*EOOJ ANSCR"'PT 07 PROCE'i"'iDINGS @ill:,)UCATroll AN@@ WELI tPE TEA L'@ TC,",",4L IC/AL PROGRLPI@IS D -,7T'r. S I CC@:" P@, G P,D C,),N'241:TTEE Ma y 2,"T l@,74 1-71@OOVER !IE-POR'I'I'@G COLNIPtkNY, INC. Oilficial Reporters Wasbir@gtoti, D. 5 6 6 arc DEPARTMENT OF HEALTH, EDLTCATIOIJ AND WELFARE DIVISION OF REGIONAL BMICAL PROGRAMS AD HOC REVIEW COM4ITTEE Conference Room G-H Parklawn Building 5600 Fishers Lane Rockville, Maryland 20852 Friday, May 24, 1974 The meeting convened at 9:45 o'clock, a.m., Dr. Herbert B. PahL. Acting Director, Division of Regional Medical Programs, presiding. PRESENT: Mr. Peterson, Chief, P&E Dr. Winston Miller, Minneapoliso Minnesota Mrs Jessie Salazaro Albuquerque, New Mexico Dr. Leonard Schertis, Baltimore, Maryland Mr. Joseph de LaPuente Dr. Paul Teschan, Nashville) Tennessee Sister Ann Josephine, Notre Dame,. Indiana Mr. Kenneth Barrows, West Des Moines, Iowa Dr. Joseph Hess, Detroito Michigan Dr, Albert Heustis, Three Rivers, Michigan i n Dr, John Hirechboeckp Milwaukees Wiscons Mr. Robert Toomeyo Greenvillep South Carolina Dr, William Vaun,, Long Branch, New Jersey Mrs, Florence Wyckoff, Watsonvilles California Mrs, Silsbeep Acting Chiefo O&D Mr, chambliss,, Acting Deputy Director Dr. Herbert Pahl, Acting Director, DRMP Mr. Francis Nash, Eabtern Operations Mr, Richard Russell@ Western Operations Mr. Michael Posta, Midcontinent Mr. Lee Van Winkle, South Central And others C 0 N T E N T S Reports by: @e Mr. tee Van Winkle @outh Central) 7 Mr. Michael Posta (Mideontinent) it Mr. Richard Russell (viestern Operations) 23 Mr. Francis Nash (Eastern Operations). 25 Discussion re equity of treatment by two s ubcommit tees 36 Criteria I Oklahoma 43 Bi-State 45 Loulsia6a 47 Discussion re policy matters 56 60 @Recommendations to Council Motion 6L Recommendation amended 71 Vote 77 Adjourned 81 P R 0 C E E D I N G S ---- - - - - - - - DR. PAHL: I would like to call this session of the meeting to order. There may be one or two of the committee still getting a cup of coffee, but I understand some people had to depart. I believe we still have a reasonable amount of acti- vity before we can conclude the overall meeting. But before w(., go on further, I am sure all of you have probably noticed thal; Silsbee has been able to join us this morningo and I hop, that we don't have any more relapses which we had the other day, Glad to have you back, Judy. I guess probably one of the biggest disappointment in her life was to miss the other day. We will be busy briefing her as to what is going on. The purpose of this meeting really is to have one of the panels inform the other what the actions wereo very briefly. And any really important points that may be pertinent to that action, each panel has had certainly a few very excit@.n moments and some very difficult moments and I believe that this information should be shared with the group as a wholes because we are taking the full conunittee's recommendation to the Council and also we hope to have all of you back for tiie July review and you should all hear at this time what the actions were. It is clifficult'to do this, as you know from past experience, because having not shared in the full length discussion and read the applications, you may feet that some or the actions are overly harsh from what your present lnform- tion is. But that' information may be outdated by 18 months or two years or so. So what I would like to urge us all to do is not try to reopen all of the sessions which we have just gone through, but use this as an Information session, Anil I propose to do this in the following fashion,, and thetis to, first, take Mr. Chambliss' group of applications and have the two desk chiefs run down alphabetically the ones that they were responsible form and give you the highlight and any point wffch they feel you should know. Now, because we are still on the confidentiality of information and conflict of Interest, I should say that when your own conflict of interest region comes upo we would like to have you out of the room. These will be very short presentations; that is, a few minutes on each. Because we have 53 and we are heading for getting out this morning. So really don't wander clown he hall and start that long distance telephone call* It will almost be an In and out. On the other hand,, I believe that perhaps one or two points may require more than that few minutest because there a@e some serious considerations that have come to my attention, an,] I believe you will perhaps want more than just a sentence or two, So that.you will be better prepared to understand the applications as they come before you In July. The other matter isot least Dr, Teschan, maybe some others, have some points you would like to raise for group consideration possibly formal recommendation for policy issues for the Council and other matters. So as soon as we finish thist,@ie will be willing to entertain any kind of further discussion on points to the staff or points to the Council that you wish to make. Now, if that is a satisfactory agenda, I am sure we can proceed rather quicklyo and I would likes first of alL. to ask whether that fits in with the way you feel we might best convey a Large volume of information over two days. .ALL right, first I would Like to ask, Bob., let's take yours f lrst. Do you have any general comment you want to make for the group about the total set of applications, and then we will go right Into them? MR. CHAMBLISS: Yes. I might say as a matter of general information that panel A handled the applications from the South Central and Midcontinent areas. We handled a total of 28 applications and the total request from those applica- tions amounted to $65.5 million. The overall actions recommended from this panel,, total $50 million$ $5Op273@913. We are going to ask, then, for the respective branch chiefs of the South Central and Midcontinent Branches to give just a brief summary of the individual actions taken by this panel. Lee,, will you proceed. mR. vAN WINKTE: I don't propose to get Into the specific rationale behind this and how they arrived at these decisions but basically I am just going to give you what the decision of the panel was. On Alabama$ they considered-- DR, PAHL: Give time for people to go In and out of the room. MP,. VAN WINKLE: There is no one from Alabama. DR. PAHL: Just in general. Okay. MR. VAN WINKLE: In Alabama,, they considered this to be an above average region and they recommended funding at the level of $2,028,389. There were no specific recommendations other than that, Flbridap no one here from there either, Is there? This was considered to be a superior region and was recommended at a funding level of $2.7 millions Georgiat another region that was considered to be superior, was recommended at'a funding level of $3,,629o757. On Georglas they don't propose to. come in In July at all. This Is their total request. Illinois was considered to be an above-average region, was reea.,nmended for funding at $2,816,935. Indiana was considered to be an average region, was recommended for funding at $L.,121,159. Memphis was considered to be an above average region, was recommended for funding at $2.6oo,ooo. Michigan I believe we have some people from Michigan? MR. CHAMBLISS.- Yes, we do. DR. HESS:.)5ut I have no conflict of interest. DR. HEUSTIS: I come from Michigan, I have no con- C!" flilct of Interest. Do you want me out? DR. PAHL: Please, if you will, (At this point, Drs. Hess and Heustis withdrew from the room.) MR. VAN WINKLE: Michigan was considered to be an average region, was recommended for funding at the level of $2.5 million.' DR. -PAHL: Let the record show Dr. Heustis and Dr. Hess have both left the room. Thank you. (At this point, Drs. Hess and Heustis returned to the room.) MR. VAN WINKLE: Mississippi was considered to be a led for funding at the level of superior regions was recommend $2.2 million. North Carolina, considered to be a superior regions recomme nded for funding at the level of $2,375,522. Northlands (At this poin4 Dr.'Miller @ithdrew from the room.) MR. VAN WINKLE: Dr. Miller has left the room. Northlands was considered to be a below average region. This largely'ha-d to do with staffing difficulties. Was recommended for funding at the level of $1.7 million. (At this points Dr. Miller returned to the room.) IC. VAN WINKLE: Ohio Valley was considered to be an average region, recommended for funding to the level of $2o3O5o636. -'South Carolina was considered to be an average region, was recommended for funding at the level of $2,2 million. Tennessee Midsouth, DR. PAHL: Dr. Teschan. (At this point, Dr. Teschan withdrew from the room.) MR. VAN WINKLE: Was considered to be an average region,, was recommended for funding at the level of $20133,972. (At this point, Dr, Teschan returned to the room.) MR. VAN WINKLE: Dr. John Hirschboeck is leavings (At this point, Dr. Hirschboeck y,ithd,rev,,@from the room,) MR. VAN WINKLE: Wisconsin was considered to be an average region, was recommended for funding at the level of $2 million. Now, there was one common thread I think that went through all of these funding recommendations, in terms of some reductions, is the fact that'irrespective of the superiority or excellence of the regions in many instances there was a question whether the amount of work cut out could be accom- plished in the amount Left. I think that was probably one common theme that went through that. DR. SCHERLIS: Sum total. MR. VAN WINKLE: $32o3ll,370. That is all of these. DR. PAHL: Thank you very much, Lee. Are there any comments or discussions of these applications? -YeE;. DR. SCHERLIS: This will come upo I am sure, as we discuss other sections but looking at the target figure of some 35-plus against the recommendation of $32.3 millions does that mean we will have at the most $3 million for the Jul@ request? I know it will add up In the different groupso but is this the sort of calculation we will have to make in terms of what will be available in July? DR. PHAL: Yes,, I will go Into that at the end of the full recitation here,, DR. SCHERLIS:, Fine. Thank you. MR. VAN WINKLE: I 'could mention thatthe total May request that was being considered here came to $41,159,472. MRS. WYCKOFF: For this group? MR. VAN WINKLE: For this particular group, DR. PAHL: All right, thank you, Lee, Mike, would you please take your group of regions, MR. POSTA: Just as a beginning, the 14 regions from the Mldcontinebt Operations areas,, requested in their May L application $24,436,527. Of this $24 million in request, $17.,962..843 was recommended for approval First region in this group Is Arkansas, .DR.TESCHAN: Would you get a little closer to the mike. MR. POSTA: Okay. Arkansas, reviewers felt this region was an average one. They were concerned with the lc6s of Dr. Silverblatt, a top-notch coordinator; because of this they did not feel tha; the full amount of $1,830,000 request should be approved. As a result, their recommended figure was $1.5 mil- lion. Bi-state, St. Louis, reviewers considered Bi-state to be average to below average. The request of $10128,000, roughly, was cut to $800.,Ooo. This is approximately $71,000 below the projected 12-month funding level,' Poor leadership, particularly with reference to the RAG involvement, was noted. Theyhave never received triennial tta@uss Their track record was considered below average. Coloracio-Wyoming.9 Colorado-Wyoming was considered above average to-supe'lor. Thetarget figure of $1,5 million r, was recommended, which was about $280,000 less than was re- quested. Intermountain? No problems. This region was considered above average. One reviewer in individual grade sheets considered it superior, They commented on the good staff. However the application was most ambiguous. The region was considered to be overly funded by some of the reviewers,, Including staff. The panel recommended that $2 million of the $3.85 mLl lion request should.be approved and this compares to $3,6 mil- lion target for this region. Iowa. (At this point,Mr. Barrows withdrew from the room.) MR. POSTA: Iowa is considered above average to superior. The request was approved in the total amount reques-i- eci of $1,061,349, which Is about 80 percent of the target figure, (At this point, Mr Barrows returned to the room.) MR. POSTA: Kansas. Kansas was considered average to above average, appro"ved $i,,633,380,, which is $1000000 less than requested. This region had requested about 78 percent of the. target figure. Louisiana? This region was conside red below average. This never has achieved triennial status, It has always come in for an annual type of an application. Leadership Is still in question. The coordinators on a haLf-.... time basis. Howevero the request of $985,?L2 was approved as requested,, which is 77 percent of the targeted figure. -Missouri. This region was cons idered average region. The reviewers felt that the region has improved significantly over the Last several years, As many of you are aware, this,. particular region put an awful Lot of emphasis on computer and hardware in the past. They have completely gotten away from this particular thrust and are getting into outreach programming. The MS needs and requests in this particular application should be reexamined by the health service agency staff. The reviewers felt that the program staff was too high. and that the application was considered to be too ambitious, The reviewers approved the targeted figure which was @9 Approximately $7L5,000 was trimmed from the budget request. Nebraska? This region has never achieved rienn a ny of you will recall, their funding was cut status and as ma back aft-er the divorce from South Dakota several years ago. The reviewers felt that the Nebraska's application wal@ the best they have seen to date. They note considerable im- provement. And recommended a new funding Level in the amount oJ $912.,000, which,, in essence,, was $50,000 below the requested amounts but over the target figure, DR. PAHL: Before we leavepmike, was that considered an above average or superior? General rating? MR. POSTA: I can't be sure. DR. PAHL: Okay. MR. POSTA: This region was reviewed by Mr. Thompson and he commented on theapplication, but I don't recall seeing his notes or his grade sheet. New Mexico. (At this point, Mrs. Salazar withdrew from the room.) M. POSTA: Considered an average region by the reviewers there was some concern about Dr, Gayp their excel- Lent coordinator Leaving. Howeverp the panel felt that the region was still in good hands with Dr. Walsh's takeover. This region will not be comin g in for July I funds. The target figure of $1,644o754 was approved, which was approximately @L.1 million under what was requested. Two particular projects were noted. The health edu- cation for the public wasconsiderbd overly ambitious as far as its funding request was concerned, and it was suggested that an out-of-state group visit this partlo ular project.. give an unbiased report, submit It back to the coordinator for possibL( rebuclgeting to other areas, Also the EMS'project-is considered to be well in exces of double the amount of the current application. Most of the cuts were in those two areas. (At this point, Mrs. SaLazar returned to the room.) MR. POSTA: North Dakota,, this region Is considered below average. However, the reviewers noted that this has beet the Lowest funded region of the 53. The target figure of $582,5L7 was approved or redom- mended for funding., which is about $L80,,Ooo less than was re- quested. OkLahoma, OkLahoma was considered average to below average region. It never has achieved triennial status, The target figure of $ltO62,237 was approved; $320,000 was trimmed from the request. The reviewers felt that a new thrust in dealing with hospitals through regional development area districts was a significant improvement over the old thrust, which dealt with continuing education programming. South Dakota. South Dakota was g,ivenan outstanding review. The reviewers felt thi-s- region-r-as you recall earlier, I had mentioned the divorce with Nebraska? Both regions, Nebrask4 and South Dakota, have definitely improved. Maybe the divorce was great. Anyway it was given an outstanding review, The applic-ation was approved in the amount requested of $729,417, which Is over the targeted figure. The target figure in this particular region was $571..095. Texas, This region took the longest of any in our paneL,, well over an hour. It was sort of a unique request. They did request 98 percent of the targeted figure and had stated in the application that they would not be coming in with a July application assuming this particular application was approved. The application was for $2,333,1531, The'reaL,'-problem as the reviewr saw it was that approximately $1.5.miLlion of the request was in the form of an open ended contract calling for five programmatic areaE! froli which requests for proposals would be submitted to the various consumer and provider organizations within the state. We were apprised at the last minute that about 62 applications had been received, responding to tho6e requests for proposals C> .9 t of $6.2 million. And the RAG had requested the in the amoun review committee to allow them approximately $1.4 million,, $1.6 million considering about $200,000 of the request was in the form of a developmental component to give them approval to check on June 28th at the RAG meetings and to submit to the regional medical program form 15's which are your summary sheets, form 16 your budget sheets. So that they could begin those contracts promptly and get a full 12 month project period behind them. Considerable debate took place and it was decided that the review committee could not in all due conscience approve an open ended application of this sort. They wound up by approving $1.1 million at this time which would take care of the continuation activities and theirogram staffo and had recommended that this be brought-to the attention of the Council that meets in June with the proviso that after the RAG reviews their 62 or more contract proposals and submits the 15'sand 16's intoDRMP by July 10th, that this body, the Review Committee, would be able to review them so that funding could begin immedj- ately after this next review body would meet. So that they would not have to "o again to the ugust review. DR. PAHL: Thank you very mucho Mike. Sister Ann. SISTER JOSEPHINE: I am sorry, I am so used to responc- ing to Intermountain, I did n ot move to Indiana. .(Laughter) DR. P.AHL: We are glad to have you with us, Sister. (Laughter) Is there any general discussion on the applications that Mik-e has gone over? DR. HESS: I would just comment that listening to what little qualitative comments we hacl@ that I would guess that, ii generalo your group used the rating system a little bit more liberally than ours did. It Is hard to tell,, but I would just raise that comment. Maybe as you hear the other half, you might keep that in mind. I think one of the important things we ought to do now Is to look at the matter of consistency of rating and con- sistency of fundino- decisions between the two subcommittees. DR. PAHL: Dr. Scherlis. DR. SCHERLIS: I think in all fairness to our group, we want to be considered extraliberal or noneredibLe,,i4e have never been accused of that, Our group never reached decision as to average or superior. I was wondering how you all arrived at those. I thinkyou got a f lavor from what we said, then decided we reall@ meant they were superior. We did not as a group really say these things. MR. VAN WINKLE: I took these off the rating. DR. SCHERLIS: Got it off the review rating? NR. VAN-WINKLE: That's right, not as the group* DR. SCHERLIS: Final block. DR. PAHL: This represents staff, analysis of the rating group results. DR. TESCHAN: The question concerning the Texas discussion which I thought was extremely interesting, I note from the sheet here th@,y-@ are triennial status. I was wondering whether that set of provisos for review here of the 15's and 16's was in accord with triennial management policy? I would gather that that has been decided lnthe first group, so it is just for information as to whe- ther or not that essentially takes from a triennial approved region decision up to this group? It is a policy question. DR. PAHL: Yes. I think It had to do with the mag- nitude of the funding. I wasn't in on the entire discussion. Pe'rhaps somebody can- elaborate. But'I think the problem here wasnot-- the question was not to remove flexibility from a region, but it was such a -- I don't remember the exact amount but it was such a large amount that I gather the panel didn't really feel that it could handle the decision making with the informationthat was at hand, Judy, do you have something to contribute? MRS. SILSBEE: I have a question. I was wonde@ ng if the same consideration had been given to the Georgia appli- cation which was somewhat similar? DR. PAHL: Perhaps that can be answered here, Lee,has the same consideration been given 'to-.'the Georgia application? I&R. VAN W INKLE: We cl id nt ha ve the same d if f I c u It I e,, with Georgia. The Texas application did not have sites. It did not have project directors. It did not have budgets. The Georgia application was full blown. MRS. SILSBEE: Except It Is still under review which is the only difference. The principle is the same, Lee, In both those appli- cations. MR, VAN W INKLE: It did not come out, Judy, in the discussion. DR. TESCHAN: I would respond to that by saying your answer, Lee, Is entirely satisfactory to me. DR. PAHL: Yes, Dr. Miller. DR. MILLER: It might be brought out again that we h).d rather extensive discussions about this Issue, and in several RMP's -- not Georgials as I recall either. Maybe we didn't pick It up - the principle of whether a region under the present system would be allowed to have the equivalent of a developmental funds slush fund., fund of money awarded to them without us knowing what they were going to use it for exactly. I think although we didn't ever pass a motion to that effe ct, there was general agreement in our group that we could not authorize a bloc of grant components in this review- process, We have trouble defining some of these as to whether they were block grant components or not. Some of them come awfully close In other ways. But anyway this was the issue that we grappled 'With and Texas@ was the outstanding and the most extreme examples DR. PAHL: Perhaps Dr, Heustis. DR. HEUSTIS: I would ask Dr. Miller if you would be willing to correct the record for his words and delete that little few adjectives he used after the word "developmental grant"9 It bothers me. I wouldn It want to even say the word. (Laughter) DR. MTLLER: Yes, I am happy to do that. DR. PAHL: -All right, that constitutes the findings of panel A. I would like to ask Mr. Peterson if he would care to introduce,mke any general comments concerning panel BI And then proceed along the same lines with the individual applications. MR. PETERSON: Panel B was transcontinental in scope having looked at 25 regions handled by the Eastern and Western Desks. As its chairman I was-very pleasantly surprised, perhaps not the word but by the serious self-disciplinecl way in which this group,operated in the face of the same con- straints that I am sure panel B was under except for lack of information, time, and what have you. I think it will be clear as'you hear from Dick and. Frank, but the panel judgments and actions were more nearly critical than otherwise. We did re-review our actions this morning on some sort of overall comparative basis, but only in three cases were some minor 10 percent changes made in the recommencla- tions that previously had been taken by the panel in the two prior days. Since we are probably going to be breaking and everybody is going to be running off, I would also like to take this opportunity now, rather than trying,ti seize it, later on, to say one other thing. I think at a time when the federal government and Public Service Is held in generally lower esteem than it has for along, long time The credibility of this government and the public's faith In it would be far greater if they could see the kinds of actions that are taken by groups like this to see,:,the submerged. part of the iceburg, not that tip that attracts the headlines. For that reason I would