUSTIS: They mentioned particularly some of the foundations have picked up the check for some of the projects which had gone on THE CHAIRMAN:: Great. DR. HEUSTIS: Now how extensive this is, I don't know H POPTING CO, INC. 320 Massachusetts Avenue, N.,'. W;t@hingtnri D@c 20002 223 or how wide. 37 MR. BARROWS: Good well boy, that's the acid test to this hard-earned DR. HEUSTIS: Whether this was two foundations or twenty foundations I couldn't -- I believe my notes are not clear. FROM THE FLOOR: Could you tell roughly how mahy grantees there are, other than their sponsoring grantees programs? DR. HEUSTIS: You would have to help me there. DR. HIRSCHBOECK: Let's see the agencies other than central staff that are handling the money -- as grantees. MRS. SADIN: They have subcontractors -- or contracted, that is, most -- for instance, all of the health service activities are contracted to the independent facilities. They are calling their shorts And almost all of what they have, when they develop a program element, they have sent out RMPS, you know, throughout the state, and in which they really outline what the'17 want and then they contract it out. They have in their access, which is going to be coming in in July, they have had something like -- from their RMP they have something like 250 -- isn't it? I think it's 250 letters of intent, which is the, way they go about -,his business., HOOVER REPORTING CO- INC. 320 tiiassa@husetts Aver@@e, 224 8 In answer to some of,your questions on the definitions of area offices -- one of the things the CHP -- or some of i them, told us -- was that well now that they don't have the area offices in California, that we could kind of take their place in terms of local input. And when-we mentioned that to Dr. Mitchell, he said ? fl "Yes, do you think this is the first time I have heard it They have never communicated this to us. [Laughter.] Some said that they missed the area offices and some of the agencies said they were glad they were gone. You know, it was kind of a 50/50 kind of thingi almost through-: out the state. The result of the definition of area offices really you know they had something like a three-months visit when HET,@,' audited them and this was the latter part of 172 -- that was a fact that one of the strongest recommendations was that they not have all of the area-- offices. And I think Paul Ward took the opportunity to follow the advice of the HEW auditors, and they now have a northern field -- it isn't just a central office, they have a northern field office and a southern field office. THE CHAIRDIAN: Yes, but these are quite different. ifrom the old areas. These are essentially administrative HOOVER REPORTING CO, INC. 320 Moss3chusetts Avenue, fall.t 225 wt 39 or for program development, and monitoring purposes. MRS. SADIN: Right. DR. HIRSCHBOECK: One.@ wonders whether they shouldn't really make two @MPs instead. MR. BARROWS: Right. From a management point of View this is too damn big for one MRS. SADIN: Right but MR. BARROWS: But we can't do anything about it. THE CHAIRMAN: I think that represents, though, a very conscious, deliberate, decision made at the time P14P came along and involving what, at that time, were a lot of the influential people in California. At that time you will remember, Breslow was the State Health Officer, and Brown was the Governor, and they made a conscious decision and they wanted a "state-wide" RMP even though it might be juggled. They came out exactly the opposite from New York, which now has six or seven RMPS. So they didn't blunder into it, and I'm sure, like any decision, it had both then and in retrospect both its plus and minus qualities. MR. BARROWS: Well, there's not much we can do about history now. What's the recommendation? SISTER ANN: I was interested in your comment where you said the technical experts work under the direction of the 40OVER REPOPTING CO, INC. 320 M3ssachusetts Avcnue, VJnthinatnn f) C.' 226 Review Committee of would this be inhibitory to the technical experts? DR. HEUSTIS: Are you talking to me? SISTER ANN: Yes, you indicated in the report, that the technical experts work under the direction of the review committee. What's the purpose of bringing in these technical experts? DR. HEUSTIS: Well, I think the purpose of bringing in the techniml experts, as I understood it from a person that made a site visit too, with me one time when we got into this discussion -- is that this is to get rid of the local bias and the local conflicts of interest and the local antagonisms between the centers from which the experts come. SISTER ANN: Then you said that they work under the direction of DR. HEUSTIS: Well, the "direction" -- perhaps if I said the overall direction or overall supervision DR. HESS: Or "they report to" MRS. SADIN: I started in on that to review particularly the manpower, and they do bring in top experts and they have to counteract the ones in California -- and I think what was meant was that the recommendations go into a review -- but it isn't DR. HIRSCHBOECK: But this is exactly the point I was tryingtd. make a little while ago. I think that'the distance 40 VF.R RFPOPTING CO, INC. 320 fla@@husetts Aver,@ e, N.','.1 nil 227 wt 41 !!between the RAG and that technical review process, is at least' at the time that I was out there it seemed to be a larger: gap than really should be. That the RAG should be much more closely involved in the actual review of the project itself and not just take the report with the badge of an expert pinned, onto it. MRS. SADIN: I don't know if they changed it since lwe ve been there, but they now have a member of that RAG present at every one of these which helps tremendously, and he reports back. THE CHAI@IAN: They have two standing committees. A review committee, and; An evaluating committee. Under the Review Committee, the technical experts operate in a panel.fashion, sort of. They look at the new projects. The Evaluation Committee, on the other hand, doesn't have that close line of the smaller committees, and they are the ones who look at and then forward to RAG. And then, both of these standing committees are RAG people, on continuation, so that they have that kind of relationship And what goes through RAG, if it's a continu- ation of the Evaluaiion Committee -- if it's new, it goes to the technical panel. So it's the overall "umbrella" supervision HOOVER REFORTIVG CO, INC. 320 @,iamchusetts A-vepue, N.cl. 228 I of the Review Committee. SISTER ANN: And then @re, too, on page 3 of the Staff Comments, they have 70 requiring surveys, four kinds of positions -- they are adding the 19 -- but one of the concerns is the proposals are not being monitored and evaluated on a systematic basis. And here, I just wondered if adding more and more people would complicate the issue. MRS. SADIN: There is some urgency to this. In fact, they have added evaluations to their staff, and they are asking -- part of the 70 is for more., But we had, after their supplemental application we sent an advice letter back to Mr. Ward. We had suggested that such a vast program would merit that they spend more time on surveillance and monitoring. And when we were there in April -- if anything, they had gone the other way. They are sending the people in the Southern Field Office to the Northern Field Office and require a monthly progress report. So if anything, they have gone overboard. So they are monitored all their people in their Field Offices are monitored -- every single contract -- and' this is the contracts mostly, so that they have a condition written into the contract. H PORTING CO, INC. 320 tlassachusetts Avepue, N@' .i '4ashingto.-,7 D,C. 20002 229 wt 43 DR. HESS: I see. DR. TESCHAN: I would like to say that the evaluation effort of what public accountability of funds really means in terms'of output benefit -- that whole concept was jelled for all of the MIPs in the country by the initiative of Paul Ward and that staff in California. And a good deal of some of the numbers you are seeing, John, and all the rest of us are aware of how that ultimately became generalized in order to get the data together, to show to various critics what the numerical impact of these activities was. I am interested that you consider that some of it became a little bit more Compulsive than others but I understand the atmosphere in which such compulsion can be generated so that I even have some tolerance for that as well.. MRS. SADIN: In terms of the H.E. Doctor, you asked a question about the manpower. When we said "supplemental funding" in July of 172 California of course as usual, got the most money in the supplemental funding for manpower control -- they started out with something like 10, plus the Central Coordinating one. They tow have something like 15 and they just about cover the state. Some are in the planning stage but most are now independents consortium with'independent,boards. POPTING CO, INC. 320 Massachusetts Avenue, N.r Washijitlon, D.C. 20002 230 It's interesting though, that at conferences like 4 the schools of Allied Health Protection -- and they have had some -- there's a national conference in Boston this year they had Dr. White speaking in some of the consortia of the directors. The people at the conference were so excited about it that they then sponsored their regional California conferences they have done some exciting things. But it is a lot of money, though. DR. HIRSCHBOECK: Well, I would like to see it sometime, to see how it functioned. It sounds good on paper but I would like to DR. TESCHAN: Well, John, the thing that bothered us 0 is that each one of their nine regions was about as big as one-point-some million as most of the other RMPs we are talking about -- and to see Paul Ward, in one application, with a dissolution of area offices, just boggles my mind. And Ken s point of "management, how do you get ahold of it?" I am surprised at the HEW Audit. We know a little bit about the origin of that, or nave suspected some of the origin of it, and I'm wondering whether acceeding to it the fact that it has some budgetary require-, ments -- isn't a "giving in" to what would in Ken's view be sound management since we would have insufficient data to male 0 HOOVER REPORTING CO, oilC. 320 Piassachusetts Aver, e, 231 wt 45 or to be able to make that judgment from here. MRS. SADIN: Well, some of the things Dr. [Hirschfeld] has said -- nobody knows this is going to happen -- they had more than a norm -- they recognized that -- perhaps not DR. HESS: You are dealing with a state of some twenty million people, and $2 million for health, education though it seems a lot in one lump sum, is not a disproportionate amount for the population. THE CHAIRMAN: Al, you've been trying to DR. HEUSTIS: Yes, I've been trying to push and I would like to make a motion. THED CHAIRMAN: Fine. We have a request here for a little over $8 million and we have an indication that California will be in -- and this is a request just for continuation and program staff. Roughly, they are at the $6 million level for all new activities in July. That would total, if my figures are correct, almost $14 million. DR. HEUSTIS: If you would then look at another colLLTn you would note that if they did that, they would then come to 111 percent of the amount that you requested for them. And because both John and I have rated this as "Above Average" it seems as though, in conformity with our HOOVER REPORTING CO,:,ic. 320 Massachusetts Avep,,t N.,. LjV;;thir,iinn F) c 2ilf,02 232 6 ill policy of rewarding the people that do well, and taking away i from the people that don't INDEX I would therefore, move that it be funded at the MOJMION requested level, some $8,170,374.00 [The motion was properly seconded.'] THE CHAIRMAN: All right, we have had a motion to approve at the requested level of $8.170,000 DR. HEUSTIS: 374. -- it's a separate item. THE CHAIP14AN: $8,170,374. Are there any further comments, or any additional questions? SISTER ANN: Excuse me. Are there any things that you feel we should look at, or that you think should be looked at, serious enough that by reducing this funding (since they are coming in in July) might be an impetus for them to look at the funding? Are there any points or things that bother you about the region that maybe could be looked at? DR. HESS: But the point is, there is no time for them to look at anything. DR. HEUSTIS: I guess the answer, as far as I'm concerned, Sister, is th at I thought it was a good program f with good management and that the CHP situation bothered me H PORTING CO, INC. 320 M3s chlsetts Avpnue, Wastiip,2Lo,,i. D.C. 20002 233 but that has been resolved satisfactorily for the moment they still ought to work on that, but at this time I think I would say "no" to your question. SISTER ANN: As I read those notes here and the Staff Summary, I'm not all that impressed with the good management, and I think part of it is because it is-such a difficult region -- and as I have heard it reviewed from time to time, and the management hasn't been its strong point. But as Dr. Hess says, there is nothing that can be done about it now except@- in terms of a recommendation. MR. BARROWS: I feel as you do. We can't reverse history. I would certainly not recommend this as a model program for the new House Resources Agency it's too monstrous. SISTER ANN: Well now I would think thatwould have to come through -- it would make me much more comfortable if that came through as a -.--recommendation. MR. BARROWS: But I don't know what it's bigger than both of us. MRS. SADIN: The target that's figured though, you know, which is, I guess, less than what they -- less than the $14 million they have communicated over the telephone and they have allocated percentages to each program analysis -- and' lof course if that came down to -- say $12 million instead of $14 million -- the man had written 25 percent of 12, etc HOO'IFR REPORTING CO, INC@ 320 faas@c[iusetts Avenue, ti.1-@. @]nKhii,.oinn THE CHAIRMAN: They have pretty well -- you know, I wt 48 assume there is some ability to make adjustments at the tail ;,end of the process. But they have gone through a process lby which the RAG has said in effect: One way of expressing lpriorities is that we'll put essentially 25 percent of our money into the access program -- now whether that is X-plus $2 million lor X-minus $2 million -- so I do think we have a notion lboth here and looking at a new application, of what the or where the cuts would come. DR. THUP14AN6 Yes. Question. THE CHAI@.N: All those agreeing with the recommend- ation to fund at the level requested indicate. [The motion was properly put to vote and passed by a vote of 6 in favor and 3 opposed.] THE CHAIIU4AN: In that case, I guess thatis by default. I can't think of any better solution. There should be one, but I canOt think of it. O.K. for California. RTING CO, INC. H p 3,'*Ch@osetts Avenue, N.L Washin@,top, D.C. 20002 (202)5466666 235 THE CHAIRMAN: O.K., Bill, since you guaranteed uS, last night, that you could dispose of Puerto Rico in ten minutes, we'll take you up on that. And then after Puerto Rico, we'll see if the group wants to take some coffee. You and Joe -- I'll call on you first, since you are on the site visit -- well Maybe you were too, Joe, were you? COMMENT:@ No. PUERTO RICO DR. THURMAN: Just a reminder of the fact that a site visit was asked for by Council, as to whether or not Puerto Rico would get any money at all -- whether they should be discontinued. Mr. Nash was on the site visit with us and the most important thing about the site visit was that we had a multi- lingual team, and I think that resolved all our questions because in our meeting with the Puerto Rican group the Coordinator now, he was the Associate Coordinator before he has the respect for the program and control of the people. They continue to have real translation problems, even during the site visit and even though we were multilingual. Some of the concerns that came out were only handled by a girl who was even more fluent than the Site Team was. The RAG is very strong. It's very representative despite the differences involved with Puerto Rico, and poor N PORTING CO, IN' .. 320 Massachusetls Avenue, Alas,hiii,Mo@i, D.C. 2@002 236 wt 51 transportation and despite the phaseout as concerned that ipart of the program in toto, the RAG has continued to work quite well. The real strength of the program as far as the future is concerned, is that 70 percent of all health services in the' island are public, and the grantee being the University of Puerto Rico which is also a public agency has forced the staff to flow from agency to agency, but neverthei-esst has iworked quite well. I think the most eloquent thing that we heard was several testimonials that came from cnnsumer groups about what Puerto Rico and the medical program had meant -- the delivering of health services to the underprivileged groups in the continuing organizations. Ther-rojects were just superb, when you really under- stood them (which is not true on paper, and this has been our problem the whole time.) They have an operational VSRO which is phenomenal in every sense of the word. They have a ver y good plan for their EMS and they are working hard at the geographical spread. I think that this program, having gone down there thinking it wasn't worth supporting for another day -- the Site Team came away totally satisfied that it was an excellent liprogram, and I would recommend approval of their request. HOOVER REPOPTITIG CO, INC. 320 fiasL@chus2tt@ Aveiue, N.c,. 1) r9 @,-l Cil 237 DR. TESCHAN: Second. THE CHAIRMAN: Joe. MR. de La PUENTE: Well I have many good things to say about them. I have discussed with friends of mine who lived there and who have been living with the government structure, which is quite monstrous -- and they speak of Puerto iRico RMP as "La cr6me de la cr&me" as far as entered into our conversations -- with living over there. And under the circumstances I have written -- I wrote a lot that has already been said, but in summary, "Ithis application represents tenacity in the face of austerity in that a viable program is being presented. It is possible to enhance the staffing pattern with the introduction of a physician who possesses some training in the field of epidemiology, and this is tremendous. It is apparent that the Regional Advisory Group has continued their efforts towards program development and review. Their track record in terms of the number of programs that are eventually adopted by the community appears to be better than average. Most of the present priorities appear to coincide with the needs of the Island. Special attention should be paid to assuring the dissemination and application of findings for additional sites lin Puerto.Rico. HOOVER REPORTING CO- INC. 320 fliassac husettsAven,-.,N.E. 238 But I c 3 ertainly, strongly concur with the present recommendation. THE CHAIRMAN: Thank you. Yes, Al. DR. HEUSTIS: I am impressed by what was said. lIn fact I was so impressed by what was said that I looked over Iinto the next to the last column on this tabular sheet, and I noticed that Puerto Rico is one having the honor or distinction (or otherwise) for requesting the lowest amount of the allocated funds, for any group. i THE CHAIRMAN: Yes, the lowest percentage of that so-,; called target figure. DR. HEUSTIS: Yes, the lowest percentage. THE CHAIRMAN: Yes. DR. HEUSTIS: Now, with the obvious need, and I say obvious" need, it's from what you have said after a one- week visit -- and when I was there under different circumstances and not for RMP and quite sometime ago Is this because they were tired, or because they were@ discouraged, or because there was a lack of understanding on the part of what RMP was looking for? Why this low figure? DR. HESS: I don't think that's a good measure, I i lat all. .io.@PORTING CO, INC. 320 Massachuetts Avenue, Viashir,gion, D.t,. 20002 239 nd to th DR. THURMAN: I think I had better respo at. I agree with you, 1 don't really think it is. It's not a matter of being tired, it's not a matter of being fed up, or anything else. This program has been going and again, we didn't understand how well it worked with all the other health affairs and activities. Now they have wanted to avoid an outward appearance of affluence, and that's why they were so well accepted, as Joe points out. Again, I would just emphasize that -- not in talking to people who are getting anything out of it, but in talking to the little people -- and these people were able to speak in Spanish to the people involved -- it really is the cream of the program and they felt that they can use this money wisely and not jeopardize the future of anything else -- and they would only ask for the money they think they can use well. DR. HEUSTIS: Now in view of this, do you not wish to retract the statement that you made yesterday about the people "always asking for more than they need?" DR. THUPJMN: No, these people have asked for more Ithan they need. I would never retract a statement, like that. [Laughter.] N PORTING CO. INC. 320 Ma@mchucetts Avinue, N.,. Washinpton, D.C. 20002 24o DR. HEUSTIS: For the moment I thought I had you, ,lie but I couldn't go further DR. THURMAN: No, I am going to defend the sheet, a little later on, with the fact thatI think it's useless, so I only bring that up No, the only place that -- the place that I would criticize their budget, if you still look at the core of the staff program as to what was indicated earlier -- they just pick up all the staff, and they didn't really, physically pick them up, they just moved them to other budgets within the medical science campus, and try to find a place for them and then they kind of flow them back. And that "flow" is very worth while for the very reason you bring up -- that these people will be able to do an awful lot with a very little bit of money. So that we are approving more money than they can truly use right now, because they are funded through other mechanisms. So that I'm not defending my very dogmatic statement too much. [Laughter.] DR. HESS: The point is: How many people are there in Puerto Rico? DR. THURMAN: Higher than New York City per square H POPTIfiG CO, 14C. 320 Massaf@usetls Avpni,,,, t4.E.1 Wastiington, D,C. 20002 241 foot it's the most densely populated region in the United 11 States. MR. NASHii About 2.5 million I guess. DR. THURMAN: But a higher density than New York City, per square foot of ground. And yet the most of the island? you couldn't set foot on if you wanted to, because of the trees and the water. MR. NASH: Dr. Heustis, that figure may change 69 percent -- depending on what comes out of their application that they will submit. DR. HEUSTIS: I didn't care to exp lore that any more but it just seems as though where there was need was there a language problem. But I think my question has been satisfactorily answered. MR. NASH: All right. THE CHAIPJA-AN: We do have a motion, and a second, on this one -- to approve in the amount requested, which is $696,862.00. Is there any additional discussion? All those in favor [The motion was regularly put to vote and carried unanimously.] 14 PORTINCI CO, INC. 320 Mi@chLsetts A@@e nue, ,iv3sh,!;Igton, 242 THE CHAII"J.@l: O.TL,@., it's ten o clock. I-,Thcit is the Pleasure, of the c.frou[)? !)c) we eiant to take on another one or do %.7e want to break for fifteen minutes and have a. cup of coffee? Do @.7e have anot"Llcr ten minute one? How about the- Tlountain States of Idaho, T',Iontina, 1,7yoi-iincT, and Nevada? COI@l-!'F-NT: Is that al@,7ays that same four states? It's al@iavs been a little unclear in m,7 mind'. T,-Ihat -f Ive r(--@irl now su(-(gcsts it's sort- of a northern It half of ,,'4"7ominc-@ -- it doesn really make much difference 3 T.7 a %,-,Iol:lina has been @l-llPs "Poland" -- there are three R!I,Ps to plot over; in the mountains: Colorado, I.,7yoming, and the mountain states THE !IOU',-,4TAIN STATES DR. 1,TcCALL: They have aot a table of staff and a priority croun, and a nriori-tv setting on a nri-oritv basis, they have handled that in a hiah, medium, and low qrouninc, in this application -- which is a good application -- clear and I think it presents a picture of the recion pretty .,7ell. Tllev have had rouion review certification visit and manaae-@ient assessment visits which came out as, I think iorettl;, r,.u ch all "T)luqes" from that rcaion. Assessment of their past performance and accomolish-1; ment has also been prettv aood. 13 21 -Vyt 58 The current proposals seem to be in accord @@7ith their stated objectives and priorities, and I think they are feasible. m .Lhe CIIP there are four A Agencies and seven B r@lgencier, that have to be dealt iiitla by this Regional "-Iilcdical Program, and thev have received in this anplication, comments from all four A t%(4cncies, and four of the seven B 7@gencies are included. The Ida@o 71@ t%cfencv disapproved one of the projects I the ',?Iivsical assessment field -- nurses -- and the B Acfency had neqative conT..cnts on @ibout four nroj(-cts -- but i.@cr(z! no an in Jcpth study or criti-cTuc of t,iose -- it ,.,as just one sentence co@n@%ients. I state that to sav that I don't I-lave anv to evaluate the aualitv of the CliP revie@q and relations',i4-ns therei but these there -- the c:,,,tert of the necative t-,,,.oe col-l@T-@,ontc, @L-'iat !;"Ould nece,. deali-na %.,Titi-i b,, the @j@P -- and from the a-,)-olications, I Tiould -feel r(-,asonz,)ly comfortable, although I %.7ould Learn the Staff to corimt--nt on these if they @.7ould wi-s.@'i to deal ,@7ith the-,i. This anolication contains 27 nrojects. 11 of these Are for continuation, and 16 are new,-- making u-,o in dollars an eleven continuation of about $1.5 million; and the si--.teen new ones, at $640,000 -- the stal'f buduct being some quarter of a million dollars -- the total recuest $2.4 million. 0 244 They intend to applv for asapplement of some $220,000.00 in iulv. I rated this ",70DOve Averaae. THE CITAIP-T.@-:I: Thank vou, Charlie, and Joe. DR. IIESS: T generally concur with that. it is evidence to me that the T)eople i-ilio nut this -ioplication tocTetl-l r thi.nj,. clearl-,7, ly, and are i,7ell organized, and. are concise usinrT a-c oroce0ures. They have atterinted to reach a n,,j r on r i L out and provi@to cood service to all four states, and they hav,--l offices in each of t@ie four states, and seem to have aood @7or'i-.incT relationships .,iith the state governments, and the CTIIP and so on. Just to co.=Lent on ti ,@iat one oroject that @,le have ne-,ative coruTcnts on -- aiven a little priority in the so i think that mav be a result of the C12,,'.T) Tlcvie@,7. I think'the Cl,"@D comments on that narticular one were relevant but that Has taken account of. The onl,,- real (,iur-,stion I had a@.)out bu(Ic-et @.7as the rather larce amount of mone@i qoinq into EIIS from -?.IIP. I liav@, no doul:)t t-'!,at in that area of vast distances and so on that an @','!S system is an important element to aet organized and Qoina. stantial increas in -I!.IP But there has !)ecn a su..) money goiiia into that and I SU'OT.)OSC that it @.7ould be ap,?ro,,oria@-L@ to sort of flaa that as an issue and as]-, then to take a close 245 look at that when thev pet their Qrant a@iard. )R. TI"CCALL: la- @T 7bc, it Tioul.d be aTDproT)riatc-, to have a staff comment on that. DP,. IIESS: Yes, I was going to say, that somethi,,-l,, I meant to point out -- and because of the di-stance, of course@ it miaht well be justified, but vou can't tell. CI'IAIT@L@l: Yes. Some of the -- while a good Dart of this is con'L--inu- ation, sor,-- of that continuation is really e@,.nansion, and it's largely in the E',!S area. Dick, T don't 1-no-.7 whether ,iou .,ould want to cor.=.cn@- on this, or -,,ihe4-"Iier t'ii,-re arc any nolicv issues. I I . nTiTSS@LL: 2@t this point there are no noli-C,17 there r-Io,@s not to ',oc any police,, -but @.,7 (-I ha-,,e flagged this to make doul,)I.,l sure. In terms of the E"S program in the 'fountain St--.-nltes area, all of these -oroarar,.s startc(f@ out l@7it,i assi-str-ince- c"tates in i@-erms of vcr-,7 small contracts. Like, '.Icvada, for instance, started out v,@,,itli ',17,r,),DC. and as a result --,7ou can sec. I.Ilontana, is t,ie same i,.7a-,I. Idalio. So this is one of their big major program we do have some concerns about that larger DR. TIT,SS: This is one of the thincrs that im-,)ressed 246 me about their management teclini(-iticls; and that is that they ,ic contract ii(:-,c@lanis-i as a device for getting thina.,3 used t, dona that they have identified and Perceived as a means and ,-@ave im-mcoiatelv talr(--n the initiative -- as opposed to @,7ai-tinc for it to coil,.c a.n. -,%nd I think this reflects verv sound, soniiistica4--ed r,anac,@-,,@o-nt on the TDzrt of !ITTIT). T TI. ',TCCAT,I,: Just one other thin, one point that I think riat,7be the Staff r-t4lcr.'Iit N,7cint to cor-uient on, too. It is no-,"-e(-; that t.-ic,7 clcarl,,7 SI-10@7 the allocation of dollars an,', proarar@3 -- and o';Dviousl-,,,, there is a .;ti-ong C;ta-F-f, and have genera-,ed and involved. in a lot of this anc. seem to be involv@-ri @.7ith and mentioned in these nrojects the grantee acency. I n r,,, a nof t'@'le activities, I am )rctty sure treat somebody kne-..7 the rcaion better than I did, m,isel'L -- and that this %.ias acceptable %.@ithin the recTion it @,,lasn't too muc'Ll@ generation. Is this il'IS ex,)ci-id4-ture, for T)rcnarati-dn for a system, for the purchase of hard@.iare? @ilP,. RUSSELL: It's Preparation of -- rather than the nurchase. TI-IE Sandy Flyther and Dicl@ aussell %iere both out in the Mountain States, I que@,s this @.,/as pro.'oal--@l-," 7-,Iarch, or carlish, on a rcvie@,7 verification of the m@---acieni(-,nt. 2LI7 -)@l-)incd: i@evici,.7 Verification Of "@anac N-it 62 it ,I,-!3 c( - Temcnt Assessment --- so r3erliaps Sandy ind/or Di.cl,, V7OUld have some comments as it relates snecificall.y to CHP and also the aoi.lity to manage project,-, under the aeqis of T)roarart staff vil-iich I thinlr. I heard Charlie raise a question a!Dout. Sandv. 7,TIr.HE: BasicallN7, the CIIP rclationshin @iithin the rouion are good. There is one probleri, Perhaps, but they are @@iorl,-incT on t'liat, tr@7inq to get that ,.Iorled out -- but Generally, the relationships are cood. C'IP is in fact, CIIP generated some Drojec4.- ,@7iti-iin tIi.ie rccTion rela4L--j-on-@hi,)s are '-,,asically qooc@. T- ,,T,nic'@-i is, just reall,7, the grantee -- thev !lave no resnonsi-bility 11',iatsocvcr as far as the projects are co,@Icerne(3.1@ Staff and proaram staffs @asicall77 are -@esnon- sible for monitoring t,iat sort of tiiincT -- %,7hich is -ju-@t grantee. t LIJSSELL: I %,7ould -- you Irno@.i, we spent reall-,7 a -v7hole -,,zeek anu- covered, I think at least t@,,o counties ev@r@ da,7, and this is @.ihat it takes. Before He @.,,ent out, @,7e had some concern, really because @.,,e didn't understand that program that well -- as to how one mandqed the proarams in four states from that Reqlonzil Office and i-7(-- @,7(--rc- vcr@7 much irinrcssed Haiti the co-,qmunic@-iti@@'i among the staff and the whole setuD. We kept looking, and 63 looking, and looking for something wron(i and we really couldn'll-@ find it. And I talked i-7itli -Ilocl !,Iercl:er, who had the @lancigemen-'@- Assessment and his impressions were nretty much the same as ours. DP,. HESS: @,,Iell I ended i-iT), based on what I read in here, civi-na them "roo(f@" ind "Excellent" i--atinqs.in nearl@7 everv cate(Tor,7 -- and I ti-iink it @-!as one. of the b(-:7,t orcTanizeC.@ and ma .T!Ps. c managed T BART-'O"-,S @-7hat's the number? T .JE CIII@J- T,'Iell, the 11 !)or is our in the fountain I'@f--a'---c-,s -- tliicv are ar,,- case of the in(7 for @'2.2 ii-.,il-licn no, I'm sorr,i 2.4 million. They did indicate, as I think one of the reviewers said, that they Hill T-)e in for a verv (I)v comparison modes 4- su-,or)lemental additional amount of $200,000. DR !!cCALI,: I recommend $2.1 million. DP,. HESS: I had written Oo@qn $2.2 [Laughter.] So ,7(-, are prettv close. T .)R. TESCI!21-r..- $2.15. [Laughter.] THE I,-7e Have a notion of recommended fundi-.@c! level of $2.15 million. Is there a second? [Th(,- motion pronerly seconcle-cl..] 2119 DR. 4av we discuss this? 64 THE Certainlv. DR. T'I'IUPj,,!N@4:I have no disagreement with everythi.,@ic,, that J:)oth of them 'ilave said about the --,ianaqement. But on some of these projects and the funds for them are absolutely unreal. Now if vou @@?ill turn back to the Staff Sheet here in our little circy book -- and we have already hcard the concern expressed about ""'IS -- and I share that concern $131,OOiD.00 for "levada %,,,hich is for @@,,orkinq on the THIS Program on which they have been @iorkino for ten years. @',,Iow E,@IS in ilontana and Idaho both, make un to $350,000.00 not to mention il.,Iievada's share. But look at some of these other projects. Area- wide, thev would simnlv scare you to the tune of $270,000 and as I listened to this motion, we are talking about a little over 8,000 -,)ersons at the most. 170@,7 you fiaure that 8,000 births -- and jou are going to have rouahiv 120 children that may need intensive care a year -- and -,iou divide that by the two hundred some thousand dollars and it's an astronomical figure. 1,7ell, N.,ie Tnove on dov7n to the breast cancer .@71iich regionally continues to be funded at $30,676.00 and that's an old -)roject, again. 250 And the T@ecrional medical audit system development project, $177,000.00. Let's see, there is one other here that rocl,-,ed mv ")oat, but I've forgotten @7hich one it was But 1 just, I really have no disagreement iiith the management and I know the difficulties of communications and organization -- but the fun(7@iiig of these orojects, I think I am goi.n-t to move to a mountain state now and [Lauqhter-I 7 TIIIE C!IAI The@r need a medical school. !)P. They reall-,i need one. like the staff and the P )P. TES('il2V,I: soundr:, AG are a,,,,ifullv TI-IE CT AIL@-,T,@4: joc, Ithink 7ou want to sav 3o:,-et, DR. l@IESS: 17ell, I @,,,as cToincT to sa,.y that one judgment here about nun-!De.-s of neonlo has to be modified h,,, the distances and the distribution of t-)onulation in those areas and it's ri@ judgment or esti,iate, that i,7ith the TDoioulati-on spread out the way they are, it's qoina to be more costly ,Der person, %to cret some of this more sophisticated services organized and available than it would be in a denseli no-oulatc@, region. So I would make some allowance n my mind for the geogra-@)liical distribution of the population, vou ],:now. so that doesn't upset me too much. 251 the use Al@,T@l: I have a comment to make on of medical services -- because the regions intending to being in Salt Lal-,e rial.it near the University of Utah, -o7here they have funds for the Reqional 1-i-edical Program for juzt the same kind of service and are crying for, you ],Ino@%7, neol-)le to tiie service. I,,n,,t for an air traiiF@i-)or'L' being available in terms of this service, and t',-Ic birth rate goincT down ;-i ver,7 if T.7c jiirt I-,ne-,.7 ho, think tiat is i this T)ro,7raT-,i overlan-)(-d T-7i-th the other nrorTraTn!-,. But this one DrouraiTi, I kno,,,7 is croina to ;De co@-,--)eti- tive and neither of thc,,i are c,TancT to be a';-)le to use their funds effectively. DR. TilUP.-'!@1-1: @i?e could al,-L-,ost buv each babv a plane for this -,OneN7, and let's fl-17 them in. [i,auahter.] '@'!TLI . B AP TZr@) -7S That's a tough thina but mou're oneninq a T,,7hole new tliinc, there i,,,,,ien you start tallzina about numbers of neor)lc and t'@ic other Dro4.)lems. But in connect--ion @,7ith these costs, is it true, or is it not true, t.-iat these -)eoir)le have further to qo in these things -- and theV don't have the present resources that many other reaions do? DT-1. IIESS: 1,7cll, there's no medical school in the ar,711.a nor in the region -- and the@? are trvina to relate -- you kno@@.-'l 252 they are trying to relate you 1 @no@-i, they are trying to build .up their secondary terciary resources in the region. But for medical schools, thev tried to relate to Utal-i, to Oregon, Seattle and to Denver. Those are the four, I guess. DR. THUR.@@@l: They no,,,,, have a Medical school for associates -- ,r)R. IIESS: There 's one developing there, yc-,,c-, and t'!,Iat's the first one in the region, and it's Dust gettina 1 goin(7. TI-IE @,Tell, @.7c'vc heard some comments reaardina budget -funds, and T),-grti-culirlN7 as it relates to natal orojects. Dicl@? MP.,. P.USSi'LL: I ,,iould. like to respond to f3i-s-tcr @-nn'.'@, concerns about the c@alt Lake inter-mountain -,)rogram. 1,7e have, @.7e in have sort of -out the to t'ne inter-regional executive council -- the three coordinator.* You '@-noT,-7, that Council ,,7as formed to avoid ti@- tv-oc of you are tall-,in@ a;Dout, during the phaseout, for somc ot7-aer reasons, it just didn't aet off tire ground. It's back in action, no@q. T.-"e have a complete listi-na that came in just a counle of days ago, of every community listed, and which -@IP is programmed there. 1'.Ie are very concerned about the effectiveness of that committee 253 and we think we are qoinq to see some improvement in there, in their action. DR. TIIUTITIT@4: Yes, and vou lznoi,7 TIR. RUSSELL: In terms of transportation there, i7e have found on tT.7o trips, t.Liat to get to I-T@el(,na, "Iontan@-i, one i-aus'L-- cfo to Portland, Orecion and spend the night. '@'hat'@:, E,,.,Dout the onlv @7ou can got there. DR. li@ISS, Acttiallv, ,71-iat tliev are-. trving to do is @116,00,0.00 is develop local resources and train 1 peonle on ti-ic-, local le-,rcl to be able to T)rovide tire hiq,qer I But that's a cr,.-t-i..cisr,,i of Tn,.i@ia(-e@@lent. l@-- shoT.-is @lLl6 there and $'@.107 on o,.ir sheet -- .in,,i 117 else that difference. is l-,et@-7,@e-n that piece of paper Fnd. ti C You are_, lcol:i-ncr at the vello@.: DR. TEcjC--@l@"I Could this be a typoaranl-iical error? DT.Z. T'I U !-L\@ I it i.,,ould -be less thin a hun@, babies -- at the most i- t @.7oLild !)e. 1'-'O Keith 8,000 c.,-nected births in this nonulation -- and that would, of course, not be every bal-),t7. IIE T@7c-11 mavbc @.7e have -- I don't know T)lclc and I ,.7cre hiicidlincT here ma@7be @,7c have an arithmetical error -- but the -,,clloi,7 slicet .ql@iich you have in your I)oo,,z and vihich I aather Dr. TI-iurrian was looki,.i(7 at, is a staff Output. 25)-', T -ng at this too -- it does DR And I'm lool,:i short 116. THE Yes DR. r'LIIIU@@@l-T, But even at 116, this project is alitterina in cold because -- we have intensive care over all the country and DR. """cCP@LL: And thcv can c,,ct -ntensive care ever-,7 place else, too. DP,. But if you look at -- a lot of this is if ,rou loo,". at the staff slicet and get huncT up on that, vou; are talking a!Dout 'Pl.5 T,7,illion for continuation of eleven projects and some of those -- the last time this came un for rcvie@.7 @,,,ere DR. TICCALL: @,600,000 for the eleven You're tall@ing about the continuation, DP,. TT. In the continuation t'-,Iey are asking fo-, $1.5 million for that. '-HE CI-IAI@',LTu'4: If there are no more comments or questions, the Tiotion on the floor is to approve $2.15 r@illic,@-ill for -',,Iountain ctates. All those in favor. [The motion was reqularl@,- put to vote and carried with 6 in favor and 3 oidposed.] 2 5 TIIT-' C I T,@. I'" think it x@iould ):)e good,, if i4-- @...7ere the conc(--,-Isus of ti.Le cfrouT), tho,,Igl-i, in reT)nrtincr your recommendation to Council -- and assuming they agree in the feed!-)acl, to the !,Iountain States @)l@IP -- that to indicate that there @,7as some concern N-7ith ti-le dollars invested in some of these projects and singling out neonatal., among others, as a oood exajli,-)le of that. DR. T,@SCIIP@l: I thin,',, @,ie otirTht to have a decision no,,7 as to @7hat the actual n-Lui,-)er is. if there are three or four @,ie have several differ'.-,t anO. there oua',,,(-- to be a @@ay to tell the we have to decent thE-,ir,-rnlicatioi .)R. !TESS: I thii as the DR. TESC'-',@-i Ti-re are tT,7o nlaces in the a-o-,-)licatj-c) one is the 16 that vou are lool,inc.T at and I Plant to ]@no@%7 TIIE CIT2N- IT 1,7e 1 1noT..7 I can see 16 shoi-7s $234,000.00 and that includes indirect costs. DR. 'I-IIIUT@?IWl They multinlv one vear by !!R. t@USSrLL: 1,7here are you aettina the 116 from? t What -oage is that on? DR. IIESS: Pacte 105 DR. TIIUPIU@'T I'md page 199. @L'O. 7 I don't r-,ean to set hung uD on the intensive- carq 256 There are an awful lot of high priced and an awful. lot of continuing projects, and I thought I would just go along with the advice DR. HESS: 1,7(-,ll again, this is an area-wido thingi that covers four states -- and that's roughly, $ 25,000.00 per state for developing this care -- and I don't thin',, that is excessive at all. Cli'AI Well, there is some incongruity, I tiiini@-., bet@,7oen the annlication tlie@7 have preT3ared, and the fi,--rur,-,s on the T'orrq 15 and 16 -- @,71-iicii o@@viouslv don't aarc-c. print- I'Llhe figure that @,,7e have translated to the out here is tic Eorri 16 -Ei.cure. DR. TT T UPI' 17\ ",I Yes FUSSELL: I'll see if I can find it on the other sheet .7hen . . . (Laughter.] THE @iell are thev askincT for two ;,,P-ars? DR. THUPIIZ@'. T'IT3. PJJSSELL: If Icould call your attention to page 21, Consolidated Budget :',equest -- 21 of the Application. Because I think this shows how @iountain States Programs it's right in-the middle of the page. The 116 - 231 is budgeted as a discreet project aotivi.tv -- and add to that @91,738.00 which is the rest of t he )T'@ecional Program -- the cost of that. 257 wt 72 That brinas the cost up to 207. DR. T,!cCALL: That is what I questioned. That was the additional budget allocation on the staff looked like about 45 percent of program activities THE CITAI,r-'-14-A@-q: Well, I think that one of the rhinos we have seen, or at least I have seen, and I suspect this is the case in 'L'Iountain c"tates: Some of the more sophisticated reaions (if that's the adjective to use) in California certainly in this class at this juncture, from the n@anaaerent standpoint -- California is budcTcting a aood deal of its nroararLi staff as sort of a i,.)roj6ct item and each of- tile proarar@l cle.-icnts -- at least from mv first !land observation there, that seemed to be a reas.onable form of nrogtam budaetiriql so that a Chuck t ite, ,,Tho literall 7 -,.nenOs, if not full tine),@ a major -)ortion of his here on health services educational activities and and one or t@,7o ot.,,ier -)eonle @.iho are tAe way t'@i(-,17 are set un, the people l@71-io -,,ioni-tor aoarticular program element theV ate sort of the cost of that -,3rocTram element -- as a separate nroject -- and there -,aV be soTie of that here,, also. -PUSS7LL: There may be some of that. I don't think it is thouafl. This is the case: say, for example, that they are g,oina out into a programed area and they will call a nrojett like "area wide neonatal" vou Ino%,7 -- that is a program thru@ti 258 that's a project -- thei7 may have two or three funded activitil es a contract, or an agreement etc -- affiliations So to save tinie, they have budget set aside like you know, M,@S -- if thev need to support a Governor's Conference on neonatal or @@7hatever, then that money is considered a recional" budget rather than tacking it onto an individual project. DR. THUR@@'LA24: But I think I hear what vou are savinal but that says that they have qot $54,000.00 -- if you go al the v..,,a y baclr, to go to consultants to Dut on the regional nroaram.. But vou aet hunq un on one nroaram, or one pro)ect, and that shouldn't be. It's the T)hiloso,,)h,,7 that I am speaking against, to do ov6rfundinq of- orojects for %,?hich IL-here is no validit,, and the overfunding of continuation nrojects. 11.5 million of the @2.1@or the @2.4 that tliev 'liave requested for continuation nrojects some of @.yhich are six I and seven vears ago -- and that is tot aood management. Did vou move that the staff and that they should Dav particular attention to this? MR. RUSSELL: Yes, @.7c will clarify this be-fore it aoes to Council. DR. H'-i,,TSTIS: I sunport thi-s. MR. RuSSE,;LL: ',Tell clarify this. O.K.? TIIE CITAIT@IAII: O.I'@. And this is a prize item for Council, that the Cor,,,-@,ittee, @.,Yhile it did vote a recommendation N,7@4 of 2.15 -- it had so.-i-o- significant concern in this regard and hopefully reacted out and nrovides the Council @.7ith some additional clarification so that they mialit take a critical look at this region, perhans differently than thev @,7ill for most, because the@r are accepting. @,7our rccornn@endation. DR. HEUSTIS: The aTaount of monev for each of these activities -- it i,,,ould be helpful to the determination as to @.,,hother this ,,,,as accurate or not. !1'411. RUSS'-LL: Yes, i-7cll I think I @.7ould, have to noin@ but here that @@7hen v-7-- looked at so,-.(-- of those activities, it 1.7a.,3 as a "continuation" and this P,.icans that thev are continuing in that nrogram area. DR. YCCALI,: Yes but the saj,,ie activitv - tha4k-ls the RUSSELL: no, it does not -mean t e same activity. OTTS @IP,. DATI@. I\-re .,7e on that breal: vet? TIIE Yes. (Laugliter.] Let's TDleas(-- be back !D-,7 a fuarter of eleven -- T i i-iould certainly lilze to )Olis,,@.1 off at least t,..7o more recTions before lunc;-i.. [The assembly recessed for coffee at-10:31 a.ni.] 26o [Proccee.inqs were resumed at 10:501 THE CIIAIPI--ITill: I thought we would jumn to the Tri- State, at this juncture -- that ,,iill take care of the last of the regions where Dr. @IcCall is a reviewer, and that will let hin, without any problems, get away bv-midafternoon for per his earlier understanding. So we have Sister Ann and Charlie on this one. I don't kno,,i -,@7hether you t@,.,o have -- I saw you huddl"na at coffee -- I don't l-,no@.7 @..7hether you had aareed as to who T,,as aoinc to lead off, or TRI-STATE TI'E C,-i.,,II ..'P2T: Charlie -- Massachusetts, -@hode Island, and @-le%q F-am-osi-iir-c. Dil. !.!cCALL: Plight. Tliic, is three states fron 7-1/2 million t)eonle -- and 5.G of that 7.5 -,iillion :jeinq I in '-.Iassacill-isett-,; 740,000 in liar.-osl-'Iirc; and cl'50,000 4,-,on -liodc Island. find at the outset, I think I would also T)oint out in this particular annlication, as far as additional near activities, '-Iamoshire is not in this application, but they were a little slower in getting their rcvic-,@,i and tiiincfs in -- and nlan to come in the suDnle@-nent --.@.7hich will be in the Julv 1 aDnlicati-on. So the "tri state" is reallv as far as this is concerned, a "bistate" of ',Tassachusetts and Rhode Island for this Particular application. 261 t 7 6 I thinl: it's also r@,Fi-k7]Dr@, a little bit helpful initially to lool-I a little bit at the histor@7 of this rc<7ion, because in m@;, jud(f,,-,.ent, in addition to a couT)le of ,notice questions, it's not our -- the ma-;or Question is not coina to be cTualitN7 of staff and program, as much as the funding level -- and it's in this region iihich v7e'v(z-,had a rather exnonentiall-,.7 risina le7iel of funding from one 1.2 million to 1.9, to 2 million -- ancl t.,ieji luri-?inci to 6.8 millioii in 1973, -,)rior to the nhar@-eout, i,.,,ith a current six months current level of 1.4 I giaosc:, that's a six months level of fund4-ng. 4 So that at the L. L 0 !. ,7 'lien the-,7 hit this T)eal-, of -_hc-i.- i gr@,,,th .7it-'-i tire;,, '@)ic,- staff of soi@te 46 nroQram activities going on, util4-zi-nc-, tire contract rather heavil@,- at t@IE,@L. tirio and I l@acl@d,,ror) it a- i .-Lons and thev nu@@ it into a little at tn- ctrrcn4- .Dn ' i c @,'- 4 botlk--e@- nersnective. It means -It,at L@-hcl,r have hid <7oo&, experienced leadership at t'lic staff -- the staff, as I mentioned, T.!as a rather 1--ia staff in '73 !Dut it has become a rather small staff- at this poink@- in tiT-@ct i-7ith six full time Professionals and five -oart Tind there lies also a oint that 'v7e may want to focus on a little bit in terrqs of -- as it has come un -,oreviouslN7 lfiat deals ;Dart time professionals and t-@'le 262 efficiency of same and ef f(,Ctiveness. The Reaional j\dvisorv group and revie@v process, I cent rcviei,,T certification thin'- arc cTobd. .-hev ',iave had re and management assessment visits also by the Staff. Their program and aoals of objectives are kind of interesting. -,hev are verv candid in pointing out, as I sav that they respond floxiblir to national priorities and focus and try to match these to coincide @@7itl-i local needs and that, obviou 1 ma,7 be alittle more fundina strategy than S program strategy and is not based on an analysis of data from the region, per se. But it see;---@ to Pc that the counterbalance of that is that as vou look at the nroqram, they are very candid to say that "this is the %,.iav ,7e do it" and v6t the,, do focus as tliev respond to national focus, to cTet the dollar and do deal ,iit' it -Ln a reasonable, rc-,crional @uality r-nhey use this sl@-rateq,7. There are a coinle o@ @-zhen vou look at proposals @ielve got, in the application, there are at least one or t-,-,,o Police issues to be- raised. r-Ohey are reauest-Lr@a in the staff budget, some $210;000 to contract for the p',,I,,,si.cal manicement and monitoring in 1976. I-.Tell noi-7, tlic)-t @,7e 11 have Sor TIIE .e Staff guidance on that. 2 3 MCCALI@: @,,7c-@ll I mean, that amount needs to be 'rest in mind, and that has to I.-.)c dealt with. Now '@7hat is the police on activity in '76 -- and liavincT the Grantees dissolve a contract with someone else to monitor the continuin activities so as j@nd the Pevie@i Committee to keep in mind that reaiiest is for $210,000.00 -- and it could go one way or another depending on @,7hat the nolicv decision is. P,,nd the other is, not only within the monitoring thereof that request of a little over $200,000 -- it's $205,000, for a fourth year of fundina of an [IVIEXI a PI-iode Island !Tealth Science Educational Council, Tnavbe state wide in Pliode Island. And Mr4 Lawon, former Delouty Coordinator, has returned to Rhode Island as the Director of that Particular nroara,7. -- state-T.%7idc, in scope -- an@, 4L9 also '-he S4-at Coordinator for the e at a 10 percent nart time, as one of @-ie narl-- ti-qe there. So I think that needs to be focused unon. it seems to me that this thina was -founded is the second year of its fundinc.. It was funded initially at $600,000.00 ',Dut cTot off to a sloT,7 start, and I think this is a sioiiificant amount of T-,one,%7 which is left'in that, that theV are using at the rorent. And the comments in @7our staff you miaht indicate in one visit there, there @,Ta@, E--,omp, Question of the effectiveness of the wav this going and vet since that 2021 time and those questions Caere raised, !lr. I,a@@,,,ton has tal@e-n i,@7 9 tile leadership of this project -- one should ma'jle a point there. So those t@io issues of the contracting for fiscal monitoring and That fourth year of that st,).te-@-7ide project on that level of @200,000 I thin'--, @,-,,ould @@,,@int to address this. It seems 'clear that Island has 'iiad some p r o','D I- 7-@. 7, in analvzinq its Priorities and objective-,- and c--ctivitiefl@' cthcr so well as a -,iithi-n that state don't real].,, iiold tocr pro(-Tram but I au,--ss that is not too surprising, according to the stratcav. T@-s far as Cl-i@P one state aaencv is d,-san-nroved has disannrove,-! a project. A-.n-d two B carried tlii-s thev have just. given me a cony of a letter from tile Coordinator, dea'L-ina .iitli these, and it seemed that one had to do with the reqj-onal4-zation of new born care activity. [Lauahtcr.] That @4as so,.,acthinq I.,.7anted to call to Dr. Thurnan's', attention. [Laughter.] DR. THtJPP4,,@ Good thing I'm not paranoid. DP,. @-IcCAI,L: And this :3 AcTc-,ncy that voted dis- anproval of the thing that -this i@ Iliid rated as one of the hi471,lcst Priorities lie since (Totten approval of tile 265 as thev ii-ivc- advised b-,/ the Project Direc@Lor B Agencv that their questions liav(-, been satisfactorily ans%iered. 0 .And the B Naencv also had a certain hypertension a particular coiint-,7 program that had -been involv(@,c, !:)v but that has been resolved b7 the fact that the sT.@jeepincT r)roaram this letter sak,-s it .7as not to be included, to begin @-7ith but in an,7 event, it has been reraoved nov7, and $1.6,000.00 ir3 rerqoved from the bud,-et, i.,iiiich involved that particular COU.-Tit@". -@ncqL the other area of nec-ative res@onse vou see, as @@.,e had to do il,,ith -- a cardionulrionarv Subcommittee nroaram.for resuscitation -- and lacl@: of coordination Keith axis -- and this '".as not baan tot,-.llv resol,.red, but it is bein,7 aOdrcsseJ in this lctte- And I thinl@ -L lil@u necCi some staff con.-ti-,@-nts g ng cor.cernin of three stat---@ 7 and not really understan(-@incl, the c,-P-ocTra-'@A-,. of the n-Li@er!-; of the acencies or the degree of cl ertise, i a,@ not 7 disturbed these three necTaL-ive c(-,riunentf--,. I am sa@,i-s-,-c4-cd thev arc beina dealt @.7ith ind would have no reason to that tile C!7-P relationship bet@,.r(--en the three states ,.@,,,ould ':De unsatisfacto@@l -- but if I am not correct, I v@iould like for to the Staff correct t@iat impression S'-"OLOIII: There are 68 of these- in 'I@lassach-Li,-t@-ttz,, ID(-licv,-. 7!r. '!.ur-)I-iy'@; neg.,tc-,F, their oric4Lnal 266 negative comments by showing that they had, in this anolicatioi, erroneously sent in a letter -- and I believe it was a negative one Nvnen in actuality, it @,7as part of a project which was removed. They are also @"lurphv has, as a result of the @leview nrocess, put on a CIIIP representative on the Executive Board. He has funded a $93,000.00 A Agency pro3ec in 'i-low HamTDshire ,And so bi and larao, I think the A and B aaenc@7 representatives are going along pretty ,iell. T,-7e re vou through, Charli(-,? -@,'cCP--LL: Ycr,, Iam. '7e THE CIIA.1,7!@' @T: then neri.@lans @,7e can cTet S4-ster -,-@n's review of this recTion. ,@d tlicn, certainl,,, co,-,iin(T back to the nolicy issues ar-,oncT other things, I think tl.-;.at Staff c@ocs have some auidance, and sor,,.o. idea of @yhat @-7e are uD to on that one. SIST--!', Z-'--IN: I really don't have anything to add to that at this point. THE CHAIIU47UT: You were on the last site visit SISI@ER @'qN: No, I wasn't. But I would just like to kind of see how some of Dr6blems I have heard over, and over again, have been resolved. rn -JE CIT T lu@ i .LI @IAI ,Iell, T'll leave the problem reso 267 to ri,,7 col.leaqucr:-,, 7ran3,, [',adqE--, and @'tolo V. ,T,ct Lie con,,P..i--,nt, thouc-f'@i, on the t-@@7o polic@, issues., T i7c-@ did in indicate to all of the it -@,,!as permissible, and @7ou are reall,7 (foi-ncr to see 't--his in Tl'!,c,,tro York this af k--ernoon, to pro!-)ose activities 3:)C-"ond June 30, 1975 -- if tl,,iev @,oi@ild )De carried out under -Z .1 I contracts valicil@7 entered into x@.7i.th funds obligated before June 30, 1975. AiiO. there is one suc@.i i-)roje-ct narelv the :r -A 11 I-an@ But .,iti-iin tl-Le parameters of our uolic,@ that doesn't that 7,ce,-,Is to be o.'r.. rcsrect --,o t,@i,- @.71iich Tr-i.. ,,tz,,tc -if -tor t'i -1 e T3roinoscd for iionitorinc, c r 4 o ci @.:?e are -,,7aiti-na Lol4@c-,,, c!ui@,ance. E@'.r a i,@ J, a r, I itold !-)Before ,,ic roconvr@nc@,. -14--i-iat there is @ T@c3-,Io that hopefull,7 @@7ill some sort of decision t'@iat T.7E,- @@ioulO, @@.,,'.'IatcvLr funding, level @.@iould be rcco,-jar-,nc.@,c2 D"?, t'@ii.s groun to@a%7 -- tla@t it in affect nal- a condition or a hold on t'-iat $210,00o.r.10 until the issue can be resolved. ,,'ie Oton't have an ans@,,7er to it. It does brina up an interesting issue on @@,7hici-i there ,@!as somc. agonizing debate among some staff and others about that if @?c arc croin(-, to see activates, at least I I nro,3oseci for continuation June I-Oth next year, at @.z'fiicii ooin@, at leaslt-- sta.L-fs at this point in tiT',)(@; 268 we are not allo-,,7ina (iram sta ding beyond that anv pro., ff fun date -- and, you know, who i,7as goinu to monitor the projects. We had all kinds of@glib answers, grantees, which is at least conceptually valid -- where there is a grantee that is not a free standina corporation. In those instances, i.,ie felt that this hadn't been the first time that a Federal Droqram had been phased out and the monitoring of activities bevond its authorization and funding did seem to got taken care of -- not necessarily 1.7ell, but I can remember the chronic disease orogran that became a part of @TLP three or four vears ago and there was some Federal monitoring of it. So we, in effect, have in a sense I suppose -- said "that issue will just have to take care of itself, 7.-Tid t@7eire not goina to DR. McCALL: One aiiestion that occurred to me that might have some relevance there- or grounds is the region -- at the time this region had the high level of funding of almost $7 million and multiple activities named in the contract -- they have indicated currently -- there is some, maybe $3 million in these contracts still under way. Will these be continuing into '16? Even not considering net activities, were there rhinos contracted for that long, that there's going to have 269 to be a monitoring of, regardless of @,7hit,ls done here? TIT-IE 1.7c].l maybe rrz,,nl,,., or Gerrv can e.nsi,fc-r that question. I don't I,,no@,@z. NASH: I lno,@i of none by -- except PIITISEC the onlV one hangina on is PJIISEC. STOLOV: -- because the exocnditures are now reaching a point of projected rionthly exnenditure rate and tillev need ti-,at money to carrNI them over to the ne@q legislation, so we don't @.,!%-,CALL: 'IlLirfnhv said, "I-I@,7 did thev arrive at the fiaure of @210,000.00 ncc@s@,arkl to m(-,nit [@,IAST4 T .@tink the anF,@,i(---r t.,-icre is t' @,t ,I"'-;F,C pr j-cct, is a lo- of- monc--@, left over from the first fe@,7 7ears. Ccrr-,?,, do @7ou I.Tolll-7 much @-,,as that? @@'@,out little over The77 spent @-200 200 so it ,qa7 at 593 -- a little 1(--ss than 400,000 398. Tilley told me t:-iev @,7,anted the $1@00,000.00 for a fiscali officer, a booll-.1@eeiDer a se--rct,.ir,,,7 and an evaluator the-,7 needed some supplies, some travel, frinae benefits for those crrouns -- and there is definitcl,,-.a budget schedule. The coordinator @.7z-tnte@l, lv7lien discussing, this @,7ith i-rie, was ver-,r practical x@7hen he said, "I-ilien thev get their 270 award notice, half of the Council meets in August." There is "x" number of months for these projects to be VLable. If the grantee, which is a free stand, has to close, he reallv has to terminate his projects around February,'for him to close shop in June. So it hurts the project, and at the same time it would not be practical unless they could find out whether the free standing grantee SISR."ER A-",TN: Is this goinc to be kind of an excepl-ion,in this case? Or is this the beginning of a ne@,7 policv,.> I-!R. 7,IASII: Tell as I sa-,i -- all the free stan inal corporations Drobal3lv face the same thina. THE CHAITEU!Pll: They are the onlv ones that have proposed to deal with it this i@7ay, and as I said, clister Ann, we in staff, after some agonizing discussion to date, decided you know, that that problem x,7ould have to be handled in some wav. But that ,@ie %.7ould permit, on the one hand, oroaram activities to continue bevond that point in t im I think, you I-.noi@i, this is an issue qruite apart from the unsettled,policy -- will- it be permitted is something that the groun can address itself to. T,,7e mav not have as a result of the decision, we ma,7 not have any ontibn, it mav be precluded. On the other 271 hand, the group nay have some views unon -the desirability of it in any case, I don't 1,@no@,7. OT,7S PIP,. BARR I don't think tl-iere s much dispute in some cases. I don't know whether these are the an-oropriate ones or not, but there will be a legitimate need for continued monitoring b@rohd the life of the program, and there should be a reasonable mechanism for dealing @@yith that. Does anybody feel differently about that? !To@tT @,7@@iether these present a legitimate need or continued monitoring or w'i'leth(@,r this is the best mechan3sm, I just don't knoo,@. '."ha-t i DT.Z. s wiat has been the experience ,.,7ith the Ohio Proaram that was ohased out -- then s@.@.e of their activities being monitored I .L@l, I (ion't T'IE inow if anything -- i can sneal: to it, ,jTohn -- one of the Ohio activates, for exa-,Pnlo, there was an [P@HEC7E',]-lilze activity up in the Cleveland area i which .ias continued after the Northeast Ohio Areas phased out i it was continued under a T4910 grant, ..,Yith funds ao'-na directly,: to the [;UIAC-I-,]. I assume, but don't really know, that the P-,Onitorinal that has taken nlAce in that instance has been essentially sta@f monitoring, you ]-.no@@l, from here. There is not a ,@ortheast Ohio li'll,4,P, I don't think (Case Western 'reserve] @%T'liC'Ll was the arantee in the old -@,Tort).-ieast Ohio it!IP, has cast 272 any lona shadows over that. t 87 MR. NASH: No, they are doing the evaluations from that activity. By the i,7a-,I, @,ie will see that activity in a later application in Western P.A. if we get to it today. "HE CHAIP,'i'.IP-l@: Well, we have heard from 14R. NASFT: Excuse me. In view of the RIIISEC thina ,.ihich concerns me a little bi'L-. -@,--rom Staff -- the fact t@iat i,@e have about 400,I),)O. left over from the first t@-70 years and here thev are asl-.-@ng for 200 000. more -- I don't know -,7heL@-her that concerns any of N7ou people or not, but DR. 41@-CCALL: Well yes, it does. T,@7ell, Charlie did bring to the attention Derhans vou .iant to elaborate. --here ,Tas a staff visit -- and this is pre-7@a@,7ton --'@,,,hic7.,i involved., I )-,elieve -,,-ou said Dr. [@iargulus] and he was the Director of the program, is that ri(7ht? "PI .'TASH: Yes. 1 equestioned as to @.7hethe-- t hat orograTn was on target or not. He felt they were cfoina bac'rz into the traditional sort of Health nanpo,@7er activities rather than -follol,.7inc7 tile T,,IP concept. So iDer.@,aT3s with La@,7ton there-, they can get the thing back on track but I just ..,onder if thp-v rcallv need that much iioney- SIST'-PR I was just looking at this 6.8 here 273 on the line-here and the 1.4 next year --,and you @@7oiAld just 8 kind of knower that @.ierc overfunding. S?eaking of funding, I have a COI'Icern: From these captioft descriptions, the real .nerits aren't clear -- at least in the Countrv rjuide -- but here l@7eive got 4,7,7o projects for @,.7:iic'@'i thev are asking a most a half million liudks -- a stud'7 of Health nolicy in !a-,sachusett!l for '@238,000. Health services in tir,.ie of economic transiti $250,000. 'J,,Toi.7 1cq-on't kno,,.7 ,7hcit they are li.]-,e, but sicTht unseen I l@7ould like to take -L@hose on, on an entrepreneurial basis. DR. McCALL: 2\.nd the last one, that naval base in Rhode Island Bc- careful navy, the're goina to call vou a "Tliu@-nan" if vou're not careful. (Laughter.] 7@17. B@@T?)-,,. -,IS I don't Grant to annear cynical or aree,-Iv IJIV- T'.Iiio are the snonsors?- jl!R. STOL@7: @@he Covernor of Rhode Island s-,)onsors the rhode Island one; and @!orris(Donnahuel, t,Lle former President of the Massachusetts State Lecrislature ana no@7 ,,7it-h the Tiniverrit,,r of Massachusetts, ,@as asked to loo,'c- at the state policies issue as a.transition to JL-.ne legislation. T'.,ie (.T.Uestion staff raised in reference to -,'-iode Island and @.,e called t,-Ie '117,7 negional r)-C-cice to cr a 274 better handle on it -- N.ias the need for this in P-hode island 9 for two counties in Pjiode Island --,but the 8taff told us that one out of every ten peonle in !-Ihode Island i.%iere unemz)lo@7@e, as a result of the Defense pullout, and in the tivo counties one out of every five jobs @,7cre hit as a result of this. And half of the jobs were ',j'avv'and the other half was for civilian sunnort of the Navy installations. @nd tile (7-overnor is bringinc! ne,7- industrv into the area, and there-is ci vacuum iiiti-iin that area of the health services -- @-7hether it be later T)erforTPed by I@-L.1-1-0 or TDreoaid health practice or something like t.-iat. But they felt that this ..,Tas an area for focusing on at this tire @IR. BAP,'Pol-,7S: T,Ielll @,.Tith res--ect to this nolicv study, in ',Iassacliusetts, mvlc-,tue-@tion @,7OUld i-)e: 17hat in the hell is CHP and @7,'P been doina for the T)ast six or seven -,.7ears if it's qoing to take 1,2'@18,000 buclzs to come u-o @7ith that I iiould think that @;7ould have been the auts of iihat thev had been doing. THE (7,r--rr-t.7, do -,7ou !'lave any -MR. STOLOV: Well, I can only say that if you read the CHP reports, both the A and 13, thev do suT3T)ort the project, thev feel it's a necessary oiece of unfinished business that tillev need in the health planning transition. Thev did question the U of @lass Has the 275 proper agencv or a governm(:-iital-agency, since the governmental agency is clos@ to where the policy is beina made. Bu they did support. This came from the A and B and PIIISEC @@7ell THE CITAITb',W--I: T,7ell I hear questions, being raise at least by Mr. Barrows, about tiio of those large studv nrojocts. I can only speculate, but 1-iavina sat in I,-Iasiiincyton, I do ),-,no%.7 that the closi@,icT of t'.ic 1-laval base at l,'.Ieil,por t, there were literally full naqe ads in both of the Ilas,,iincfton papers over a neriod of -- I sun-pose a month -- not everv dav -",ou kno@q, sort of public ads Pleadin(7, @,7it",l the T?resident not to close the 'LTaval base at ,,7hich eventually @ias done, of course. Pyid no doubt it had a verv sial.-lificant economic impact. And also, 1 also hapnenod to kno@@7 that the nov--rnor of !Id-iode Island is the Cliairman of the Governors Conference you know the Conference of governors held a committee -- he testified in that L-.,7 before the Senate on the IT.ealth canaci4 @@sources Planninq legislation. Those are just facts -- but vou knot@7 the pressure I am sure for getting as many Federal dollars to fill that 17,avy vacuum in R@'iode island, you know the political and other i pressures, I suspect, have been very fierce. DR. TESCII,,@'@: l@,Tell, I sort of read the question 276 t as: Ilol,@7 @,iould you spend a quarter of 'a million dollars in a vear, and get something out that is worth a quarter of a million? .7knd studies in general., tend to be pub lished and never read. 7-IR. BA-RRO'IS: 'tTo, this is the type of tliina -- I don't kno@,.7, ,.7e can't resolve it but I don't know m@i Conaress can intelliaentlv evaluate anvthing when thev get this Nickel,, !,!6use stuff. T-lere @.7c are, dealinri @,7ith this clisaste -o r roble,,i with a rec,,ional m--didal nrocrain mechanism using this to treat that DR. TT--'S C 1 this is merely nutting a Band-Aid on it. DR. Exactlv. million bucl:s is BATII-TIOT,,7S: @O a cfuarter of a just cone. T17. S'LOLOV: I discussed this with [Ilr. T7alker] Tqho is the new Coordinator of I-Ili-lod(-- Island, or fill be the new Coordinator, and I mentioned stqdN7 Of the $1.40 Der capita goina into Rhode Island, as opposed to 45@ in Mass, and 75@ in Ilampshire -- an d although this is an economic disaster area, when you look at the whole state of Rhode Island, it is a large project and Lawton 277 said: We i-7ill be lookina at it, not only from the two counties, but possibly utilizing it for the State But this is sort of off the record, but the question has been raised, at least to me. IIT.Z. BARRO@IS: To me it looks like two professional staff goodies. THE -@ut to get back -- sorrv DR. HEUSTIS: Can I refresh my memory, can I have P,i-,l Pip-morN,- refreshed? TIIF, Ci'-IAI r@,o ahead, Al.. DR. ilEUSI@IS: Is the -- is this the same mro3ect as has t'@ie health olan education T)rolect that already has $400,000.00? THE CII-@II7,-t-@l@l: Yef" that's their i@T.Eci@ i-@- e activity, @.7here there is annarently a carryover annroachinrT $400,000.00 fro-i -,orior a@.,ards -- so @,,e are talkincT about rouahlv $600,000.00 for t,.Io ?earr, for that activity. DR. HEUS'LIS: This is leaal -- just 7es, or no ."he moneN7 is STOLOV: Yes. obligated. DR. HESS: Could we qet a,descridtion a little bit more? I think it's very, very difficult to make an,7 kind of essential judgment on a one line statement of a title of a project and 1 thin k it @,.rould be helpful, to me at least, 0 knoi-i where to fit in this thing -- if @,ie could hear a little 278 3 more descrintion as to @.ihat these tx,.io projects are the science and (Science Council) and the health services in time of economic transition. DR. t@,!cCALL: The Health Science Educational Council tal,,es in -- the ir,@-)ershin includes all educational health services institutions through the State -- public and nrivate consortium molded into a data base which coupled i-7ith the sophisticated determination of their needs and result of manno@,7,--r su-)-ol I and distribution changes -- maxiinum benefit. Specifically, tais -oronosal is asking for a fourth vear. DR. '!'-OSS: lqhat is the monev used for? DR. -@,'CCNLL: I don't kno@@7. D'.Z. HESS: I knoii these one-nage summaries are not very explicit about these. T for example, is this to some of it I am sure, is for administrative ipurnoses, or is it to nay for faculty, or for conferences, or partly sunoortive -- DR. Tic,-'ALL: Of the 8200,000 rc(-uest, 123,000 is salaries and iyages, In that request is 5,000 consultants, $13,000 rent $5,000 communications 279 $7,500 cori-outer data processina. A,-id of course I have nothing at all concerning t e $400,000.00 carryover. And maybe -- I have not been to the Region at all so I really can't -- TTC)@,7 M DR. IIESS: anv schools are involved in this thing? DR. McC-@LL: The nuTrO,,-)crs aren't in the summary list at all. 'F'411. STOLOV: All the institutions in Tz;iodo Island CI-IAIT?I"@l@,T- Tv,,Iell ho,,7 ranv are there? That's Bro,.,n, Tler.-broil@-c, and -D@-OOLOV: @d there are community colleces as 'T-,7ell, in 'Rhode Island, and La@,.itonis letter r,,,aV be riore spedif-ic -- it does smell out some As to the $400,000 figure ti-iat @,7as as of a fe@q rfionths ac-io -- so the sr)endina rate at the end of this fiscal year nrobablv v7ould be reduced They do nlan to do a lot of subcontractina locally and if you Granted to corr,.cnt on that, Dr. -!,@cCall, as to whether DR. T-ICCALL: This letter is dated ".'@ay 10th, from Bob Lav7ton to Jerrv -- says that . . . interests of 7,hode Island in terrms of 28o 5 regionalizing its health manpower and the continuing education of health Professionals, lies in a fourth year of support for !!I.,TSEC" (Or @-7hatever it is) "In its developmental neriod. This is the product in part of a- slo@.7 start, @4hich is perhans not so unusual considering the difficulty of establishing a viable and coordinated consortium of many forces. "First T- @.7ould sav, and mv presence here is the proof of this, that the concent behind !ZIHST@'C and t'@,-l corinitment of the Dul)lic and nrivate nartners to its success is still excellent. The eleaance of -@IIIS-@C'--, design i-iill be co".@lir-,,.enteci b,,r the productive results of its nrocTram. "Some of the irliAediate and specific objectives, ne-,,71y crystallized, are -L-"Ie follo@-i-ina-. "The develon,-.ent of criteria for need in t.',,.e !-.a]or health Professions. This is essential to determining the gaps after the completion of a current inventory of active professionals, no@v in process. I consider this@, a difficult and pioneer ina, but necessary effort. "2. A major exploration and development of a position on Phvsician extenders of all kinds and their certificate n or lidensure. This @,7ill include an inventory of tic authorized and informal extenders, plus a determination wt 9G of the needs for them, ly type. "3. The application of a successful desian of core curricultirt and career ladder already developed exnerimentallv for inhalation therapists, to other professions. "4 A coordinated Program for continuing education of Physicians similar to the 'comoactl successfully developed in Florid.a. 5 A-malor effort for the continuing education of physicians, r)iiarmacists, and nurses on the @robl6r,.s of drug interactions DR. HESS: can ,.7ou tell from the budoet sl.'iect or an@,-,.7hcre, ho@,7 much the colla'@:)oratina institutions are contributing to this overall nroject? DR. @-,!cC7-k-LL: .@zo, this is not sho@.,in DR. HESS: into monev is sno@@in DR. McCPTL: '@To money is shol@7n as comina from other, sourcesp on the record that I have. DP,. HESS: In some of this there is a legitimate concern of the educational institutions, and I can see %,7here RT,IP can form a linking, a coordinating function. But you no,,q, you kno@,: the hard ,,iork of doing this is basicall@)'i; an institutional resnonsibilitv. DR. TilSCHPI,,T: You don't have to provide them @.4-ith a link DR. HESS: Yes 282 7 TIIE In response to your other question, the $250,000.00 studv health services in a time of economic .transition -- skipping through here, this is in the office of the Governor of L@'iaode Island -- but some of the specific activities -- and I an reading: "7mticinate that during the funding period, include an assessment of the impact of base closings on the deliverv and financing of health care in the affected cop.1munit'.7. "A forecasginq of sundly-deriand relationships for health services resulting from information obtained in the assessment, formation 0, policy ontions and the coordination of various olanning efforts with State plans and resources and then thev go on to talk about economic and ot,ier rqattnrs I sunpose -- I suspect that there's an a@-ifull lot of economic as well as health in that but again, I can't that's a backdron. DR. TESCH7'@Z: T)o @you have to get do@.,Yn to brass tacks.! I,ie don't have enough information here to get a'Llold of this one in the kind of detail that would justifv utting a half million into something we don't kno@,7 @@ii-iat. it looks like a pig in a pbl-@e situation. A site visit would be in ord6ri and seems to me i 283 since @,i' site visitinct- 56 e are noT,7 proarams, or 53, @,7e might as well site visit this one. SISTER AIRT: Pit this time, at this point in time, @.7e have a demonstration pro4ect that can't be completed in the demonstration time -- so their @,ii'lole project system needs to be looked at in the way they @ve desianed these. @And then there's one here "for regionalization and maternity for newborn care in Massachusetts And this hasn't been brought un with peonle Ratio are going to be tiie providers and the consumers and there will be some emotional issues, -o7e could stir ulo a hornot's nest if they are not ready to Use this. So I mould concur that this this seems to m--- a program that needs to be looked at, at this noint in if @ie are going to give funds. n.'IIE CH2 Iho is the (-,u@,, @7it-i the action in T L this arouT)? DR TESCHZ.,A: Thurman. (Laugliter.] TIIE C'.'iAIP@WI: Seems to re that more than almost any region @.7c-have looked at, T have heard a lot of concern exnre8sed about individual projects which by an larae, In terms of dollars, are significant. @".vo studies, each a quarter of a million, the continuation of Phode Island (7.-IJ.1,NC whic'@i, if you @.7ill look at the carryover funds, is at least a half a million. 284 So those are certainly -- and between the three 99 or among the three is getting -- and I don't mean to e because I think the neonatal. one is around $80,000.00 about $600,000 out of an application at this point of $1.9 or roughly one third of the project -- the group has some serious concern with and I think we need to flag that for the Council. ll,qD'zrX DR. I'@EUSTIS: I move we approve it at a million MOTIO"Q dollars. DR. THUPI!D@,l: Second mean to co .tESCII.P@'.': Second I don't m,,oete i,7ith ,-ou but THE CHAIr@@tV-1: We have a motion and a second, to approve at a million. Chuck, I think I saw a little strain DP,. P!CCALL: Excuse me, I think vib haven't heard from Sister Ann on this SISr."EP, @.iN: "4o, ilm DR. HETJSTIS: If mv motion is premature -- I'm DR. @-icr-ALL: I assume that v7ith the time restraints it may not be practical, at least in mummers, to have a site visit. I'm. hot sure. If it were, I would support that. But if .ie are not going to be able in these unurual circumstances, to have one f' and @..,e've got to come un @,iith igure and it's certain that whatever we recommend -- zeroina in on all these concerns 00 -- specifically -- so that if we took the $600,000 back that would leave almost $1.3 million and surelv it's not that simple in mv mind I was thinkina about $1.4 million as a recommendation. DIR. BAR.010@,IS: I think that is ref lectihg the ,.y lole pattern of their approach. If @Tou were to describe this as you do meat, this has more fat in it that anv cut we have seen to date, and probably ever @,7ill DR. THT,'R@@@,T: Can @.ie speak to the issues raised, i I-I.ow June and Julv are not bad months to cet tne I citations rai.sed if there are available personnel. Can we advise Council that this oroaram, because of all the rhinos that have been discussed here this mornina, badly needs quick site visit. THE Tlini-site visit There mav even be the possibility, although I can't vouch for this, that one could mount a mini-site visit bet,,veeni now and the Council A-leetin which one of the Council ers might -- a one-dav sort of thing. DR. 7,!cCll,,LL: I think that's highly desirable. DR. TES(711,7%2,1: Because I certainly couldn't supoort this figure -- I'm havina difficulty supporting million. 7 a DR. HEUSTIS: I agree. 286 I.-IR. BARROl,.7S: I agree, yes, I'-a with voui DR. IIEUSTIS: I'd like to get this in as soon as possible, I guess DR. HESS: I think you have to recognize that currently funded at an annual rate of about $2.7 million j)R. TI.-T@UR@i-kTT Joe , vou we 1 1knoiv that ,,76 have never discussed this Drogram but everybody has said that it has been overfunded. 'I@@ell, is the suggestion one of reallv ttvi.nq to mount a mini-site visit, either before the Council convenes or certainly immediately after before a funding decision is --ade to really Shane the reconi-,endation as to the funding level? Or do you want to out a base fundina recommendation in and DR. T--@-CCALL: I %'70U'-Li like to see us go that route of the mini-site visit before, preferrably before the Council DR. TIIURI-lu,@,",': Could I make an alternate, substitute motion suggestion? Or whatever we reallv want? If you read Stan's first paac-., here, they are as]-@ina for 1886 tv7o continuation projects, and eleven ne%-i projects -- that gives them a T.)rogram before the $671'000. and if you add $324,00 to continue the two pro3ects for a 287 period of time, you do come up with a base of a million, 102 really. And so I thin],,, @@7hy not let's -- this 671 fiaute they don't currently have those people now -- why not let's arrive at eialit, or a million, with an understanding that the site visit would either add to or subtract from but no fundina is possible without NP-ST-1: ,%nd no continuation fund.ina just @qant to mal-,e sure I understand N),ou no,,.7 -- no continuation f iLndino next vear the @200,000. for the [,'\,IIAC@.