like to say thanks to panel B and all of the groups, both personally and professionally. DR. PAHL: Thank you, Pete. Dick, why dori It we take your applications first? MR. RUSSELL: All right. DR. PAHL: And proceed along as we had before. MR. RUSSELL: I Will go alphabetically. Arizona was considered a below average program; funding recommendation,is $860oooo, which is approximately 64 percent of its request. The reasons for this action, one is that the program is not in conformance with the RMP grantee Regional Advisory Group policy. Two, the program Is under an extreme influence, perhaps'control-of a key representative of the grantee. The third area is the questionable effectiveness of the coordinator. While there are some indications,,changes are being brought about in the program, this is attributed primarily to the deputy of the program who has brought about some change,,; however, with the history of this program, the group came up with this recommendation. California. (At this point, Mrs. Wyckoff withdrew from the room'*) MR. RUSSELL: Let the record show Mrs, Wyckoff excused herself. In the initial review which was yesterday, Califonirt was rated as an above-average -recion, and it was recommended that it be funded in the amount requested, $8sL7Os374. MR. PETERSON: Are you going to indicate-- MR. RUSSELL: I am getting Into the record, Pete, the gro@,o did reconsider the action in California this morning, and inview of the rating and the needs of CaLiforniao the group decided to reduce the amount recommended for California to $7,353,000, which was a 10 percent reduction in the amount requested. The third program is Hawaii (At this point, Mrs. Wyckoff returned to the room.) MR. RUSSELL: and Hawaii was considered an average rating, This Is primarily due to the recent change of coordina- tors who has done a tremendous job in a reasonably short perloi of t@o It was recommended. however, that Hawaii be funded at $I,l million. Mountain States Regional Medical Programs which covers Idaho, Montana, Wyoming and Nebraskao was considered to be an above average to superior region. There was some concern perhaps that the budget was inflated. And the panel recom- mended a reduced level of $2,150,000, And there was Indications staff should get additional information on the budget which we feel very comfortable in doing. I know we can get this before Council. The Oregon Regional-Medical Program was rated as a superior region. Recommendation was in the amount requested $10201,357. The Washington-Alaska program was rated as a superior, oO77,311. region with recommendation as requested, $2 And I believe that is all six of them. DR. SCHERLIS: Do you have a total on that? MR. RUSSELL: No, I am sorry, I do not. DR. PAHL: Frank., would you please then take the regions that you have and describe them briefly to us, MR. NASH: All right. Albany -- can you hear me, Pete? Albany was viewed as a superior region in all respects; recommended funding leve was $io66,ooo. Central New York was an average regio,n; reco@nda- tion for fundino, was $615,000. Connecticut, below average to poor, funding Level recommended $510,000, Greater Delaware Valley, rated as above average region, and recommended funding level was $2.3 million. Lakes area was rated as below average to average program; recommended funding level was $1 million, That figure,was arrived at by taking the current Level and deducting the cost in the application of all pro- jects that had been funded for at least three years, plus one- half the cost of proj-eets requesting two years supports which they had several, Maine, this was the superior region in all respects; recommended funding level here was'$L.7 million, $1,760.,Ooo. DR. SCHERLIS: Hold it. MR. NASH.@;.'. Yes. Let the record show Dr, ScherlJ-s excused himself. (At this points Dr. Scherlis withdrew from the room.) DR. PAHL: Frank, that changed. MR. NASH: Yes. This, the recommendation by the panel yesterday for @ne was $1.6 million. This was reconsid- ered in our meeting this morning and final recommendation was for $I,,76oooooo which Is about 90 percent of their targeted figure) and this Is the only application we expect to get froo Maine. Maryland, recommendation for Maryland was for terming.- tion of the program. This was based primarily on the four Items; one was lack of direction by the RegionaLAavisory Group. Two was lnspective coordinator. Three, disinterested or self-serving grantee. And four, end product of supported activities in the'past period would be useless. am sure you will want some discussion on that. DR. PAHL: I think this Is one of the points why we did want to have the total group involved because this obviously Is a very serious recommendation. And I certainly would entertain any discussion by the committee even though a number of 'ou have not been involved in' the details, but to raise any y questions of those who were involved in this or for further clarification before this recommendation is passed on as a committee recommendation to the National Advisory CounciL, All right, if not, Frank, will you proceed with the other applications. MR. NASH: Metro, D.C., this was considered to be average to above average region. (At this point Dr. Scherlis returned to the room.) MR. NASH: I think the panel-noted improvement In thiE region over the past years. Funding level recommended, $1.1 million. Nassau-Suffolk -- anyone here'from Nassau-Suffolk? This, the recommendation for this program was for termination and due to some problems with the Regional Advisor5 Group$ their Lack of direction and Leadership, the fact they have had three coordinators within the past year or two, there was great concern over the leadership. Capacity of the present coordinators problems between RAG and grantee organization, again this was a recommendation for termination. They may want to discuss this. DR. HESS: An Important factor, there Is another very Important factor too that was notrmntioned; that Is, the lack of a capable staff on board which to my mind is a very central concerns MR. NASH: Thank you. DR. HESS: The unlikelihood they can recruit capable staff and do anything in the time available. DR. PAHL: Thank you. Mrs. Wyckoff. MRS. WYCKOFF: I would like to ask about both of thes( that are recommended to be phased out. I would like to ask about both of these that are recommended to be phased out. Wou Id you say that the principal reason Lay with the traumatic effect of the cutback on'their programmer was it clue to something internal that couldn't be corrected regardless of what happened? DR. PAHt,': There are a number of people In the room who I believe might contribute to that. But Dr. Heustis his @hancl up first. Does that pertain to responding to Mrs. Wyckoff? DR. HEUSTIS: I think I can do this. The procedure in these areas was of long standing and failure to respond over a considerable period of Years with diligent staff effort and previous recommendations ofthe Advisory Council, this was taken careful considerate, deliberate way with full under- standing that staff and Council were reasonable people and if they accepted the recommendation they would make such arrange- ments for an orderly termination of the program as in their Judgment was best. DR. PAHL: Pardon me, before we proceed further, I think the chair has erred in not asking Dr. ScherLis to remain out of the room probably during this discussionend I have a feeling it may go on for just a few minutes. Don't wander away too far, please, Dr. Scherlis, Sorry, that was our error, (At this point Dr. Scherlis withdrew from the room.) MR. BARRCWS: Our arrival at this decision,occurred with great deal of anguish and discussion. We were influenced by another very important consideration, the upcoming course of planning. It was pretty well concluded that the new pro- gram, whatever it is, would be better off to start from scratct than to have this ineffective building block to work on. DR. PAHL: We certainly appreciate having that com- ment, I believe there are some others who may wish to comment on this. For examples Mrs. Silsbee or Mr. Nash and others who have been involved. Judy, would you care to make any comments? Does staff have any comments to add to this discussion at this point? Mrs. Salazar. MRS. SALAZAR: I have a question, Dr. Pahl. What is the timeframe In which- these two re-ions are tobe terminated? What type of on-going funds and what amount would they have for. appropriate termination? DR. PAHL: I can't answer that question because I haven't been in on these discussions unfortunately. Dr. Heustis. DR. HEUSTIS: The committee left the timeframe-- really, we thought It ought to be done as soon as it could be done in orderly fashion and Left the specific timeframe up to staff and Council, DR. PAHL: Dr. Teschan. DR. TESCHAN: Yes, and we also said probably the present budget would have sufficient funds to assure an orderly phaseout and.if not, the recommendation includes language, as I recall ito to ask, Council to afford the region sufficient funds for an orderly phaseout. MR. PETERSON: Yes,. the words early and orderly are part of the recommendation without being specific in terms of 30 days or 90 days. DR. HEUSTIS: We felt so strongly about this, we wanc;e to be careful and not water it downwith the full understanding that we were dealing with reasonable people as far as the staff ancl-the Council were concerned, and they would take the orderly process. DR. PAHL: Thankyou. Is thelvfur.ther discussion on this applicatiod? If not, Frank will return to the rest of the applica- tions. MR. NASH: Okay. (At this point, Dr. Scherlis returned to the room.) MR. NASH: New Jersey, this program was considered to be superior in all aspects. The funding level originally recommended yesterday was for $2.9 mil Lion, @ow, that brief'.., meeting this morningo the recomm endation was changed, the final recommendation being $3ol9OiOOO. N@i York Metro, this was considered to be an average program with funding recommendation of $2.5 million. -Also going with that is recommendation to Council that If dollars areavailable, New York Metro be given a high priority to receive additional funds. This was an application for over $7 million and about half cfthe activities were proposed for two-year support. Northern New Englando this was considered to be an average program; recommended they have a funding level of $700,000. And that the region be given advice to terminate support of their data collecting activities there, Puerto Rico was considered to be an above average program, recommendation for their funding level was 69518 2. Rochester, Rochester was judged to be a superior program with funding recommended of $3,061,471. DR. HESS: Explain that. That is mainly for staff. They have $1 million for projects coming in, that accounts for 'low figure. NR. NASH: This was really all they asked for, this particular application, because they only asked for staff support and continuation of ongoing activities. Their July application will be considerably in excess of that. Susquehana VaLley seems to be a below-average region, As a matter of ra-cuo i'Delie've 'the panel had some serious reservations even as to the viability of this program. Recommendation here was for $400,000. This primarily to support staff and very small amount for projects. Tri-state., this was considered to be a below average to average retion. The panel had many questions I believe which we were unable to resolve. The panel highly recommended a site visit be made to this region prior to Council meeting. The recommendation for funding was $800,000. And I am assuming it was the Intent of the panel that should the site visit get some of these other questions resolved, then that figure could be raised prior to recommendation of Council. Is that correct? Virginia was considered to be an average region, Funding level recommended was $1 million. A,nd with advice to us that we express concern to the region, particularly over their ability to fill the many vacancies that they listed in their program staff budget. West Virginia was considered to be a superior program. The recommended fundinm level was exactly what they requested In this first application, $663,132. This is basicel- ly a program staff support plus two small projects. The region will be coming in in JuLy with a much larger application. Western Pennsylvania, this was considered to be an average program. The recommended furfi ing level for Western Pennsylvania was for $1.2 million,, Plus $170,285 to support the Mahoning Shenango HEC project in Ohio. DR. PAHL: Is there any further question or clarifi- cation on these? Dr. Teschan. DR. TESCHAN: I would like to refer again to the Arizona application and to ask if the reporter clarify -- as I recall, in our panels Arizona was thecnly program which at thE time of the processing had not completed its rev ew process certification and I believe our recommendation started out to be that there be no further allocation unless that process were completed. During the discussion, however, we found that indee@ that project was well under way,, that some of the influences that would be inappropriate under the -August L972 policy were, as a matter of fact, being rectified. And the question I have is whether your notes and recollection Is that the recommenda- tion of panel B was somehow contingent on the completion after process that was already underway. The question I am simply sort of raising is the issue of approving funding for a region that has not been certified. Do you recall that, Dick? Where are we in that? MR. RUSSELL: I don't recall it that specifically. I will ask Mrs. Sadin If she will comment on this discussion yesterday, MRS. SADIN: No I think what we said was their RAG was going to meet and at the next RAG meeting,, they were going to consider the revisio'n, already looked at the revision of bylaws. They needed 30 days before they consider this would take place. It has not taken place, but they said it Will. DR. TESCH-AN: I think it is almost a truism. I don't th ink there Is any issue here particularly, but I gather it is understood or we should understand and make clear- ty a matter of record that review process certification will be essential for Arizona before dollars will f low. In other words, it seems to me that is a basic assumption under which th@ regions need to operate. DR. PAHL: That would be a recommendation to the Council, then the Council condition on the grant award, se restric- Underthe court orders staff may no.t.impo tions, but we may obviously.carry out any Council conditions or grant awards and this recommendation would be taken to the Council. , That is my understanding. DR. TESCHAN: But the application, Ins truction or the current cycle says clearly all applicable policies will continue to apply except those specific interdictions which had been specifically rescinded, DR. PAHL: That is correct. DR. TESCHAN: I have no evidence August 1972 policy does not apply. DR. PAHL: Yes, Dr. Heustis. DR. HEUSTIS: I think it might be in order to clarifj what we did this morning and to -,make, perhaps panel A undex- stand the three rather modest changes that were made. Staff over the evening took the material which we had prepared yesterday and organized it with all of the superior projects together and above average, thenfigured out some percentages. And so we tried to take a look at the numbers we had come up with on an Individual basis yesterday and to see whether In fac-t we had treated them In context with what we thought the process and merit indicated. That was the reason for the relatively minor changes that were made this morning. I think it was a good device and helped some of us to see things all in perspective. DR. PAHL: Than@ you very much. Are there other comments from anyone concerning the activities or conclusions reached by either of the paneLs? Dr. Hess, DR, HESS: Yes, I would like to have us spend a few moments on what I @ould consider one of the major items of business for us to attend to this morning and that is the equi by of treatment by these two subcommittees* I am particularly concerned- about those with whom we have dealt harshly and on the other end of the scale. I would like to just raise one question about one region that may have been treated by panel A more generously than would have happen@d had they beenreviewed by panel B. Because'I think this is something we have to be very much concerned about when we break down into.putlic sub- committees this way, that the decisions that come out are not too much a function of which group reviewed a particular regioi. Now, perhaps let's take them one at a time and let's take the easiest first. That Is, I would like to raise a ques- tion about intermountain and its level of fundlng,whichp as I understand, Is $2 million. It was rated as an above average to superior regions according to my notes, They apparently to $2 million, and are funding, their annualized rate) close they were granted $2 million. Well,it is $1.8 I guess. Ardthey are going.to be comeing in with -- let's see-- MR. POSTA: Between @400,000 and $500,000. DR. HESS: $500,000 -- for another half million in July, that will have to,be dealt with, This region does overlap to somedegree with Mountain States and does it overlap with Colorado-Wyoming at all? SISTER JOSEPHINE: Yes. MR. POSTA: Yes, s'ir, DR. HESS: Okay. Is there some way of knowing on a sort of FTE concepG how many people this region'serves? MR. POSTA: I believe Lee has got the po pulation charts back here. MISS RESNICK: It is complicated as Dr. Hess sug- ,.NR,.POSTA: That is six states involved,,right? MISS RESNICK: We know it covers all of Utdiand a portion -- small portion of Colorado,,a portion of Montana which is part of the Mountain States-- MRS. WYCKOFF: And Washington-Alaska has also some turf problems. DR. HESS: With Intermountain? MR. CHAMBLISS: Yeso they are also a part of it. MISS RESNICK: But since I am not the reviewer and aLs, wasn't called on to support the population distribution I am a little hesitant to quote'anumber of figures. I don't know what went into their programs as they developed their estimate And how they gcttogether. of nee I think there Is a three-region committee that looks at it from that Point of view, isn't it, Mike? MR. POSTA: Yes. For your information, in panel A. what did come up was the turf problem that we have had for a number of years with the three regions concerned, and on May gthp the coordinators of all three regions got together along with their RAG chairman and went over everything that they have in the hopper at the Prb.Sent time: what they are fundingo together with the May I requests together with the request for the use of the $6.9 million that was restricted and went through allof the applications to be assured that one region knew what the other one was doing, and got their endorsement. They approved everything In the application with the exception of ten activities and those ten activities could not be funded until this group got together againand they have two definitely scheduled meetings a month from now, the first one, before actually funding consideration would be given to any of the approvals that would come forth from Coun- cil. I don't exactly understand-- DR. HESS: Maybe it is not an answer able question. MISS RESNICK: I have some better figures on the population. We estimated last spring that the Intermountain program roughly was responsible for $1.9 million. That took into account Utah, a portion of Wyoming, a small portion of N6Vdda',' a'piece of Idaho, and a piece of Montana. It Is very rough. We have a map that kind of overlays and so on, DR. HESS: All right. That sounds fairly reasonable. And Idon't have any real question about thatv about. that re- gion. Iam satisfied. DR. SCHERLIS: May I interrupt for a moment? I am trying to discern the relevancy of that Issue. -Are pu suggesting we should give dollars per population that would make our task very easy2 DR.HES@: No, that should not be the only basis, bu -1-think'-we do have to look at the amount of money going into a region in relationship to not only the population,, but the quality of the program, needs to peoples the other resources 'they have towork with. And all these factors ought to enter into our judgments about what is appropriate. And that we should not take a narrow vision and look at the quality of the program.alone, as the sole criterion upon which to base judgment. So I am satisfied-- And I know that we have been looc- Ing at quality andwe have got your rating and all that kind of thing, but I do think that we have to not be unaware of the' number of pe ople to be served and the kind of Problems that exist in the region. MRS. SALAZAR: Dr* Hessp would You speak to the Poirt then of, in my view, certain element of inconsistency in the elimination of two regions this morning? These reaions have people in them and they are still in existence. DR. SCHERLIS: Shall I leave the room again? Will YOU stop that for a moment? DR. PAHL: Off the record. (Discussion off the record.) DR* HES8: Okay, I think my concerns at the high level are satisfied, Now I am concerned about some of the actions or recommendations that our group made in relationship to Isome ofIthe-- well, Ithink we need to share this a litt-le more in depth, Also I think I would raise a question as to whether Some of the regions that group A revieweC. if in fact we as a group as a whole are going to follow that and support the recommendations of panel A, Whether or riot similar recommenda- tions ought not be'niade for one or two regions reviewed by pan(i A. I got the A and B mixed up, but maybe You can follow the sense of what I am saying. Too.. based on-your discussion, the two that I thought ought to be looked at again in light of this factor are Louis iana and Bi-state. And questionmark Oklahoma. Now, I think the most efficient way to do this is to Look at the criteria which group B used for making the recommendations and ask group A how those criteria apply to those regions in question. .,The reason I single those out,, number one, the region3 are still on annual status which means there is a rather long history of not performing very well or they would be on triennial:tatus, And number twoo they were--well, again,, as I listened, I wondered if maybe we as a group were a little bit more strict in our application of the rating criteria than group A. And so therefore the rating of average or below average may not mean the same for the two groups. So could we just review now the basis for our recom- mendations on the two regions were, one, the unsatisfactory nature of the current. leadership, program staff Leadership; number two, the leadership of the RAG and feeling of weakness at that leveL, thirdly, the status of the grantee; and fourth, the role of the grantee -- fourthly the nature of the program specific projects which were put forward as representing the implementation of a program concept. DR. PAHL: Before we proceed, Dr. Teschan has a comment and question. DR. TESCHAN: I want simply to amplify or illustrate those four points didn't come out of the air. The first three will.be recognized by I hope everybody here as almost a direct quote from page one of the August 1972 policy as to what are tt.2! essential ingredients of an RMP. You have got to have a coordinator who is capable, You have got to have a RAG that functions. You have to have a grantee that will stay in its fiscal administrative box. And to that, then, the committee appropriately in my view, added the outputs in terms of dollars in and what then happens Is In the region in terms of project as staff activity result. So this wasn't an arbitrary set-- it Is simply c I ti'ng the ground rules on which all regions need to be judged. MR. BARRC)WS: Plus the consideration the new program would be'better off without having this to-- DR. P-AHL: Dr. Scherl is., I believe, has a comment, before we respond to what those points wer in hese cases. DR. SCHERTIS: I admire the fact you have set up what appear to be rather rigid criteria. I think it is the Interp- retation of these.criteria of the individual proejcts that obviously you have to fall down and have to fail, Because as we are speaking for the coordinators who are resigning, seekina, other positions, who have found other positions, I think a great deal of our