%] until that. T,-iev have @,@-00,000 no@,7, so it- hurt them at all TI-IE Would @7ou accept that as a Gul-)Stitul@---, notion? D--I. HI@USTIS: I didn't understand that vou've c'ianc.,--,a DE X ?@,IOTIO'-.1 it any except to add the site visit DR. '.T--ll not really. I said, going @@ac,- to the fact that @.7e don','- o,,@7e ther..,, anything,, in -@hat sense of the word, for ',iealti,@ science council because they are carrvlnff this monev for-,7ard. I was shooting for @300,000 which really wouldn't hurt them by the time we@ran the site visit here. DR. HEUSTIS: 1',Iould you change a million to $COO,000' DR. THU-R:.@T4: Yes. 288 DR. HEUSI@"IS: Well, I would support that. 3 DR. TESCiT@-IT: P@-id I second that also. "@'HE O.K. what I have heard -- what we have then, if I understand it, is a minimal, interim -- or not "minimal" necessarily but interim funding level recom- iiidl' )" Ytiendation of $800,000.00 %-7ith a strona recommendation that IOT I O@; T some kind of a mini-site visit be made to @.ristate, lookina at some of these new activities, and also the [..@hacl,:] to determine @-7@.lother that figure should be u Ped, and if so p . ',-io,..7 much -- or indeed, that it i-.iicT!,it even be lowered. Ts that rcuahlv the sense of the notion, T3ill? DR. Does that include the $200,000 for r,ionitorinc,- activates? DP,. ',,:Io that Tiir)cs that o ut. T Dr.,. IL@EUSTIS: You are eliminating that. 0 . DP,. TESI-'.Ttl@'@l: ,r\nd we would love to Ir-,nO@-7 iT'-iat the P,Ar, has been thinking. MR. NAO-H: @-lo, the RAG didn't really approve this, I don't believe. THE CHI%IPI,"@ 'J: T:Ilerb is here, let's tr@7 this idea o t[ u on him, to see if this is reasonabl e the Regional il'I!?.i T@IASFI: He'll be sorry he -i-iall;ed in on ti-i i s a t this tine. TIIE CHAIRvL7"'l Herb, we have spent a good deal of time with Tristate, recentl@7. @,.Ie are concluding now, and 289 perhaps more than a@v other region, serious questions have 4 been raised about a small number of projects -- several new ones that total half a million -- continuation of that i@iode Island PIT.P.C'-@ for which an additional $200,000. is being asked, but -.For which there is some $400,000.00, or mavbe $300,000.00, in catryover funds. And the arouT3's recommendation, which hasn't been voted on, but which is on the table now is to recommend an interi,-,i funding 'level of siri oly $OUOO,000.00 in the place of ,il,r million request -- Y;7ith a strong recommendation a roucr. ti iiat some kind of mini- one-dav site visit be made to Tkistate to look at several of these large, new stud,7-lil:,e activities that are being oronosed, as i,,iell as the -orogrcss and needs -- future needs -- for t,qe r@.-,-Iode Island [A!-II bit-@ier before Council -,..Ieetinc,-, @.,7hich is a short @-ire at.-ta,,,,, or about three r@7eels',s or less than tl--irec i.,7ecks; or be--Fore the final funding decision is made. -@joi@-i this is the first tir.,.e we have come to anv kinc, of a recommendation. I think there are enough serious concerns about specific activities, and questions I,IR.'PAEL: l@lell ..ie, of course, have not beet site @visiting other regions, but I think it's an unusual set of circumstances, in some-thing like this, there is no reason that we couldn't accommodate that recommendation. 290 But I @.7ould much Prefar to have the site visit 05 prior to Council l-Leetina than after Council THE CHAI,@IA,@-1: And presumably, includina somebody from Council bod@;, from Council and liaison. i4R. PAT-IL: Some I think the Tristate one, particularly, has given us some questions, internally also, and this certainly reflects, perhaQs a little bit more em-aiLatically the issues that have come to my attention. Ile can accommodate that recommendation, and -@ii 1 1 act on it. We can't accommodate many site visits because of the tir@ie involved, but certai.nl-,7 in unusual circumstances N,7 e c a,-L i 11'2,. B,-NRIZOIIS: I-,7cll this need is dramatic, too. '-,HE T-.Ie do have a motion to t@iat e---fect, ti ,ien let's call for the question if there's no further discussion. All those in favor [@-he motion ;ias Droperly put to vote and carried unanimoa@-lv.] !.!El@l JERI;EY: 6 CTIAIP-2,@l: O.I'\,. Paul. DR. TESCll-7VLi: Well, the New Jersev application is a little longer than West Virqinia, but has about the same aeneral qualities in being able to describe simply and in relationship to the tegion's needed goals and their shorter term objectives which have been arrived at by explicit': process, so that you can follo@,.i it. '@"h6re are corporate arantees -- tlie,prograin. serves 7.2 million Deople. Thev have established sixteen professions al.s and some eight clerical beoplo a proximately, and they p are asking a Drogram staff support to the tune of $825,000.0@-.@ They have ciaht nrojects, as far as I see it, and i this gnans, reallv, the entire set of goals relatina to access, sunoort of categorical -- suDnort of quality assurance!, activities and some efforts in the area noi-7 of cost contain- ment, and a beginning exploration as to hoi,7 the 10-1.IP and the P@,T mav be getting readv for the next development in tle legislative activities. Thbv also function on the contractual svstem. -,hey have a large contractual buduet -- that's essentially how they are functioning. Thev have an interesting staff organization so that in addition to the usual essential managers, that is the fiscal, development and evaluation type thing, they also have 292 11 time a procTram develoT.)Tient who has a named, on-line, fu manager that has to do with the subject matter -- so that there is somebodv free -- and so vou qet the sense that there is a very discrete program assigned responsibility for the conduct of these affairs throughout the region If you read a and sort of a tiaht, e)tnlicit X-ray. c,@-iart you,can understand exactl-,T hoi,7 thc.--,i are proceeding. Our past e'xnerience is 'coherent @.,-ith the idea that the P2'IC- appears to be extreT-.t--l-,r explicit and active, and has some of the -most effective neople including one of the !'Ien't)ers of this Council in the otl-ier oanel this committee on the panel -- who has been not only extremel-,7 'j',no@.;ledcTe- i able, but verv articulate about the Program in nresentincT hot the PJIP should be- @-ior.@ing in developing not on y CIIP capabilities, but the nrojects in virtually all the areas. I am interested that there are t@@ient@.;, arantees a@-io,7.c-,@, the thirty some nroject-,. They had 30 operational i?rojects but not all of them are current, I might add -- and 7 developmental ones. So th t anona that entire groun there Are quite a nu@--r of arantees @.7hich annarentlv are the recipients of the'contractual funds -- Primarily operating out of Program Staff. So that it's not either centrally managed or grantee managed, or an@7thing of the sort -- you qet the feeling there that there's a good dissemination of resnonsi- bility in the operation of the Oroaram. 293 One of the fascinating thinas about llow Jersev 08 has been the @,7ay thev have been on top of so many of the new issues in terns of better access -- emergency medical services -- quality care insurance including assistance in 'OSRO development -- but also, more explicitly than almost anv other program I l@nO@,7 about, though the Staff-ina kno,,-.7 y better than 1, of course, for good reasons. But the most expelicit e-@,nerience I have had in setting standards for (.Tualitv for certificate of need tvne activities -- i.e. the technical review crrour)s, or the committees have put together standards of excellence, or standards of aualiL-Y care, in a whole varietv of specialized and snecial'L--@i 7,crvicesi P-nd one gathers from the narrative, that these have, in fact, been used in certificate of need and that the 122,T Corn,-iittees have been used b CIIP certificate of need t e activities i y yp for advice on the basis of standards -- but not onlv the standards have been adonted bir CIIP but the staff has Participated in the review of certificate of need and given the professional and technical advice to CIIP delibor- ations. !Tow that's reall%7, one of the first e,.-Dlicit IL D el,] and other anDronriate T)eoole's attention, that interaction is a reciprocal nrocess and that we should have Mandated bv regulation quite aside from legislation reciprocal interaction and re-@nonsi!Dilitv, mutual responsibility, 4- e-,-iolicitlv direCL-ed frori the head of the CIIP P,-gency here, to all B -@3,qenci.es particularly, what thev do with the @ls is a different strv, of course, and it's up to then. Secondlv, that so far as our deliberations in this Committee and in Council, that we should ignore the negative C'@"P comments, except as (a) number one the B Aaency informs the local P,l@4P of their criteria and revie@q in common Drocess nreciselv as our P-@IP informs the B kgency of the @.!P"-, review of common oro3ects -- total reciprocity. (b) number ti,7ol that the B Aaency shall furnish to the MILT' acTency, e,."-,)Iicit statements of the objectives and priorities and as need statements, against which 29b targets their development. So ml,, feeling is, yes, vie recognize and feel entirely appropriate the PTIP should respond to CI-IP 4ust exactly as said -- no argument. f-.@ut that it needs to be done at the sane professional level to i,ihich ',R!,,P is 1 N! LT-i 1," called. That needs to be established as a .PBCOI@ll,!F,I,TD being Sim-ile issue of basic integrity betv7een the t@170 nrograms Darticularly if thev are aoina to be legislated into some kind of relationshin. I',o@'T that's a formal recorr,,.endati6n I would like to have this aroun discuss and cbnsic',er at some point. It's a digression from the current thinking and And no,,,7 m,,7 final,, to sum it un, I think this is a beautiful n roarar..i,, a ton level oneration: Our feelina is that w6 would probablv recommend the funOina a-ooroxi.r,,atel@y 15 to 20 nercent above the current taraet but minus a out $600,000 is duo about JtlN7 lst and that comes out to be a!3out @ll-.9, million. And that the Reqion essentially should be congrat- ulated for the .iav t'i-le-i r have proceeded. r)'.1. IIEUSTIS: IViat @,,7as vour figure IcTain, please? D R. E, S C, $2 . 9 DT-Z. IIEUSTIS: And then you're qoincT to knock them do@"7n by amillion? MR. ilASH: T'Aii8 application is 3.9. wt 112 I,,T . BARROI@',,'S: Yes, Nie are knocking them do@,7n bv a million bucks. DP,. TESCIIAII: I thought that the recommended funding relates to the taraet, about 15 to 20 nercent above the tarae@- minus.about ,@601),000.00 in Jul-,r. The@,, are over target b@r some I forget @.7hat D',n,. IIESS: Tliev are currentl,.7 funded at 1.6. DR. T'-SCHPjq: And I thought that from 1.6 to 2.9 it's a substantial rise anct it allows a little monev for the i Julv 1 Council situation, and it brinas it a little closer in line -;ii,--h -;Yhat the -ficTures a-,)t)ear to be, ,,.7hich are available for the nroqram. I ,iould have no objection if some-hod T%7anted to y fund there. @-lly or in some larc,.Ter amount, Vou knoi-7. u TITE CH.@I !A@l: @,.Iay'-,)e .7e ought to, since l.'Ilr. Barro@.@-- was the other reviewer on this, hear from him before .je carr@, the matter of fundina level, or other comments or observations further. MR. BARROWS: Ply revie,.i is pretty much a reflection! of j st what Paul has said. In short, the program leadership' u ranks, participation, I thought, Has su,,oerbi In fact, overaill I came out i-iith the impression that this @ias particularly in depth, the type of program I i,7ould recommend. Period. @.h6 relevance of their nast activities and the q8 proposed activities in the broad, PIIAP mission, was just top notch, and more than that, the,,7 are relevant to the needs of their area -- Particularly the underserved, seemed to be just right on target. I was deeol-,7 i-iirressed. They had another attribute which N-7as outstanding and this to me, and really this is maybe a philosophical matter with @,71lich you P,,,av not all acTree,: We need the ideas, the (--xt)ertiso of acade-.iia and we need the suT)-r)ort of t e GoVernrtent if we are rcallN7 goina to (Tet anything reall@7 done in the mainstream of ir..@nrovina. It's cTot to come from tiie T)racticincT, Professional level, and th6v have done more than anv program I have seen, to act the practicing nrofessionj involved. With -t.'Llat, I came out !.,7ith juf-7,t this ver77 ton rati-nc,@ and 1 dismissed the CIIP thing as a ventilation of n,--r@,onal pique @7hici-i had to merit. I ECT.IAIT'-?!@p@ !@.aybe I ought to ask Franl,,. I think we have an issue that is resolved here, Frani@ on the '!!Z.. NAS@"@: You mcaa on the C"-P? Yes, riaht. '@@@TASH Yes 7oll, of course Dr. Thurman is certainly accurate in his description of the letter Dr. [Pord?]'s affair -- it Has ',Deiutiful. Pnd I have since heard from t'tie region that the 4 B Agency Board anvroved, I mean, recommended anproval of this application -- so I thin]-@ thit this ]:)it of "spleen venting" by the CHP Director who has onl-,r been on the board about five months in that Particular agency anywaxr is 'LIIE CTiAIR!,@l@l: Have vou oot anv more insights on the warfare in Nev-7 JerseV, ',Torthern NL@w Jersey, Tom? FROPI TIIE FLOOR: That's not my bailiwick. TA"@ CHAIPJT@@i: Oh, oli, that's right. Ne@.7 Jersev that's a conout. (Lauahter.] DP,. T4@ISCHAIT: T'm lust callin@! for fairness and ecualit@, CIIAI@!@,l T,IDll that is a -- the letter ,7as a Director's letter, but the Board -- under v7hat duress or -oror@inted by @,,,hat reason, did tai@c,- iction criii-tc on.-po.,3i-te to that, abnrovina the Jersey anT)lication. I realize you're just as,'-Iin(T for fairness and equality I'@R. @.@ASi'!: r-Lo reneat, i-7e iyiav have a -Dolicv question in this particular region. One of their proposals is to establish 3 PS70s and 1 don't know whether i-ic can use our money for the actual establishment of PSP-Os or not @14P,. BARROI,TS: Is that to be establ ished, or just to provide the Preparation activities? !,,IR. PAHL: Ilri not sure, it's backun support. 300 COI.1,@r'ilT: It isiil-t actual. support here, though. u 't 5 TIATE It may be an issue that i@,,c want to flag, though, and get into some consultation, if we haven't, with the appropriate-PSPO staff here, and defending unon the outcome of that, we mav, or may not, i-7ant to highlight something for Council. I have the same question in my mind. It certainl,7 is, in one sense I think, verv consistent with the kind of qualit-,7 assurance activities and standards settina or standards development, that has characterized one r@iajor thrust, Of the Jersev -rl@LIP. on the other hand, 'Bureaucrats have a ,t7av of BARRI,)I,7S: Pete, I read that as sinT)ly a resnonse act readi to helT)incT the ri(--dical coruiunitv for this program and '@IIE CHAI@L@il: 11-c nav want to c'-Icclr, un tiat @S7.0 -staff, I think., in anv case just so that neonle don't have their noses out of joint around here. T DTLZ. T'-7SCIT 121..-'T: T.ic basic funding of the PSRO comes from the nrocessincf of the business -- so '1,7ou knout, it isn't goina to take the actual financing of the DSRO-is not a problem. @IP,. PAHL: '@'.,iev want to T)rovide the same type of sun',Oort but it's a B a@encv. T.Zo,li are there anv other matters or If 201 or coi%-nents or questions of the two reviewers, or of the that matter, that relate to 1',Iew 4 6 staff, for @fc,,rsey R'klP? DR. HEITSTIS: Do you think Barro@.-is will acree with the money figure? I-IR. BAPROI%7S: Well I was a little more generous. I'ri not as qood at nickina figures out of the air as vou fello@,.,s are but I would sa@7 that when we wind un, this should be in the nreriiium category -- verv clearly in the nteiiii,an,i Cdtcqor-,,.@. A.@TOT,I, There that fioure is, I Oon't IJ7,no@,.T. T.-7p-]-l, the@7 are askincT, as raul has indicated, t'-ie7 are r(--aiiestiiid in this a-)nlication alriost 84 million -- 5,3.970. They have indicated, and that does not incl-uOc anN,, neT,i activities in one sense, alt@-i.-IOUC7,-l t'@iere is sor,,e nc,q 'oroaram staff activi-L.-%i, I gat'ier, and scnic e:@nansion and t'ie@y in @.7it:-l a Jul,i an@-Dlica4L-.ion that tIL,@,el,, s ti,7. a, at @1'000,000. DR. T"l)rlT:41- 11 like I sa I have no objection to UnDing that amid, but I just didn't know ho@.,, to'do it. DR. HESS: Let rtie ask you a cou-,:)le of questions: -,.,Iu@?er one !,That t" c - lation of the rea4.on? .L)ouu SCTT,?VL DR. TE Li Seven and a iialf. "!P. NASII: 7.2, really. DR. IIESS: And is this just the state of -Tc@,rscv? 302 HE c:-T @r i @,ight, it follows the state line. 17 There is some overlap with Treater T)elaiiare Valley in the Southern and less populated -- Philadelphia and Camden area, and the Cranberry I Bogs and the resorts But I think certainly ilc3T.7 Tcrsey ?!,IP has defined itself as the entire state and, indeed, have conducted activities throughout the state. 7,-IP,. i:@'.A.SH: They sent a staff nerson down to Southern @Te@@7 Jersey, and T)aid the salary and all bxnenses for a year in establishing the South Jersev CAP agencV. Thev consider themselves a state-wide program. Rod r,urT,,)I.-.y? TI'@E CIT7 I\ I @ 7',Tl @l -)ac- today Oh, t.7es, -,ocl literall,.7 is from a management-a8sessinent visit to I'@@ew Jersey earlier this week. '-;-4R* MERCKER: I spent Tuesday and T,@Tednesda@,r -,,,ith the Proaram Staff of the @le,-,-,7 -urersev reaional ',",Iedical Program and their management is excellent. The nrograr. nanaacment in -)articular they are ii the nrocess of tal@incT full corporate responsibility from the the TJniv-crsltv medical School -- and thev "lave dcvcloned the additional pol'ICI,, basis for this, @,ut they still have some administrativ e rianaaer,qent policies to develop. But their nroaram management was 5uDerb. Thev have a wav of operating hv health specialty areas, @,7!iere:their staf.L- 303 interact extensively and effectively with the @-it 118 members projects. It was very, verv impressive. THE CHAIPJ@,9-,IT: I don't think we have -- unless the Chairman missed it -- a formal recommendation on the floor to -- of course a fiaure iias mentioned, but I didn't ask for it, nor did I hear a second. 14'-Z. BARR(Y,,7S: I'll second that. DP. TFSC@IA',-,T: I m beginning to hear a concensus because if- ,.7e have a 7.2 -- and it's on a per canita basis Tell be talking about 3.6. T l@' C@TI T'i !,.re you revirinq your motion? DP. I',-i raising the Question. T@'ARRO'1'7,c@: I would br-- more comfortable with something like 3,or 4, or 5. '-HE CiT!@IPI!Ll@T-.T: 2.9, 3.4, 3. 3.5 V7'@-iat do I ,iear next? [Lauchter.] PUT@ de La ' ..ITB: lqell in vie@i of i-.7liat I have heard, and in vip_@@7 of the budact t.-iat I have seen, and -i-n view of .,7'ilatever I know of the @,,TeT,.7 Jersey proaram, and in ti view of ie other suggestions that have been made during T this session, - think that @,l million do@.yn from the figure they have reaiiested is too much. So I would go al.ong i,:ith 71r. Barro@.7s. T,",-IE CHAIP-Jl7j4: Sister, you have better connections than we do what do -,7ou sa-,,7? [Liuqlllter. 3o4 Barrows, there is one thina I 9 SISTEP, IVIDT: ?-,Tr haven't worked out, and that is the process of discernment. [Laughter.] DR. THUPJ.IPII: After T,7!iat Joe just said, I aaree with this, and I am certain that all of us who have seen et..7 Jersev, verv pleased 1,7ith the N-7a, are very it runs. But @,,e are talking about a reaion right none that is go-ttinalyl.4 million -- and then we are talking about suddenly 16aoinq to $3.4 million. CO@'r,IE'-!T: -.oTo, @Y3.6. on the other sheet. TTLIU@,,@-3,T: T'-,,en I go back to my criticism of the sheet. But on the other hand, I think that's an unreal lean into -- TL". BAP,,2,0',IS: @,,Iell, @7ould vou buV $3.2? DR. THT7RrvT@,l: I @.,,ould go back to 2. SISTEP,, AIIN: And I go back to $2.9 too that's DR. TESCIIAII: T,,P-iy not riove for 6,2.9? Now that's with the point that this is the superlati-,, storv,l and if the Council felt disposed to increase still further, that the Review Committee would take no umbrage of that. DR. IIESS: I would like to just make a point here: 305 egion that 0 I hate to see us uiidulv influenced by a r comes in with a huge recuest and grant a lot of fundst just because they ask for a lot of money. In other @@7ords, @,7e look at Puerto @'ZICO -- a top notch program, that comes in with a modest request -- and ,.7ou ]-.novr, prettv close to @ihat we think they can use- and vie mi-ve then, that. @loi-I this is a first rate program, but they come in you 'Izno@,v -- @7ha-t they have previously been royal", 1.7ay over qettina in the last year of funding. And somehow, that just dobs-n't sit richt. DR. Could I add sor,-Lothina aqaj-n? '@PHE CHAI@T--,@T: Certainlv 0 Bill. DR. Do you see anv need for an extra Slug OIL rrione@i for them to carrv out their corporate L--hitQ? A modest sur.-.i of r@ionev. Thev have i requested an added accountant to the staff. -N T)r., X I second the motion for 82.9. we have a motion to recommend fundina @eN@i -rersev on this annlication of @2.9, with the sense, I believe, of the qroun that certainly it reflects a favorable task toward the reaion and T.)resumably (but again one-iias to see the Proposal their supplemental uronosal should be lool,-,ed at in July by this cfroup) in a quite favoral) 3o6 That should I)c-- around @,600,000.00 Is that essentially the sense of the motion? DP,. IIESS: Yes. !,IP,. BARROI 7S Yes. TIIE CH,7\IPJt@4: Is there any more comment on this? If not all those in favor -- [The motion was r6gularly but to vote and iDassed favorably by 3 and unfavorably by 1 vote.] THE C 0.1', it's (as they say in lioll)n-7ood wt 122 "High 1,Toon" and I think ,,7ith the concurrence of the aroup, this is about the busiest time in the Cafeteria and I t hink we do have time for -- DR. TESC',IAIT: T@-io more. THE C'n'AIP@.4Tll: Ti-io more? Well then, you will have to help me identifv the eas@7 ones. !Iochcster has been Suggested is that one on which you are not the reviewers Joe? D:',. TI@v,SS: 1,7ell, I couldn't make the judgment if I @.7eren t -- [Lauc!hter.] Oh, I don't kno,@,7. DP.. The humor is qcttinq strong. I"T think @.7c are coina to have to cat in about half an hour, things are &ettina but of hand. It!ell, @.ihv don't @.yp- just lead off i-Tith TZochester and ask Joe to lead off. DR. HESS: Hess volunteers. ,IOCT-IR TR ,ST- DR. HESS: T,,Iell, this is the third aT)Dlication which we have discussed this morning in which there is an inverse relationship between the size of.the -- the amount of paper and the quality of N,71,,Iat's on it, at least in r.,.y estimation. 3o8 In terms of the overall organization of the M-SP thev seem to be well organized in terms of their overall goals and objectives, and they are consistent with the national aoals and objectives. Their review Process is clear and @.7ell defined. As near as I can tell.,from the application, the leadership on the part of the program staff, seems to be hiqh quality. identified within their region hey have the areas of need -- thev have apparently done some good bac!<.cTround .-,ori@ in terms of the identification, and th--1,7've got a -Ileaional Plan @.7or,@:ed out wl@h displays it clearl@,- and si-inl-,r on a na-o -- -oarticularlv in terms of their undersurvevs and tie nee--I of nrir-.arv care, and that tvne of One of the thincTs @.7hich I enjoyed about this anDlication -- thev have their aoals, and then at the baci. t" ,,ev have their objectives of the orojects relatec@ to 4--'ie goals -- and the funding is dis-olaved riclit alone it. (Disnlays a document.] Their overall goal here, and listed in nriorit y order the way thev nriorize the Projects -- the non6y that goes @-7iti-I it. PTIO then the cumulative total that ,.7ill ',-)e sDent on that particular goal. ';'To@,i this Particular application is onlv for a continuation of a core staff, with a small increment blIs 309 ,r,,7t 124 two small increment -- two small projects -- and the rest of what we see listed here under "goals" will be coming in in the form of projects in July. So that basically, all we are asked to do here, is to proof the cumulation of a relatively small corps staff land ti@io small projects, and this is communicated in such a well orcfana-zeo. fashion. that it just seems to me they got their heads together in that region prettv i-7611 -- and I was favorably impressed and I see no reason why we shouldn't give them i-7hajl-- they ,.-,ant. Din. I-r@@SCIT7',,-.T: Is there r,-..ore coming in i D@@. I-IF@SS: Ye-s, the@7, are comi-i-ig in -- there's a big increment cop-incT in in Jul-v L-iie zDro]ects. '%-"ou can alr_ad@7 see clearl,), ,,,hit those -orojectg are going to be and t,iey r.7ill relate -Lo t.icc So I have rated -Llic,,.l on eit'@,ier "Satisfac4L-,o@@,_,," or "FI-Icellent" in every catecor,,,T. j us t t-70 tl- at ierc @.7cre L J6 I put "Satisfactori" on hoiiever, @.,,ith rore information perhaos at staff level, the,,7 mial,.t ,.7ell be categories of excellence -- and overall" based on Nihat I see ',-iere, I have rated it as a "SuT.)erior" region. L: What's t' c "T"P? AR. PA.TI DT-11. TIIUP-",Wq: Ed Lane he sent in a nice letter savina he sunDorted the @,7holb thina 310 TH-- CIAIPJAP.'-,T: You have a region here, an R@.IP, -125 @-,,Iiich qeoqraphically is defined in exactlv the same configuration as the single area'iliide B Aaency Genesee -- they have, I think, good relationships, and I think N..,,e may even have an incestuous relationship developing in the sense that I believe Peter i@lark"s brother may become the B P@gency T 7 Director, Zenith @alter's retirement this summer. l,o@,7 this may not helD -- havina kno-,.7n other brothers, but DR. -..4o sisters? 1,3ill, %7ou @,7ere the other revi-e@@?er on this an-olication it is a vcr,7 modest one in -- both in 'P amount and in it is t--hev are proposing notq. -,ut i-Te tt,K 1-7 11 their $1.4 million a nlication is qoi g kno@,7 -ore c a,' n- n to look like in terms of s.beci-4ic activities. Joe said everything that i @-,o-Lild have said about those priorities @,ioll organizcj, stron(, @-G, grantee situation is a separate from the standpoint of i never having had a real evaluation group; and the C171P voted unanimously to recommend a proval of the annlication and sent a very good letter. So that I @-iould support everything he said, and recommend the absolute figure of $361,437.00. Tli--v also bring up the. cTu@2stion in their aT),olicitoni though, that they have put out an RFP of September 1, 174 June 30th, '76, in the @FP that t.,iey @ave distributed all 311 the way down -- this is the health care deliverv program 6 and always has been -- @?1,300,000 THE What vou are sayina, I think, is that we may see a nun,Dcr of activities.proposed in the July application, T-7liich would run beyond the end of nel,ct fiscal missible to be year -- which .qe have said is at least per looked at. ill see @@ihat we Again, I don't knout whc-!tl er i,7e w are trvinc, to look at in PI-.etro ',Tc,@7 York later this afternoon There almost ever@:ythi-ng be proposed for tr,.7oT-ars. @@'.Iell Bill, 'IOU iianted to sav somethings D R. T'@' TLUR7t@-T: I .Ioul(." second. '!'TIE Cllt' You @@7ould second o.k. DI",. HESS: I so move. laughter.] [-Lhe motion was regularly out to vote and carried unanimously in favor.] THE O..TL@., I think ,@ie have it.I think that is a record we even beat Puerto Rico on that, Joe. t 312 V127'@SHIIIGTO'.,l & AI,A-!.',il 7 THE CHAIP,,"-IP-@T: I think x.ie could, again, probably take up one more region. Dick gave me a nod from his end -- he has been in Contact i-7ith Washington a lot this mornincT, because he did have some Cfuestions i,7e thought might have some partial ansi@ers to as it relates to CA-P here. I don't kno%,i @--i'liether @,i- 1,@7ant to nroceed t7itill I,,-,ashincton and Alaska, or another region. T@'T rp'-i- t,(.,Yo reviewers on ,.ashinaton and -?klaska are T-Ar. -@arro-v7s and de La Puente. Do vou Grant to take it un? Y(--r:-,, Ithink @.7e can. This, in m-, judament turned out to be another fine program. I rate them nretty hici'ill,,,, in almost ever@7 catea6r,,, T@ie coordinator Donald [r-lar@-,,lan] I understand, lias a very fine reputation. @RAG Chairman, is a Dean of the University @i.edical School. Four mer,wers of-the University of l@Tashinaton are on the Executive Committee,, @,7hich concerned us a little bit and that's'out of seven. They did suffer quite a depletion of staff during the phaseout problem. They dropped from 52 doiin to 35. They planned to rebuild, and the re-beefing up may constitute 313 something of a problem for them. 8 M'-q. de La PU,@INTE: Yes. MR. BARR(Y@IS: Their staff organization loo'@-ed to me, logical and simple. They've got a regional advisory group of 42 and six or seven of them are from the University -- the rest from the standpoint of interest the representation is oretty well balanced. P,A('7 seems to be forcefil and active, and is still presticcou.9 enough to attract a good ciualit-,7 of neo-,ole to replace those @.,71-iose terms have e,.,.nircd during all of the surveillance of that. "Lhev've cot something like fourteen'corLmitt---as and subcommittees they are nrettv specialized, but they seer, to be functionally effective. Past Performance continuation after @T.IP in the to7o dra,.%7er. ml,Lleir direction has been right on target, whereas both the mission and their snecial area needs -- i@d I might point out in that connection that they are dealing three catecories of problems: T,-he-t,, are atertiarv center for a large aeoatanhic area. There are metropolitan areas which are fairly clasr@ic.@ And then thev have tremendous remote area problems -- Alasica and I-',Ias,iinciton both and the,,7 seem to deal with all of t.,.,emi 314 29 They have been responsive to other federal initiatives. Their regional iledical P.gencies and network all the way UT) the line, is good. They assist the CIIIP -- the ad hoc studies -- close collaboration. --,heir objectives are, again, on target. They are specific and relative to the needs. -.he proposals seem to be, to me, consistent with the expressed objectives and Priorities and they have T)laceCi the ric-'Lit kind o--c c7,inhasis on it. There has been abundant exnosure to CHP fetdback on everything - and they have aotten some feed@oack and that is not being studied. Feasibility, based on a trac@-- record -- the nature of the Drogram and special cohditio ns, looked orettv aood to me Their CHP relationships I might mention a little bit about that: Thev have t,,,7o CHPs and seven full tire staff functioning Bs, nlus some others in various stages of development. Thev maintain a reaular communications contact xqith the Bs and thev nroviO.<-, them @,,-ith -technical support and some modest funds on their enterprises. Both @ directors are on the PA.G and there is other 315 130 cross -mcip-be rsiii p. And one of their projects, Project number 88 for $75,000.00, is to develop a test idea for combining of CIIP, TUT, and to prenare for,the upcoming legislation and I thin]-, that tileN,, x-iill do a good job. I had, to start @,,,i-th, one reservation, which sort of vanished as I @.ient tl-,,irouqli it -- this ijas a program %,iliicli was su'Lficientl'v highly dominated by the University of T7a:-,'@llinrTton -- but it didn't seen to come out in the product that came out. I could find no evidence of tiat dominance. @@7het@,,ier I am @.@rona or not, I don't 1-no,,-7 but I couldn't sunnort the conclusion t.iat there @,7as test dominance. In summary, I rated them as a "Sunerior" aroun sifostantiall-,7 better than the average R@IP loo'A-ed to i-,--a relevance to mission, neecis, involvement both Drof--8sionall,, and public communities and their efforts rate - there is aggressive preparation -for the upcoming transition in planning and t-,ey seemed to be very well oraaniz6d. ,7 TDEv, And so I Tould recommend them, aaain beincr one of co-",I our better programs, if there is a nremium treatment availablc@ that they @7oulcl r-iualif,,, for it. TIIE Thank you. Joe, -,)'OU @-7ere the other reviei.,cr on this. T-,".'.at do or en iiasize? you have on this to add, s@itract p R. de La PUE-@ITE: l@ilell I iyant to emphasize that they are areas of program cmoiias-is on target ,7ith the needs fror.i @iliat I see. T,iey 'Have ver,,7 good relationship Keith the CI'IIP -- and that in that state CHP Director proposed Washington and Alaslj-.a mc:,jDers of the Reaional Advisor,7 Board and tl,.at the staff Dartici-pates and is assigned specifically of the CIT to @ior,',, i,.,ith tilde development LP Agencv. I think this is iT-@.,nortant. Thev have created many things are outside of the univorsitv enclave. I-rhe,,,, -,,.,or]-,ed @.,,it'ii the General -1@ason ,Research Center, the Seattle T-I,eqional oar I t"ie Seattle s C>c'.-Lool Districts,, r-rhe University bit :-',las.lza the State I'llosT)ital @@s::-,ociati-on, the @-TashinrTton State '-4urses -AssociaL@-ion, the 17as',.incT@on State .;-eclical T,ssociati-ori, the 3cl@-ter Administration of Iosi-)it,-Als in f7--attle -- and, last but not least, t',e -,Tort,@',7CSt Chicano Force, --From -iese pco,n fav @ih i ch t( -le I have heard ver-,7 ora' le cornj-,ients in term!:-, of T,,7ashinaton ',r-iati-n @,,-icrican neople. So 1 an .7itli "70U. 1 an im,,or@-sscd @,7iti-i 17ashinc.-ton, what they iave been doing. about all I have. ESCTI:L7,,I: ng that they i;7cre @,ia D TI. T Somebody ,,7as sa-,,7i ahead in the quality of assurance ind this @.7a[, .iell before the quality'of assurance 317 At the conference thev had motion pictures rho,@,7ing il 2 the currents of standard setting and studies of patient management -- and in comparison with what happened to patients and what standards of staff were put together -- an showed the feedbacl,, b-,i which chan(Tes in management x.,,ere effected by the output of that c.,,.ercise. I..Zo@%7 that's acomplete renal circle done on 16 mm color motion pictures while the rest of us @7ere still learning ',10-,.-7 to Spell "c,,ualitl afsurance.'l Tmd I ust felt t';iat this should be BT-@-PP.Oll'S I felt the same thina core throuah ir demonstration of foresight and orderlv nlannind for the' anticipated events. I 1 E C'@@ 1. r@),I !',I !L@,, -T I thin,'-, T,.ic-, riaht want to hear -from Dic'jc, because while relationships i-iith CIIP have been descri'--e-,'@.@ as good 1 think it was also clear from this application t'.,iaL' happened to be one that I lob},,ed at, n-,,-self, by accident when they first were cor,.lina in. I was just trying to aet a sample of @-,-.,-iat the applications loo1r.ed lil@.e. ,@d certainly, their applications drew sone fire from some of the CIITI ag-cncieF,, as you note -- indicating their @.-,.ccutive was meetina yesterday and Diclz had been in contact by phone with l@-7as,iington and 71,laslra this to aet some feedback on that 7nd that's morning, situation. one of the reasons @,ie held over on this one. 318 t Dick, what do you iiive for us? "R. RUSSELL: 1 think the concern that I had with the application was that they did not snell out how they Caere going to respond to CIIP comments. That was one concern I had. I was amused when I read the one from Sioolrane, the CIIP n Aqencv, to see this type of consiont coming frorq an aaencv which .3U.lPs in phaseout devoted 50 percent of their field iianiial to this particular ac-ro-ncv. I thought that -@ias interesting. T,7,e I 1 ,anN7ho@.i, the @@@,,ec-Litive. (committee is going to res,)ond, in @-7ritin(,, to eac;-l OA, tll-,,e neuative co-mments, and v7e will .1@iave conies of those. I felt it @7as iir,,nortant for the,@n to have a formal resnonse -- for their oi,7n record. Council ,@7ill have the ')cnefit of this letter. over that, but trie,;7 1 1. BARP..O@-7S I didn't qloss met riN7 criterion. They are in good cor@ntnication to they get feedback and thev have a legitimate and fair T,)rocess with that. ilor,,i I think that's -ill @, for dealincT .7e can ask for. 1-7e can't aslir, for evcry'oodl,l to loblr. up -- !IR. PUSSRI.L: no, I agree. But I just felt that for their protection, they should resnond. DR. T17,SCT@l-7VN:I%.7on6er, to see if you can 319 if your current readina agrees that Donald Sparkman came out 134 with probably one of the first carefully drafted revisions 0 of bylax,7r, to accommodate the Pugust 1972 EP-@IPF policy for the clianae around -- and has, therefore, a free standing self-pernetuatinq PAG. I @.?ould infer from what vou said, then, that r. ey.1 r)ers are not appointed ere is no special ri.cTht of appointment, as I gathered there -- and if there are lia-a _peninc!7, before 7 TI@EC E:cec neonle -- that that happened in the fair nlav of standard no-@ninati-iicr -)rocess. Is that correct? IITI B -AIITI T-7S don't recall seeing their nominating process,, but the end result Of N,:7'lat,-vc,-r their process, loo',-,s like aood balance e,-cent for this one thing I mentioned. And I could find no evidence of the University, or pro- universitv bias in @@7hat thev were doing. TAR. RUSS@--ILL: jmhe voice in -klaska, was Drobablv the first program that dame up and dre@.7 up a very clear letter of understanding between the University and the @IP. 'I know there has not been that dominance. 'Ooi-,T there was one occasion where the university has, as grantee, cone into the proqramatic doncern, but as grantee -- thev couldn't exercise the T3roaramatic aspect SO that it 'nasn't been a oroiDlern., let's sav. I don't knot x,7'i y people should be 320 135 surprised by the Phenomenon o@ "])itin( hand that feeds j the ,Z,-ou. It seems to Pe that much of the no.-,t-!,7orld T,7ar I, economic assistance would suggest that as a natural and, ner'@ians, not even unhealthy phenomenon. once you help a guv get on his feet, he will take a @.ihac'IZ at tlou as (7uic)r- as he @-ill.1 t c next cTuy. !!P,-. BAPROI.'@7S: Well, there iq -i certain amount of feeling your oats in that kind of thing TESCT POv.-7 r..ian,7 @neonle arc involved in this thing? Ti'IE I ani not sure it's a,@out t@,-,,o anc,. a '@ialf or three million -,)eor)l.C. 'r-Ino,@.T @llaska: nuarter of a T-.illio-n. l'i-,Iien 1 7,?a@, there it was less than rai.rfa:t CoiAnt,7, ten vears a@o. But thev are scattered out all ovcr. DR. il@7-ISS: Seattle is less than a ,-Allion. Spokane B7'.:R-@o@7S- Snokane, their snace oroblems and dulturan nrobler,,s are horrendous. THE@,' CT I think it's @)roba@Dl-,,, a little over a million, Joe. MR. T-ZUSSELL: But I don't have that I'v(,- got t@,le figures in mKi briefcase, but not here. But for the record, the applications you revi@ied did not have the salaries of the nrogram staff. Thej were 321 submitted in the reaional an7Dlication, and i@7e do have those @l,it 136 but they are not out of line. Dr,.. TIITJ TI,@ W,, I :I just Grant to as],, vou one question: You are satisfied that they are able to utilize the additional half million dollars that @7ou're c-loing to recommend,> B@,.RROT,.'.'S: T @iould have only one reservation as @,,-as said on these neople -- thev have suffered a fairly substantial staff depletion. 1 @,7OUld thin!-., thoucT@n, based on the competence of the Coordinator, and t'iej.r relationship @,7it:a both academic and nrovi6er centers -- tlicv could mount a good team. .,orried about that. has aood management. I'r,,. not too 2.1@d I think t-,-Lat th,--@7 are bcinc7 fairly modest. ".,iie,,r are juri7inrf from, no a f-i,.ndi@ evel of about 1 to 2 million and i tiiinlc- they can S@l-jec@t to this staffi-no lDro,-)lcm, I thin],, tl-ie@7 can adjust to it. DR. 1-1@-,SS: All riaht, if vou have this vie@i, their current fuhaina level of 1.3 -- so that if B@PPCO,-iS: I have 1.4 or 1.47. DR. IIESS: Ti-,7ell, there has been a discrepancy bet@7een that sheet and this one. MR. iTIUSc-'-@--LL: The latest figure i7e have, is 1.4 T DR. @TIESS ,"There do the figures come to on this sheet? The first six months? 