response to these appli- cations admittedly is based on rather soft sand, as far as 14 j trying to be as rigid as we might be a year or two ago. We don't have the potential ability of saying, well, we will let them vet started and site visit them. C> We don't have the potential threats in terms of the careful supervision. We lack the central staff,, on and on and on. Ancl a great deal of the determinations here, regar less of what we can hope or assume we use these criteria really become more qualitative and less quantitative, I think that goes without saying, just as some of the criteria used are-rather ephemeral in terms of utilizing them. Let me speak to Oklahoma. I think this is one of the three al-'nce T was a reviewer. DR. PAHL: Why don't you proceed with Oklahoma., since you were the reviewer? DR. SCHERLIS: Yes. I site visited Oklahoma, and this is a program that has changed very significantly since the time that I site visited It. The rating of average minus is probably taken from my formal review,.that I handed In and this was based In great measure upon my recollection of the area as it was when I was last there and what I could deduce from the document. Remember that none of us at this time have the bene- fit of.the very carefully documented pink sheets we used to have which I found to be extraordinarily good, And we don't 'have the evaluation of all the preceding letters, site visit, documentation and so on, There Is little question in my mind that Oklahoma has moved from what was essentially a post-graduate training program, educational parade, through the statelinto what I think now is a very exciting potential network for better medical care through the area. @They have a new coordinator, The program that he has designed here I would view as being something that could fit into whatever survives, whether It Is regional medical program or regional planning councilp or comprehensive bulk programs :)x what have you; theseere networks which I think will lead to better care in Oklahoma. I don't reach this decision Lightly. It was pretty well forced on me after a very vehement, active discussion, and I. for one, support the ree6mmendation'that has been made. The grading of average minus was from my original sheet. In terms of the discussion that took place here, I was impressed with the fact that this group has changed directions significantly, what I will think will be very helpful whatever form planning takes and whatever form actual application takes in this region as far as whatever survival will be of RNP. I could detail the document. I would say this, I was most impressed with the change. I had viewed If Oklahoma had come in this way two years ago, it would be by now one of the better states. It is very heavily provider oriented, but I think one year to go, this would be a more fruitful way of moving than in another direction. DII. P.AHL: Thank you very much,, Dr. Scherlis. Is there further discussion concerning the Oklahoma application from staff@or other committee members? Dr, Hess, I think that is responsive, DR. HESS: I am asking is there reason for optimism. I think that is putting It in a nutshell. DR. SCHERLIS: It has changed markedly. DR. HESS: The only question I would ask,, you don't lia, to elaborate-- DR. PAHL: These are Very valid points. This is the purpose for this session. It is In order. DR. SCHERLIS: I was asked at the meeting how I reacti- &d the conclusion and I wished that I had had your points score to use. I said It was a guts reaction In a great degree, and I think all of us eventually have to come to that honest admission. DR. PAHL: If there is nothing further In Oklahoma, E believe one of the other regions that could bear some discus- sion was Bi-state, I am not sure whether the reviewers of Bi-state are here or not. MR. POSTA: No. DR. PAHL: Theno Mike; could you be responsive to Dr.Hess' points and perhaps just clarify a little bit further some of the thinking that went on with Bi-state. MR. POST.A: Well, I think In my earlier summations it was as succinctly put, they did come In with an application of $L,@l million, and they were cut back to $8oo,ooo, which Is not only well below the targetted figure, but about $7L,000 below the projected L2-month funding level for this region. And that was, In my opinion, a punitive action. Now, whether that action was as punitive as panel B would have taken would be up.for debate. DR. HESS: The question I would raise is, you know, to try-to bring some consistency into how we deal with regions. Is there a staff and a RAG that can effectively use that $700,ooo-$8oo,000 next year? And, you know, have something worthwhile to come out of it that justifies that amount o money and justifies continuing that RMP? MR. POST.A: Well, Doctor, I think the main concern again is the past track record of this regi@ which has not been too good. Now . we do have reason to believe that Dr. Felix will be coming onboard to serve as coordinator, -And I am sure that many of us in the-room know Dr. Felix. He does have a terrific track record himseLfe And will be and has been in- volved to a degree in the application which was drawn up. And some of the activities that he has go t certainly the-- I shoult relate staff feels that $800,000 is not an excessive figure. DR. HESS: Your basis for optimism is Dr. Felix? MR. POSTA: At this times yes,, sir. DR. HESS: Something will depend upon which to base optimism. That is all I am looking for really. DR. PAHL: I@- there any f urther discussion or commen by anyone on Bi-state? If not, let's turn our attention to Louisiana, And again, I am not certain who the reviewer on the committee was. is there any comment from the committee on Louisiana) or perhap4 Mike, we can turn back to you, Go ahead, Mike. MR.POSTA: Louisiana did come in with an application of $8oo--$985,000, which was 77 percent of its targeted figure. This is a private corporation that Is the grantee. They do have a terrific track record as far as expenditure of funds, They have had very little unexpended balances, The Indirect cost rates have been extremely nill in this particular region. It has been well managed. They do have a couple of outside consultants who have stayed with the program since it was terminated. 140 Staff ancl the review rs felt tha t this region accepted e the termination orders or the phaseout orders very strictly, And when they said close down, that is exactly what they decided 'to do, is to close down. However, in the State of Louisiana, they have to notify the Secretary of State within six months.of termination to carry out that termination or liquidation. In the meantime, we got a continuation order to continue as a result staff did carry on. They did hire a few more,people. They brought back their deputy director. How- ever, at this time the staff Is limited in scope* They have hired four additional peopld- Dr..Sabatier, the coordinator, is back on board, about 50 percent of the time. I can truth- fully say-in visiting the region two months ago with Mrs, Zi2lavsky, that the chairman of the Regional Advisory Group and the chairman of the evaluation committee of this particu- lar progra mare exceptional people. And their Regional Advi- sory Group does function quite actively and does not fund pro- grams unless they are.@ exceptionally well monitored from the start. That is, they do not fund just to be spendino, federal money, DR. HESS: I guess my question the main thing I would ask is are they doing appropriate things for people In the region and is there good leadership there? In other words, are things looking-- is there a basis for optimism for next year? MR. POSTA: That-is speculative, Doctor. Based on 50 percent of the cootdinator's times based on the fELct this is a corporation that would be phased out on time with no expectation that this corporation will continue as a grantee, the,same as many of our say universi- ties will continue to function,ancl will be able to monitor toward the enclp I think all of this was considered when the overall comments or grading to this region was below average, DR. PAHL: Thank you, Mike. Sister Ann. SISTER JOSEPHINE: Your last comment kind of preempt3 what I am going to ask. Over the years I have heard us from time to time concerned and particularly 'indirect costs and direct costs also, when a university is the grantee agency. And in terms of utilization ofi.cl6LIarb'@to'pr'ovicle-services and development of programs, it has been the experience of this program that where the grantee agency was other than the university we got more dollars down in.services and in programs, Your last comment was a Little disturbing to m wonder are we going to reflect on that experience and do you think reflecting on it, itis going to probably 'appear in the new guidelnes for whatever this new model is that Is going to be developed? 50 DR. PAHL: I think.I can answer for Mr. Posta and say- MR. POSTA: I had' hoped you would. (Laughter) -DR. P-AH L: a number of us are hopeful that the experiences will be translated into action as we go into thiB new phase. Mr. Rubel., who isn't here this morning, I think would say that in his various task forces that he has set up internal ly to try to plan something concerning the organizational framework and direction and policies, he has :@:ineluded a num- ber of people -- for instancemr. Peterson Is In charge of one of the subcommittees working with Mr. Rubel in designation of sible health service areas. And we have pos RMP people on all of these little subcommittees. Unfortunately beyond the agency Level I am not cer- tain howmuch of what we talk about will survive, but there is a very real intent to try to take the best from both the CHP and RMP and Learn from it. I think there is some reason for optimism in this, but when one comes to a specific point, such as the one you are referring to, I don't have any first-hand information. Maybe someone in the room knows, but we are concerned with maximum impact, with available doLlarso and utilization of skills and techniques that have been developed. I think in many cases the Congress is going to be more alert to this than possibly some of the elements in the administration. SISTER JOSEPHINE: I think I am a little sensitive 0-n :this point, maybe oversensitive. But I-remember a number of years ago we were just doing a little study on one of the OEO programs and It took $6o,ooO to get $1,000 down to the people. It is disturbing. DR. PAHL: Yes. Yes4 We are having a meeting at the other end of thehall oh arthritis center program and yesterday afternoon that same discussion came up as we look at the available dollars and what can be done to have an impact, and then see the cost-benefit. So that there are many groups that are recognizing we have to reconsider -this and I do hope we benefit from It. Bob. MR. CHA14BLISS: Yes. I thin@ Sister, and there is some indication that there will bebenefits from past experience s in that in the new legislative prooo,@,als, the operating agencies are shown to be nonprofit corporations, that deals I think spe- cifical ly with the question that you were raising about the in- direct cost. There will be a new set of grantee types under the new legislation,, that is as it is now proposed. DR. PAHL: To return to the business at hand, I would like to ask if there is any further discussion on any of the 52 findings, recommendations on the applications, because if not, then the chair,W-Ill understand that the findings and recon niendations which have been made and discussed here are those which are adopted by ti ie committee and will be passed on to th@, NationaL Advisory Council. Mrs. SiLsbee. MRS. SILSBEE: Dr. Pahl, I would like to suggest that the gist of.this discussion that has taken place in terms of the bounce between 'the two, be sort of a preamble to the Council, which will have an opportunity to look at all of the actions again,'that this might very well be kind of a caveat that the committee gives to the Council In looking at the lndi - vidual actions. DR. PAHL: Yes. I think as is customary, staff does try to reflect as welles we understand what we hear for the Council, so that they can act in an intelligent fashion on the various recommendations. And we are sensitive to the problems that you labor under in two separate'groups, We had no choice but we will try to reflect the various interpretations and shades and interplay of feelings .not only by the sheets but by all the record that is here in, the staff in the room. So I think you should be assured of thil Dr. Miller. DR. MILLER: Could you give us an overall summary picture of what we have done noiq? 53 How much did we approve and-- DR. PAHL: I am delighted to do that. DR. MILLER: How does it look in terms of the July process? DR. PHL: Ye.