322 DR. HEUSTIS; P@re these figures not six months old? 137 The onlv date I can find on this document is January, 1974, and I i-7as led to believe this was nrenared as of January 1974. MR. RU@r'),c,ELL: No T)R. !IESS: This i,,iould be the funding level for the six months one through six. DR. TRU@@L7-@'l: I based this on the other one, T,7hicli is 1.5 to 2 -,.,.illion -- c@i,-i thev handle the extra half million dollars? DT@Pi",OT,7s: -- total T.)].anninq -- tallj'.in(i a!-)out Julli of another @ialf million -- I Oon't thing thev T@7ill '11)C (-etting --ver,,,th-Lnc, the,, ask for. But are vou satisfied he can rc-,asonat)1,7 use this? PTIE)S@-Ll,: Y--s. :@3ut let mn@ ans,@7er, n@cirro,,,,-. @-,-@n this nliasc came out, ti-Li:--, ctave tieri an onnor- 7 unity to revarn their staff so that it @,asn't all loss. Yes, I think thev can manace the r@oney. DR. I T,Yould rov(- @,7e ao-n. rove the re-uestc-c! level. L . I [T-.Le -,,notion was properly seconded.] THE CIIAIP-1,UUI: That's 2.77 -- as requested. is there any further question, additional comments or corrections 323 130 All those in favor [-Llhe motion ,ias r)ut to vote and carried, unanimously.] 324 C'IIAI@,-L',Il it is 12:20 and this mav be a qood 139 tiTno to I'Dr@-al,,. ,,-7e have completed n,-ne regionp. and i,ie have eialit left to do. COIr@IF,NT: Do vou think i,ie can @,7ran this up? Ti!E I think that is still -- and tliatis w'L'I.y I need to consult @.:ith r,-,y cc)lleacUes -- but if @,7c., do ilave it @.7ithin our ..7jiere,,Yithall to com@l.ete them all todav, 't thin',, on the other hand that I have. tte a:--)ility ,)ut 1 aon I -'I and the other staff, to .7r&r) sorio-, of these things un and dicl!nlay them for you. 1 thin!,. @@ic Proud have to as'lr, 17ou to sit cirouriA' here an hour after that. f.,o I think, realizing that sorie of you are -bin,7 to have to leave toOa,,7 anNr..7a,.7 C-,arlj.c, @7ou are coinc., to i have to leave todav fairl,T earl,7 tiat x.7e still are faced %.7ith a brief session to,-,.orro,7. @@ut don't kno@,@7 ,ihat colleagues are doin(.-T. I think 1,@ie can -)robil)l,,,, act throual-i N,7ith t'IC applications todat;,. T@IT". r32',.RPol"7s: Could i@ie shoot for that, and then -v7hatever time @.,re have tomorroi.,7, we could just loo,@, baclr.- and see ,.7hat @ic nave don(--? TIIE Yes. We can't do this in8tantlv [Indicatina Blackboard not that this has anything to recommend for it, but i thin'@- 325 wt 140 wave can shake some things out and aive you some idea of what your actions ,7ere, @,7.,Iat thav look like, collecti-,Ielv and the others naV want to look at it a little, too, and see maybe adjust something un, or do,,qn, something here or there where something seems to be inconsistent. But I don't think @,7e can give you that immediatclv. D@?,.. Ti7@SC'.IAII: 'L'hat is a ver-,.7 helpful chart. TTIU.T,.'!@,',I: Are 1.7e required to keep these? D". TIIUT-@,!-",' Do v7e tiaVe any other easv recTions v.ic could knock o-ff-? ,7ou T)eoole are the revie@.7ers. I @..,ould think -@ravl-)c @'Tertern Ilennc,@71vania is an easy region ITU@VW DR. T.L J: I'ri tr%ying to see if the groun Cl-l@kI@.1, I.: o, 'Testcrn ilenn,@vania ,Z. IIASTI -,Io, ;.7eSt .L Virginia is nrir,.iarl 1,,,- a continuation of --",'estern iou nav get a lot of questions on that. . . T'2@E John, ,,lou and 1.1r. Barrows we-re tiie revie@,!brs -- do vou recall any difficulties is that one that @,,,e micFht -oolis'i'l off in a brief period? DP,. fljp.@,CTIBO,@C-zl@: IIell I t'nink @@7c had better V7,ilt Until after ltnch anT,.Ya-,7. 326 ,.7t 1 4 1 TI-IT-@' CITAI@'@l: O-K- i think i-ie're doing to come to having lunch novI. So it is 12:25. Could @,ye trv to be back bv 1:10 or T:15 at the latest? You see, we have four hours and eight regions, and if 1;7e can do that [TI.ic proceedings were recessed for luncheon at 12:25.1 HEW 327 Ns-1 AFTERNOON SESSION fis arc hws-1 2 1:15 P.M. MR. PETERSON: I guess we are ready to commence. 4 Joe is not back, but before we do, I did huddle 5 briefly with Bob next door. They broke a little later than 6 we did. We are just about neck and-neck now. They have six 7 left to finish. We have eight, but I think our view was, and 8 I wanted to check it with the group, that we are going to 9 be able to finish the applications today, but there seems o be some need for a meeting# however, of a very brief duration@ 10 11 an hour or so, perhaps two hours tomorrow morn ng to sor of 12, take a step back and look at each of what the panels has done and ratify it as a whole group., that is the actions of the 13 respective panels, so that just Bob and I made that decision. 14 I see all kinds of problems that we try at the 15 end of a long hard day for both groups to try and come to- iti gether briefly. It is going to be late. 17 How do you people feel about it? 18 DR. HIRSCHBOECK: I agree with you. 19 MR. PETERSON: I know you are going to have to go, 20 Charlie. 21 You know, if there is someone else who feels as 22 Bill or others may, that in one sense the plowing of the 23 field has been done, and I think you know one would be able ?.4 to take off at the end of the day. 25 co, INC. ue, N@l. W4$ in on', D .200( hws-2 1 DR. HESS: If we can, as a group, look at the ones 2 we have reviewed, and satisfy ourselves within that review thiat we have been fairly equitable based on the factors that we 4 identify, and then the basic work is done, and it is a matter 5 of seeing if the two groups can function. 6 DR. HEUSTIS: To do that don't we have to have -1 something up on the board? 8 MR. PETER SON: I don't think the board is large 9 enough, I started doing somethings with respect to the morni@g 10 applications. This is something that I think the two groups 11 are debating a little bit. 12. This percent of target figure column I don't think. 13 that important. 14 What I was doing was to show a figure if there 15 was any for a July application so that I was keeping the first three columns, or that is, the fitst.fout columns, but then indicating the estimated July applications again trying 17 18 to group them so tha-t, you know, looking at this mornings, I find New Jersey and Rochester and several programs sort of 20 up in that first group, and Joe did ask, and I will try to get, this data so we can incorporate it for all of them, a rough 21 population figure like 3.2 million, or 2.1 million. 22 I think if you can settle for a legible Xerox copy 2.1 of a legible longhand sheet.we can have'that for you first 24 thing in the morning,, and we would, on Panbl B, take a look 25 TING CO, INC. tts Avenue, N.C. in ton, O.C@ 20002 -i- @ hws-3 I for 30 minutes at what we have done before we reassemble, 2 and if that means we get together at 8:30.instead of nine, ili that I again leave up to you, but again I sense it, and it 41 seems to make sense to me if you look at some of these things 5 -- well, we won't have that job done, obviously, at five 6 Oiclock. 7 DR. HESS: Can we find out, or do we know which 8 of these two figures are the most correct on this previous, 9 or let us say, the six-month current funding level? 10 DR. THURMAN: I think Al is correct when you look 11 back on the applications, I think this really goes back to January, and I think this sheet, although I, don't particularly 12. 13 like it, is the sheet. 14 DR. HESS: This one? 15 MR. PETERSON: I am embarrassed by numbers that I don't agree with, thus I tried to either only have one set of figures in front of people, or if one is going to put two 17 sets of figures to see if they don't agree before you place 18 them. The first column in this figure I believe is cdrreC,t 20 in this sense. It is the current six-month award times twoi 21 MR. NASH: No. It is the annualized level, on t e 22 third level. 23 MR. PETERSON: Y.es, that is the way it was explaine@ 24 to me, 25 INC. Washington, D 21 1202'@546-666 1 330 hws-4 New Jersey currently, for the current six-month 2 period has a grant of X number of dollars. The figure that is shown now in this column is X times two. That is one of 4 the always surprising things. 5 DR. HESS: I wonder if there is some staff person we can call on, whoever put that together. 7 MR. ARNOLD: I don't know where that came from. 8 MR. PETERSON: Let's not introduce another set of 9 figures. 10 DR. HESS: I think somebody on the staff level 11 ought to be checking these out. 12 MR. BARROWS: Let us have someone look into it. 13 DR. THURMAN: I think your point earlier that Dick 14 White's sheet is a sheet that was put together months ago, and 15 I think this sheet is fairly close to up to date. MRi SIMONS: This one is correct, but it will take 17 Larry to explain it. 18 MR. PETERSON: It is always a puzzle as to why we 1!) pass out three of them. 20 MR. SIMONS: This first column does not have such 21 things in it. MRo NASH: it may not have the Region's portion 22 23 of the 6.9 that was held and later released. 24 It may not reflect 1972 dollars for EMS and HSEA'S. There are a lot of basic possibilities, and maybe 25 RTING CO, INC. ettsAvenue,N.I@ iligton; D@C. 20002 (?02) 6-6666 331 hws-5 1 Grant can explain it. 2 DR. THURMAN: It does not reflect carryovers? 3ii MR. NASH: It is taken off the last award notice. 4 it doesn't tell you the real fund B picture in the Region. 5 MR. PETERSON: Can we sort of make this our prime 6 reference? 7 We will entertain an explanation from staff as to 8 what the disparities are. 9 DR. HEUSTIS: After we get through with all of 10 the material? 11 MR. PETERSON: I am always reluctant. I know I 12. should be saying yes, but I don't differ myself, and I am looking around and saying who is going to deliver. 13 14 DR. HEUSTIS: No earlier than before we get 15 through with all of this. MR. PETERSON: Mr. Pullett, Review Panel B and its Chairman, humble Chairman, sort of wanted a brief explan-:'. 17 18 atioh as to spake sets of figures, column one of a printout. I just tended to ignore it. I was lucky. I 19 thought one was more credible than the other. 20 What was the recent point in that case that gav 21 us a problem? 22 In New Jersey we show a current and annual annualized 23 at roughly $1,458,000. That I understood, and correct me if 24 I am wrong, was literally New Jersey's current six-month 25 RTING CO, INC. ettsAvenue,N.E. Wash[ gton, D@C. 20002 332 hws-6 award times two. 21 MR. PULLETT: What you do is, you double what you had in the 1974 funds that they received, plus the carry- 4 over. 5 MR. PETERSON: That includes the carryover? 6 MR4 PULLETT: Yes. 7 MR. PETERSON: Their share of the six? 8 That truly represents a total figure DR. THURMAN: 9 in the six-month period of the dollars they had to spend 10 multiplied by two. 11 MR. PULLETT: If it is carried out. 12, MR. NASH: If they contracted it out. 13 DR. THURMAN: That is obligated funds. 14 MR. NASH: It would not even show here, you see. DR. THURMAN: As we look at it we are not con- cerred about obligated funds. 17 We are talk4-ng about an operating figure, and this is the total actual operating figure on this printout. 18 MR. PULLETT: No, it is what they received out 20 of 1974 funds, plus their authorized carryover. 21 DR. THURMAN: That is what I thought I said. MR. PULLETT: You said their operating level times 22 two, and it is not. 23 DR. THURMAN: I see. I stand corrected. 24 DR. HESS: The total amount of money that they 25 ORTING Co, Inc. @320@lassachus,ttsAvene: N.[. Wa,stiit@fton, D.C, 20002 333 hws-7 have to work with during those six months. 2 MR. PULLETT: We made a distribution of 1974 fundsli which was approximately $24 million, and that went into the 4 awards beginning in Award 1. 5 To get their annualized level we doubled that, and 6 added their authorized carryover, so when you say an annual- 7 ized level in a 12-month period it is not doubled what they 8 have been operating on in the six month period. 9 DR. HESS: Are you familiar with this sheet? 10 MR. PULLETT: Yes. 11 DR. HESS: These figures are geherally.higher if 12. you double the six month present funding? 13 MR. PULLETT: They would be higher than the 14 annualized level in a lot of cases. 15 When we made the initial awards they were for a i(i six month period, so we gave their distribution of the 24 17 million for six month period,, and authorized any carryover is from the previous period, but to get the annualized level we doubled the 1974 funds and then added in the autho ized carry- over, because that was only for a six month period. 20 21 DR. HESS: So this would be plus the carryover 22 figure, MR. PULLETT: The six month period would at least 2.3 24 equal the annualized level, and in most cases exceed it. 25 MRO BARROWS: The working capital that they had to CO, INC. uel D 20 0 334 hws-8 1 work with last year. It was this figure, was it? I mean 21 up until now. 31i MR. PULLETT: That is another projected 12 month 4 figure. 5 MR. BARROWS: So in terms of real money this is 6 what the program was operating with. 7 MR. PULLETT: That would be projected over a 12 8 'month period. 9 MR. BARROWS: That is the base that we wanted. 10 DR. HEUSTIS: On this document the only date that 11 I see is funding award January 1, 1974. 12. Am I to assume that this was as of January, that 13 everything on this hseet is January 1, 1974? MR. PULLETT: If you look on the face page of 14 15 that, there was a face page. DR. HEUSTIS: Never mind. Tell me what is on the face page. I don't think I ever saw one. 17 18 MR. PETERSON: I certainly never saw a face page. DR. THURMAN: Is this the face page? MR. PULLETT: That is the summary page. 20 DR. TESCHAN: Region 17. 21 MR. PULLETT: The six-month level was actually what 22 they are operating on, on a six-month period. They are the 23 funds we have authorized. That includes the carryover plus 24 fiscal 1974 money. 25 PORTING CO, INC. 0 Massachusetts Avenue, N.[. Was 1!@@on, D.C. 20002 335 hws-9 Now, to project the 12-month budget period we 2 doubled what we gave them out of our 1974 money, which was 3@l approximately $24 million, and that added on to that any 4 authorized carryover which was based on two things, their 5 distribution of the 6.9 plus any unexpended balance they had 6 under the previous budget period. -1 DR. THURMAN: He has answered my qu6stion. I know 8 what it is. 9 MR. PETERSON: Okay, we want to get bacc to our 10 business here on the review of applications. 11 I think we have already highlighted both Western Pennsylvania and Virginia as regions we did not feel too 12. 13 prepared to deal with before. Having had lunch we might start off with Western 14 Pennsylvania. 15 17 18 14 20 21 22 23 24 25 N ORTING CO, INC. 320@Massachusetts Avenue, It.[. Wash@t@an@'D@C.20002 336 LVANIA hws-10 REGIONAL MEDICAL PLAN FOR WESTERN PENNSY 2 REVIEW BY DR. HIRSCHBOECK 31i DR. HIRSCHBOECK: The application is essentially 4 for continuation of funding, except for the addition of one 5 project, which is the Health, Education Network. 6 As stated here, this constitutes $170,825 of our 7 total request, which I understand will not be counted against 8 the total amount appropriated with PRFP. 9 MR. PETERSON: I will explain that. 10 Because of the court order which reads these funds 11 are to be made available to the plaintiff, that is to mean th 12@ RFP'S, and we had funded this particular project under 910,, 13 and thus in order to give it a legitimate umbrella we asked 14 that it be submitted as part of the Western Pennsylvania RMP 15 application, but what you people really need to do is vote a recommendation for Western Pennsylvania, and then take an auxiliary, or adjusting the one in effect. 17 18 it is a matter of administrative convenience in the event the court order would not be modified, which it 19 20 probably will not. 21 MR. NASH: Really two applications. 22 MR. PETERSON: It is really.tw6 applications, but in order to be able to continue to fund that AHEC it had to 23 com der the aegis of an RMP at this time. 24 DR. HIRSCHBOTCK: Another factor that is confusing 25 ER REPORTI,4G Co, INC. 320 Massachusetts Avenue, N.[. n e, )nnn,) 337 1 is that funding for many projects terminated on April 1. hws-11 There is a gap of two months, or three months 2 1!' and what appears to 0 really, between the end of the project 4 be a start up again of some of these same projects, with a 5 gap of no funding* 6 Now, I am getting this information principally 7 from the Forms 15, and I think we ought to have that explained 8 by staff a little later on. As far as the Region itself is concerned, at the 9 time of phaseout they were grappling with the possibility 10 of becoming an independent, free-standing corporation#, and 11 they are now the grantee, that is the grantee is the University 12 of Pittsburgh, and apparently the cost figure was very high, 13 almost $500,000, and the question was raised, I suppose, by 14 central staff here that maybe they should look into a re- 15 arrangement. At least it sounds that way in the way the text 17 reads. They set up a task force, and the task force decide 18 to stay as they are,, and that is an independent, freestanding corporation. 20 The University of Pittsburgh Health Center is the 21 grantee. The bylaws, of course, do not even mention it but 22 that is okay. 23 The bylaws are arranged such that they function 24 very independently. 25 VER REPORTING CO, INC. :320 Massachusetts Avenue, N@[. 338 hws-12 However, the Regional Advisory Group, the Coordin- 2 ator, Dr. Kiefer,who is the Coordinator of the program is 3 also a member of the Regional Advisory Group, and is in 4 various positions along the line, and still the coordinator, 5 and yet, what I am trying to say is that he has fingers in 6 many pies. 7 The relationship with CHP is difficult to assess 8 because there is only one communication which says that they 9 will apply in the near future regarding the comments. 10 I would like to find out a little more about the 11 CHP relationship here. 12. Well, they distributed quite a bit of project 13 support for the insurance development as a one shot venture. i 14 The statement is made by the Joint Commission on 15 Creditation on Hospitals, which is found in quite a few hospitals, and this area has not had the working expertise to': deal with the medical audit situation and other similarly 18 newly acquired activities by the Joint Commission, The Western Pennsylvania RMP provided funds for some six or seven hospitals or related agencies in the Region, 20 21 to get quality assurance and medical audit, and so on. As.I interpret this, this was a single one shot 22 deal that was given to these institutions,, 23 In general, I would say that this is an average 24 program all the way down the line. 25 HOOVER REPORTING CO. INC. 320 Massachusetts AvenuF.. N.[. 339 hws-13 1 I do not see anything outstanding about it, nor 2 is there anything that would seriously criticize,bther than 3il possibly a relationship with CHP, which is not well expressed!, 4 here. 5 Also, I should say a word about the staff. The 6 staff seems to be quite complete. There are hardly any 7 vacancies, so there should be the capability of carrying on 8 with the additional funds which they intend to ask for in July. 9 10 MR. PETERSON: Thank you, John. Ken? MR. BARROWS: My observations were very parallel 12 to the doctor'S. 13 14 To show you my skills as a planner, I approached my five projects alphabetically, and I have considerably run 15 out of gas on Western Pennsylvania, as it is the end of the line. 17 18 Generally, I came up with the same conclusion that this was a pretty good average type of program. The management and administration of the thing 20 looked a little bit cumbersome to me. They have a number of 21 regional advisory groups, area advisory groups, 22 This did not look like a very skillful thing from 23 the management point of view, but now I will have to eat my ?,4 I words and come back with this. They have done an excellent 25 HOOVERREPORTINGCO,'"'IC. 320 Massachusetts Avene. N.C. 340 hws-14 job of community interest and participation in this thing. 2 I might say they are really one of the better in 3!i. that respect, and there is commendable honesty in this report.,' 4 They talk about a lot of programs that are terminated, and, 5 in fact, come out and said the program laid an egg because 6 the people found out it was too much work. 7 I think it is an application you can take at face 8 value, but I came out with a good average type program. 9 MR. PETER80N: Norm, I don't know if you want 10 to come up to the table. It seems to me that there were at 11 least three areas that questions were raised about. 12, One is what appeared to be A gap in funding. The 13 other is CHP relationships, and the third may be the ubiqui- 14 tousness of Dr. Cleary, but that is something we have lived 15 with. 1(; MR. ANDERSON: I imagine the survey was made a 17 year or so ago, and we have determined that Dr. Kiefer was 18 not in line with the grant relationship. I!) The recommendation was made at that time to rectif 20 this, but during the same week, at the time of the survey, 21 also a notice came out from RMP that we were to be phased out. 22 We sort of let it slide at that time, and Dr. Kiei r, 23 as I understand, is to retire sometime this summer, and as 24 you have very adequately observed,, Dr. Kiefer is a member of the Executive Committee, and also plays a very active role, 25 HOOVER REPORTING CO, INC. 0 Massachusetts Avenue, N.[. n r )nnng 341 hws-15 1 in determining program policy. 2 I won't try to minimize this, as that is a fact. On the other hand, I think Dr. Reed has pretty 4 much determined what the r program priorities are, and has 5 tried to allow to promote these through Dr. Kief6r. 6 The second point was there has been some animosity 7 I am not sure what precipitated this,, but nevertheless it has 8 existed, and I think over the past two years my experience 9 with the Region is that they have made every effort on both 10 parts to try to rectify the problem, and here again, I would 11 be the last to try to identify what the problem really is., Now, in terms of the third area -" what was that.@ 12 MR. PETERSON: The gap. 13 14 DR. HIRSCHBOECK: Some of these projects ended in 1 15 April, and they were asking for funding beginning July 1. MR. ANDERSON: Part is due to the phaseout and 16 terms of priorities to try to complete certain activities 17 within a timeframe, and they do have a very good selective i 18 procedure to determine their own priorities, I think in all due fairness to them, they felt this 20 was some of the things they ought to complete within a certai' 21 time period. 22 There has been a certain amount of lag time, but 23 that doesn't mean the activity has completely stopped. 24 DR* HIRSCHBOECK: It is, as you read these Form 15,,. 25 00 VERREPORTlt4G CO. INC. 32d Missathutetts Avenue, N.[. n r. 9nfln9 342 hws-16 I got the impression that there is going to be a gap in fund-! 2 ing between, or beginning July 1, 1974 and what apparently 3 was a termination on April 30, 1974. 4 '-It has either been improperly placed there, or 5 don't understand what it is all about. 6 MR. ANDERSON: I am not quite sure I understand 7 your question. 8 MR. PETERSON: I think if I understand Johho he 9 sees some projects which presumably are going to stop at the 10 end of April and renewed funding beginning July 1 which is 11 being requested. 12. That does seem a little unreal, and it may be. 13 MR. BARROWS: I got the impression these were somei i programs they would like to have carried on, but,t ey ran out,, 14 15 of money, and they have some programs they want to revise. MR. ANDERSON: Local support may come to their aid for a temporary time period. 17 1 DR. HIRSCHBOECK: Here is one discreet activity 18 summary -- Laurel Mountain Quality Assurance Program, Mercy i Hospital# Johnstown, and the progress period, in the progress i 20 section which is from July or from January lst, 1974 to 21 22 April, 1974, and then the period of the.project is July, 1974 i through June, 1975. 23 In other words,.there is a period of April,, May 24 and June. 25 Hoo ER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 343 hws-17 1 MR. NASH: What is he doing there? This is some- 2 thing they initiated in January, and he is giving you progress 31; on the four months up until the time they formulated their 4 application? 5 MR. PETERSON: I was just comparing notes with 6 Tom,, and he said he really didn't have anything of substance 7 or concreteness. 8 I think both he and I can speculate about some of 9 the reasons for the less than cordial relationships between 10 the major fee agency, and I am not sure it is called Alleghen 11 County, but anyone, the one that encompasses Pittsburgh and 12, the surrounding area, and I know something I observed, I think I observed out there two years in the review process#, 13 14 and it was out on the table and Bob Carpenter was in the next 15 room and it caused him a great deal of travail as long as he was in that post. MR* BARROWS: You think they feel competitive? 17 18 You see, this has an apparatus of local advisory groups that RMP might treat as a threat or something. 1!) MR. PETERSON: Some of it may have been, and con- i 20 tinues to be personalities. 21 I don't know if the same gentleman who was there 22 when I was out there two years ago, and would dome down from 23 Buffalo, where Jack Angle had encountered him,, but is he 24 still the same person out there -- Mitch Roth? 25 NO REPORTING CO, INC. 326 Massachusetts Avenue, N.[. n r. gnnii? e hws-18 MR. ANDERSON: On the positive side they do shar the same types of review committees at the local level which 31i Is participate with RMP. the CHP 4 DR. TESCHAN: I don't think we can resolve the 5 question here, and if it is an important question in an out- 6 going way we have to cite it to them. 7 MR. NASH: The question came up about Dr. Kiefer. 8 I don't think,he is in the budget for next year. 9 MR. PETERSON: He is retiring this summer, and it 10 was always a kind of strange relationship. He was the name 11 coordinator, but in recent years he never drew any salary 12. from the RMP budget. 13 MR. ANDERSON: He was never on salary. 14 MR. PETERSON: I knew in recent years he never 15 had. Whdn Bob Carpenter was the Director, the full time sort of direct management program has always been in someone 17 elses hands, but Kiefer was not to say adamant, but he didn't 18 want to step out of that symbolic spot. 20 Maybe our problem is being solved by retirement. 21 DR. THURMAN: Looking at the staff document for a minute on the projects, the first five really are all pro- 22 gram staff, is that correct, as I read this, $731,000? 2.-3 MR. ANDERSON.- The first four, yes. 24 DR. THURMAN: So we are talking about a corps 25 CO, INC. ue, N.[. W ington, D.C. 2001 345 hws-19 figure of $731,000, and the request is for $1.9 million when 2 we really get right down to it. MR. ANDERSON: I accept your figures. 4 DR. THURMAN: obviously they are correct. 5 Then I have just two other questions. 6 Are we conflicting with ourselves in the Regional 7 program because it is carrying over for two years, and the 8 statements in it show no reference to reality about what is 9 going to happen over the next two years,, and they have not fulfilled the prima criteria initially that was to limit 10 ry 11 transplantation to one area, and instead we are supporting 12, two hospitals that are doing it in the same county. They did, it themselves. 13 MR. ANDERSON: I didn't read that. 14 DR. THURMAN: Regional renal project, to ration- 15 aliz6 transportation resources within the Health Center and iii 1 17 program due to inadequate numbers, and they said they still have not solidified the four Allegheny hospitals to bring 18 together for one transplant thing. 19 I am not so much concerned about that, or are we 20 really, for over a two year period here, looking at the 21 Regional renal transplant in the way that it should be done. 22 That is a' staff question, I don't know. 23 MR. ANDE The limitation of my knowledge ?,4 here is that the University of Pittsburgh is doing transplant 25 No REPORTING CO, INC. 0 Massachusetts Avenue N1. 346 hws 20 only within its particular Region, and they have attempted 2 to set up some satellite facilities in community hospitals 3t! that can participate with the so-called network. 4 DR. THURMAN: Everybody does that for bringing in 5 cadaver kidneys, but the way this reads, they are doing the 6 transplants in other hospitals. 7 DR. HESS: Read that again. 8 DR. THURMAN: "Rationalize transplant resources 9 within the Health Center and the limitations imposed 10 on transplants from cadavers." 11 This is a major question of the Xidney Panel about 12 whether or not they were doing it, and for hospitals. 13 DR. HESS: You didn It read the sentence you did 14 before, but it sounds to me as though they were coordinating 15 four hospitals, not transplanting in hospitals. DR. THURMAN: You have to read the whole thing, and I may have misled vou, 17 18 MR* PETERSON: This is an issue we need to get if) some specific concrete information of how many hospitals in 20 the Pittsburgh area are actually doing transplants. 21 I think the Council ought to be aware of it, be- cause we had the same sort of situation in Philadelphia. 22 MR. ANDERSON: If you are right, we will have to 23 24 put a stop to it. DR. THU One last question. 25 HOOVER REPORTING CO, INC. 320 M ssnhusetts Avenup, N.[. 347 tYb-21 1 On Project 225 we are talking about $239,000. 2 MR. ANDERSON: Project 225? You are gett ng 3t ahead of me. 4 DR. THURMAN: $293,000, and we are going to educate 5 less than 40 nurses. 6 DR. HEUSTIS: That is $490,000. 7 DR. THURMAN: It is going to cost us $10,000 a 8 nurse, and it is a two year project, but if you are going to 9 put it on a one.year basis it is still $10,000 A nurse, so 10 that is an awfully high figure. 11 MR. ANDERSON: We have flagged this, as you have 12, to. 13 This is a policy decision that has to be deter- 14 mined. 15 DR. THURMAN: I don't argue with the need for these people, but I have never seen a budget quite that high for this kind of a program, and I j ust wonder about it. 17 18 DR. HEUSTIS: How much of the $1.9 million is for projects that will be carried out in the second year? MR. ANDERSON: There are only two projects identi- 20 21 fied, 25 and 26, and the one Dr. Thurman has identified'. and 22 the renal project goes into 1976. MR* PETERSON: Those two projects all add up to 23 roughly $725,000 out of.$l..9 million budget if you assume,, 24 which I don't think we can necessarily can have in one year and 25 MassacliusettsAvenue.N.E. 3Lt8 about $ s hws-22 a half, and in another year it is saying 350,000 plu 2 would dangle over into FY 1976. Those are the two other than program staff, the 4 two larger projects, renal and adult nurse practitioner 5 education program are the two in that carryover4 6 DR. HEUSTIS: They would probably get around the 7 one year grant by making a contract or some people to provid. services and the GAO will allow this kind of thing for ger- 8 9 vices to be provided in the future. 10 MR. PETERSON: I cannot answer that. We have 11 said as a matter of policy that we would permit it, and I 12 think it also includes grants management, which was in on the discussion, and if the obligation was a valid one enteredi 13 14 into prior to June 30, 1975 that the basis for taking an audit exception by GAO-HEW would not be there. It would be a valid expenditure of the funds. DR. HEUSTIS: Is this any different than entering 17 into a contract for someone to maintain your typewriters 18 for two years? In that case I think there would be a valid GAO 20 objection. 21 This is something that was brought up earlier, and, 22 I didn't follow it at that stage,.and this is something that 211 1 think ought to be referred to'staff for clarification o 24 policy. 25 HOI EPORTING CO, INC. 320 Massachusetts Avenue, N.[. n r. )nnn,) 349 hws-23 MR. NASH: Is your question whether to contract this for two years or one year? DR. HEUSTIS: My question is is it possible for someone to use fiscal 1975 funds to provide services that obviously will be provided in 1976, that is fiscal 1976,, and 6 the only reason for entering into a contract is to subvert 7 well, that is pretty strong. 8 In my opinion the reason for entering into the 9 contract is to get around the one year limitation, 10 We can't answer it, but it should be resolved. 11 MR. PETERSON: It does seem to me it may tot be 12 good procedure, and indeed might be illegal. 13 I don't know about the latter, but this is not all 14 that unusual in terms of either Federal granting operations, 15 forward funding, and indeed in many situations, and I can remember AHEC activities, many of the RMP's I believe in 16 effect are contracted for a period well beyond one year in 1 17 the early fiscal year. 18 That doesn't make it right, but there is a great deal of practice and precedent there. 20 DR. HEUSTIS: It seems to me the funds for 1976 21 ought to come out of the text year's budget rather than here. 22 MR. de la PUENTE: A person in good faith makes an 23 application in a certain year. This application is suppose 24 to do a certain amount of work, and supposed to take one year,!' 25 HOOVER REPORTING CO,'4C. 320 Massachusetts Aven@, N.[. 350 hws-24 two years, three years, and when this period or this applica- 2 tion, if it is awarded that year, he is entitled to do his I 3i work regardless of how long it takes. li I f 4 DR.'THURMAN: What is your recommendation? 5 MOTION FOR RECOMMENDATION 6 DR. HIRSCHBOECK: I was waiting for the Chairman, 7 but I move that we approve this application for the cohtinu- 8 ation phase, and this amounts to $1,814,588,, and we will havel 0 to take up the others separately. 10 MR. PETERSON: Your recommendations John, if I 11 heard you correctly, is for the continuation of Western 12. Pennsylvania, and the amount requested Norm tells me ought to 13 deal with the total figure. 14 We will put them together. 15 MR. ANDERSON: Okay. I(; MR. PETERSON: We havea motion for Western 17 Pennsylvania, and that is the amount requested for the RMP 18 separate from this one AHEC which is an appendage to their 19 application. 20 Do 1 hear a second on that? 21 DR. THURMAN: Before we offer another motion, can 22 we go off the record? MA. PETERSON: Off the record. 23 24 (Discussion off the record.) MR. PETERSON: Back on the,record. 25 HOOVER REPORTING CO, INC 32OMas ch ettsAvenue,N.E. la u-, 351 hws-25 i Parliamentarily we have a motion with no second. 61 MR. BARROWS: Does it die? Informally then I didn't share the doctor's 4 enthusiasm. They are now at a level of $1.2 million; and 5 they are talking in terms of this and their upcoming applica- 6 tion is going to amount to about $2.6 million. 7 That is well over a 100 percent increase in activ- 8 ity, and 1 don't think based on what they have done to date 9 they have the horses to take up that additional work 10 I would be much happier, let us say, they should 11 talk in terms of $1.4 million, or something like t at. MR. PETERSON: We have in what effect is a sub- 12 13 stitute motion of $1.4 million in terms of the $1.8 million. 14 Is there a second to that motion? 15 DR. TESCHAN: I will second it. 1(; MR. PETERSOIN: Any more discussion or corrections? DR. HEUSTIS: May I say the current level of 17 18 funding according to this summary sheet I have is $1,193,000, is that right? MR. BARROWS: I said $1.2 mill on, 20 DR* HEUSTIS: Okay, and you are saying $300,000 21, more? You are saying $1.4 million is what you said. 22 MR. BARROWS: Yes. 23 DR. HEUSTIS: I think it deserves more than $1.2 24 million. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 352 ly Is-26 MR. BARROWS: I refuse to answer it on the grounds 2 it might incriminate me. I was trying to come to a figure that would be 4 appropriate for an average program, 5 DR. HEUSTIS: This is an average program. 6 MR. BARROWS: But apparently some more new vital 7 direction. 8 DR. HEUSTIS: If you were increasing it you would 9 be treating it the way we were treating some of the better 10 than average programs. 11 MR. PETERSON: I don't think we really have those 12 programs at hand. 13 DR. HEUSTIS: In my opinion you would be treating that way. 14 15 I call for the question. MR. PETERSON: Well, $1.4 million had been recom- 17 mended for Western Pennsylvania. 18 All those in favor signify by raising your hands, (Showing of hands.) MR. PETERSON: Those opposed? 20 21@ (Showing of hands.) MR. PETERSON: The motion fails for lack ofA 22 majority. 2t3 MR. BARROWS: We are ready for a new one. 24 DR. THUIOIAN: I make a new motion to present 25 HOOVER REPORTING CO, INC. 320 Massach.usetts Avenue, N@l. 353 hws-27 1 operating levels, and let's make them $1.2 million with a 2 provision that staff try to clarify, number one, the legit- imacy of the renal regional program as we now know it, and much better clarification of the nurse practitioner program, 5 025. 6 MR. PETERSON: It is still a motion of $1.2 million, 7 and those two clarifications I think are inherent. 8 DR. HEUSTIS: Can I ask a question? 9 MR. PETERSON: Surely. 10 DR. HEUSTIS: In that $1.2 million which is the 11 current operating level, is there not included $170;000 in 12. this extra separate project? 13 MR. PETERSON: No. 14 MR. NASH: That is funded by a 910 grant currently. 15 DRi HEUSTIS: So that does not include the $170,000. MR. PETERSON: No. DR* HEUSTIS: It would limit their current level 17 exclusive of this added net worth. 18 MR. PETERSON: This is just coming into the same package. It really is not reflected in their base. 20 DR. HEUSTIS: I think we are giving them $200,1000 21 too much. 22 MR. BARROWS: I will second that. 23 MR. PETERSON: Any further comment? 24 The motion is for $1.2 million. 25 HOOVER REPORTiliG Co, INC. 320 Massachusetts Avenue, N.[ 35L@ hws-28 Those in favor show your hands. 2 (Showing of hands.) 3@' MR. PETERSON: Unanimity, and this does include 4 the clarification by staff both on the renal project and 5 apparently cost per capita of educating our training nurse 6 practitioners. 7 state his' MR. ANDERSON: Can we ask Dr. Thurman to 8 concerns about that project? 9 DR. THURMAN: Before we do I move that we approve 10 Project 0044 in the amount shown, 11 DR. TESCHAN: I second. 12. MR. PETERSON: Any discussion? 13 Those in favor show your hands. 14 (Showing of hands.) 15 DR. THURMAN: With the Chairman's permission we can do that without holding uD the progress here. 17 MR. PETERSON: Certainly. MR. ANDERSON: May I be excused? MR. PETERSON: We have disposed of Western 20 Pennsylvania. 21 22 24 25 HOOVER REPORTING CO, INC. 320 Niassachusetts Avenue'N.E. 355 hws-29 1 VIRGINIA REGIONAL MEDICAL PROGRAM 2 REVIEWED BY SISTER ANN JOSEPHINE MR. PETERSON: I think again one of the Regions 3 we sort of hesitated in getting involved with before lunch 4 was Virginia, and if it is okay with you, John, I am going to 6 put you on two in a row, but I am going to ask Sister Ann to initiate the review on this one. 7 SISTER JOSEPHINE: Virginia is a program that for a long period of time kept a categorical orientation, and 9 once they changed from their categorical orientation to projelqt 10 11 and subs6quently a program, total program orientation, I think that Dr. Perez has to take care of needs in the whole 12 13 State of Virginia by meeting with all of the different agenci6Is 14 in the State and parceling out the funds to meet these needs in rather small increments in the total state. 15 The first time I went there on a site visit; which!, 17 was around 1970, the first place he took me was to the State Capital, and the first thing that happened to me, I was the 18 only one who was searched, to be sure I had no bomb, so the next day we went along with the sia,htseeing. 20 The soldier said to me when I said it is inter- 21 esting that I am the only one you searched, well, he said 22 the Berrigan brothers made you suspect. 23 The whole climate in Virginia - and I assume 24 there will be someone going to help with the staff review 1 25 OOVER REPORTING CO, INC@ 326 Massaci@usett$Avenuf. N.C. 356 hws-30 there is something very different about the climate in 1 21 Virginia. 31! There is something different about this Regional Medical Program. 4 5 Once they get the direction of what it is the 6 Federal Government wants, it appears almost verbatim in their@ objectives, in their thrust and everything, and this type, but 7 8 it is a little difficult to evaluate if it represents a con- 9 viction, represents a way to go, or represents a way of coh- 10 forming so they can move on with their business. 11 I think possibly this is not too fat from wrong. At the present time I have conflicting figures on the number 12. of staff. 13 On hand there Are.14 members, and as I see it therL-, 14 are 20 budgeted positions that are vacant, I believe this is right, and this has been, as Iremember it, an ongoing problem They have always overbudgeted the number of people 17 that they would like on board from one time to the next. They.i 18 never come on board, but the figure keeps stayin high. i 9 MR. NASH: This is a convenient way of perhaps 20 having some additional funds to take advantage of an opportunity 21 that might arise. 22 DR. TESCHAN: We have also seen some diagrams and i 23 charts -elative to capital ekpenditureso so that on any 24 correlation plot, Virginia seems to be out of line on the low I 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenui,, N.C. 357 hws 31 1 SISTER JOSEPHINE: Presently the program staff, 2 plus the program of $368,000 they are budgeting for $559',OOO,j, 31 but that includes over $200,000 for these 20 vacancies that i 4 I doubt they will be able to get. .5 On July 1 they are planning on coming in with 6 another proposal that will cost $1.3 million, making a total 7 of $2.8 million for this program. 8 As of this time I reviewed the pro'ects that are 9 listed, of the 1.9 projects listed on the yellow sheet, you 10 will notice that seven of these relate to hypertension. 11 My question would be could these probably somehow 12 or other be coordinated a little differently. I don't know. 13 You may want to comment on this, or this may be a way of just involving different agencies in this whole project of hyper- 14 tension, or maybe they are doing some research that is going 15 I(; to generate statistics or some,papet, I just don't know, 17 MR. NASH: This is an ongoing project'. and I cannot@@' 18 really answer your question. 19 SISTER JOSEPHINE: There are seven hypertension 20 projects. MR. NASH: Gene, do you have anything on th s? 21 22 MR. NELSON: No. SISTER JOSEPHINE: This program has generated a 23 24 lot of community activity. -I would say the leadership is 25 satisfactory and probably the leadership Dr6 POrez, is a TING CO, INC. 320 Massachusetts Avenue N.C. 358 hws-32 very sensitive to the different groups he has to work with 2 in Virginia, and probably one has to work with many for some period of time to appreciate this fact. 4 The Regional Advisory Group, I think, it seems to 5 me is doing a good job. 6 I notice that Dr. Neuno is Chairman of the Group 7 at the present time, and Dr. Neuno is a young Spaniard from 8 Malesia, and I have seen him stand up on several occasions 9 to Dr. Perez, which is interesting, in making the decision. 10 They have indicated when this program is phased 11 into the new program that is going to be developed by the 12 Federal Government there will be no difficulty in phasing 13 these projects out. 14 they have also phased out a certain number of 15 projects. I can't remember now how many, but they have phased i(i out without any difficulty in getting additional funding. 17 Their objectives and priorities follow the national 18 guidelines specifically, and they have listed their projects 19 under the objectives of improved availability, continuity, improved quality, efficiency and economy, and improved health 20 data base. 21 22 The health data base is one of the projects that is just beginning to be developed in the State. 23 The CHP relationships are good. In fact,, I got thel 211 I. impression on two site visits that the Regional Medical Program 25 HO ER REPORTING CO, INC. 3 Massachusetts Avenue@ N.E. 359 hws-33 1 funds a number of projects through and in conjunction with 2 the CHP. 3 Dr. Hirschboeck, any comment? 4 DR. HIRSCHBOECK: I have nothing to add, partic- @5 ularly. I am not very familiar with this Region. I had nev=j.i 6 visited nor had much to do with it. 7 On the other hand, it may be a judgment just on 8 the application, and data presented. 9 I would rate this as an overall average type pro- 10 gram, nothing unusual about it, struggling to meet the changing times and that sort of thing, MR. PETERSON: Okay, we may or may not have a 12 13 CHP problem here, and perhaps Tom Smith, who is from the 14 Philadelphia Regional office, and Virginia is serviced out of that Regional Office, has something to say in this regard. Tom? MR. SMITH: We have had a special concern, one in 17 18 particular. 19 MR. PETERSON: Which one is that? MR. SMITH: Is that necessary? 20 MR. NASH: Probably Tidewater, isn't it? 21 MR. SMITH: Tidewater, correct. Everybody knows 22 that. 23 This may be another sort of Western Pennsylvania 24 situation, I don't know, but the spec ifics had to do with 25 H ERREPORTINGCOII"IC@ 320 Ma sachusetts Avenc:-,, N.L@ 36o hws-34 ect review by-the RMP, particularly regarding the BMS pro] 2 project which apparently was not considered for review, and 3 1 CHP thought it should be. 4 Apparently the agency was not advised of this fact, 5 and interestingly, on paper it seems the relations are excel- 6 lent, because the agency director is a member of RMP, and I 7 am quite surprised the project was being considers 8 I guess I can't say much more than that. At 9 least one agency is very unhappy, whether that has to do with 10 personalities or not, 1 don't know. 11 MR. PETERSON: Is Tidewater Norfolk? 12. MR. NASH: That is right. 13 Pete, the gentleman which you are speaking about 14 is a member of the Regional Advisory Group, and the Regional 15 Advisory Group in Virginia is likely to include no new activities in this particular application. 17 This is a request for continuation of staff and ongoing projects, 18 11) They have sent out, or solicited new project pro- 20 posals for the July 1 application, and our last communication 21 with Region 5 of the 18 agencies have submitted a total Of 12 proposals which in Virginia RMP's review process at this 22 time. 23 I think what we.have here is a personality cohilic ?,4 DR. TTSCHAN: When you get this kind of news what 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 36i hws-35 happens? 2 MR. SMITH: Can he stop punching that thing over there? 4 MR. PETERSON: Let's go off the record. 5 (Disdussion off the record.) 6 MR. PETERSON: Back on the record. 7 SISTER JOSEPHINE: All RMP planning has been closel.@ 8 coordinated with the Governor's Committee, 9 This is a program that has stayed very closely to 10 the Governor's Advisory Committee, and originally then I think 11 the Chairman was the head of Public Health, and then finally 12 we got someone else as Chairman of the RAG. Then this close association with the Governor's 13 14 Advisory Committee may well be the thing that will make it possible for this program to phase into a State program, and 15 16 there are a lot of different projects. MR. NASH: This particular project you are speaking@ 17 of, if I am not mistaken, has been submitted by Tidewater CHP 18 to the Regional Office in Philadelphia for consideration of funding by John Reardon's shop also. It is also considered 20 for the July application. 22 Now, whether the RAG will approve it or not, no one@, knows as of this time. 23 MR. PETERSON; I-wonder if any of the other reviewers 24 have any observations or comments they care to offer, or i HOOV 9 REPORTING CO, INC. @32OMassachusettsAvenue@N.E. W h@,ncrtn IC n n C 70002 362 hws-36 perhaps have some comnlents? 2 MR. BARROWS: Just from the caption and titles of 3!i these proposed activities it would appear that they have pretty good program direction. 5 That is they are working on the right theme. is 6 that a reasonable observation? 7 SISTER JOSEPHINE: Yes, I think that my impression,, 8 that the Virginia Regional Medical Program is that Dr. Perez 9 keeps very close tab on what everyone is doing, and then also!, 10 keeps tab on the agencies with whom they are working. 11 I don't think he is the greatest developer of 12 personnel, you know. MR. BARROWS: I wasn't talking in terms of manager 13 ment, but talking in terms of purposes and objectives. 14 SISTER JOSEPHINE: These are the needs identified by the people, apparently. These are really in response to needso and they 17 don't look spectacular, or anything of this type,, but I think, 1.9 they are in response to the heeds that can be identified. 20 DR. TESCHAN: it is undertargeted. 21 MR. PETERSON: Dr. Thurman, as a displaced 22 Virginian, do you want to speak? DR. THURMAN: I think it would be inappropriate, 2 tl having really left the State. 24 Nothin hurts me more than to be constrained to 9 25 ORTING CO. INC, 32OMassathusetts Avenue, I.E. Washipito,a, D.C. 20QOZ hws-37 1 science. 363 2 MR. PETERSON: Do any of the other reviewers have 3@i any questions? 4 DR. HEUSTIS: I understood, Sister, you said the 5 beginning they parroted what came out of the Regional medi--- 6 Program. 7 SISTER JOSEPHINE: I think the objectives and the 8 guidelines they line up for themselves are just as close as 9 they can make them to what it is that the Federal Government 10 dictates, and then I think they try to fit into this program, 11 MR. NASH: They suffer from being too close to 12, Washington. 13 DR. HEUSTIS: I would have problems under similar circumstances, 14 DR. TESCHAN: We have agonized with Gene or years 15 in the Southeastern Group with these things, and I get the sense from what I am hearing, you know, coming in with that 17 18 background, 1 am hearing a much more positive type of situ- ation there now, and the thing I don't think is that we couldl 20 accuse Gene of, as it were, conformity as a subterfuge, 21 I think that Gene is conforming on two grounds4 One is that he is lost, you know, he realizes that you really 22 do have to play ball with the front office, and the other 23 feature about it is that the front office is asking is not 24 so different from what the situation is in Virginia as in 25 RYING CO, INC. etts Avenue, N.[. shington, D.C:20002 II)n)% r'lir,.AAAA 364 hws-38 I most other States, if not at all. 2 The main national priorities of health we are sup-i 31; posed to be recognizing are really what the problems are. 4 I don't find that an artificial situation at all. 5 MR. ANDERSON: May I say something? 6 I am not responsible for the program in Virginia, 7 but I did have the distinct honor of being on the site with 8 the Sister and two or three others two or three years ago. 9 At that time I was very impressed with the act 10 that they laid the program out in a very honest and straight 11 forward manner, not trying to please Washington, or the rest of usi but they laid the robiems out in terms of this is 12, p 13 our problem, and this is the way we are trying to deal with 14 In my limited experience with the State of VirginiA and the RMP's throughout this has been their approach to 17 trying to resolve the problems. 18 SISTER JOSEPHINE: You know, I have no reason to question the way they have gone. 20 In fact, After the first visit# when I wen on 21 the first visit, I came with some preconceived notions, but after the first visit I realized that there their response 22 was a very sincere response. 23 I realized also that they were making an attempt 24 to identify the problem, and they were making an attempt to 25 HOOVERREPORTINGCO,INC. 320 Massachusetts Avenue, N.C. n r )nnng 365 hws-39 1 listen, and then to design projects that were in response to 2 the problems and, you know, whether they were reading it 31@ correctly or not, that is another ball game, but they did 4 seem to be responding. But then it has been several years 5 since I have been there, 6 MR. NASH: I think the hypertension activity is 7 an example. 8 If you will recall, on our site visit they were 9 just proposing that at that time. They had some representa- 10 tives from two or three communities that were present at the 11 site visit, and explained the need for this sort of thing. 12. Sister, I certainly agree with what you say. 13 MR. PETERSON: We have a request here for roughly 14 $1.3 million with an indication that Virginia, and it is 15 essentially a continuation, that Virginia will begin all of 1(; its new activities in July with an estimate that this will 17 be a little larger than the $3 million plus. 18 1 don't k.now whether you, Sister, and/or Dr. I!) Hirschboeck have a figure in mind with respect to the current 20 application. 21 SISTER JOSEPHINE: I would like to ask a question. Do you feel those 20 vacancies, that it is realisti@ 22 to assume these 20 vacancies are going to be filled? 23 MR* NASH: You put me on a spot there. My personal 24 opinion is they probably will not, if we consider the length 25 CO, INC. ue, 366 hws-40 1 of time remaining for RMP. 2 You see, this is an award that will not be made ii until July. 4 MR. PETERSON: Late June, for a period of July 1 5 MR. NASH: This gives them one year, and their 6 ability to recruit that number of people for one year s 7 employment I think would be questionable. 8 Dr. Teschan doesn't agree with that. 9 DR. TESCHAN: Yes, but coming down to the question 10 of employment of the people under those circumstances, I 11 would go right along with the conclusions you woul d draw that 12 in terms of hiring and firing, there is no question about it, 13 because the people hired and fired would not have the exper- 14 ience, the background in the context in which to make those @15 judgments. (3) We cannot expect them to go out on a limb. DR. HEUSTIS: I note in a program that has been 17 18 described as average, if I understood correctly, they have proposed overall to increase their total request about 100 20 or some 100 to 150 percent. Is the program much more than maintaining it at 21 the current level the way we have done at the other average 22 things? 23 SISTER JOSEPHINE.: Yes, it is question also. 24 MY It is one of the reasons I asked about the 25 Hoc PORTING CO, INC. 320 Massachusetts Avenue, N.E. W2chinctnn n r. 7ofin2 367 hws-41 possibilities of bringing in people who they will have to 2 have to maintain or develop the kind of program to carry on the kind of program they have indicated, and I would think 3!i 4 they could not. 5 I would think that in the July review all the 6 projects are going to be there, and I think one is going to 7 have to take a hard look at this, 8 This present May 1 request I would recommend that 9 they are at the game level that they presently are, with t e indication that there is concern about the number of projects 10 11 that will be coming in in July with the 20 vacancies on the program, and it may be that can give some indication where 12 they plan to get these people, whether they plan to ring 13 them in from CHP staff, I don't know. They may know where 14 15 they are available. MR* PETERSON: When you say at the present level, 17 you were thinking then, Sister, in terms of that $971,000? SISTER JOSEPHINE-. $1 million. 18 DR. HIRSCHBOECK: I second it. 19 MR. PETERSON: Any additional questions or Comment9? 20 MR. de la PUENTE: I call the questions 21, MR. PETERSON: Those in favor of $1 million with 22 concerns being expressed, and hopefully some of this can get 23 in with the larger projects coming in the first of July, and 24 their real ability to filling some of the Vacancies, 25 HOOVER REFORTINO CO, INC. o Massachusetts Avenue, N.C. n i, )nnn,) hws-42 All those in favor raise your hands. 368 (Showing of hands.) 2 3 MR. PETERSON: It is unanimous. 4 I think we are now at 225, and I would like to 5 have one of the staff people we asked to come down specifically 6 for out next project, the Metropolitan New York and Lakes 7 Area, which is Bert Kline, who previously handled those 8 Regions when he was with RMP. 9 Bert is now in Planning and Legislation, and if 10 there is no objection I would like to move on to that Region, 11 because this is a very unusual application in one sense. 12 I donI.t know whether, Bert, you or Frank, or I 13 should set the stage, by the nature of this next request. 14 Suppose you come to the table, Bert, and het us 15 have a brief comment or two so that everyone will have the IC'. backdrop for the reviewer comment in the nature of this next 17 application. 19 20 21 22 2il 24 25 HO PORTIIG CO, INC@ Massachusetts Avenue, N.C. n r ')AnA9 369 hws-43 1 HEW RECOMMENDED MEDICAL PLAN FOR THE 2 METROPOLITAN NEW YORK AND THE LAKES AREA 31! DISCUSSION BY BERT KLINE 4 MR. KLINE: Well, Mr. Chairman, what kind of back-' 5 ground would you like, a little on the program,, and how it 6 got where it is right here now? 7 MR. PETERSON: I was thinking of everything for 8 two years. 9 MR. NASH: If you gave a little rundown on what 10 has happened to the organization down there, because we used to have real problems in that region, 11 MR. KLINE: I will take a couple of minutes for 12. 13 those not familiar with some of the history of New York 14 Metropolitan Area, which in approximately 1971, I think New 15 York Metro had some severe communication problems between the 16 then Coordinator and the grantee. At that time I was associated with the Metro Board 17 18 of New York and the staff, and also the Regional Advisors, and it just seemed it was sort of a shell game. The grantee could not very well keep track o whati 20 was going on at the program level. 21, The staff was kept fairl y well shielded from what 22 was going on, and likewise the RAG. 23 As a result of all this the situation with eVeryonO, 2,4 was sort of reaching in to see what they could pull out of 25 PORTING CO, INC. 320 klassuhusetts Avenue, N.[. 370 hws-44 I the program in terms of support for their particular efforts, 2 a little lobbying going on within the RAG, lobbying going on within the grantee, a little bit of lobbying going on with 4 the Coordinator. 5 Staff morale was some kind of shot. 6 Well, any way, some dynamics beg an, and we started 7 off with the management assessment visit, and started into 8 getting into some of these problems, documenting some of the 9 problems. 10 This went on with some recommendations. Some fund 11 were cut back, some were reprogrammed. All during this time the staff turnover was 12 tremendous, and through the course of eight or nine months 13 with some pressures perhaps from here in the ways of money 14 being held back, and so oh, things began to happen by Novembe 15 of 1972, that the Coordinator had resigned, and by December of 1972, if my memory serves me correctly, Dr. Thurman, the 17 grantee, resigned, and we had more or less during the-course 18 of the year of 1972 sort of cleared the deck, which was kind 19 of interesting, because at that point there had been a 20 residual staff which was waiting and somewhat eager to get 21 on with the job they could see very clearly, but could not 22 get to. 23 Dr4 Harrington, who had been the Deputy Director 24 at the time, was named as the Acting Director. 25 HO ERREPORTINGCO,INC. q')n M,,tui'.hiicpttqAvep,,;e N.[. 371 hws-45 1 Jack Ellert who had been the Evaluator at the time 2 was named as the Acting Deputy Director of the Program, and 311 they began to make some changes which had long been recom- 4 mended, and to do it rather effectively, and it was about tha 5 time that RMP's became the phaseout victim of the budget. 6 This, then, throw everything into sort of chaotic 7 situation but I think in terms of looking at this ar ticular. 01 p 8 application, in terms of talking to some of the people up 9 there, I tend to suspect now that their staff is getting just'! 10 a little better. 11 In any event, their application has been certainly 12 stronger than it had been in the past. Their organizational 13 structure is a little better. 14 What they did do in this particular application 15 was to, 1 think, they read the directions rather carefully 1(j as a matter of fact, and what I can gather they assure 17 within this application the grantee would assume responsibility for all activities which extended beyond the period of June 30, 1975, so they asked for monies for two years, by and large. 20 21 I have broken it out in the little yellow sheet there about $3.0 some million for the second year of activ- 22 ities, and a total of about $4 million for the first yearis 2 t3 activities, which include staff and other activities, with 24 the grantee saying, and being recorded herein, that if RMP 25 HO ER REPORTING CO, INC. 0 Massachusetts-Aveflue, N.[. 372 hws-46 1 is phased out at June 30, 1975, they, themselves, will take 2 responsibility for monitoring and surveiling t at money* I think in the instructions that went out, I thinki, 4 this was deemed As somewhat illegal, so they took the legal 5 approach and requested almost $7.5 million, and that is kind i 6 of where it's at. 7 I don't know if there are any further questions 8 on this, 9 MR. PETERSON: There may be after the reviwerse 10 We have Dr. Bill Thurman on this one. 11 Dr. Thurman, you want to lead off there? 12 DR. THURMAN: I think Bert has filled us all in quite completely, and excuse the term, Sister and other ladies 13 14 present, but I have never been more bastard on a site reunioni 15 than we have been there. We had to meet with all the medical school deans who wanted to quit because we were there. 18 We had real concerns, as Bert indicated, right then about Arronson's ability to take over a bad situation. He had nothing but fighting going on in his staff; and there i 20 was absolutely no question that the staff was totally blodkedi, 21 off from participation in this program. 22 It is just unreal, and yet, there was a talented 23 staff there. 24 I think the present application reflects the fact 25 PORTING CO, INC. 320 Massachusetts Avenu@, N@l. n r )nnn) 373 hws-47 that Arronson has taken over very well. He has pulled to- 2 gether a staff that is adequate. They have also put together an application that irl 3 it was inconceivable they could have put together before. 4 Our real concern is that he looked at that moment 1 5 like a terribl weak sister -- and that is not a pun, Sister y 6 Ann -- we didn't think he had it. 7 I think our other major concern that is still 8 reflected in this application, and that is one that I have, i 9 is that this, in essence, was then, and is now, a one-man RAG'@ 10 in the presence of Mr. Popper, in a way, and I think if there 11 is anybody who did read every fine line and figure out how 12 they would do it, and swear he-could monitor it for the coniin 13 two years is the RAG Chairmant who is a very unusual indi- 14 vidual. 15 This RAG Chairman is very much dollar-oriented, 16 1 and he orients the dollars to the RAG, and that does show i 17 through in here occasionally. 18 There is no question in my mind that the staff is far superior to what it was, and there is no question Also 20 that in the preparation they have much better morale than theyi 21, had before. 22 I think that the weakness of the RAG is not becausei@ 23 of lack of interest in that some of them really took us over 24 the coals, but they also were not informed, and I think that 25 HOOVERREPORTINGCO,INC. 32OMassa@.husetts Avenue, N.E. 374 hws-48 1 again I would question whether or not they are truly informed 2 now about what is going on. 3 They were not informed then about the difficulties 4 with the schools, which I think was unfortunate, and made it 1 5 very unfortunate for us, 6 I think the school situation now is well handled, 7 I mean because they got outof it. 8 You will notice from the list of projects in here 9 that there it still an attempt to carry forward to each 10 school some RMP money, or we have used the term the day of 11 political payoff to keep things running smoothly. 12. On the other hand, some of those projects are 13 quite good and strong. 14 In reference to the projects there are some very 15 strong ideas, but most are carbon copies of other programs 16 within the Region itself. 17 My question was whether or not all the projects, 18 that the same thing could be strengthened by corps staff I!) leadership with multiple outreach indications. The examples are kidney, manpower and hypertension 20 21, problems, and so on. I feel the money here is going to be wasted, but I 22 have been wrong before. 23 We have spoken of the problem of the continuation 24 of the money past June 1. 25 HOOVERREPORTINGCOII'IC. omassaousettsAvence,N.E. 375 hws-49 1 The CHP has never worked out of New York. Th eir 21 relationship is good -only because CHP does not have the stren. 31 to react yet, so it has given it a cursory review. 4 The CHP is becoming much stronger, and if this 5 program goes on, the CHP will get into it. 6 All in all, I feel this program has significantly 7 changed since the days of our last visit there, and it is well 8 reflected in this document; the changes that have occurred 9 and have taken place. 10 For that reason I support the program,, and would 11 call it now a slightly above average program. 12 I think it is clearly better than some of the other 13 programs we have classed as average in the past two days in 14 leadership and direction and everything else, 15 I will come back to the figure after Al has had his say. 16 DR. HEUSTIS: Al worked under the constraints of 17 18 what he had available to him, which was the written document, 19 and I take respectful exception to the staff saying that they 20 followed the direction that at least in my copy they did not number the pages, and I never had so much trouble to find 21, anything in trying to relate back and forth, to try to get 22 things going. 23 I did not have the appreciation, not having done 24 this before, when I took a crack at the first because it was 25 HOOVER REPORTING CO, INC. 2')n, Aventie. N.[. 3(6 hws-50 the thinnest, which was Connecticut's, and the one I took a 2 crack at second was Metro New York. 3 MR. PETERSON: Is that when you called and said 4 you weren't going to be able to make it? 5 DR. HEUSTIS: Just from the document I am not pri to this other information, but just from the document I was 6 7 not too impressed, and as you have said'. I certainly wasn't 8 impressed with what they have done in the past, and it seemed 9 as though they had great difficulty in sorting things out, 10 for example; and it was very confusing. 11 For example, there is an item that has a different 12. project number that is in twice for $947,632. 13 MR. KLINE: Project Numbers 50 and 62. MR. PETERSON: This is the EMS? 14 MR. KLINE: Number 50 was their pilot of last year 15 which was not supposed to have the money attached to it this year. 17 DR. HEUSTIS: My problem was this was widely 18 separated in the organization and getting discouraged, I wondered 1'f somebody said let's just duplicate this without 1 20 too much thought. 21 I guess you folks have so much more valid inform- 22 ation than I have that my very discouraging report, and my 23 rating as far as this goes was below average, and as far as 24 the other kinds of things, it looks as though the program 25 ,HOOVERRtPORTINGCO,INC. 320 Massachusetts Avenue, N.[. 3TT hws-51 leadership was satisfactory; the program staff didn't impress 2 me too much. 3i The RAG which was satisfactory in the past in performance got a low rating. 5 The objectives and priorities again were satis- 6 factory. 7 The proposal is satisfactory, and one feasibility 8 I just didn't really think it was very hot., and CHP relation- 9 ships again, you tell me there is no CIIP, and I rated the 10 thing as pretty good. 11 MR. PETER80N: There ibnlt any, in one sense. 12. There is a funded areawide C'fiP, and in so many major metro- 13 politmi areas, Washington, D. C., still doesn't have one. 14 It was very slow in getting organized, in getting funded, 15 and even now I suspect that Bill suggested it is not ea y functioning, and it is difficult not to have at lease Adeauate'; 17 relationships with someone who is not functioning. MR. NASH: Pete, I was up there in P6bruary and 18 March to take a look at their review process, and we had a 19 20 representative from the CHP Agency also Visiting with us, and I I don't know how far along they had gotten with their mission 21 of developing-a plan,, but certainly from what he told us the 22 23 relationships between the two organizations douldn't be better. 24 MR. KLINE: This was interesting too, because all i 25 @IIOOVER REPORTING COI:NC. 320 f@iassuhusetts Aven,ie, N.[. hws-52 the way back to, I guess about 1971 or early 1972, 1 am losing, 21 track of time now, they did have good relationships with 3 .1 whatever existed in the wav of CHP. 4 THE CHP was coming into existence at the time, but I 5 there was a good working relationship right from the outset 6 with the CHP. 7 DR. THURMAN: I didn't mean to imply it was bad. 8 It just didn't exist. 9 The problem is there was nobody there to argue 10 with. 11 MR. KLINE: I think the CHP, although I am not sure@. 12 if it advanced along the same kind of slope and graduated 13 advancement that was going some time back, it should be 14 functioning reasonably well now. 15 DR. TESCHAN: There is a $1 million proi6ct on i(i this, Health Care Services. That is a pretty big figure, and 17 it is a one year -- well, I guess two years. 18 MR. PETERSON: All of those projects which have a 1!) C are essentially two year activities so the annual cost againi 20 is roughly, I guess, about half of that. That is still a $550,000 activity, 21 DR. THURMAN: That in actualitvo the design of 22 23 this program is superior probably to most other programs we run across of this nature, 24 DT. TESCHAN: To what? 25 RTING CO, INC. etts Avenue, N.[. illflon, D.C. 20092 379 hws-53 DR. THUP14M They are trying to make all of the hospital rooms and clinics operated by the City of New York, and also by private hospitals much more in touch with each other 0 4 and much more of a regional type of referral, so that the 5 lady in Queens who decides she needs a ceasarian operation 6 can go to a hospital there rather than come to a hospital in 7 downtodn New York. 8 That is what the impact and the plan was, an 9 their ability to get the great majority of the hospitals in 10 the area to at least consider this. 11 It was easy to get the City of New York, the city 12. hospitals, but they brought in a lot of the private hospitals There is a lot of fighting going on in Westchester County, 13 and certain parts of Queens, which have never gotten any 14 15 money at all, and metro New York City. It is overly priced here just like the EMS prograipE 17 are overly priced, but it is a great idea as far as trying to 18 deliver health services to an amorphos population that cannot be reached well at this moment. It is overpriced. DR. HIRSCHBOECK: Are we going to judge these 20 projects on the basis of one year funds, or two year funding, 21 or what? 22 How do we handle the desire on their part to circun- 23 vent these? 24 MR. BARROWS: Let me get some preliminaries here. 25 HOOVER REPORTING CO, INC. .120 folassachusetts Avenue, NI. i@ 380 hws-54 Is the nature of these projects such that they cou d 2 have been presented as one year, or will it take two years to 31 get the job done? 4 DR. THURMAN: Of all the C project in here, prob- 5 ably about 40 to 50 percent of them, that is a tough guess 6 now, need two years to really come to fruition. 7 Take the program we are referring to, the $1 8 million program, on the other hand is going to be financed 9 either by the City of New York hospitals, or the consortium 10 of New York hospitals if it goes into a secon year. 11 MA. PETERSON: I guess John's question, I wouldn't 12 want to provide an official RMP response, this is almost a 13 case of one,, the extent to which Metro New York has asked for 14 two years support, and my own personal view, and underscoring 15 the word personal, is that 1 think we need to look at this 1(; in terms that say to Metro New Yor:k, or any other Region that 17 really has done this, here is an amount of money if you want th 18 do some activities over two years you are going to perhaps 19 feel the pinch in other areas, because most Regions, you know, 20 if we were to consider most regions, I suspect there are some 21, activities which they could have looked forward to multiple 29 funding on a grander scale. I think it disposes of a difficult question. I 23 don't have a real answer to it. 24 25 Maybe Bill Thurman's recommendation will help come HOOVER REPORTING CO. INC. '47n Miec:iehiitafft Aupniip N f 381 hws-55 I up with an answer. 2 MR* KLINE: I would like to comment on that one 3 point really, the $2 million project in particular. 4 That project has A series of discreet activities. 5 Were they to receive reduced funding on that particular thingd 6 they would fund particular activities on a priority basis 7 within that $1.2 million. 8 DR. TESCHAN4. Was there evidence of some priority 9 setting? 10 DR. THURMAN: It is not in order, on that list. 11 gert's point is a good one. It was asked for undet 12 RMP from the standpoint they could involve everybody with 13 RMP dollars, whereas otherwise'the City of New York is going 14 to fund it for all the City of New York hospitals. They believe they will combine with some of the others, and the 15 County Medical Society is going to fund it with Queens. 17 Its availability as a plan will become somewhat more difficult. 18 19 DR. HEUSTIS: That makes very good sense, I think, that is that approach. 20 MR. BARROWS.- Looking at the thing in a very broad 21 sense, and taking into account the population we serve, which 22 is what, seven million or eight million? 23 DR. THURMAN: They say 14 million. 24 MR. PETERSON: That is probabl a little too high.. y 25 HO ER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n I' ')()An) 3b@ hws-56 MR. BARROWS: We are talking about, let us say, 2 ten million people. We all go by the extraordinary expenses 1 3 1 in New York, the extraordinary amount of time it takes, the 4 extraordinary difficulty in getting things together, as witne,@s, 5 trying to get a CHP. They have been working on that for 6 eight years now. 7 When you look at all those together And you con- 8 sider there what they are asking, it is really kind of modest, 9 it seems to me. 10 MR. PETERSON: Bil , you said something which 11 suggested to me at least that you might have a motion in your 12. hip pocket, or recommended funding level. 13 MOTION FOR RECOMMENDATION 14 DR. THURMAN: I move we approve it as a slightly 15 above average program, and we throw out for discussion here, i(i discussion of $2.2 million. 17 I think if we do that, my own opinion is, and t at 18 is all it is, is an opinion, they will look hard at some of these projects. 20 I am afraid some of the buroughg of New York will 21 go out. But there are some very significant steps they can 22 make in developing health services in Metro New York with that kind of money. 23 MR. BARROWS: It is about 30 percent lower than 24 25 last year. HOOVER@AEPORTING CO, INC. 320 M ssachusetts Avenue, N.[ - 383' hws-57 1 DR. THURMAN: No, they are operating on $1,142,000 2 now, 311 My figure is in the range of $2.2 million to $2.5 4 million. 5 I have read Bert's recommendation, and I can't 6 @gue with it too much, but I have ended up with $2.2 7 million. 8 MR. PETERSON: Did you say $2.5 million? 9 I was thinking $2.2 million. 10 They have indicated to us Metro New York, that 11 they will be in with an application in July of around $2 12 million in addition. 13 MR. NASH: That brings it to a level of $441,000, five percent above the target figure, assuming both applica- 14 15 tions are approved in the amount requested. DR. THURMAN: They requested $7.7 million. 17 DR. HEUSTIS: My problem, I go along with the $2.5 18 million, and my problem is really this. I wasn't anywhere 19 nearly impressed with the written document, but I sure am impressed with some of the things that they were trying to 20 21 do together involving Metro New York hospitals, and certainly am impressed with the problems of doing things such as an 22 area of New York City, and this two year business,, I just 23 am not particularly impressed with that. 24 What I was really trying to do is wrestle with the 11 25 "DOVER REPORTING CO, 320 Massachusetts Aver,je, 384 hws-58 fact that really on the past record they didn't deserve very 2 much, but it looks as though maybe they have a new lease on 3 life, and that they could do something, and if you could come 4 up with some kind of a figure that would give them a little 5 help, but certainly not everything that they wanted. 6 DR. THURMAN: That is why I gave them $1.3 millions 7 That is not an insignificant amount of money, except when you 8 look at.8.5 million, nine million, or ten million people. 9 DR. HEUSTIS: I look up there at the greater 10 Delaware valley. Is that Philadelphia? 11 That is really the only Problem I have in this. 12 DR. THURMAN: Well, if somebody wants to go higher 13 and 14 DR. HESS: I wonder about going up to $3 mi ion 15 or something. New York is a health care jungle, and my guess is that New York probably hat had it. 17 18 This is a small staff, seven full time professional;, 19 no planned incremental, so that was one of my concernsi can 20 a staff that small handle it. 21 Do they have the administrative mechanisms to 22 handle this much money? Mr. Kline? 23 MR. KLINE: I had the same kind of cbncerni and I 24 cannot answer it, because I have almost an all new staff. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. hws-59 The only new people being carried over are the 2 Deputy Director and Director. 3 MR. PETERSON: How long ago was it? 4 MR. SIMONS: Bert was up there in 1972. 5 MR. PETERSON: Really, that information on the 6 staff is completely new. 7 It always has been a small staff, as you know. MR. NASH: Pete and I were up there, at least on 9 a part time basis, some 60 percent, four physicians, and these 10 are people with excellent reputations in New York City, an 11 it was their proposal then to hire a full time nonmedical 12 staff to assist these four people in various program areas 13 in which they are working, so this would add tremendously. 14 DR. TESCHAN: How about the financing? 15 MR. PETERSON*. Maybe Tom, who has been part of the management assessment effort has some insight. MR. SIMONS: The grantee does all of the accountin 18 for them. I don't think there is any of that going on, on the staff level itself. 20 21, DR. HESS: So we don't have to worry about that. 22 MR. SIMONS: One other thing, as far as staff. Jack Eller was with me on a management assessment 23 to another place. They have hired on a part time basis a 24 physician to work with them. These are physicians who have 25 REFORT!NG CO, INC. 0 Massachusetts Avenue, N.[. 386 hws-60 reached a stage that don't want a full time activity, 2@i but they still -,Lnvolved. 3!! 