-,, I am delighted to Co that. Because by coincidence, it makes calculation which I had made back in March appear very brilliant when really it was just sheer coincidence. The total figure that apparently the/two panels have approved with the various modifications this morning comes out to be aIrecommendation of $85,047,297 for June Coun- cil awards. If Council goes along with all committee recom- menclat,@ons. This is from an anticipated amount available for boti June and August awards of $114 million -- let's just leave it at $114 million, because you will recall from the discussion I had the other day, because of the unsettled state of the litigation, we are still talking about between $109 million and $114 million, If, however, we-do have the $114 million available for support of RIAP recular type programs, the recommendations' $85 million asa result of this committee meeting would represe,'Ii usina, 74-1@ percent of the total available funds. This is very encouraging. Because back in March we had to establish an allocation mode between the June and 54 August Councils and we had arbitrarily at that time set aside 7@ percent, precisely, for,June and 25 percent for August. And at that time we didn't know-- we hadn't even issued the Instructions for regions to prepare applications. -And we also didn't knoi4 within $30 million how much would be available to us* So as I say, It is sheer acc ident and not due to som@ Texas instrument that was hidden away somewhere. So basically you have approved 75 percent of probably what would be the dollars available to us. If the Litigation does award $5 million to the Deparb. ment for some of-its other purposes, which are certainly directly connected with the forthcoming phase, this would still bring us within about 79 percent; your recommendations would be about 79 percent of the total funds available. So that come your July meeting and the August Council me are right oh target with about the proper ration if you go back to my 75/25 percent. Dr. Schertis, DR. SCHERLIS:. @,ny of these projects will st,4 .rt as of a certain date, but obviously won't reach full staff or full operation for a significant period of time after that. What happens to those funds which are left either at a local level or at a national level as of July 1975, give or take whatever period of time the extensions are? DR. PAHL: The only strict requirement which the Administration has placed on this is that RMP's may not in- cur obligations beyond June 30, 1975. Thus contracts can't-@be written beyond that le'gth of tineand there comes a moni- n toring and surveillance issue at hand, which is the same one that any prorrre,m faceei@which we faced last year as prorre,.m is scheduled to terminate and how do you handle on-going activitiE!.@ We are.'ac'u-iv'ely involved, as I think I mentioned yes- terday, in trying to get the-Aelministration to put forth what a federal responsibility is. I don't believe we have the exact answer., but in general, over the coming monthso all.'Of us who are involved in headquarters operations truly believe that there will be mechanisms developed and guidelines developed that moneys would be able to be spent for the purposes intended and there will be continuation of monitoring and surveillance, We certainly don't wish to see contracts entered into and then June 30, 1975, everything terminated again. And we are trying to plan since we have a whole year ahead, the answer isn't here, but that is the clear intent and interest. Novi, with the business of applications aside, I believe, I know Dr. Teschan has one or two points which he would like to bring to the committee's attention and perhaps there are other matters of business before we adjourn, Mr. Barrows. 56 MR. BARROEIS: I just wanted to take one moment to say on behalf of ray fellow reviewers how much we admire the strength and dedication that staff has exhibited during this extremely trying time. You have got.a great bunch of people here,.compe- tent. They are straight arrows and whom you can believe. We hope you can keep your team together. (Applause) DR. PAHL: Well, on behalf of the staff, it is a pLee- sure to hear it. I already know it, but I do thank you very much. There is nothing we can do without the staff that we have. They have been extremely loyal under circumstances whict you recognize as difficult and which Indeed has been the case. So thank you very much. That is one of the rewards for being one of the faceless.,nameless bureaucrats, able to accept that on behalf of the staff. Dr. Teschano would you like to bring up the points wti@ you mentioned to me before the meeting for committee discussior? DR. TESCHAN: Sure. Ken Barrows has just preempted point one. I look at Ken for having said it the way it needed tc be said. The matters that I think we might consider as a orouf) C:) 57 are som recorlmendatior-is to Council, generally three. One we have already dealt with I thinks and might go without sayin7, but I hope that Dick and others who were preparing these things might also focus again on the point that we do need to reiter- ate that we would recommend strongly to Council the whole facts in the matter of thooe;policies that your RMP'B has used throu,7,t the years and I refer specifically to the August 30th issuance of Council for 1972, that they be very sure that as a matter of fact each region is in compliance with that policy before funds are allocated, That is to say, that that can accommodate a firm contingency. I think that is not only correct from everything I have said, but it is also a fairness and human -- Its' essential intrinsic Integrity in the program be maintained so that all of the regions are dealt with thesame way, I am very sensitive to Dr. Hess' concerns on that and I think we did a good job. I was satisfied and learned a lot in Listening to how we dealt with that particular issue. This is raised much in that same viewpoint. Now, the other two things I happened to have written out I am going to leave copies with Herb here in just a minut-e and they are issues that also came up in our discussions in bo@t panels undoubtedly, but I want to put the following little comment; that is, while I am sensitive and meet at every hand in all of the discussions I have the kind of thing Dr. Schorti3 pointed out we just seem to have this year left, Lord knows the coordinators have been faded with that in their regions and in discussions with 'one with the other. But the critical issue is I think we have to look at the context of the era in which we Live and not .zimply be caught in what appears to be the near-term procmrammic potential or efforts. We are bold on every side that RNP Is going to finisi so our job here is to give i't a decent burial and to utiLize funds as well as we can, and allow slippages because Lord knows there are slippages. I would take the-other view that we are not dealing with the next year. We are dealingin history up to this time, and we are dealing with many years to come in which this particular year is one of several turning points. I don't think thi-ols a one turning point; I think It Is one of several turning points. Therefore, I feel if we are going to conduct our business responsively we need to conduct it with a clear recognition that what we do now and the integrity with which we do it must necessarily influence to an unknown, but to some degree what happens hereafter. So that when we have considered some of the regions and when we sounded a little bit pedantic, perhaps, in citinm the August 1972 policy, that you have got to have these ele- ments and there has to be regional support within the region and a good imave in a region for a region to warrant continual o 59 et cetera. We have done that with the notion that If the RMP in a region is goin@ to be useful for something hereafter, then it needs to have that quality of Image or quality of function in a region that is going to be worth something to build around as the foLlow-on version, following RMP, et cetera, It is terribly lmportant.that the issues and profes- sionalism and quality which are so clear in the superior region application particularly, be the hallmark in contrast to all th( other alternatives of which there are plenty. So it is really on that basis that I feel the Council now has a particularly vital turn in the road, a fork n the road to confront. Either the Council can take w@ t to me seems to be a defeatist attitude in saying, welL. we are only here to occupy space and to while away the hours, or the CoLAncil can contribute in some small measure to tidying up the situation. And in strengthening the regions for the transition period. Therefore, it Is with that in mind that there are two statements in perhaps somewhat-- well, there are two state- ments that in my view this group might consider for recom- mencation to the Council for a formal policy statement to the region. In other words, it is not just a recommendation to the Council, but recommendation Council take these and issue them as- guidance policy to the regions in the country for their bO implementation and guidance, it is a two-step operation. First of these has'to do with getting ready for the next phase. And a statement which says that might.read some- thing like this: "In view of legislative developments now underway fo-Y further evolution of RMP, In association with the CHP and HIIL-Burton programs, in the interests of national health planning, Council ':encourages RMP's to develop brganiza-- tional readiness, structural changes, and any remaining regional relationships which'ar-e appropriate to lead,, participate in and accommodate the anticipated new opera- tina- structures and requirements. The purpose of this C> orientation is to preserve for the new formats within the states and regions the capabilities and voluntary .cooperative relationships which the-RMP experience has created." That sounds a little platitude an 'a-Itruistic, but I think if we have organizational structural arrangements in a regions that defeats the region's capabilities in getting ready, being an appropriate participant in the new development, that those organizational changes should be made. The second recommendation for Council policy and the request to HEA, as I understand, might read like this -- and It has really to do with CHP's -- it might read like this: '@ihile recognizing legislative mandate and DRMP regulations regarding R14P-CHP relationships Council requests that the national CHP leadership transmit to areawide CHP (b) agencies nationally the mandate for fully reciprocal relationships with RMP'S, especially in calling upon RMP assistance for professional and technical input Into ongoing CHP plans development; and In the interests of fairness and full reciprocity Council furthermore agrees and instructs ad hoc R@IP review committee and staff to set aside any influence o negative CHP comments upon an RMP application unless the commenting CHP(B) agency has provided the R14P with, one., the criteria and a description of the (b) agency review- and-corament process and two, a List of the (b) agency objectives and priorities upon which at least a part of the RMP response should be focused." DR. P.AHL: -All right, thank you. DR. TESCH.AN: I would like to move the acceptance of these, or for any purpose, DR. PAHL: Thank you. Perhaps the committee would like to discuss the first of these in order, or have the first one reread. 