14R. Iked to Jack Eller on the phone 4 the other day, and he ha@4 extremely high praise for the part 5 time people. 6 I queried him about the size of the staff once 7 again, because that has been a c hronic problem with him, and 8 I said I noticed yov have some part time people, and he said 9 they are very helpful. 10 MR. PETPR'-;ON4 I think that is a case where the 11 proposed additional positions would come in, would it not? 12 MR. NASH: Yes. 13 MR. PETERSON: We have hot been consistent. 14 DR. HESS: Does that mean seven additional pro- 15 posed full time professional clinical people? 16 MR. KLINE: Yes. 17 DR. THURMAN: To get back to the staff sheet one 18 more time, the $88,000 is in overhead and is what pays for Iq all the accounting and financing mechanisms, and at the New York Acade my of Medicine in the program staff figure there 20 is a $88,000 overhead, but that pays for their accounting to 21 2:>. the New York Academy.,, DR. HEUSTIS: I would like to support the motion 23 as made with the proviso that when this comes to the Council, 24 and should there be extra money, that the Council look upon 25 N ORTING CO, INC. 320 chusetts Avenue, 14.1. s inaton, D.C. 20002 87 hws-61 the needs of New York in a fa-,7orable fasA@Aion and that my 2 thought about increasing, is whalt.- 1 about the needs of 3 it New York City more than anything else. 4 MR. PETERSON: You have any problem with that? 5 DR. THURMAN: No. 6 MR. PETERSON: We have a motion for $2.5 million 7 for this May 1 application for Metro New York. 8 Any additional discussion? 9 DR. HESS: I may just ask what will that do now? 10 Let's say.that they come in with a batch of new 11 applications in July, and a certain number of those are again 12, passed. They still have the freedom to reallocate within the 13 two decision making periods, so if they want to boost, for 14 example, this Medical and Health Care Services, they can out 15 of that total package that we are not bypassing a lower figure now, we are not necessarily restricting their ability to increase funding in that particular project. 17 18 MR. NASH: No. As a matter of fact, about a month 19 ago Dr. Arranson And the RAG Chairman came in and met with 20 Dr. Paul, and they explained at that time that their applica- tion is going to be roughly $7 million. That is the first 21 22 application, and the fact that they would be asking for support for many of their activities over a period of two years. 23 24 Obviously, Dr. Paul told them that seems like a little high figure, but go ahead and send it.in. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 388 hws-62 1 There is very little else you can tell them, becau e 2 they c.,a-n request anything they want. I They did say that they would take whatever was 4 recommended in this award, and would have their RAG meeting,, 5 and they would look at their total @gram. They would 6 prioritize the activity and select those that they wished to 7 fund. 8 MR. PETERSON: I think in response to what I heard 9 is your policy kind of question, that New York Metro, or any 10 other Region, would have the kind of discretion and lattitude 11 within the two awards which becomes a single pot of money again within the Councills policy regarding discretionary 12 13 funding to move things around. 14 The problem that they would have in the short run, 15 of course, is that they are not sure of how much they will get 16 out of a July application. There may be some things that they have got in 17 1 18 this application that they would want to defer starting until I 19 they see that, or some things that they might start at, start I at a minimal level, and depending upon the outcome of July 20 extend it. 21 But the general answer to your question is yes, 22 they would have that kind of discretion. 23 DR. HESS: Then these projects will not be in the 24 next package. 25 @HOOVIRREPORTINGCO,[?!C. assachusettsAvenu@-,N.E. 389 hws-63 1 MR. PETERSON: No. 2 DP. HEUSTYS: But there is nothing to prevent them 31 for funding these projects after they get their July money. 4 MR. PETERSON: No. There are a few caveats, but .5 I didn't see any projects that involve construction of some 6 kind. 7 DR. HEUSTIS: I look at this arrangement as perhaps 8 simulating the use of non-RMP money that I feel confident is 9 there, and whereby perhaps instead of paying for the whole 10 thing as far as this working relationship, the city emergency 11 rooms, that they might pay for part of it, and the city might 12 pay for part of it. 13 MR. PETERSON: We do have a motion on the table for $2.5 million providing for the Council looking at your 14 15 recommendation given the needs of New York City, that there is some leeway, and that we look upon it favorably. 16 Any additional comment or questions? 17 If not, all those in avor signify by showing your 18 hands. 19 (Showing of hands.) 20 MR. PETERSON: Okay. We had one member absent. 21 We did what I was trying to avoid doing, if that 22 clock is correct, and the cafeteria is now closed, but I was 23 wondering, we have five applications left, and I think we 24 can get them under our belts if we probably work until 5:30 25 HOOVER REPORTING CO, INC 320 Massachusetts Avenue, N.E. 390 or so, 2 Would you people like, despite the fact that the 3 cafeteria is closed, to take a stretch a t this point? @4 (Short recess.) 5 MR. PETERSON: Well, let us proceed now with the 6 Lakes area. 7 Mr. Barrows: 8 MR. BARROWS: I will try to be brief. 9 The Lakes area is a nine county area in Western 10 New York ancl Northwestern Pennsylvania. I think they are 11 asking $2,072,000. 12 I do not have the last year figures here. Last 13 year they were running about $1.4 million. 14 Their Executive Director is Dr. John R. Angle. 15 He has been in the program since its inception. He spends 80 to 90 percent of his time with it. The RAO Chairman is Father Garrard, an educator. 17 18 The Executive Committee is composed of four officers. 19 The professional staff has 19 full complement. 20 They have 13 on board of the complement, and need six. 21 I might add that by my guess they are well supplied with chiefs, but they are short of the important Indians. 22 In the Regional Advisory Group they have 43 people, 2.3 24 two from each of the nine counties. The rest are fairly diversified by interest and background. 25 CO, INC. ue, N.[. 391 hws-65 I There is a substantial non-provider representation, 2 In fact, it is almost like a CHP Advisory' Gz,oAv"p, usua y 3 routine about their processes. 4 They have a very elaborate structure. They have 5 25 committees,, and it looks to me as if there are a certain 6 amount of overlap, and what have you. 7 It appeared to me that their processes were demo- 8 cratic, but awfully complex. 9 Their major thrust normally has been along three 10 lines. The main one seems to be education, 11 I, too, think we are giving more I.ip service to the Current RMP mission than they were actually. 12 13 For example, these are things that I am not that 14 particularly acquainted with. They are asking for $154,000 15 for the telephonic electronic program, $200,000 for a tumor 16 registry, which I understood was pretty well half full. Area prospects for success undertaken seemed to 17 18 be fair, reasonable. Their objectives and priorities are adequately 20 stated transmission of new knowledge, regionalization, and improvement of delivery, but they seem to treat cohtin- 21 uing education as the way to achieve all of the goals. 22 The proposal looked to me like something of a 23 residual rural mission. 24 The feasibility is good and bad. They have a fair! 25 RTING CO, INC. Ma husettsAvenu,,,N.E. 392 hws-66 1 showing of State and local cost sharing on some of their pro- 2 grams which would suggest some commitment -@f them. 3 They have two CHP B's that they 6n Western 4 New York and Northwestern Pennsylvania. Each has a repre- @5 sentative on the RAG. Five of their county committees are 6 joint. They share in their development review with CHP. 7 When New York expressed its concern whether the 8 large majority of these proposals relate to the major goals 9 of LARNP, of 21 proposals they disapproved eight, because 10 they were not related to the-goals, where they had weak planning, and they approved two with major conditions. Now, I would say that ordinarily I can understand 12 13 the sibling rivalry between CHP and RMP, and there is a lot 14 of ego trips and petty bickering, but this letter from the 15 Western New York B Agency struck me as being a pretty darn rational critique under a proposal that had been submitted tol them. 17 18 That was my impression, in any event. Generally, I would say that this is a weak average 19 20 program, slow in responding to the 1971 mission. They have a staff shortage of what I think are 21 fairly key people in any implementation activity, and that 22 will limit their capacity. 23 I have some question whether the staff and RAG 24 structure are functioning effectively. 25 110 REPORTING CO, INC. 320 chusettsAvenue,N.I. @l n p )Ann,) I f hws-67 1 As I say, I wind up.with a no better than average 2 rating,, a kind of wea,,@ -,lj.erage. 3 I would be glad to hear somebody elsels view that 4 might be more cheerful. 5 MR. PETERSON: I am not sure I can satisfy you on 6 that score. 7 Dr. Heustis is the next reviewer, and I can say 8 that.he is charitable, but I cannot say he is going to be 9 charitable about the Lakes Area, and perhaps the best way is 10 to ask him. 11 DR. HEUSTIS: In general you almost read my notes. 12 This was one of the ones that I think that I made 13 the remark that the first time I went through this I lot a pretty decent impression when I went through it fast. 14 15 Then when I went back and read it more carefully 10, and tried to put things together, I had great difficulty trying to pinpoint the reported specifics, for example, short 17 18 term goals and priorities may well in fact e 3st, but t ey were not emphatically stated, and not with sufficient speci- 19 ficity at least to satisfy me. 20 21 I found it interesting in the classific.ationdf 22 the projects that some, if you classified them by the so-called major thrust, there were three of them on the use of knowledge, 23 one on Regional linkages, and nine had to do with personal 24 health in one wayi and they also classified them another way, 25 HOOVER REPORTING CO, INC. @320 Massachusetts Avenue, N.E. 394 hws 68 1 three for health screening or assessment, three having to do 211 with patient care, one coordination, and six on manpower dexelopment and education, 4 That, you can see, is where the emphasis is. 5 couldn't find any information that was very helpful on how 6 the staff planned to implement the major thrust, and I could 7 not find any information on how the relative priority of the 8 various components was assessed, although they do say the 9 priority was assessed. 10 My comments as far As the CHP, I have the same 1.1 reaction to the letter from Western New York, in which they 12 very specifically commented on the new projects. Of the five new projectsi two were not approved, 13 and three were approved. 14 15 Of the two that were not approved, they had to do 1(5 with regional hpertension and the preparation of ntrse@@, faculty. -17 18 The three that were approved had to do with ambu- latory health planning, somebody in the household. 19 I think with the extent and capabilities and,the 20 program staff, I just can't help but wonder why they couldn t 21 provide sufficient information in health planning to put some 22 of these things together to stimulate those asking for grants 23 to get something done, 24. Apparently they didn't, because as I analyzed 25 Ho ER.IEPORTINGCO INC. 320 Massachusetts Avenue, N.C. n r )nnn,) hws-69 1 the money figure here, somewhere'that out of the total recfuest 2 of $2..072,000, almost $800,000 or slightly less than one-thi-ti 3 was listed for the program staff. 4 In addition, almost $1.1 million was liqted for 5 Activities for program staff activities, leaving sponsore( 6 projects only some $215,000 as far as others were concerned, 7 It would seem to me that in one way it could be 8 a little onesided. 9 DR. TESCHAN: You are saying the staffing isn't 10 adequate enough to handle that amount of business? 11 MR. HEUSTIS: No. the staff ought to be concerned, 12 to be responsible, and to get others to try to handle the 13 projects, rather than running it themselves. 14 it looks to me if you have a difficult Region and 15 a capable staff, the easiest way, at least to my thinking, is 16 to distend it and carry it out with your own group, probably a very limited usefulness in the long run, because it goes 17 18 when you go, The harder way in the long run is to get somebody 19 else interested in carrying out the good idea so that it has 20 a greater chance of staying. 21 22 I guess my general belief is that those projects that are carried out by others probably have got, on the whole, 23 a greater probability of being funded into projects. 24 DR. TESCHAN: Continuation funding? 25 CO, INC. ue, N.E. 396 hws-70 DR..HEUSTIS: Yes, yet dealing with strong medical 211 schools, and with a strong situation we know the difficulty at least in getting started. 41; In the overall specific assessment I thought the program leadership was good to excellent. c- I thought the same about the program staff, the 7 Regional Advisory Group, a little lower, satisfactory; per- 8 formance and accomplishments,, satisfactory. 9 I have trouble with the objectives and priorities, 10 and I had to break those down as poor, the proposal I wante 11 originally was higher, but again it is on the poor side. 12 The feasibility again is on the poor s de, an 13 CHP working relationships, in spite of the disagreements, it 14 looked as though there was the opportunity to communicate, 15 and on that my judgment is good, even though there was differ- 16 ences of opinion expressed. 17 I weighted the whole program the same as my 18 colleague did, on the low, average side. 1!) MR. PETERSON: Well, I think there have been a couple of concerns expressed that have been shared by staff, 20 21 and I will call on Frank, and also ask Bert two or.three 22 things that we had some questions about. MR. NASH: I will make a comment about the CHP. 23 24 What Dr. Angles did, was as soon as he got a pro- ject in and before it had gone through his own review process,, 25 Ho ER PEFORTING CO, INC. 0 Massachusetts Avenue, N.[ n r gnno? 397 hws-71 ne sent it to CHP agency for review. As it ended up he sent in 21 pr ojects. The com- 3 ments were received by CHP. 4 The Regional Adv-;.sory Group approved themselves only five of the 21 projects. They did approve one that the 6 CHP recommended disapproval for. This was the one submitted 7 by Niagra University for training nurse practitioners, and 8 the Region explains to me that the CHP agency there does not 9 have a nurse on their staff. 10 The Regional Advisory Group thought from a tech- 11 nical standpoint the CHP's comments in this particular case 12 were not really accurate. 13 MR. PETERSON: There were a couple of projects 14 or activity concerns that you at least noticed or mentioned 15 to me. 16 MR. NASH: You will notice Project 1, the Tele- 17 phone Network, that activity they have been supporting now for 18 about seven years, and they propose to continue this in the coming year, and even a year after that. 20 DR. HEUSTIS: There were some two year requests I failed to men ion. 21 22 MR. NASH: That is right. 23 This for me is a staf f person. 24 1 think in the past if they didn't have a policy we practiced it at least that RMP would usually fund an 25 HOOVER REPORTING CO, INC. 320 ssachusettsAvenue,N@l. I 11 398. s, perhaps 1 activity for three years, and then on rare occasion hws-72 2 for another 12 to 18 months, at the most. 31 Staff would wonder if this concerns the Committee 4 any that they would continue to fund this thing into the 5 1970's. 6 MR. PETERSON: Let me mention one thing in that 7 regard. my offices a couple of years ago, we contracted .8 9 for a study of these types of networks. I don't recall t a 10 the New York one was one of the subjects of it. 11 The contract was an abysmal delivery product y 12 Systems Development Corporation, but one of the things that 13 we pretty well knew beforehand, and they did manage to d6cu- ment the ability to find continuation funding for these kinds 14 15 of telephone radio networks was fairly low. 16 Now, I think in Wisconsin there was about as much success as anybody had, and that was in percentage terms of 17 18 what, 50, 30, 20? 191 DR. HIRSCHBOECK: The University extension con- tinues to support it. 20 MR. PETERSON: I know in Wisconsin it really was 21 the University Extension Service, and you were looking at 22 nurses, as well. 23 DR. HIRSCHBOECK: We were just augmenting their 24 program. 25 ORTING CO, INC. VO Massachusetts Avenue, N.E. Washington, D.C@ 20002 399 d hws-73 MR. PETERSON: But there had not been a very goo 2 track record on the whole. Wisconsin is the exception. 41 Anybody seeming to get much money to cost share 5 or to continue funding these activities, once they are empty,, 6 to pull its dollars out. 7 I think that may be a reflection of-what is 8 happening in Western New York. 9 I don't know but this is the staff's concern4 10 This seems to have been part of the Western New 11 York - Lakes area package of projects since the year one. 12 MR* BARROWS: It has never been my impression 13 that RMP was designed to provide continued operation of service. 14 15 Here, you are asking for about one-third of a million dollars for this network that is seven years old, and their tumor registry, that alone they are asking $200,000. 17 18 I would think once you establish whether it is 19 going to fly or not fly on its own, that is the time for RMP 20 to get out. 21 MR. NASH: I asked them for the tumor registry,, 22 and they said they had funded it for three years, but you need at least five year support to gather enough data to make 23 these things useful in feeding back information to physicians. 24 MR. KLINE: Can I comment on that? 25 HOOVElt REPORTING CO, INC. 320 Massachusetts'Avenue, N.[. 4oo hws-74 MR. PETERSON: Surely. 2 visit Mr(. KLINE: In 1971, December, a site 3 strongly suggested that the program get out of that tumor 4 service registry because it was not felt at that time that 5 it represented a very strong project. 6 At the time the indication was that it'had been 7 contracted or planned for a five year effort. 8 This plan as it now shows carries it into the 9 fifth year and on into the sixth year. 10 I tend to have a little bit of concern about 11 that. The other concern that I have about this program is 12 that it doesn't look very, very much different than it looked 13 three years agoo which is kind o amazing. 14 This is sort of like a static program. The rural 15 program has been going on for three or four years. The tele- 16 phone collection network, from the day the program opened. The tumor service registry almost from the day the program 18 opened. 191 The two activities essentially are there, emer- 20 gency medical service and their area health education center, 21 and the other activities they have are relatively.small and 22 new. I guess my primary concern is I looked at this 23 with a tremendously huge staff, and they do have a very large 24 25 staff,, and they do have some very excellent people on that H PORTING CO, INC. 320 Massachusetts Avenue, N.E. 401 hws-75 I staff. 2 The problem is they essentially haven't come up 11 witn a roctram. 4 MR. BARROWS: They don't have the leadership. 5 I have concluded that the program that wasn't 6 doing much probably wouldn't change, and the upper limits Of 7 my responsibility would certainly not warrant coming forward withIA proposal that does much more.than continue their 8 9 present funding level, which would be about $1.4 million. 10 MR. PETERSON: Let me add one thing regarding a specific activity which Bert singled out as being one of the 11 12 few newer things, and that was the Lakes Area Health Education 13 Center. 14 Now, my information is roughly 18 months old, but 15 we did staff visit a large number of the health services educational activities back in May, June and July of 1973. The old one that I went on happened to be the 18 Lakes Area one, so I don't have any personal comparisons to be able to make, but I do know in talking to people who were 19 on that site visit, and more importantly, the others who 20 would have been on a far broader range of site visits, that 21 was one at that point, one of the weakest ones4 They had 22 real problems with getting any kind of commitment, 23 This asn't a matter of domination. They had what 24 was admittedly an extremely difficult, nasty situation in 25 PORTING CO, INC. 320 Massachusetts Avenue@ N.C. 402 hws-76 1 Erie, Pennsylvania where you have two hospitals jockeying 2@ for some sort of number one position, the medical staffs,, the 3; physicians in the community being staffed sort of, you know, 4 their appointments with one or the other, and at that point 5 was one of the weaker looking ones, and I don't know whether 6 we have any later information, and it wasn't in the prog- 7 nosis for good progress, and was not all that good in the (5) 8 health educational center. 9 MR. NASH: They still have the same Project Direc- 10 tor for this. 11 MR. KLINE: Pete is commenting on the Erie, Pennsylvania Health Education Center. 12 I visited five emergency health service projects 13 14 last year. 15 Of the five we visited, 1 tended to suspect that it probably ranked at the top so probably offsetting the possible deficiency in the health activity, their medical 17 service activities were performing very highly. DR. HEOSTIS: I wanted to ask Mr. Barrows if he 19 20 would accept a slight amendment to his thought of financing at the current level -- that is financing it at the current 21 level less or a deletion of all of the money for project 22 that have already been financed for three years, less a 23 deletion of one-half of All the money that is requ6sted for 24 the two year projects. 25 H ORTING CO, INC. 32OMassachusettsAvenue,N.C. Washingtor" D.C. 20002 403 hws-77 Staff is going to have to helD figure that arith- 2i metic out. 3 MR. BAR-ROWS: That would be suitable to me, pro- 0 4 viding the net answer isn't more than they got last year. 5 DR. HEUSTIS: It would be substantially less than 6 they got last year. We should probably indicate on that, that our 8 Committee is dissatisfied, or expressed soma dissatisfaction 9 with the way the program has developed. 10 DR. HESS: I do not think you can be that strong. You can give strong advice, but you cannot delete 12 line items, can you? 13 MR. NASH: The only thing we can do is give them 14 X number of dollars and advise that they then rechooso these 15 things in the seventh year. 16 DR. HEUSTIS: I am not deleting the project. I am deleting the money for the project. 17 is MR. PETERSON: We are not arriving at a figure. 19 DR. TESCHAN: That is your 3ntent, but the net 20 effect is a bundle of money. 21 DR. HESS: Rearrange it any way yo.u want. 22 MR. PETERSON: I think what we have heard reflects, in part, the concern that the staff has whatever the figure, 23 assuming Council goes along.with this, because this is their 24 policy, pointing out and taking notes of it, and the fact that 25 RTING CO, INC. 120 Massachusetts Avenue, N.@. hington, D.C. 20002 4o4 I I hws-78 several of their activities are well beyond that point and 1 2 that they ought to be governed, hopefully, accordingly without, 3;!l in effect, saying you can't do it, but they are. 41 Whatever figure, if we are talking at the present 5 level, or something less than that, this request as I loo 6 at it totals roughly $2.3 million. 7 If they get a significantly less amount than what 8 they have requested then it seems to-me they are going to 9 have to make some hard decisions. 10 MR. BARROWS: Let me see if I understand this. 11 If my arithmetic is right, we would come out not 12 too far apart on this. 13 There is $200,000 for registry, $154 for electra- network. Those would be out, and half of this remaining 14 15 $150,000, another $75,000, knocking those out would reduce this thing by $225,000. 16 17 They are asking for $2 million. 18 DR. HEUSTIS: My statement was their present level 19 of funding. 20 MR. BARROWS: Excuse me. 21 DR. HEUSTIS: I propose to knock the $225,000 out from the $1.4 million. 22 MR. BARROWS: That might be a little severe. 23 DR. HEUSTIS: Do you understand the process? 24 DR. HESS: That takes it down to $1 million. 25 ORTING CO, INC@ 320 Massachuset' s Avenue, N.[. Washington, D.C. 20002 405 hws-79 DR. HEUSTIS: The process is we do not provide 211 money for projects we have already financed for at,least li 1 3! i three years, second, the report shows that they have been 4 advised on at least one of these that they had some advice 5 back in 1972. 6 The other is that we provide only half the money 7 necessary for any -- that is half of the money requested for 8 anything that they have requested for two years, which really 9 doesn't do a very great disservice to the remainder of the 10 program. 11 DR. TESCHAN: I don't like that. It crea es a 12 problem. 13 You are,handling it in a way that riles everybody. 14 DR* HEUSTIS: I make a motion to bring this to a 15 head, that we say that staff has to do some arithmetic, 16 because I cAn't come up with the figure, but $1.4 million 17 less the other two items. is MR. BARROWS: Let's round it off to $1 million. 19 MR. NASH: What figure are you using as their 20 current funding level? 21 Apparently we have two different figures here. MR. BARROWS: 1 wag using the one on this sheet, 22 23 the current and the annualized. 24 DR..HEUSTIS: We rounded it off to $1.4 million, and we started to subtract from $1.4 million. 25 0601 IORTING CO. INC. chtisetts Avenue, N.C. =fl, D.C. 20002 4o6 hws-80 MR. NASH: The sheet I have shows $1.81 million 2 current, and the annualized level. 311 MR. PETERSON: We are really in great shape. We 4 have two sheets that have separate figures. 5 MR. NASH: Mine is dated May 20. 6 MR. PETERSON: What is the correct figure, $1.4 7 million? 8 MRS. WILSON: Yes. 9 MR. PETERSON: It seems to me with having done 10 some hurried arithmetic, if we were singling telephone, .11 tumor registry as having gone beyond the three years, having 12 those three other small projects that were asked for two 13 year support, that rough analysis is about $400,000, and I 14 think that is what you are talking about. 15 DR. THURMAN: It is $1.370 million minus $354,000 16 minus $65,000, which is $419,000, so $1 million takes care of your recommendation. 17 18 MR. PETERSON: You would make that as a recommends-, tion? 19 20 DR. HEUSTIS: I accept your arithmetic* MR. PETERSON: I take comfort from the fact that 21 Bill Thurman agrees with me. 22 DR. HEUSTIS: He was agreeing with me. 23 MR. PETERSON: l.was not at odds with someone 24 elsels number. 25 RTING CO, INC. etts Avenue, N.C. Washington, D.C. 20002 407 hws-81 I Is there a second? 2 DR. TESCHAN: I second. 311 MR. PETERSON: Any additional discussion? 4 I would just point out that we do have an estimate 5 that roughly a $500,000 plus application would be coming in, 6 in the July cycle. 7 If there is no further discussion or question, 8 those in favor raise your hands. 9 (Showing of hands.) 10 MR. PETERSON: Those opposed raise your hands. 11 (Showing of one hand.) 12, MR. PETERSON: We have a seven to one vote. 13 Before we dip into the next application, could I 14 ask a question of the group, because I have been handed a 15 note asking me what time will be good for us to reconvene 16 with Panel A tomorrow as a single group, and I am Assuming 17 that if we are going to allow ourselves a little time to review 18 our own actions, that whatever time I tell them we will need 19 to allow ourselves a half hour in advance. 20 Is the group willing to get together at 8:30 tomorrow? 21 22 If that is satisfactory I will do that. Now,, we have four Regions. I am going to try to 2tl get away so some of you who.have been reviewing more than others 24 here at this particular point in time I wonder, Sister Ann, 25 co, INC@ would you be ready to takea look at Maryland? enue, N.[. ngton, D.C. 20002 4o8 hws-82 1 HEW REGTONAL MEDICAL PROGRAM FOR 2 THE STATE OF MARYLAND 3: MR. PETERSON: Now, here again I think the staff 4 person involved, Frank and Gene Nelson, need to be pcepared 5 to supplement this. 6 We have the free State of Maryland. It was seoar- 7 ately set up from the beginning. 8 MR. SIMONS: Hopkins is a grantee. 9 SISTER JOSEPHINE: Johns Hopkins is the grantee 10 agency in Maryland, and one of the criticisms of the ongoing 11 criticisms of the Maryland program has been its very close 12 affiliation with Johns Hopkins University. 13 The program leadership is relatively poor. I get the impression, and these are just impressions at this point,, ]@4 15 but I do get the impression that the strength of the Maryland 16 medical program has been to kind of maintain a broker image in the area, and to use regional medical program funds to 17 18 just give to other agencies so they could carry out their work, and I think they describe this type of available money 19 . .-contracts. as mini 20 When we were there about three or four years ago, 21 I remember there was a question raised by the site visit 22 committee', whether or not this was a good way for them to 23 proceed, and after it was discussed with the group, the con- 24 sensus was that this practice should, if not be eliminated 25 PORTING CO, INC. 320@MassachusettsAvenue,ii.l. @l W@ingion@ D.C@ 20002 ih*- 8 3 be modified. But I notice it is still being carried out. 2 The program staff is satisfactory. However, they 3i! draw very heavily on staff from affiliated programs, partic- 4 ularly of the other universities, and that is not altiays bad. 5 The Regional Advisory Group looked, on paper, to 6 be adequate, but I would have to ask the staff person working 7 with the program whether they are really aware of what is 8 going on in the program, or whether they simply go along 9 with programs that are outlined. 10 Past performance and accomplishments have been 11 satisfactory to poor. 12 It was difficult for me as I looked through this 13 program to identify, to really identify a program that was the 14 program of Maryland rather than the program that is going on 15 in other institutions without close coordination from their 16 Regional Medical Program. 17 The objectives and priorities are satisfactory 18 as they are stated. 19 The proposal is inadequate in many ways. Featibility is checked inadequate, and the CHP 20 21 relationships in the written document appear to be good. 22 The overall assessment I gave the program is e ow average but I am simply going on the material that was here 23 in the book. 24 25 MR* BARROWS: Let me ask a question, as I don't CO, INC. ue, N.L Washington, D'(. 2001 i)lo hws-84 know the area that well. 2 In Maryland can you get very far without being 3 pretty closely identified with Johns Hopkins? 4 MR. NASH: Either that or the University of Mary- land. 6 SISTER JOSEPHINE: It may be there is no other way 7 to go about it. 8 DR. TESCHAN: Where is the element of limitation 9 you are implying? 10 SISTER JOSEPHINE: I think I am probably reading that into the proposal from the impression I had on the site 12 V' isit, where it was very difficult to sit down with the staff 13 and to have them, you know, really identify a program and tal 14 about a program. 15 The ones who could really do it effectively were I(; those who were carrying on the program. It was usually from 17 one of the universities, and it was always someone from Johns 18 Hopkins. 19 I would be interested, and I may be over reacting,, 20 but I would like to have the person who works on the program 21 reflect on that. 22 MR. NASH: Unfortunately, the person who has worked on this program for the last three years now has other employ- 23 ment. 24 25 That person is not here, and I think one of the ORTING CO, INC. 320 Massachusetts Avenue, N.C. I on, D@. 20002 ---- ---I ii I 411 hws-85 1 things that has been pretty typical of this program in the 2 past, the observation of site visitors and people who study 31 the Region is that this particular program has never really 4 taken a good look at the needs, and then made an effort to 5 develop a program within the State that would help overcome 6 those needs; that the projects and activities they have 7 engaged in appear to be opportunistic. 8 Somebody comes up with an idea, and they say let 9 us fund it. That has been one of the major complaints about 10 this region in the past, and to a certain extent it may still 11 be true. 12 MR. NELSON: I might say my identification was 13 about two weeks, and I am no authority. 14 Basically, I made some notes saying in reviewing that they were criticized in the past for three major things 15 failure to Acquire sufficient staff to do the job, depend- ency'to concentrate in Baltimore, and I mean Baltimore City, 17 and a tendency to keep the program to themselves. 18 It seems to me we are looking at a different pro- 19 gram this year, and, in fact, whereas they had 22 projects 20 21 last year, a great number of w YLch were in Baltimore and environs, we are now talking in terms of, let me see -- let 22 us talk about these three concerns, and first failure to 23 provide sufficient staff. 24 They have, in fact, as a result of Advice letters, 25 D@ .200 412 hws-86 1 moved from 4.5 people to nine people in this application. 2 This is something that they have been constantly 3 prodded to do. 4 The second concern is concentration in Baltimore. 5 They have five projects. One provides planning and services 6 in Ocean City. This is planning for health services in the 7 Ocean City area. 8 One is a CHP Planning Seminar for Consumer Orien- 9 tation throughout the State of Maryland. 10 They are requesting $25,000 to, in fact, un(er- 11 write orientation of consumers to the CHP Plan. DR. TESCHAN: Is that the Health Plan for Maryland ? 12 13 MR. PETERSON: Except for the title. 14 MR. NELSON: I think it is quire indicative of 15 the good relationships between RMP and CHP. I might add that I talked to Eugene Gunthries, 17 who was former Director of Chronic Diseases, Public Health I Services. Ho just left under questionably circumstances two 18 or three weeks ago. 19 20 Up until that time the limited information I had is that his successor is continuing with his concept, very 21 22 close cooperation between the two hospitals. A third project, even though it is centered in 23 Hopkins, involves care services for the poor in out atient p 24 departments, correlating with Hopkins in the outpatient 25 PORTING CO, INC. 320 Massachusetts Avenue, N,E. VI shington, D.C. 20002 413 hwk-87 department. 211 DR. THURMAN: That is Number 056. MR. NELSON: The Manpower Planning and Data System,, lie 0 4 mor,,, effective use"of manpower and related services in hospite1 5 outpatient service department. 6 We have a fourth program involving SAEA concepts, -1 30 health education agencies. 8 DR. TESCHAN: Which one is that? 9 DR. THURMAN: That is 058. 10 MR. PETERSON: Those are the most undescriptive 11 project types. DR. TESCHAN: Let us come back to that. 12 13 MR. NELSON: The third concern, the makeup of the 14 RAG now shows involvement of an amount, a large number o consumer groups, and groups representing.@ the poor,, and so 15 forth, so I think the program has turned itself around. The percentage of increase in staff would be 9 17 18 percent. 19 As to projects they have $760,000, a little less 20 than half of which is for projects, a little more than half 21 of which is for programs. DR. TESCHAN: Another $442,000 due in July. 22 MR. PETERSON: Well, we have requests here, as 23 Sister Ann indicated, for $762,000 or $763,000, if ou round y 24 it off upwards, which is slightly above what their op ating 25 PORTING CO, INC. 320 Massachusetts Avenue, N.[ - 'Nas-hingto,i,-D@C@ 20002 f I i 414 h b-88 level is now. 21 They have indicated they will be coming in in July 3 !I for about $400,000. 4 DR. THURMAN: Could I ask a question? 5 MR. PETERSON: Surely. 6 DR. THURMAN: On @e total program staff they have 7 a figure of $144,000 under "other." 8 Do we have any idea what that is? 9 Is that beyond salaries and wages? They have a 10 total of the other category. 11 MR. NELSON: $125,000 requested for contracts and 12 studies. 13 DR. THURMAN: Then Maryland has not changed in the 14 $125,000 plus the $57,000 listed under 058 which goes to 15 Johns Hopkins Computer Center, which has always been the i(i biggest argument we have always had about Maryland, so it has 17 not changed. 18 MR. BARROWS: It sounds like a program with a lot 19 of paper shuffling to me. 20 DR. HESS: An indirect measure of RMP impact. 21, Last month I was at Hopkin,s on a site visit for another program which is supposed to have an outreach compon- 22 23 ent, and it was evident from the level of thinking on that- 24 proposal that for this, this had a lot to do with the school of public health among other things, but RMP's had little or 25 PORTING CO, INC. 320 Massachusetts Avenue, N.[. 'tl@shingloh, D.C@ 20002 415 hws 99 1 no impact on the thinking of those people, and they did not 2 know really how to go about, you know, needs assessment and 3, this whole ball game, and effective RMP would be educating 4 somebody about it. 5 I rather mused to,my8elf that this seemed to be 6 further evidence of a rather weak RMP. 7 DR. TESCHAN: It didn't occur to the Project 8 Director to ask to get the project data., 9 DR. HESS: Neither were RMP's mentioned once, and the people didn't seem to know how to do it. 10 This was really a very self-serving application, 11 12 as I viewed it, self-serving to Hopkins, but not necessarily 13 to the community and the State at large, which it was supposed 14 to be. SISTER JOSEPHINE: I got the impression the com- 15 16 munity at large doesn't really know what the RMP is, and the 17 Program Director really has funds that he gives out to other agencies, and the people in the agencies are the receivers 18 of the service, and really aren't aware where the money comes 19 from. 20 DR. TESCHAN: It seems to me we have an inactive 21 RAG in terms of directing it, an inactive coordinator as 22 defined here, and we have a self-serving unconcerned grantee 23 in terms of the principles of the program. 24 If I remember the basic notion of the essential 25 Ho( PORTING CO, INC. 320 Massachusetts Avenue, N.[. Li 16 hws-90 1 ingredients of an RMP as defined in the August 1972 policy, 21, those are the three essential ingredients so that if we don'ti 3@@ have the essential ingredients it says we don't have an RMP. 4 Why isn't a motioii in order to discontinue Mary- 5 land? 6 DR. HEUSTIS: Make a motion, and I will support 7 it. 8 DR. TESCHAN: I so make it. 9 MR. BARROWS: I don't share your Abrupt change at 10 this time. 11 In support of what you said, there is a fourth 12. striking deficit in this, and that is the end product is 13 useless. 14 I don't care if they give it to this guy or that 15 guy if they are coming out with something that is beneficial. There are a lot of play things for the computer people, so I would say in addition to these other weaknesses 17 18, their end product is not impressive. 19 DR. TESCHAN: There are four important reasons 20 not to spend the money. 21 MR. BARROWS: But you get the other point, the 22 reason, and that is for the Council. I don't think it would be appropriate or us to 23 24 make recommendations, but yesterday we pretty well agreed you are not going to get a leopard to change its spots this late 25 @,,,NG Co, iNC. 320 Massachusetts Avenue, N.C. Wash'iny,ton, D.C. 20002 417 hws-91 in the day, that we are not going to create any great changes 2i in any of these programs in their remaining life scope. I think probably in order to avoid capriciousne-bz$ 4 we better continue the policy basically of the past without 5 any wild swings up or down. That would be my conclusion. 6 DR. HETSTIS: We have here, for the first time,, 7 that has been spelled out the three things, and the one you 8 added, and it would teem as thougl) quite a part of our func- 9 tion was to make a recommendation to the RAG according to the 10 motion that hat been duly made, and supported, and I would 11 like to see those four items put in the motion so we dot't 12, lose them somewhere and let the Council see what we think 13 about this overall situation. 14 MR. BARROWS: I will buy that. 15 DR. HEUSTIS.: The motion you say that You would now buy is to give them no money, and that was my intent, and 17 see what happens, because probably there isn't anything that 18 could have a better influence upon the whole IRD structure 19 fok someone to stand up and take the bat and swing it. MR. BARROWS: Let me ask you a question. 20 21 We have been told by legal, who has wiser And 22 finer minds than ours, that part of our job now is to prepare for this transition to a new type of combined agency, and 23 what the impact of ending one right at this time instead of 24. retaining a leap year fund upon which to build 25 PORTING CO, INC, 320 faassachusetts Avenue, N.[ n r )nnng Ilia hws-92 1 DR. HEUSTIS: If you will pardon me, the egg that 21 is rocking in &the box doesn't do much good to keep it in the 3.. refrigerator. 4 DR. TESCHAN: I feel that the new planning corpor- 5 ation is going to need a widely based representative operation 6 with clout, that the worst place to start from would be one 7 of these, and that we do the entire process of representatives 8 of health planning a greater service by getting rid of 9 grantee. MR. BARROWS: Right now you have reason in there 10 ,l that I can buy that this future entity will be A lot better 12. off by starting from scratch than it will be trying to build 13 on some pretty weak foundation. DR. TESCHAN: Especially when you have all the 14 15 years of badgering. Now, Hopkins and company have to learn, in my own 17 view, it is long since time that somebody got somebbdy's attention. 18 19 I know some of the people who-are involved in this, and they have been disastrous in other places they have 20 attempted to manage. 21 MR. PETERSON: Let me see if I have a sense of what 22 1 hear the Review Panel saying in effect is it would like to 23 propose to the Council in effect that the Council give serious 2,4 consideration to terminating or phasing out, I think we might, 25 ORTING CO. INC. 320 Massachusetts Avent,,e, N.[. intent @C 20002 419 hws-923 1 you know, whether it would come to an end June 30, the Council 2,1 doesn't meet until June 14 and 15, so I think really the termination or phaseout would entail some money based upon 4 a conclusion by this group that what we have here is a largel@ 5 inactive,, ineffective RAG. 6 I had written down, and I don't think you had used 7 the word, and I am searching for a word --. a coordinator who 8 is ineffective, a grantee that has been self-serving in the 9 sense that it has managed to use the program for some of its 10 own interests for a long period of time, and this is a situ- 11 ation of longstanding, where there is really little, if any- 121 thing, to show in the way of accomplishments, any output. 13 MR. BARROWS: The end product is the thing t at impresses me. 14 15 You don't have anything coming out with these bucks. 16 MR. PETERSON: Is that the sense? 17 DR. HEUSTIS: If you would not object to the word 18 termination, and we have a full idea that the Council being 19 a reasonable body will probably give them some time to phase 20 out if they accept the sense of the motion. 21, MR. PETERSON: I was trying to summarize what I 22 heard said, not necessarily putting my views on the table, and 23 241 I certainly would like to hear some response from Sister Josephine, who did review the application, and you conducted 125 ORTING CO, INC. 20 M3ss?chu$etts Avenue, N.C. "ashington@ D@C. 20002 420 hws-94 the site visit. 211' SISTER JOSEPHINE: I would agree w ith this. 3i! The question I would raisc at this point is to 4 phase this program out. 5 How much of this $684,000 do they have? 6 MR. PETERSON: Current? 7 Gentlemen, do we have any idea of what Maryland 8 may have in an unobligated balance come June 30? 9 They have been operating at a fairly modest level. 10 I suspect their balance is not likely to be large, Sister. 11 SISTER JOSEPHINE: You see, that would maintain 12. staff during the phasing out period. 13 DR. HEUSTIS: There is nothing to preclude the Council from putting in whatever money is necessary to do 14 15 whatever they want. SISTER JOSEPHINE: Yes, and between now and July we might have some communications. 17 18 DR. IIEUSTIS: I hope this is the whole purpose of 19 the arrangement. 20 DR. THURMAN: I move the question. 21 DR* HESS: Just speaking for myself, I am not prepared to vote on that at this point. 22 23 I would like some time to study this application. 24 This is, I think., the most drastic recommendation that we have considered today. 25 ORTING CO, INC 320 Massachusetts Avenue; ii.1- Vi@ington-I D.C.20002 hws-95 1 DR. THURMAN: We made this recommendation twice 2 before,, though. 3 DR. HESS: Termination? 4 DR. THURMAN: Yes. 5 DR. HESS: I don't remember that we have. 6 SISTER JOSEPHINE: This was conside 7 1 think when this was reviewed these same questions 8 came up.. But I think this was reviewed the same way the 9 same questions, that is this morning. 10 DR. THURMAN: The Sister is very charitable. The 11 person who reversed us the last time was the Council. 12, DR. HEUSTIS: It is Council's responsibility to 13 do what they think. 14 MR. BARROWS: I think we ought to do the honest 15 thing and Pass the buck. i(i MR. PETERSON: We do have a motion, 17 Rod Merker recently, I understood from Frank, 18 that he recently -- well, I don't know if that is within the past six months or past two weeks, had made a management 19 20 assessment visit to the Maryland RMP. 21 MR. MERKER: It wasn't recent. It was two years 22 ago, and I think you have a good acceptance of what I found 23 two years ago. 24 I found no overt domination by the medical school, but a lack of leadership on the part of the Advisory Group, 25 ORTING CO, INC. 320 Massacliusetts Avenue, N.C. Viashington, D.C. 20002 422 hws-96 I which enabled the medical school to get what it needed from 2 the grant, and I think you all know there was a large 311 epidemiological body or school supported in the school for i 4 four years. 5 DR. HEOSTIS: Mr. Chairman, the question was calle( 6 for, as I recall it. 7 You remind me of an Episcopal Bishop, Pardon the 8 pun, Sister. 9 MR. PETERSON: The question has been called. 10 I will make.a specific point because we will be 11 getting together tomorrow, and you will have a chance to look 12 at an application. 13 Some of these people will have slept upon what I 14 understand to be the motion. There is no reason that we could not, if you and others see fit, make the motion tomorrow 15 that would, in effect, modify or remove this item, but given the motion to recommend to Council the termination of this 17 18 program within a reasonable period of time with such funds 19 as may be considered, and we don't know the carryover situa- tion for the reasons indicated which I tried to summarize. 20 DR. HEUSTIS: Did you say this has been done twice 21 before? 22 DR. THURMAN: Once before we asked for a site 23 visit, because the point he just made that we were supporting 24 an epidemiological study. 25 No RTING CO, INC. 320 Massachusetts Avenue@ N.L-. ashington, D.C. 20002 423 hws-97 1 DR. HEUSTIS: Have we ever recommended to Council? 2 DR. THURMAN: It was recommended t o Council that 3 consi deration be given to terminate the Regional Program. 4 DR. HEUSTIS: Would you object to an editorial 5 change to the motion that we repeat the motion that was made 6 by whatever it was, the previous Review Committee, that this 7 be terminated? I think this gives further emphasis to it. 8 9 DR. THURMAN: The only thing I would have to say 10 to it is that it was recommended to Council that it be con- 11 sidered for termination, and Council voted to keep them going. DR. TE8CHAN: Put something in there like a conna 12 and then quote in view of the past recommendations 13 14 MR. PETERSON: I am not sure I have that. 15 Well, the question has been called for about ten minutes ago. Those in favor raise your hands. 17 18 (Showing of hands.) MR. PETERSON: Those opposed raise your hands4 (Showing of one hand.) 20 MR. PETERSON: There is just one opposed, and the 21 motion is carried. 22 MR. BARROWS: Pete, may I ask one thing? 23 MR. PETERSON: Surely. 24 MR. BARROWS: In this message that we transmit to 25 N ORTING CO, INC. 320 Massac.iusetts Avenue, N.E. Washington, D.C@ 20002 4p- 4 hws 98 1 the Council, do you contemplate including the fact that we 2 faced up to the impact on the upcoming legislation, and came 3@@ squarely to the conclusion that we would be better off start-ii 4 ing from scratch? 5 MR. PETERSON: What exists is there is not a re- 6 source for HRP, or anything else that might come down the 7 pike. 8 This is just my praseology of what I heard. 9 MR. BARROWS: I thought we said it would be more 10 harmful to have them around than to start from scratch, 11 MR. NASH: If it is to be a State Health Plan organization, it is highly unlikely to be the agency. 12, 13 DR. TESCHAN: I think it is arrogant. I keep 14 hoping that our encouragement to a transisti6n stance will 15 allow them to tidy up their relationships so at least they iti are in the running. The alternative is to lose what is there, and the 17 health field hardly can afford to lose any more than it has 18 19 already lost. MR. BARROWS: I am not quarreling with you. 20 MR. PETERSON: Okay, we have three Regions left, 21 Metropolitan District of Columbia, Nassau-Suffolk, and 22 Susquehanna Valley. 23 2A 25 co, INC. ue, N.[. i@,hington, [.C, 200 425 hws-99 HEW REGIONAL MEDICAL PLAN FOR THE 2 DISTRICT OF COLUMBIA 3ii MR. PETERSON: I wonder now if we could turn to 4 a sister jurisdiction of Maryland, namely the District of 5 Columbia, or the metropolitan District of Columbia RMP, and 6 Joe, if you would lead off on that. 7 DR. HESS: The Metropolitan.Washington RMP is 8 one that I know from past reviews that has been of some con- 9 cern. 10 It is, however, in a ttiannium status. The grantee is the Medical Society of the District of Columbia. 12, 13 The Coordinator is new since I remember the last 14 review of this Region. 15 Their broad goals Are to provide assistance to 16 CHP's in developing plans, and incidentally, within the last 17 few months the CHP has been organized in Washington. 18 A second goal is to increase availability and access to primary care services, and to improve along with that 19 20 possibly the hospital care, and a third one is to regional- 21 ization of experience and secondary and tertiary health care resources, 2ix The letter of submission which is signed by@the 23 Chairman of the Regional Advisory Committee is quitd enthusi- 24 astic, and I would like to read some sections from that. 25 H60VER REPORTING CO, IN' 1320 asmchusetts Avenue, Ni. 426 hws-100 1 This is written by Dr. John A. Kenney, Jr., Medica' 2 Doctor, Chairman, Metropolitan Washington Regional Advisory 31 Council. He says , and I quote: 4 "First I would like to address the past perform- 5 ance of MWRMP. I have had the privilege of serving on 6 the RAC since the inception of MWRMP. From this vantage 7 point, and from my faculty position at Howard University, 8 I have been greatly impressed by the significant contri- 9 bution MWRMP has made by improving the accessibility and 10 quality of care of the underserved areas and populations 11 in the metropolitan region. 12 "Certainly the activities with which I am most 13 familiar are those at Howard and Freedmen's. Houever, I 14 W'll cite several of the most noteworthy projects: 15 "Howard's Cancer Radiotherapy project provides the seed funds that have assisted in developing one of the highest quality cancer treatment centers on the East 17 18 Coast. 19 "Freedmen's Stroke Project has demonstrated that 20 the mortality rate and the cost of quality care can be 21 greatly reduced. 22 'The Kidney Project (Howard, Georgetown, George 23 Washington, D. C. General and Arlington) has demonstrated that the three medical. schools can cooperate And further 24 25 involve D. C. General and a suburban hospital in t e HOOVER REPORTING CO, INC. omassachusettsAvenue,N.E. 427 hws-1 1 implementation of a coordinated regionwide attack on 2 kidney disease. This project is moving. Alrea one 3 facility has indicated that they need no additional 4 funds. It appears that all facilities now participating @5 will be self-supporting by July 1, 1975, thereby per- 6 mitting any new funds to be used for expansion or new 7 locations. 8 forecently initiated activities include the EMS 9 regionwide planning contract, a nurse midwifery pro]ect in 10 the inner city, and expansion of hypertension control. 11 "Several other significant projects include: 12 "Coronary care nursing training - Howard. 13 "Cancer Registry - Department of Human Resources. 14 "Inhalation Therapy Washington Technical Insti- tute. "Pediatric Pulmonary Georgetown and Children's Hospitals. 17 18 "Second, I would like to comment on the current 19 viability of the Program. The RAC is enthusiastic and 20 active. Even with the on and off directions of the 21. past 15 months the RAC and its Committees have een active in promoting the principles of RMP'S. 22 "In the past three years the RAC has developed 23 into an "action" group. In the first few years of MWRMP 24 the RAC reacted to proposals that were submitted.' In 25 H60VER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. w@.@.@tnn nr. gnfing 428 -iws 2 developing the last applications the RAC has appraised 21. the needs and acted to allocate 'blocks' of funds to 3ii help meet these needs through requests for roposals p 4 and subsequent contracts. The current application has 5 again been developed within this concept." 6 From that, you can get a flavor of the view of 7 the Chairman of the Advisory Committee. 8 Just as one issue in the composition of the RAC, 9 which is comprised of 73 members, 15 of these are minority 10 members. They have a current professional staff of eight, 11 and they want to increase this. 12 Now, I may have, myself, misinterpreted these 13 white sheets. Apparently they propose to add nine, if that 14 is correct. 15 I thought this was an increase from eight to nine. 16 MR. PETERSON: I am not sure. I would have to ask 17 staff. 18 In most instances I think the proposed was a new 19 total, but in some instances - well, I think this again is a total. They are simply proposing to increase the staff 20 21 from t6n to 134 DR..HESS: Well, in terms of the accomplishments 22 they have establishe d several primary care clinics, and have 23 been working on improving specialized services in the area of 24 heart disease, coronary care, hypertension, patient education, 25 HOOVER REPORTING CO, INC. 0 Massachusetts Avenue N.[. 429 hws-3 1 and obstetrical care. 2 In the area of quality of care they have initiated 3'i projects on review, utilization review, a Regional Cancer 4 Registry, a Stroke Station, Cardiovascular follow up and a 5 bacteriological screening project at G6orgetown. 6 Projects which they cite as increasing efficiency 7 and utilization include their cancer, heart disease structure, 8 high blood pressure, and kidney project. They have a fairly good record of jo int funding 9 10 and phasing into other funding. Ten of the 19 projects are jointly funding, and 12 seven have been phased out, seven of 19 phased out and con- 13 tinued under RMP funding. 14 In terms of their CHP relationships there was no 15 active B agency in Washington until recently. Their coordination seems to be satisfactory with 16 17 the B agency in Maryland and Virginia. There is some funding of B agency activities in 18 this proposal, and there is an agreement, a written agree- 19 ment in the application between Metropolitan Washington RMP 20 and the Washington B agency as to how they will work togethet.1 21 It seems to be a fairly clear and well defined 22 document. 23 In terms of looking at the program priorities, I 24 think this is an indirect measure of where the influence, 25 co, INC. oe, N@l. 430 hws-4 I that is, much of the major influence in the Metro Washington 2 RMP is at the moment. 3 The-number one priority is kidney activities. 4 Howevdr, the amount of funding is not excessively large. It 5 is about one-tenth of the total. 6 They are proposing $100,000 for kidney Activities 7 out of the total program budget of $1.1 million. 8 The second is nurse midwifery, $71,000. 9 Next is primary care activities, $332,000. 10 The next is health care for senior citizens, $150,000. 12 Next, hypertension for $150,000. 13 Next, emergency medical care for $100,000. 14 Next, chronic constrictive pumonary diseases, $165,000. 15 Assistance to CHP's is for $132,000. Now, the largest single proposal is the one 17 18 relating to primary care of patients, $332,000. 19 I thought it might be worthwhile just to discuss 20 this proposal in a little detail so that you know what is 21 involved in this rather major project. 22 Their objective is to develop facilities at hospitals to provide more high quality primary care to non- 23 24 urgent.patients who appear.at hospital emergency rooms. The approach is to go to hospitals which have 25 Hoo IORTING CO, INC. 320 tiassachuseftsavenue, N.,. W3$bington, D-C, 20002 431 hws-5 I emergency departments and to work with these hospitals to 2 determine the quality of urgent and non-urgent patients who 3.1 appear there, and develop a body of information which will 4 then allow these hospitals collectively to plan for better 5 primary care services to help take the load off the hospital 6 emergency rooms. 7 There are also in this budget some funds for some 8 facility reconstruction, as well as some equipment purchase, 9 so that it is more than just planning, but also some reorgan- 10 izational facilities, in order to be better prepared to take 11 care of the patients who appear at the emergency rooms for 12 primary care. 13 SISTER JOSEPHINE: How many hospitals do they 14 have? 15 DR. HESS: Three to five. They want the best IL@ alternative system. 17 MR. PETERSON: They are D. C. General, Freedmen s, 18 maybe George Washington, Georgetown, and -- wells is that it? I!) DR. HESS: The hospitals are not listed here. 20 MR. PETERSON: They said three to five, so there may be a couple of others, too. 21 22 DR. HESS: They don't list them in this synopsis 23 of their plan. 24 It was unclear, just to further comment on the project, it was unclear whether the primary care project will 25 HOOVER '.IEPORTING Co, INC. 320 Massachusetts Avenue, N.[. n f, )nrtn,) 11 432 llwb-6 I need funding after the first year, or whether it is something 2 that could be accomplished. 31 It looked as though it was a steady reorganization 41 and some revision of facilities, but I am just assuming that 5 although it is not stated, that the hospitals, or some of the 6 sources will pick up the cost after this first year. 7 Looking at the overall project, program proposa S, 8 the medical schools are still quite heavily involved. 9 There,is a project in here for something like 10 $55,000 for health care for senior citizens, which indicates, 11 in a short synopsis, no provision for continued support. 12 It did appear to me like this was, to a large 13 extent, direct services to senior citizens, showing an area 14 of need, but not reflected in this description. 15 What their thinking was, was about future funding beyond the funding of RMP. 17 This particular one was sponsored by TV&A in Washington. 18 Overall it seemed to me things were a little bit 1 19 better than the last time 1 heard this program rev ew, but 20 21 still overall I could rate it no better than average program. 22 The.thing that I found that offered some hoDe was the fact that they are trying to address, and apparently have 23 addressed in the past primary care in trying to expand these 24 services to the underserved population of Washington, and I 25 @HOOVER REPORTING CO, IPC, 320 Massachusetts Avenu@, N.[ 433 hws-7 1 am sure they are considerable. 2 I checked them. I might say there was a farily .3 'I well developed and outlined review process, the Committee 4 structure, and the staff structure, which appear to me to be 5 satisfactory. 6 MR. PETERSON: Well, thank you, Dr. Hess, 7 Joe, do you want to give your report? 8 MR. de la PUENTE: I found the program, in my 9 opinion, and considering past experience, as better than 10 average at this stage of the game. I mentioned its priorities, you know, no neces- 12, sarily one, two, three, four, five, and mentioned the reasons 13 for these projects. 14 Let me say that the projects are timely. They 15 are addressed to not only the present but the future needs 16 in an area where there is a great deal of need, in an area 17 where if health insurance comes through we are going to have 18 a lot of expenditures. 19 In the particular areas that they happen to be 20 attending to, ergo, the elderly, and ergo, the needy, I was impressed like you were in terms of the primary activity 21 that because what they are going to do as far as the descrip- 22 tion that I read is going to be an operational research and 23 analysis in which they will consider all the present resource 24 of personnel, equipment, floor space that is being utilized 25 N ORTING CO, INC@ 32OMassachusettsAvenue'N.C. Boston, D.C. 20002 434 hws-8 1 right now to serve the groups that have to be served. 2 Then they will follow this study in proceeding to 31,1' alternative programs to these hospitals, and help serve these' 4 populations. I agree with you. I think it is a one-shot invest- 6 ment, but going to be a worthwhile investment and a 7 system in which you get these different hospitals, Georgetown, 8 George Washington, D. C. General, et cetera to decide, you 9 know, what type of priorities they can attend to, or what 10 type of priorities they cannot attend to, and where the 11 patients will go. 12. In addition to that, they are going to be helping 13 and providing monies for working with the planning agencies 14 which relate to this particular project. 15 The other project I was impressed with, and this 16 is Priority Number 4, is the one for senior citizens, because I 17 at this point, since the senior citizens are poor,, and they 18 happen to have Medicare, they go to eitner the nursing homes 19 if they are able, or to private facilities, or they are in and 20 out, one admission after the iiext, and from what I read the 21@ visiting nurses would be providing care in the home, and also they will have preventive programs in areas where theyare 22 allowing the senior citizens in terms of making sure t at 23 emergency episodes do not occur, and if the emergency epi 24 25 8odes do occur, that somebody will take care of them. N OV REPORTING CO. INC. 0 Massachusetts Avenue, N.C. ill- n r, innni 435 hws-9 1 I think this program, in my opinion, will save an 2 awful lot of money for the District of Columbia in the near 31 future. 4 DR. HESS: The thing I was looking for, and may be 5 just an oversight on their part, but I hope the@,are thinking 6 about it, is that they can demonstrate that for the population 7 that they reduce the hospital costs., that what seems the 8 logical outcome of that is to go to sources of payment and 9 say,, look, put some of your money in the home care, and not 10 so much in the hospital. But that was not written in. 11 MR. BARROWS: That is always under consideration, 12, and I Am not too optimistic about that. 13 From what you fellows have said, and for what it is 14 worth, it sounds to me as if these people are tackling some 4p 15 monumental,, very real problems, and the amount of money they I(; are talking about is relatively small for what they are trying 11 to undertake. 18 I think we ought to resolve any doubt in their 19 favor. MR. PETERSON: How about some of the other reviewers 20 here? 21 DR. HEUSTIS: I have nothing to add. 22 23 DR. THURMAN: Just two .procedural inquiries. 24 The $132,000 is for assisting CHP. Is that proper? MR. PETERSON: It is something which we in out 25 IORTING CO. INC. 320 Ma husetts Avenue@ N.C. ssec Was4ington, D.C 20002 43'0 hws-10 instruction guidelines for applications, it was one of several 2 areas that we were asking to assist with CHP planned develop-I 3 ment. 4 I cannot be sure from looking at the computer prin 5 out that that is what it is. 6 We do have a case here, though. I was unaware, 7 Joe, and you corrected me properly, that there just has been 8 an areawide B agency organized for the District. They have 9 long been without one, and the one in Northern Virginia, they 10 never could resolve the Virginia-District-MAryland problem. 11 There is probably a lot of catching up to do in 12 one sense, and I think it wouldn't be considered inappropriate! 13 in a policy sense. 14 Whether the money could be effectively used is 15 another question, which I cannot speak to. If anything, we sort of pushed them in that direc- 17 tion, at least as far as Mr. Bell i s concerned. He is prob- 18 ably looking over our shoulder. 19 DR. THURMAN: I support the need. 20 My question was purely policy, and the other is 21 policy also. There are $80,000 here in kidney projects, all of 22 which on July 1 are going to be funded from other sources. 23 1)4 Other than that I support it. That is a policy question. 25 HOOVER PEPORTING CO, INC. 320 Massachusetts Avenue, N.[. 437 II MR. de la PUENTE: As far as the kidney project, 2 if I could speak- to that, as long as Georgetown is involved, 31! and I feel confident that they are upqradinq in the total 4 eastern complex, they have tissue typing, and they have some 5 transplanting, and they are operating in the eastern complex, 6 which is from Atlanta to Boston, and which they interchange 7 patients with the computer, and with tissue typing information 8 oh the computer, which in my opinion helps. 9 DR. THURMAN: Don't misunderstand me. All four 10 of those can be paid for as of July 1 out of other funds. 11 I am not sure that it is proper, because mine is 12, a procedure and I am all for supporting them but all four 13 of the things that are listed can be supported from other 14 funds as of July li this July 1. 15 DR. TESCHAN: Which other funds? DRi THURMAN: Medicare and the Kidney Dialysis. I MR. de la PUENTE: They might well go into that 17 18 type of funding, but if we don't have this complex in which, 19 for instance, they started deciding-how much do ae charge 20 for procurement for an organ, cadaver, how much is it going to 21 cost to tissue type every patient on hemodialysis waiting for a transplant; start making all those cost values, and 22 they won't have as good a chance of certifying those costs, 23 24 and some of the people will-have to pay for it. 25 DR. THURMAN: I was asking a policy question. That HOOVER REPORTING CO, INC. 370 Massachusetts Avenue, N@l. n , @@nn@ 438 hws-12 I is all. 2 MR. PETERSON: That sort of thing you might want 3 to note, 4 MR. BARROWO-: Might I ask a question? 5 MR. PETERSON: Surely. 6 MR. BARROWS: I know that Medicare and Medicaid 7 will be paying for reimbursement for services delievered. 8 Do they also have funds for development costs? 9 DR. TFIURMAIQ: All of us are building in develop- 10 ment costs. 11 We are being reimbursed for Medicare for organ 12 procurement,, tissue typing and dialsysis right now, and we 13 have the lousiest system in the country out there, ip 14 I was under the impression that none of these types of programs were going to be funded, other than that by July 1. 17 DR. TESCHAN: One of the projects is to reimburse the institution for the procurement of unused kidneys. 18 1 You know, that is not, so far as I knov7, in the 19 Medicare reimbursement. You get reimbursed for the ones you 20 use and transplant. 21 One of the projects talks about reimbursing for 22 the cost of the harvest of the unused. 23 DR. HEUSTIS: But isn't it built into the cost of 1241 the ones you used? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue@ N.[. 439 hwls-13 You divide the total cost by the total number of 21@ patient days served, and that is it. 3i DR. THU@IAN: I didn't mean to get us off here. 4 Let me say again I am in support of the two re- 5 viewers. 6 DR. HEUSTIS: Can we hear again where you rate 7 this program in terms of average, above average, or below 8 average, from the two reviewers? 9 DR. HESS: The first time I read it I checked it 10 in the above average. 11 The next time I read it I went through and looked 12, a little more carefully, and I put it on a line between the 13 two, so in looking and thinking of its past history, instead 14 of being on a plateau, I think this program is on an-upward 15 curve, and because of that I am willing to extrapolate a I(; little bit and give them the benefit of the doubt based on 17 recent past performance. 18 With that in mind I would like to propose a level of $1.1 million. They are currentl at $1,756,000. They -Y asked for $1.27 million. 20 21 As I look at their priority ranking and their 22 programs there is onei the pulmonary diseases for $65,000, and assistance to CHP's of $132,000, it seems to me that the 2,3 CHP's @hould be able to stand on their own two feet now, and 24 25 1 don't see why RMP should need to support that, to that HOOVER REPOR NG CO, INC. .320 taassachusetts Avenue, N.C. 440 hws-14 1 tune. 1 2 That accounts for $200,000 right there. They seem 3 l@i' to be moving in the right direction. 4 There is an area of substantial need, and so forth 5 Mr. Chairman. 6 I would make that as a motion. 7 DR. HEUSTIS: This is the full yearly HEW pro- 8 rated amount,, your $1.1 million? It is 100 percent of the 9 targeted available funds now in Column C? 10 You see, what I was getting at in my other ques- 11 tion was they are going to ask between this application and 12 the next application for a50 percent increase over their 13 money that they have right now. 14 DR. HESS: They are going to ask for another 15 $500,000. DR. IIEUSTIS: Or a total of $1.7 million, and the i 17 targeted allocation is $1.1 million. 18 If we give them more, then we have to take it away from somebody else. 2.0 DR. HESS: I don't think we need to worry About 21 that for the moment, because that is not a target type figure, 22 and I think this -- I don't know the population, ut my guess 23 is it is probably in the neighborhood of two million people. 24 MR. PETERSON: I. am glad you asked that question. DR. HESS: It is an urban area. 25 HOOVER REPORTING CO, INC 320 Massachusetts Avenue, N.[, 441 hws-15 I MR. PETERSON: It is a little over two million 21@ people, 2.1 million. The District of Columbia, I think, has just under 0 4 one million people, but you have two big bedroom areas in the 5 suburbs. 6 DR. HESS: There it seems to me the management is 7 picking up now, and that there is an area of need. 8 DR. THURMAN: I second the motion. 9 MR. PETERSON: There is a motion of $1.1 million, 10 and we have a second. 11 Any further discussion? 12, MR. de la PUENTE: I just wanted to add I hate to 13 limit them oh the CHP that much. 14 MR. PETERSON: I don't think I heard Joe say he@ 15 was going to cut it out. DR. HESS: We are going to issue t e money. 17 MR. de la PUENTE: Is there any way we can put in a recommendation there phasing out as many of the kidney 18 )I 19 activities as soon as the self-stpport is available? 20 DR. HESS: Some of these they have listed. T y 21 state no additional funds requested on there. They have already phased out some. 22 MR. PETERSON: These are the residue of a number 23 of kidney Activities, but even these are continuations, and I 2,4 am assuming, and I have not looked at the application that 25 HO( FORTIPG CO, INC- 320 Massachusetts Avenue, N.C. Viashington, D.C. 20002 442 hws-16 1 close, that most of these will really have come to an end 2 sometime during the next year. DR. HESS: They have a priority 1 ranking, so we 4 can't go in on a line item and scratch out something they havt; 5 on Priority 1. 6 I just don't think we can do much with that., Mr. 7 Chairman. 8 MR. de la PUENTE: Then I have no objection. 9 MR. PETERSON: We have a $1.1 million recommenda- 10 tion.. 11 Any further discussion or question? 12, All right, those in favor raise your hands. (Showing of hands.)@ 13 14 MR. PETERSON: It is unanimous. 15 17 18 20 21 22 2.3 24 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,;4.1. HEW REGIO14AL @IEDICZ@ PLAN FOR LONG hws 17 1 2 ISLAND, NEW YORK AND NASSAU-SUFFOLK COUNTIES 3!1 4 MR. PETERSON: Well, we are down to two Regions, 5 and it is a quarter to five. 6 I think we are going to switch gears and touch 7 upon Long Island of New York and Nassau and Suffolk, 8 Do you want to lead of f on this? 9 DR. HIRSCHBOECK: This was to be the model combin- 101 ation, twin agencies, and it was split off from the Metro- politan New York, and put under the aegis of Stoneybrook for a while, at least. 121 13 With the phase out of RMP the Nassau Regional Medical Program lost its Coordinator and I believe mush of 14 its staff, at least there are a lot of vacancies here, and there was a shift from this program priorities. Incidentally, the NAssau-Suffolk Medical Program 17 and the Comprehensive Planning Council jointly produced the 18 priorities for the Region. With the split, with the phaseout of the RMP 20 resulting in the split, all of the planning projects were 21 deleted from the RMP priorities, and the remaining ones have 22 to do wi-,h increasing health manpower availabilityt increasing 2.1 coordination, cooperation, resource sharing, instituting hew 24 preventive health measures, innovative improvements in 25 HOOV REFORTINGCO,INC. 320 Massachusetts Avenue, N.[, ni, 7nnn) 444 hws-18 professional continuing education and priority number 5, 2 developing within the purview of 89-239 RMP legislation, ambulatory care services. 3.. This seems 0 4 to be --he project that they have put 5 the most emphasis on in terms of their priorities and planning 6 for the future. 7 Also the PSM project is underway, and a kidney 8 project. One gets the impression that this application, whe 9 10 he reads it, is really dealing with the.broad plan worked 11 out prior to the departure of the Coordinator, Dr. Hastings,, 12 and there is not much room pro3ected here, other than a data base development for ambulatory care in Suffolk County. QL 13 14 Everything else apparently is a holdover from the grand design of the previous activity and programing4 15 As far as the leadership is concerned, the staff 16 Dr. Hastings has, it is extremely weak. 17 Everybody on the project is at a Master's degree 18 level, including the Coordinator. Those proposed for employment are mainly from 20 social work, and then there is a serious question in my mind 21 as to whether this staff is going to be able to follow through 22 with the project in terms of leadership and evaluation as 23 described in the document. 24 The relationship with the CHP agency, one gets the 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[ 445 h,vis-19 1 feeling that CHP is sort of taking over. 2 The Regional Advisory Group is still a discreet 31 entity. 4 The CHP agency has endorsed everything in one 5 letter. 6 The projects that are being proposed are contin- 7 uation projects, except for one, that is the data base con- 8 tract for ambulatory care. 9 They-do expect, however, to bring in six projects 10 in Julyi new ones, and there are some continuations, so that 11 I think we ought to hear from staff about the real state of 12 affairs that exists between the CIIP and the RMP there as to 13, whether there is any prospect of this staff being improved 14 back to what it originally was. 15 Doctor Hastings is the Coordinator. 16 MR. PETERSON: Do we want to ask Paul to present 17 his review first, or would you want us -- well, I don't know 18 to what extent the staff has any comment. 19 we really are down in one sense, and not only did 20 Glen Hastings leave, but Harrison Owens, who had been in many 21 ways, I don't recall it was his name, but he certainly was functioning as Glen's deputy. He was acting for a period of 22 what., six months? 23 24 Harrison has left, and went to NIH. The present Coordinator who has been there a couple of years, he was 25 HOOVER REPORTING CO, 1:4-C. hws-20 446 their evaluation person. He is an East Indian. 2 I site visited Nassau-Sqffolk. I was on the last 3(j visit. I had some contact with Persade. My impression of 4 him would be that maybe he holds a few things together, but 5 I don't see, for a variety of reasons, his background, and 6 what have you, by that I don't mean the fact that he is an 7 Indian, but he is a numbers man by and large. 8 I think he is fairly new to the health field, and 9 I certainly wouldn't see a great deal of positive, imagina- 10 tive leadership coming out at least through his person, and 11 I think the other staff there have some problems as relates 12 to the grantee. 13 MR. NASH: Why don't we hear from the second 14 reviewer? 15 bR. TESCHAN: In reading the document it is put i(i together with a good deal of mental confusion on the part of 17 the author, or the Conunittee didn't talk to each other, or @18 was put together at different times with interruptions. It is hard to follow with groups of projects they are talking about and what the status of the projects that 20@ 21 are being described are. so there are some projects-that are 22 not described in the narrative, or their rationale developed 23 in the overview, and there are som ethat are described 24 several times, or more that. once, in different ways, so you 25 can't tell whether they are talking about a rejuvanation of I RTING CO, INC. chusettsA,,e"ue,N,E. D.C. 20002 447 hws-21 of an old project, or a new project, or the relationship 2 between them. 3;,i There is a minor confusion point here to tidy 0 4 minds in the sense that in the one form, the 158, there are 5 the progress reports that relate to 1971-73, and the proposal 6 relates to 1974-75. 7 There is a one year's gap in the situation, which 8 doesn't overly distress me, but it sounds as if there is a 9 problem in terms of accounting for what happened to the 10 projects in the meantime, and how do we now ask for new funds 11 if, in fact, in the meantime either the project died com,- 12. pletely, or survived with other funds since then. 13 Should we not be over on new funding altogether? 14 Why do we recur after a year's absence? 15 Now, that may be just a technical question on how i(i the numbers appear. It may be an administrative type staff 17 thing, but I don't understand it, and it doesn't make any 18 sense. it) The priority statementsi these things are two or 20 three years old. I was on a site visit when Glen was still theret 21 22 and I remember distinctly the long discussion how they got 23 the priority, and this is really .Hastings' work, and-it hasn't 24 been revised since, and you get the sense, the end of review 25 process is sort of a Xeroxing of something, HOOVER PE?ORTING CO, INC - 320 MassachusettsAvenue, N.