7 What is the committoe's am sorry in a sense that so many of our members had to departs because I think these issues are Important ones, and I am also sorry Mr. Rubel is not hero for the closing session, because I believe that he 62 would have been quite impressed to see. the kind of activities and discussions that have ensued over this period, And also, of course, with this theme which is something which we are all,concerned with, the' reciprocity of action. But beyond tt iat, what is your desire in this matter? Woub you care to discuss these? Dr. Scherlis, you look like you are about to make a comment. DR. SCHERLIS': Sort of digesting what you said. I anree completely with every word you said and woul(i be pleased to second. My big concern is really what effect this would have -As all the people at this table have, I have been on site visits where you have contact with various (b) agencies and-(a) agencies, and I must confess that in terms of profes- sionalism and in terms of objectives and goals, I hav e to say one can point to rare instances, at least in the space that I have been able to visit, where (b)'agencies or (a) agencies have been relatively effective My big concern is really what will happen to all of the work which RMP has accomplished? I remember when RMP's first started, trying to describe what-regional proper.@venture,iqas.. These words were meaningless to me. I 'think in terms of their effectiveness, the various projects that wecarried out only speak to a small 63 part of the accomplishment. I strongly support both statements. I just question what will happen to them. Perhaps you can alert us to what you view as the probability as to what will emerge from CHP and RNP and Hill-Burton at this time. I am more impressed with both the planning and pro- fessionalism and the discernment of need by RMP as compared to the (b) agencies and (a) agencies, even those communities where they are supposedly relatively affected. I think- there Is an obvious need for these groups worV,Ing, together. This Is a problem not only of logistics, but day to day political strategy and this is where I have a real concern I am more impressed with the relatively objectivity of RMP's as compared to the relative lack of objectivity of (a) and (b) agencies. The sorts of letters that you read and request after request from the regions in terms of the review process of (b) agencies and (a) agencies, we like that. But we don't like this one. We like that one; that one is just great. And you come away with you just don't know what the basis for the evaluations are and this is where I would strongly support both of your statements. I would just -hope that they would do more than just 64 go to the CounciL. I viould hope that whoever sets policy, whoever that mioht be$ whatever dark room, that somewhere this would -glimmer in and possibly shed some light on what could be a very complicated prot-,ess, DR. PAHL: Well, without responding completely to your question, because again I don't think that I can speak i from a nonbiased point, of view, I do believe that. from our ob- servation of what It is we do in RMP, relative to what I see happening In CHP'S, I must say that as the program director here, I subscribe to everything you have just said. We are trying to work more closely in headquarters relationship. We have been Interested in trying to, as you know strengthen the CHP individual agenci es, planning pro cesses. I honestly don't know 6ut of my personal experience of one program that has actually tried to do more to cooperate with and support another program than RMP has throuah the years, the comprehensive health planning effort. And it is only recently that the headquarters staff have been interacting and that is as a result of this fune- tional reorganization that is going on. I think the statement is a very good statement. I would be pleased to give it maximum impact within the agency because I know there are many Individuals who feel the same as you have expressed that there is an imbalance hero in the way this is being discussed, looked at. -And to the extent thau the Council would like to adopt this as a recommendation,, whether they would or not this is what we are trying to do as staff. But I think it could have some greater force if it w e a Council recor@noation. Perhaps I shouldn't say anything about the first one since we haven't discussed that point.. So from staff point of view, we would not be adverse by any ,neans to @akin such a recommendation to Council, and I believe a recommendation by them to the -Administrator and he@,.d. quarters staff, and perhaps higher throu-h the Department C) could, again, bring to the attention of peo-ple the feeling and sense not only of this group, but of the entire organization tiat is connected with the RMP program. This has been said over and over again. This is ano- ther way of saying it. But it is a good t-ime to say this because it is important. -And I believe that it could have so,,n() impact and it should be said, because I think what is being stated is true. So ,aany times the RMP's have tried to assist and get the advice of the local agencies and in fact have found that there is very little relative to the kind of streng-il and there are many good reasons for this. It is not deraean- ing the CHP (b) agencies by any means; there are a good many reasons. But all of this should go toward providing a better future for all of us. I thinkwe are looking to the future, not trying to 66 investigate what happened in the past. DR. SCHERLIS: Point of information. As you made the motion, where did you wish this to be transmitted to Council or to Council and to appropriate agencies? DR. P-AHL: It can be both. DR. SCHERLIS: It can be both? DR. TESCH-AN: I felt the first step, formal Council recommendation, that then becomes instruction to staff to get the message at the staff level here. But I am more concerned-- well@ equally concerned at this point that the regions have strong Council backing and I recall clearly,when Council made a statement, I don't think Council ever understood how impressive that was to coordinators, regional advisory groups et cetera. This Council pronouncement of encouragement, et cetei,e more or less I expect from region to regions but generally had a lot to do with how we shaped our sort of concept of how we should be conducting business. So while intangible, I feel it has a terrifically important potential impact and particularly now. So a' strong move to Council, and if Council then says it, it becomes encumbent on staff as executors to some extent@ on Council advice, that that would carry forward in the further deliberations. DR. PAII L: I presume this recommendation would be a 67 recommendation by Council to the Assistant Secretary of Health, because obviously our Council has no responsibility over comprehensive health planning but through the Assistant Secretary of Health. A'nd there could be coordination of efforts within the bureaucracy* Sister Ann. SISTER JOSEPHINE: Yes, I too would Like to support this type of acuiviuy., And, you know, in reflecting back on the program and in reflecting on something that came to me in a note from one of the members here, you knows the Regional Medical Program has had something of a Year of Camelot; you know, we return to Camelot. And the knights retUrnod and the armies of the Middle East shing up -- (laughter) but, you know, it is so gratifying to me to see we still dream dreams and that the innovative program, you know, still has that spark. I believe that we canltsay a thing too often, because one day someone might just listen ancT hear it is what we are saying, I would think it is very important that gets wide- circulation. DR. PAHL: Mrs. Wyckoff. NRS. WYCKOFF: I agree wholeheartedly with that statement. I hope somethin@ can be done so this conversation and 68 this resolution we have will be passed along in such a way that it will not be lost through the decentralization process that seems to be contemplated, I was very sad to hear you all act as though you were goino- to be gone very sood. DR. P-All L: Not everyone, just-- NRS. WYCKOFF: It just means HEW regionalization, which is very aii'f'eren t from our R14P re'gionalization, I hope that;something can be put in the mill so that this will not be lost in the dreadful shook of pulling the center magic apart. DR. PAHL: I hope so. I don't think this is the point, to get into that, But it.is quite possible that under new legislation be that enactment of extension legislation for the individual programs or health resources planninc, legislation, unless there is quit- a different environment I suspect the Department will probably make the determination that this program should be decentral- ized in the regional offices and our staff-fully understand this, And this would mean basically very few individLats would actually go to regional offices, because they would firfcl satisfying work locally which most of them would prefer to do, so that would mean positions would go to regional offices. Our staff would be reduced in members by that amount and functions would be shifted to regional office and the 69 character of the program I would have to say I think would probably suffer In the initial stages at leasto because there would be many new faces handling RMP responsibilities in the regional offices. 14RS. WYCKOFF: Will decisions be made at the region- aL level for many of these things we are now making? DR. PAHL: Yest that is what@i s contemplated. ICS. WYCKOFF: That is the thing, DR. PAHL: We will have National Advisory Council, that will come back. IM. WYCKOFF: If that is kept in the legislation. DR. PAHL: There are so many if8. But the armo ur is not completely rusty. Dr. Hess. DR. HESS: I fully support these two recommendations in principle and would just like to suggest a possibility of an amendment to each of them. The first one, as I thought about that, 1 wondered if I were an RNP coordinator, how would I respond to such a general directive when you don't know what it is you should.be shaping up for or moving toward. Ana so the amendment would be that if Council apla-o.v@E this, that it be part of Council and/or staff responsibility t) keep the regions informed so that they will know, you know, be In receipt of advice as to how best to prepare for this kin@i of transition. 70 Novi, I know that is very hard to do and the time and the nature of the advice would be very important to not keep things in a turmoil on the basis of chanaing signals, But,nevertheless, just to say that without any further guidanceaq, to what that means may not be as helpful as we would like to have it be. So that if you can get the sense of that really further specification of that-- DR. PAH L: appreciate that, Actually I have a problem with perhaps two words in here, which I think bear directly on your point. If I may read the statement again, Paul, and then show what my concern is, because this is a concern that Is shared.by many of us in headquarters in order to try to be most helpful to the groups we are serving. The statement reads: "In view of legislative developments now underway for further evolution of RMP, in association with the CHP and HiLL-Burton programs, in the interests of national health planning, Council encourages RMP's to develop organizational readiness"-- And here is where I would like to delete "structural changes." and any remaining regional relationships which are appropriate to lead, participate in and accommodate the anticipated newoperatinrr structures and requirements. The purpose of this orientation is to preserve for the new formats within the states and regions the capabilities and voluntary cooperative relationships which the RNP experience has created." The reason that I personally, although we will take your recommendation to what it is you wish-to say to Council, 'I have problems with having the Council encoura,@"e but the reason the rerlons to develop structural changes at this point is be- cause that is one of the primary uncertainties and is still th subject o de ate. Organizational readiness capability,,closer cementing CD of relationships in the regions is all to the' good. But both CHP leadership and we and Dr. MargoLis and Dr, Endicott in our various capacities know, both privately in the office ancl,pub- licly@ have urged groups not to jump the gun into what'they presume-to be the proper organizational structure, So I have a feeling in reading these words about organizational structural changes, this would encourage some people to move perhaps faster than would be for their own good. In terms of keeping regions informe(; I think we all again, in our separate capacities, and with what knowledge we have, are trying to do this. Some groups are moving ahead. For example, there has been a change of grantee in Northern New England just recently, but It is not as a result Y2 of the last few months' thinking, They have been doing this now for a couple of years and thinking about it. It has had a lot of thought. Others are trying to anticipate the exact outcom of the Legislation and are trying to be there when It happens, and both Mr. Rubel and I and, as I say, our administrative superiors indeed are cautious people against undue haste. That was my only concern, Paul, with your statement. But I don't want to impose my concern on what may be the committee's wish to transmit. .So I would like to have that point of view further explored, If you will. DR. TESCHAN: I would like certainly to respond to that. Sometimes I think this kind of discussion, or at least issue we are now talkinT about, is a liattle bit,, oh,, a little -- it is distinctly unsubstantial. It is ethereal, First of all, practicalities are nobody is really going to go to a lot of trouble in any RMP to make largo changes into something they know not what. There are, after all, some pretty practical figures and they have a limited amount of staff time for such busy worlc. Moreover, I also think it is important for us to rem(@.m ber that instructions or encouragement or guidance coming down from Council 9,nd staff.is also paralleled by a good deal of 73 information transfer between regions through the coordinator organizations in HS-1. Moreover', all the coordinators are perfectly capable of reading the legislation and reading the repo-rts on the committee hearings, et cetera,'and so are members of the RAG and some of them do. So there are several routes. I don't think either .having it the way it is or not having i-t the way it is is real- ly going to_have any enormous impact. I sympathizeviith this an d if you feel more com- fortable and if the Council would then be able to be saved, all kinds of minutes of backing and filling on such an unsub- stantia.1 point, I would be perfectly happy with the notion for of getting oriented toward, making preparations for or sort rather.than to actually put on paper and get signed in som crucial way a specific thing we know not what at the present time. Critical issue, it is almost code, It is hard for me to say what needed to be said. DR. PAHL: ExcelLent statemen4 really is. DR. TESCHAN: But what is meant by structural changes specifically is the not ion there are structures in some of the regions, either the way staff is put together or t he way RAG Is built, or the way the relationships actually work between them,, or who the grantee is or how that whole business works, under the August 1972 policy, which effectively for many of 714 the prime movers of health affairs in states and regions vitia.-,( the'significance and possible impacts of RMP. If RMP and RAG finds that Is the case, that particu- lar corner of that statement was to open the possibility that if there are serious -- if any part of that is a serious ball end chain to the image and function of an R14P.in:.,' a,region, thiE; would be a good time to get that out and to get it settled and to move on its own merits, quite aside from what the fut.ure might be. DR. PAHL: Sure. DR. TESCH-AN: It is to encourage those changes, t@C y up.the ship, plug the leaks, get the thing ready for sea. Because we are going to be in highe4 heavier water for awhile than we are right now. So I think we really ought to get underway with It. DR. PAHL: To be specific-- DR. SCHERLIS: He would like to have his statement launched, I gather. (Laughter) DR. PAHL: To be specific, we have had a spate of inquiries in &olng into not-for-profit grantee structures. C> That is all we have been trying to pull the bit of brake on for their good as well as for what we believe to be sensible reasons, but certainly not internal rearrangements, and the kind of structural changes you are talking about. 75 DR. SCHERLIS: You would not be adverse to removing those administrative covers -- what are you talking about? What kind of structural DR. PAHL: We are heavily involved with it., more people are involved. It is their insistent demand we are here to serve. DR. TESCHAN: My feeling on that, if in the region thereis serious problem with a structural situation -- DR. PAHL: Specific. DR. TESCHAN: -- let Lis,say, for example,, a nonprofit corporation mode would be bet,ter for very good independent region reasons: then let's go now for a nonprofit-- for its intrinsic merits in th@ regions not for something down the road. DR. PAHL: That we are doing. I think we have a sen3E and I think it is a very excellent statement. DR. TESCHAN: We can take those words out if that part of It is understood. DR. PAHL: Is there further CiscQssion? Dr. Hess. DR. HESS.- Yes, On the second statement, again I wa- looking at the practical application of that, and if your Intent was that that would be applied in this next upcoming two reviews, that being the case, I don't know that there would be information to be able to apply that criterion to 76 knowi4aether or not each (b).agency had submitted its criteria and priorities, and so on,,to the RMP'S. I don't see how that is implenientable during the next-- these immediate two reviews -Ln the next month or so. DR. TESC@N: I don't think that should bother our deliberations, I think it is the resolve of our group and if Council backs It,, which is really the question, then I think we can deal with CHP comments on somewhat more official grounds within the RMP review process than we felt really comfortable Li doing up to now. I have been concerned, but reassured by the last two days. I was.concerned when I came here that we would be worry- ing. We would be unduly influenced by insubstantial grounds f:>: negative comments from CHP. We have not been to. What this will do as I see it, the purpose is really not to influence us so much if we already agreed to It, but I would hope it would strengthen Herb's hands and that of his staff in conducting their business with their counter- parts in these new a.6 hoc subcommittees. And will also influ- ente the regions In how.they deal in the future,, regions at thL.9 point, seeing'the ascendancy of CHP, may be increasingly en- dowed as to how to seek I think this puts it on a simple professional basis. DR. HESS: My only concern is for these immediate applications. DR. TESCHAN: WouLdn't i-i-orry about it. DR. HESS: it seems,to me a little bit too tight to apply. MR. BARRUIS: Without respect to the recommendations the fact of the matter is our panel, panel B, concluded that all we can do would be to exai-aine the r-,MP's share in this rela- tionship. DR. PAHL: Surely. MR. BARRUIS: They had done what they were supposed to doo We had no way of measuring the other-- I think that is a factor in the recommendation to the Council involved. DR. PAHL: Yes. This picture certainly will be presented to them, so that they can view this In its proper perspective. DR. HEUSTIS: I would like to call for question on the motion, as editorially amendedo without having you read It again, DR. PAHL: Without reading, all those in favor of th(@ two motions, the first one as amended,, please signify by saying .11 aye. DR. PAHL: Opposed? (No response.) DR. PAHL: Motion is carried andrecommendations will be transmitted to Council. DR. SCHERLIS: May I state it be carried unanimously, 7b just for mntter-of recorCi DR. PAH L: Carried unanimously, You might be Interested in hearing the arthritis groi status report. I am happy to report they probably feel if they were panel C, they have the tougher problem. They are working very hard. Dr, Roger @son from Nebraska is serving as chair- man of that group. Welhave a very fine ad hoc group with Y3 applications requesting I believe it is$16 million with $4.2 m, lion earmarked for the support of these pilot arthritis center3 The group yesterday spent the better part of the day discussing -- this is a brand new concept.,not only program, for us: but brand new concept as to what are the elements whici should be in a center and how to give vari ous weighting to these elements. (Discussion off the record.) DR. PAHL: The arthritis panel is struggling with $16 million in requests, with $4 million available and they spent the better part of yesterday trying to develop the element and important features of centers, And they scanned through the applications in a descriptive fashion, one by one, and about last night the time that you broke up I believe they did also and came back to work at eight o'clock this morning an( are working today, possibly tonight, and possibly into tomorro@i morning. Because they feel it is also important not just to 79 spend @4.2 million as you feel it is not just to distribute funds, impounded funds, but to get something more out of thiso,to get more than the sum of the parts. I am very pl eased to say they are very much aware of it, and therefore I have a request to make of our own staff tc stay around this afternoon and do their post-committee work in the officeso because some of the people that you have seen departing in the-last half hour or so here are being requested to go into that room and tell that ad hoc Arthritis Committee the capabilities of the region for managing what is a special arthritis program. So we are not trying to divorce this activity out of the RMP activity, I told Dr. Mason we couldn't be holding the Arthritis Committee at a better time for having a full survey of 53 regions with as much Information as we can accommodate right now* So I thought you would like that status report and soimhow those difficult decisions will be made. Before closing, I would like to reiterate Mr. Barrow@l, comment s f rom my ow n pol n t of vi ew, and I know f rom Bob s poi ni-I of view on our own staff efforts. We have been carrying two activities of arthritis an([ RMP applications simultaneously. You do recognize, because you have been with us for a much longer period of time, the bO kind of' work and quality of work that has come out and you have duly acknowledged tha.t for-which I am very appreciative. The Arthritis Committee prior to the end of yes- terday @,lso expressed itsappreciation for the quality of the staff work, clone by agroup who I had never seen, who had never seen ar hri is applica ion, had to read textbooks, listen to experts,, do homework, and do staff work for that committee. .I think my very real personal impression &s I come away from thes e two and three days of meetings is that I have never been associated with a program that has risen really to the need that they have, and done so in such a high qualit@ fashion. Many of them have been holding two jobs over the mortt of May in older to get these materials for you, and so I' personally thank them. I know both Bob and Mr, Peterson, chairinc, the other paneL@ do, and it is very nice to record that and I am sure the Council will appreciate all of the work. But in addition to that, I would also like to thank you. It has been a very difficult job on your part to have been away from the many changes that have taken place and then to come back and with the kind of short time and the extremely heavy workload, to do the kind of decision making that you have. I think this morning's session has been particularly gratifying to me to be able to discuss some of these points, 8 I and issueso because we do feel a real respoiisibil@, ty not for winding down a program, but for moving into title new phase and maintaining the strength and Improving it where we can. So again we thank you very much and we will look forward to seeing, hopefully, all of you in July, and wish you well on your return trips. Meeting is adjourned. Thank you; ,(Whereupon, at 12:00 o'clock, tibon, the meeting was adjourned.)