[,I 448 liws-22 1 DR. HEUSTIS: This is what I wanted to convey. 21 DR. TESCHAN: I get the feeling that if this docu- 3,i ment is reflecting sort of the state of affairs then it says t! 4 that 66 members of the RAG have been asleep. 5 It says the grantee has been asleep, and it says, 6 that I don't see a focus around which you can organize a next 7 step. 8 I don't know where to turn to fish for that focus 9 of the new entrepreneur relationship that is needed in the 10 thing, because one thing on the CHP business, the two agencies 11 say they are going to reexplote what the lesson is from the 12. experience they have had. f 13 If the document is any indication, I can't tell 1 14 there has been any. 15 Well, in view of this, I think that we are tending to go somewhere between a below average and a poor situation, and one where I don't see where there is viability, 17 18 I frankly don't know what to do about a funding 19 recommendation on it. 20 I think maybe we ought to hear from staff, and maybe we will be a little more illuminated than I am at the moment. II 21 22 MR. PETERSON: Jerry, you have any comment that 23 speaks specifically to the point? 24 To put the question crudely, how bad is the situ- ation? 25 flOOVER REPORTING CG,'ic. 320 Ma. sachtisetts Aven. 4119 hws-23 1 MR. STOLOV: VTe. have members from Grant's manage- 2 ment here. 3ii We are about in the fourth recite of their bylaws 4 and RAG grantee relationships. 5 When we tried to review their process, their RAG 6 was rally dominated by the corps in terms of numbers, and we 7 asked that there be a change in numbers, and they did adjust 8 that change. 9 The auditors were out there for ten weeks, and they 10 came up with a whole pot pouri of items which represented to 11 Dr. Paul, Mr. Silbus and operations people. 12 They felt, though, the RAG was dominating the 13 corps, but this is only a sideline to what they did find. 14 They did look into some of the projects you have 15 mentioned, as to the gaps in time, the Nassau-Suff6lk believes, 1(; they can reinstate from all indications. 17 DR. TESCHAN: I did have one more comment on the 18 project, that there are two kidney projects, the relationship between which is unclear, and we don't, or the don't seem to 19 y 20 have a lot of content and don't have a specified relationship. 21 I am a little less critical of the same situation in the EMS story, because the counties appear to be big enough 22 and the divergency between them sufficient, and the location 23 24 of the population centers sufficient to justify two separate operations in that case. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 450 hws-24 1 The kidney game is different, because both of them 2 talk about relationships to metropolitan New York and the big eastern consortium, so there is reason for more coordination 4 than I find. 5 MR. STOLOV: Could I just ask that we get to the 6 issues that staff looked at? 7 MR. PETERSON: That is what we want to get to. 8 MR. STOLOV: EMS Communication Project. We touche 9 base with Region 2 Office, and the same people applying for 10 the equipment dollars were the same people applying under Mr. 11 Rearden's program and RSA under the new law. 12. This was almost the identical Proposal, even more 13 dollars to them. 14 Well, it was briefly presented. We asked the EMS 15 Communication Specialists to look at it, and we consequently heard from Region 2 that they turned it down. One could draw a grey line between whether they 17 18 did mention communications in their original proposal. How- ever, we were asked to highlight it because of the magnitude of the dollars. 20 That is where we stand in EMS. 21 In Kidney, we asked the Region, before they sub- 22 mitted their project, to have it reviewed by outside consult- 23 ants. 24 They got one consultant, got one one night in the R ING CO, Nc. 320 chusettsAvenue,N.1, Washington, D.C@ 20002 hwa-25 Kidney meeting in Chicago, and he dictated something over the 2 phone,, and we called him today to get his impression, and he 3 agrees with Dr. Teschan, that the two projects should be 4 brought together into one, and this shows suppoktinq two 5 institutions rather than getting a new thrust. 6 DR. TESCHAN: He shows no CHS function, and it 7 shows no RMP coordination, so it is a total bust, no matter 8 which way you look at it. 9 MR. STOLOV: In terms of the proposed staffing 10 pattern and the present staffing pattern I think we asked the 11 Region, and they only sent in -- they were allowed to budget 12. the $6.9 million, and they elected to put into sta -@c, 13 prior to this application what they actually QL sent in was what! 14 they were budgeting into. 15 We haven't seen the new coordinator function. The. RAG had a committee, and they have 70 applications to coft- 17 sider, so@ from the nearby regions, et cetera, and other 18 people. 19 Well, they chose their own man for the job. we have not seen him function. We did ask him to expand on the 20 organization chart, and he had four health analysts reporting 21 9-2 to a girl who.was in the program since it started, for four 23 and a half years. She was the grant's management gal, and 24 did a good job at it, and we were concerned the poor people reporting to her, she has a BA, and she has four and a half 25 HO E REPORTING CO, INC. 320 faassachuselts Avenue, N.[.i i, Ann,) 4 F- 2 hws-26 I years of experience, and her experience was another factor 2 he looked at in the decision, but the organizational chart 31@ has changed. 41 He has sent in a new one, having two report to 5 his evaluator, and two reporting to her. 6 Again, we questioned the decision, but haven't 7 seen it in operation. 8 The seven vacancies are social workers, as you saic, 9 Dr. Hirsdhboeck. 10 MR. PETERSON: Tom, did we have a management 11 assessment visit at the same time as the review verification 12, visit this year? 13 MR. SIMONS: I have almost lived with that Region. I have a very hardnosed view. 14 15 I think Frank better talk before I do. MR. NASH: I think it was over two years ago it 17 was recognized that the structure and relationships between 18 the grantee institution and the Board of Directors of the RAG of this program there was something very much wrong there. 19 20 I think they had a 25 member Board, each of w om 21. was also amember of the RAG. The normal procedure for the Board is to meet, dis- 22 2.3 cuts the business. They would adjourn, and 30 minutes later they would convene a RAG meeting, and most of the time some @14 of the RAG members didn't show up. All the Board members 25 IOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. nil ')nnnl) hws-27 were there, so the clear dominance of the RAG in the whole 2 decision making process was by the Board grantee institution. 3 d This gave us a lot of concern. They were advise 0 4 they should be concerned about this. They would send us back letters assuring us that they would do this. Then they would get involved in phaseout, and so 7 from our part we didn't follow up on it until we got the one 8 year's extension. 9 We have been after them again to straighten out 10 this situation, and that is why we are now looking at their 11 revised bylaws, and I think Tom is later review of those indi- 12, Cates there is still the possibility of dominance of the RAG 13 by the Board. 14 I don't know how we will straighten this situation 15 out. Does that cover part of it? 17 MR. SIMONS: Yes. I don't think it has come out 18 that RMP and CHP has separated. MR. PETERSON: Yes it has. 20 MR. SIMONS: There was mention of the HEW audit 21. that has been up there ten months. 22 They came in and met,, and had a very long report 23 on the Region. They selected five projects that ran when they first went in, based strictly on the time the project ?4 occurred, and the dollar volume, and they traced it from there 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N;C. nr,)finn) 454 11 b-28 I from the time it started up until it was complete. 2 Now, all five of them they considered a dismal 3119 failure because of the poor management by the program staff. 4 They now ask them to select two more teams, to give 5 it to them. 6 MR. NASH: The audit report doesn't bother me 7 quite so much, because this is a reflection of what went on 8 in the past, 9 The question that concerns me is what is the future 10 for thisprogram. 11 MR. SIMONS: I'have two more points I would like 12 to make. 13 I think the philosophy of that region, the three 14 or four times I have been up there, seems to be we are going 15 to do what we want to do. 16 We will try to write it to make RMP's and the Councils believe we are going to do what they say but we are 17 18 still going to do the things we want to do here, As far as the domination of the program by the 19 20 corps, as Frank said, I don't know how we are ever.going to get them to stop that. 21@ 22 The climate is still ripe for the corps to domin- ate the bylaws still provide for domination by the corps. 23 ol The only way that they are ever going to change is 24 a very hard approach from here. 25 H PORTING CO, INC. 32 as chusetts Avenue, .4.1. Washingioni D.C. 20002 hws-29 I think the recommendation you made for Maryland 2 would be a little kind to them. 3; DR. TESCHAN: You made the funding contingent on 4 their compliance, either get with it or ship out. 5 MR. STOLOV: The letter from Dr. Paul said exactly 6 that. Unless those bylaws are changed to meet our conformance, 7 and the Region -" 8 MR. SIMONS: No if 8, ands . or buts. 9 DR. THURMAN: I move that we approve this program for a level of approximately $150,000 for staff phaseout. 10 DR. TESCHAN: I second. MR. PETERSON: The motiono if I understood it 12 correctly, was $250,000 for staff phaseout. 13 DR. HEUSTIS: Aren't you rather generous? 14 DR4 HESS: I don't see how that is consistent 15 with the decision you fellows made on Maryland. DR. TESCHAN: Then I am missing something. 17 DR. HESS: I wasn't ready to vote with you for or 18 against it. But it seems to me, from all that we have heard, 20 that this program in New York in nearly every dimension is 21 worse off than Maryland, and the vote, as I remember, it was 22 to recommend termination for Maryland. 23 Now, if Maryland deserves that kind of vote, I 24 don't see how you, in any consistency, can vote any money 25 PORTIKG CO, INC. 320 Massachusetts Avenue, N.[. Washingto-1. D.C. 20002 456 hws-30 I here. 2 DR. THURMAN: That is not what my word was. I 3! don't think we ought to fire these people tomorrow by term- 4 inating all funding, and $240,000 will carry them until their 5 staff can find other jobs. 6 DR. HESS: You didn't make that proviso with 7 Maryland. 8 DR. THURMAN: Yes we did. We said terminate it 9 with adequate time. 10 DR. HESS: Okay, the same general language. 11 DR. THURMAN: Except to make it worse in Maryland. How is that.7 12. 13 DR. HEUSTIS: I thought the motion we voted on before was we recommended termination, and left it up to the 14 15 good judgment of the Council to bring about an orderly term- ination, without out getting involved. DR. THURMAN: I will rephrase my motion, and let's 17 18 make it the same as Maryland, but a little worse. In that way we will have the same terminology, 20 because I think the program ought to be terminated. DR. HESS: I call for the question. 21 MR. PETERSON: Let me be sure that 1 have the 22 motion correct. 23 The motion is termination at the earliest possible 24 moment. 25 HOOVER REPORTIIIG CO, INC; 32ONlassachusettsAvenue'N.E. 457 1 st the termination. hws-31 DR. HEUSTIS: No, ju 2 MR. PETERSON: Termination with only such funding 3 as may be necessary to provide for'the orderly termination. 4 DR. HEU8TIS: Bu@- you didn't do that for Maryland. 5 MR. PETERSON: I think what we are hearing now is 6 we are really acting on a kind of generic motion that we will 7 rephrase the Maryland one accordingly. 8 MR. BARROWS: Funds sufficient for an order y 9 termination. 10 MR. PETERSON: It may require slightly more funds 11 than one or the other for the orderly termination, but that 12, is a minimal amount of funds, really. 13 DR. HEUSTIS: Why cannot we as a review committee 14 recommend to the staff, as I understand it, we recommend 15 termination, and the staff, under whatever it deems best, make whatever it thinks is a proper recommendation to the 17 Advisory Council? 18 MR. PETERSON: As to funds? 19 DR. HEUSTIS: It puts us firmly on the record as far as termination, and what you do with it is the orderliness. 20 1 21@ MR. PETERSON: Termination with such funds as staff 22 finds necessary to make that an orderly process. That is poorly phrased. We don't know. 23 24 MR. NASH: The Department would insist on this, 25 any way. HOOVER REPORTING CO, INC. ki r 458 hws-32 1 DR. HEUSTIS: with such funds as are necessary. 2 MR. PETERSON: I want to make sure whether it is 3 in the motion or not that we have the sense of that. 4 Termination is a guillotine. 5 DR. HEUSTIS,. There has been so much pussyfooting 6 around on this thing, I would like to use language so nobody 7 misunderstands what we say. 8 What they do with the language after that, after. 9 I understand it, is fine. 10 MR. PETERSON: I think I understand the language. 11 DR. HEUSTIS: I am glad you do, but do you have a vote on the Council? 12, 13 MR. PETERSON: No, I don't. 14 DR. HEUSTIS: I would like to be sure the Council 15 understands what we say. MR. PETERSON: I will reduce the motion to one wor 17 which will be "termination," and we will supply appropriate 18 parenthetidals. Again, I am just trying to get a sense here. 19 20 MR. BARROWS: It is very important to avoid an appearance of capriciousness and arbitrariness on o r par 21 that this termination be provided with whatever is necessary 22 for an orderly termination. 2.1 MR. PETERSON: Early, orderly termination. 24 Termination with only such funds as is necessary. 25 HOOVER REPORTING CO, INC. 32OMassachosettsAvenue,N.E. 459 hws-33 1 MR. NASH: Any program that I have ever seen in 2 HEW that has been terminated, the Department insists on an 3! orderly termination. 4 MR. BARROWS: We should mention that. 5 MR. RUSSELL: RMP would go to any RMP and say send 6 us your plans for going out of business, 7 DR. TESCHAN: They will either roll over and die, 8 or scream and come in here with all kinds of important reso- 9 lutions. 10 I wouldn't mind July 1 in that sort of situation 11 to review if the y have more life than we have seen in two 12. years. 13 MR. PETERSON: On both Maryland and Nassau-Suffolk 14 I have a sheet of paper in front of me, I am filling in the 15 last few figures on, in both cases I am showing the figure i(i of equal to or greater than zero. 17 There is a motion now. All those in favor of the motion raise your hands. 18 (Showing of hands.) MR. PETERSON: It is unanimous. 20 21 MR. BARROWS: This will include the proposition we faced on the impact on the new program. 22 DR. HEUSTIS: This has the same reasons Mary an 23 had. 24 MR.-PETERSON: The set of problems are not all that 25 HOOVER REPORTING CO INC. 32 MassachusettsAvenue,N.E. 11 hws-34 different. 2 Grantee Number 1 is of a different order. It is 3' not a Johns Hopkins with a grantee domination vis-a-vis the 4 RAG, questionable leadership, and certain results of no @5 significance. 6 Well, we are down to the wire now with.just the 7 Susquehanna Valley, which is the central part of Pennsylvania. 8 Let us move ahead. 9 Joei you were one of the reviewers here. I wonder 10 if you wanted to lead of 12. 13 14 15 17 18 19 20 21 22 2tl 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N@E@ n P )nnni 4bi hws-35 HEW REGIONAL T-EDICAL PLAN FOR THE 2 SUSQUEHANNA VALLEY MR. de la PUENTE: This is an application for 3@i @4 $721,606. 5 On July 1 they are going to come in for $705,000. They have 14 positions, including three physicians devoting 6 7 25 percent of their time to staff functions followin t e 8 recommendation of management. They have been successful in filling three addi- 9 10 tional key positions with former RMP staff who are rejoining 11 the program. 12. The present request is for a fully via le program. Their activities are addressing themselves to the Regional, 13 what the Board concedes as need in the primary health care, 14 availability of services for room area and accessibility to- 15 the urban service. They are with the Pennsylvania @ledical Society, 17 which is providing excellent physical management sources4 18 The staffing pattern coincides with their program. Many parts of their program are grants. The grants 20 present an opportunity for realigning their staff pattern in 21 a manner which coincides with their new plan. 92 The present application is for support of_their 23 positions from July, 1974 to June 30, 1975, as well as two 24 months of support. 25 HOOVER PEPORTING CO, INC. 370 Maw busetts Avenue N.[. C- - ----- 462 hws-36 1 Their July 1 application will emphasize project 2 support. 3 At that time they will present approximately 18 i 4 projects presently under review by their Regional Advisory 5 Board. 6 While they represent present activities, their 7 application does not include comprehensive updating of their 8 plans. 9 I have not seen anything as to how they are up- 10 dating their plans. 11 They intend to continue the AHEC activity in South 12 Central Pennsylvania, as well as the Area Health Education 13 System in North Central Pennsylvania, and the ambulatory patient dialasis is also going to be continued. 14 15 What they are going to do as far as new activity 1(; is concerned, is to facilitate the development of Regional 17 Health Authorities, and adequately address the need of inte- 18 grated functions of health plans, implementation, and regula- 19 tions. 20 As they develop their plans they will have active participation of the B agencies in the Susquehanna Valley 21 22 Region. 23 One of the major concerns regarding this Region is the evaluation of their activities. 24 25 This is the problem I have with this Region, how HOOVER REPORTING CO, INC.I 320 Massachusetts Avenue@ N.I@ -11 463 hws-37 do they evaluate what they are going to do, and how do they 2 decide what they are going to do next, and what are their priorities, 4 SISTER JOSEPHINE: I have some of the same problemi 5 that Joe has. 6 As I looked over the proposal I got the impression 7 that they got on the bandwagon very quickly to phase out the 8 program, and they ended up with three people from 22. 9 Then.they hired and they are at a level of 14 now,, 10 and they propose to build it up to the original level, and 11 they realize when they get the whole group in they are going 12, to need to develop them to have some program to work on. 13 All they are going to do now is to tie up for a 14 poor staff and a development program which is the only thing, 15 a development to develop that corps staff so they will be i(i able to identify some projects, but there are no plans for 17 how they are going to implement the projects, or how they are 18 going to develop the project. 11) This creates a real problem for me. 20 MR. de la PUENTE: Maybe staff can help us. 21 What was the story? 22 SISTER JOSEPHINE: Another thing here, too, their 23 past performance, there are three things that they identify,, 24 and one is that they have been able to elicit qrassroots involvement, but you don't know. 25 CO, INC. 464 hws-38 1 They talk about the coronary units which were one 21 the first types of things, which began when the program of 3 first evolved. There were five. Now there are 30. 41 They had a management consultant firm come in and 5 help them learn how to develop a program. 6 I feel they are very much in the same place as 7 when they first started the program. 8 MR. BARROWS: Sister, you better be careful. You 9 are going to acquire a reputation of a hanging judge. 10 DR. TESCHAN: She is helping us to be one. 11 SISTER JOSEPHINE: This is the way I have to rea 12, it. They are going to get the kiss of death any how. 13 MR. STOLOV: I thought maybe Tom would comment 14 since he was on the management assessment* 15 My visit was the last visit, where the RAG met on this application. I could supplement maybe what the reviewer, 17 had to say. 18 MR. SIMONS: We were up there in January. There were two people at that time, plus the secretary. 19 20 There was the Acting Coordinator, the Fiscal man, who has been there since the day one, I suppose, and the 21 22 secretary. They had spent the entire year of the phaseout 23 doing absolutely nothing, just sitting there reading the news 24 papers, 25 HOOVER REPORTING CO, INC. 320 Massuhusetts Avenue, N.[. Washinvton I) C 20002 465 hws-39 MR. PETERSON: In Harrisburg? 21 MR. SIlfiONS: They were reluctant to hire people 3.1 because the Coordinator had almost a paternalistic attitude, i 41 although some of the staff wanted to come back. He didn't 5 think they were fair to themselves to want to come back. But 6 now with more money, they will come back, he thinks. 7 This was just a very inactive operation. 8 MR. PETTRSON: You were at the RAG meeting when 9 this application was considered. 10 What kind of life did you see? 11 MR. STOLOV: I attended not only the RAG meeting, 12. but the Executive Committee meeting. 1 41 13 The first thing that impressed me was that it was 14 at the Pennsylvania Medical Society Headquarters, which is in 15 Camp Hill, and the grantee is an ex officio member of the Executive Committee, so most of the people in attendance at the Executive Committee meeting were physicians, and if you 17 18 are in the Medical Society building, which is quite impressive, lo but there was adequate-participation in the Executive Com- mittee. 20 2@l This wag around April 17, so one of the physicians 22 just paid his taxes, so he was carrying the torch at that 23 meeting, and he was trying to question the Coordinator as to 24 dollar.expenditures. Most of them, I still believe, are similar to one 25 )iOOVER REPORTING CO, INC. @@,ilsafhusetts Avenue, II,[, i 4.66 hws-40 of the comments we made in another Region, that this is a fund- 2 ing strategy rather than a program strategy that at this timei I due to the conservatism -- well, they just appointed a 3 4 Director at that meeting. He was Acting Director, so there was a sort of sitting on the fence sort of attitude there, 5 6 as well as due to low salaries that the grantee has in this 7 structure. v 8 This was a negative force. However, the Executi e 9 Committee is behind the Coordinator, and the RAG was well 10 attended at this meeting. It was a well attended RAG meeting p 11 They had minority representation there? and eople made their voices known, and after the RAG meeting, And they 12, reviewed the arthritis applications, as well, and we did note 13 some positive progress. 14 The Chairman was also well liked, and is a good 15 Chairman. Staff went just like Nassau-Suffolk staff. They 17 were at the position where you are today, because this Region 18 wanted to put its rebudgeting into staff at that time, and they sent us their staffing pattern, and we asked them to link 20 it to their goals, objectives And priorities, but I think, as 21, Tom mentioned, they are very slow to move,, and have to have 22 the dollars in hand before they will move, and I think this 23 was a negative point to them. 24 As to evaluation, this last Saturday they had an 25 H OOVER REPORTING CO, INC. 120 Massachusetts Avenue, N@l. 467 hws-41 I evaluation. One of the reasons was one was just appointed a 3!@ member on the staff. They evaluated the two AHEC's there 4 with outside consultants, and they were at a point where they 5 were handicapped because of the dominance of this medical 6 clinic, and one of the physicians in charge is on the Executive 7 Committee as well, and up to this point they were really 8 handicapped by not performing an evaluation. 9 However, they did conduct evaluations on Saturday, 10 and the evaluation report will go to RAG. They did, however, use their outside Consultants ,2. and staff, and this is the first time they have probably (8) evaluated something on a scale like they did. 13 14 MR. BARROS: It seems to me, from what you have 15 said, what we are dealing with here is essentially a rebuild- ing of the budget. 17 Do you think that is going to bear fruit? MR. STOLOV: I think that we iden tify about $142,OOD 18 in vacancies in this budget, and the question is when you read 20 their narrative, and realize what they went through in the steps they have to take, this is one thing, but they were 21 quite honest to say that they may not fill all of these 2 --.k positions, yet their RAG and Executive Committee gave them 23 authority to go ahead with the strategy DR. HESS: Can you tell us more about Chad Holmes? 25 tOOVER REPCRTING CO, INC. 120 Mamchusetts Avenue, N.[. 468 hws-42 1 Apparently he has been appointed in May of 1974. That is 2 this month. i it MR. NASH: That is as Coordinator. 4 MR. PETERSON: Maybe I could offer a little 5 historical impression of this Region. 6 One of the first times I visited I spoke to the 7 RAG in the early days of the program, and while I have not 8 been a frequent visitor, I have sort of kept an eye on it. 9 It seems to me this is a program which is in a sense almost like three distinct faces to it. 10 11 In the early days when the Pennsylvania Medical 12, Society was still the grantee, but in the early days the firs Coordinator was McKencie, and I don't recall the first name, 13 14 who had been an employee, I think he had been the Ekecutive 15 Director, and at that time there was indeed,, a great deal of pulling and tugging between the grantee and the RAG, that 17 was trying to make itself felt, but did not have a great deal 18 of, it seems to me, moxie behind it in there ind vidual y. 19 and certainly collectively. 20 Well, that issue began to get clouded. There is the new medical school over at Hershey, Pennsylvania. I 21 don't recall if the Dean is still there, but despi te the 22 fact that the medical school at Hershey was put in the business 23 of training primarily physicians, some of the impressions 1 24 got, and I can remember a Dutch uncle talked about that, ')5 HOOVER IEFORTING CO, INC. 370 t@,issuhusetts Avenue, N.'L. '169 hws 43 that Harold rolled with some of the people from Susquehanna 2 Valley. The medical schoolls interest was to get some money to do some things that were pretty, at least some people who 4 knew better than I, was certainly exotic, and totally in- congruous with any total primary care. ,5 6 It sort of shifted from the Medical Society and 7 got clouted by the medical school, and as a result of that 8 Dutch uncle talk they did bring in a Doctor Ector, who was 9 from Philadelphia# and I think he started working in trying 10 to build some sort of program objectives which had never really existed before, but really got caught up -- well, I 11 don't think he had been in the post more than ten or 12 month 12, 13 before the ph.aseout order came, and I don't know what his motivation was. He didn't stay around very long. 14 Since that time, Chad Holmes has beeft first Acting, and now he has been recently confirmed as a Coordinator,, but they not only have looked forward to a fairly rapid phase- 17 out, but I think it does sort of reflect a Region which prob- 18 ably never did have much momentum or sense of direction. There was not too much to reach back toi and Holmes, 20 he was job hunting actively for a while, but with his con- 21 firmation as Coordinator, I guess he stopped doing that. 22 DR. HE8S: Was he the fellow sitting around 23 twiddling his thumbs? 24 MR. PETERSON: I assume so. 25 HOOVER PEPORTING CO, INC. 320 Massachusetts Avenue, N.[. ni, )iinn,) 470 hws-,44 1 Well, any way, they. got down to the Acting Coordin 2 ator or Finance Officer to close the books, and the secretary 31@ to do the typing, and they all read the newspaper, according 4 to Tom. 5 Holmes was there the whole time. 6 DR. HEUSTIS: Is there anything there worth 7 salvaging? 8 DR. HESS: No point in trying to gear up a program 9 for a phaseout. 10 MR. PETERSON: Do we have any idea? 11 Susquehanna Valley has indicated they are asking 12. for a little over $700,000 now, which is about their current CL 13 level, and they have indicated they are going to come in with 14 another $7OOiOOO package. 15 Any idea of what it specifically looks like? MR. de la PUENTE: They talk about improving the 17 quality, the high quality care in the Valley Region. 18 The Second Region is to improve the high quality health care, and then they speak of each mission, and how they are going to do it, so I think in here an awful lot depends 20 21 on what they come up with in the other application. 22 How they do that I just don't know. MR. STOLOV: There are some plusses, when they started 23 getting.rejuvanated that they have supported the B agency 24 directors at one of the B's previously not supported, and his 25 lio ERREPORTINGCO,INC@ 320 t,'.assuhusetts Avenue, N.C. 15 hws- I name is in, referred to by the budget staff. 2 The second point is the Region is in the State 3 Capital area, actually, and there is a need in that area to 4 coordinate with the three unidentified B agencies and the 5 RMP. 6 I believe this Coordinator can do it. He has the 7 personality. He has a Mastor's in Theology. He calls it 8 theracit medicine. 9 Any way, he is well liked, and the other point I 10 want to mention is the RAG Chairman is a specialist in cardi- uite devoted and a good leader, and he has the RAG 11 ology, q 12, support at this go around. MR. BARROWS: Would it be fair to say at the mini- 13 mum this will be a built-in block for the transition if we 14 keep this program going? MR. STOLOV: I would ask the Committee to encouraged; 17 that. 18 When Doctor Ecort left, prior to his leaving they were going to come in for a triannual. they actually had 19 100 applications in-house. This is an indication of some 20 21 identity in the community. What they plan to do is to try to bite on some of 22 those back applications. 23 MR. BARROWS: Lets give them a reasonable budget 24 and see what they come up with in their next one. 25 HOOVER REPORTING CO, INC. 11, 320 Massachusetts Avenu@, N.C. 4 hws- 4 6 DR. TESCHAN: That sounds great, except,what I 2 think I have heard up until now, until you just said what 3i) you just said up to now we are going to need a couple of 4 Dutch uncles. 5 One did not carry very far here, so it seems to me 6 that the Chairman and the Coordinator, or whatever else needs 7 to be invited down here has to come, and you have to line 8 up and lay it on in te of what needs to be done up there, 9 MR. BARROWS: Could you give them a transcript 10 of this discussion? 11 MR. PETERSON: I prefer not to do that. 12, DR. THURMAN: As you look at their budget, what OL 13 they have proposed is $498,000 in staff, $95,000 in definitive 14 projects, and $127,000 in grantee administrative costs. 15 Going along with what Mr. Barrows said, why hot think about $95,000 for the definitive projects, because 17 most of them are transitional projects for a few agenc3-es, and added to that, $250,060 for program staff. 18 I am making a motion that we not terminate, but 19 20 we ought not to commit this kind of money until we see what 21. is going on. 22 MR. BARROWS: Your recommendation makes,a lot of sense. 23 We have a good Coordinator. We have a good RAG 21 1 I guy up there. I think the two give you a ray of hope. 25 HOOVER REPORTING CO, INC. 320 Massachus tts Ave ue, N.C@ p n 1, -- I t I @ hws-47 1 MR. STOLOV: And the grantee follows the financial 21 practices as to their philosophy and their whole salary is 3 something else. 4 DR. TESCHAN: You will need a bellows in addition 5 to the dollars to get them started. 6 DR. HESS: In circumstances like this I wonder if 7 MPq7be I am just thinking here, if he could so how learn a 8 little something from the fellow in Rochester, Peter Mott, 9 as judged by the grant application, and I never met the man, 10 except I like the way he thinks, as represented in the appli- 11 cation, that organization that is there, and the way he got 12 that thing lined out, I wonder if a little apprenticeship 13 with a first rate Coordinator, and looking at what a first 14 rate Coordinator does with an application, if it would not 15 be helpful saying, you know, much more than you have to o better. He needs some direction as to how to do better. 17 I gather from what you say he has the interest and motivation. 18 1.1 MR. STOLOV: He did expand from three to 14, and a lot of his staff are following him. 20 He does have some leadership that did come to 21 work for him. 22 MR. PETERSON: Let me make sure what figure you 23 were coiDing up with, Bill, and what the basis for it was. 24 You said leave the $95,000 in projects? 25 H ORTING CO, 114C. @320 assachusetts Avcnue, N.C. ttiatoii, D.C.20002 474 48 hws-.@ 1 DR. THUPJIAN: $250,000 in programs staff activities1 2 which would also bring then $60,000 in grantee administrative 3'fi; costs which is $310,000 and $95,000 they have asked for in the,, 4 projects they have, which is $405,000, so why not 00,000? 5 That will not make him lay off any of the 14. 6 It will give him some room for expansion in that 14. This 7 will carry his projects, and pay his overhead. 8 MR. PETERSON: And try and see what their July 9 application looks like in terms of any hint of A program 10 there. 11 MR. BARROWS: Is there any way of gett ng t e reasoning to them? 12. 13 Could you do that, Jerry? 14 MR. STOLOV: We have to send a policy feedback to the Coordinators, but we expect whatever comes out of this -- 15 I(; DR. HEUSTIS: There are only about three or four 17 instances in all of these discussions we have thought there 18 might be some real value to get some information back reason- 19 ably soon. Would it be possible for the staff to discuss this 20 with the higher ups, to see whether or not, in a very small 21 number of cases an exception to the general rule could be 22 made, and that maybe some of these people could go? 23 DR. TESCHAN: I have a question. 24 Out recommendation is to Council who has charged 25 HOOVER@REPORTING CO, INC. 320 @Aassachosetts Avenuej if.[. 49 475 hws- I us, and it seems to me if Council says we don't want any parti 2 of that, we will do this. 3' DR. HESS: I recommend staff do that. 4 MR. PETERSON: Your recommendation is for a feed- 5 back? 6 DR. HESS: No,, officially. 7 DR. THURMAN: That letter you signed made us repor 8 to the Council. 9 MR. PETERSON: You have an official legal status 10 now, You are legal. 11 DR. HEUSTIS: Shouldn't they give us a copy of 12. that letter to make it legal? 13 DR. TESCHAN: It is a little techinical point and 14 we might be overridden by Council. 15 DR. THURMAE: Staff has the option to ask if Council approves, ask somebody to go with them to explain all of this.i 17 The staff can ask about that. 18 MR. NASH6. If Council approves this, and of course, this information goes to the Advisory Letters, you know. 19 20 MR. PETERSON: I thought I heard Al say something different. 21 22 Here and in a few other instances we won't have Council action until the 14th or 15th. I don't know if it 23 makes any difference, but I.thought I heard Al suggesting if 24 it is agreed at a higher level. 25 @HOOVER REPORTING CO, INC. j2o @oassa@husetts Avenue, N@E. 1176 i hws-50 DR. HEUSTIS: I gather from the discussion there 2 was no great enthusiasm for the suggestion I made, so forget 3 it. A DR. HESS: There was, indeed. 5 DR. HEUSTIS: My suggestion is, as soon as possibl 6 after this meeting, that in a very small number.of instances 7 where you believe it important, that the staff seek the 8 approval of a higher level in this organization to at least 9 informally discuss with the local people what we have talked 10 about in those instances where it will be thought to be bene- 11 ficial to the program. 12. DR. THURMZLN: I second. 13 MR. BARROWS: I move it. 14 MR. PETERSON: In this instance if it is concurred 15 in by Dr. Paul that we would get back to, I hope, if t@- RAG i(i Chairman is an impossible mover, indicate to them in frank 17 terms the Review Committee's recommendation will still have 18 to be looked at by the Council, That we have serious reser- vations about the Susquehanna Valley program, but would be 20 looking at their July application largely in terms of whether 21 there is any indication of some kind of program being performed 22 there, and they need to keep that in mind. I don't think they are going to generate any new 24 projects, but it may make a difference in terms of their priorities, and how they present what they have in the pipeline 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 47 hws-51 now. 21 DR. HEUSTIS: When is the deadline? 31i MR. PETERSON: July 1, but for most Regions this 41 means their RAG's are going to be looking at things. Most of 5 them are scheduling meetings in mid-June, or early June. 6 MR. RUSSELL: We have a precedent and can handle 7 this and accommodate the concerns of this group. 8 What I hear this group saying is that there should 9 be a staff visit. 10 MR. PETERSON: Maybe we ought to ask Holmes. 11 MR. BARROWS: Let's clarify this thing. 12@ We are not preempting the role of the Council, or 13 reporting decisive action, but we do feel under some obliga- 14 tibn to help the programs. 15 We think it would be in their best interest to know some of the concerns and some of the reasoning that went into this discussion. 17 18 What they do with it is their own business, and we 19 are not reporting any definitive action. DR. TESCHAN: The site visit isn't the term. 20 MR. RUSSELL: It is a staff visit. 21@ MR. PETERSON: I think in some ways it is particularly 22 more effective since we are not that far away. Harrisburg 23 a little over a two hour,drive, and let's see if we can't 24 is get the Chairman and Dr. Holmes to come down for a half day 251 HOOVER REPORTING CO, INC. 320FOassachusettsAveliuf,,N.C. hws-52 1 visit. 2 Sometimes the direction in which you move is most i 3 helful. 4 DR. THURMAN: Excellent. @5 I call the question. MR. PETERSON: The question is on a 400,000 recom-; 6 mendation for Susquehanna Valley with the communication to 7 8 Holmes, the Chairman, that he meet here as soon as possible. Does that meet with your concurrence? 9 10 DR. HEUSTIS: The appropriate division of that 11 within program staffs and projects. MR. PETERSON: All in favor raise your hands. 12 13 (Showing of hands.) MR. PETERSON: The vote is unanimous. 14 MR. NASH: Remind them of the confidentiality of 15 deliberations particularly in the case of Maryland. MR. PETERSON: Yes, particularly Maryland and 17 Nassau-Suffolk Counties. 18 Are we agreed then that we will try to get together 19 at 8:30 tomorrow? 20 I will have something in some kind of rough shape 21 to pass around then. 22 We are planning, according to the last communica- 23 tion I got from the other side of the wall, to reconvene as 21 a single group, or as a whole, between nine and 9:30 tomorrow. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu@, N.I@ hws-53 One final thing, if.there are any of these, partic- ularly as thev relate to Nassau-Suffolk and Miryland that have not been turned in, please let me have them back. 4 We will meet again at 8:30 tomorrow morning. 5 (Whereupon, at 5:50 p.m., the meeting adjourned, 6 to reconvene at 8:30 a.m., the following day.) 7 - - - 8 9 10 11 12 13 14 15 17 18 1!) 20 21 22 23 24 25 @OVE ING CO, INC. s@ !O Ma sa.husetts Avenue, N@l. n i, gnnng