B&B ltqFoRmikriom & lm^=E MAkm^=EMENT 200 @logaz M=Ituz-tn SOUL"Amn Upplaca M,&SRLJBO$tC, 0404otV"odo Z0747Z 0 USA6 24@l 10 E001 745 NATIONAL ADVISORY COUNCIL TRANSCRIPT June 13, 1974 W Li D - NATIONKL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS BOARD MEETING 9:00 A. M. Conference Room G-11 Parklawn Building Rockville, Maryland Thur@day June 13, 1974 WHD-151 C,O N T E N T S SPEAKEP/MOTION EEGIN MOTION PASSED FAILED Doctor PAHL 3 Doctor MARGULIES 5 Doctor GREENE 19 Discussion 26 Mr. RUBEL 29 Discussion 41 'Dr. GOODMAN (Item 6) 51 Discussion 55 Mr.-REARDON 63 Discussion 71 Doctor PAHL (Report) 75 Doctor GRAMLICH. 8,5 MOTION (Minutes) 98 98 98 MOTION (Mrs. MARS) 118 119 119 ARTHRITIS 128 130 131 -do- 136 136 144 -do- 145 148 153 -do- 154 155 CALIFORNIA 169 173 174. GEORGIA 175 179 181 LOUISIANA 182 189 190- .PUERTO RICO 191 196 196 MISSISSIPPI 197 209 209 NORTH CAROLINA 2-15 221 221 SOUTH DAKOTA 2,22 223 224 INTER-MOUNTAIN 225 243 244 244 246 SOUTH CAROLINA 147 250 258 Substitute 261 261 273 1 3 @qD/en, P R 0 C E E D I N G S DR. PAHL: Good morning. I would like to call the meeting of the Ilational Advisory Council in Regional medical Programs to order, and I would first like to welcome to the council table the new members of the council. Since we started a few minutes late and there has@ some socializing, I have a suspicion that most of the new members at least recognize and have perhaps said Hello to thei current members of the council. Since we will be here for two days, why, we will make every opportunity to.get you acquainted with each other, but we do welcome the new members; and we are very happy to see the standbys here with us. In that connection I would like to say that we are particularly happy to have three members on the council who represent reappointments. We feel very fortunate in having Dr. Kamerof, who cannot be with us at this meeting but who did attend the orientation meeting last month,, llr. Sewell Milliken and Dr. Ben Watkins are ]lack with us, and we are very pleased with that. I would like to.comment, for everyone in the room, that this session of the council meeting is the open session. We are delighted to see a number of visitors with us. We wonot take the opportunity to identify you, although we do know who some of you are; and I would expect thatt at the appropriate time, before we go into our closed session, 4 possibly very late morning or early afternoon, we will make an opportunity for any member here of the public to make whatever statement or comment he feels to be appropriate. And if that does occur, I would ask the individual who wishes to make a statement to please identify himself for the record. And if he is representing an organization, if he would please identify that organization or unit. I wo uld like to introduce to you the people here at- the head table. I must say this is a pleasure, We have been known to use smaller and smaller tables over the past years. So it's very nice to see a full complement down this end and also up here. I think that most of you, or a good many of you of course, know Dr. Harold Margulies in the center here, who is'the Deputy Director of the Health Resources Administration, and will be making a presentation to you very shortly. Again, most of you are familiar with the fact that Dr. Margulies was a director o f a program for several years before moving into this position as Deputy Administrator. On my immediate left is Dr. John Greene, who is the Director of the Bureau of Health Resources Development in which bureau we are located; and Dr. Greene has taken some tima this morning out of a very busy health manpower legislation activity that is going on currently to comment, and I think 5 we will have'some comments along those lines that will be interesting to you. On Dr. Margulies' left is Mr. Gene Rubel, who not only is the Acting Director of a comprehensive health planning program but also has the responsibility for coordinating internally and in conjunction with what we believe to be the new legislative directions, the Health Resources Planning activity of the Bureau, and is Associate Director fo Health Resources Planning in Dr. Greene's Bureau of Health Resources Development. Mr. Chambliss, on the far end of the table here, am sure you all have met. I know that, as the Deputy Director of the Division of Re' ional I-ledical Programs. And 9 Mr. Ken Baum, on my right, through whose good offices , and Mrs. Eva Handel at the entry table, this meeting has been made possible, for all of the mechanics and materials that have been coming to you. Now, with those introductions out of the way, I would just indicate that we have a very heavy schedule for this particular council meeting, and in order not to unduly delay the other activities that these gentlemen have before them today, I will hold off my report to you and first ask if Dr. Margulies would give us some perspective from the point of view of the agency on matters that I know will be of interest to you. Harold. DR. IIARGULIES: There are two or three general subjects I would like to raise with you, without taking up too much of your time, but all I think relevant to the deliberations of this council, and I think to the general level of interest which you have in-the health affairs of the nation. When this council last met, a number of you were not present, so let me briefly sketch once more the organize-' tion of the Health Resources Administration, so you know what is in it, and what it represents in terms of federal health activities. In fact, it's probably useful to those of you who were here before, because there has been enough reorganization to be confusing even to those who are very close to it. The Health Resources Administration was created with the belief,, which I think is basically valid, that there is aneed to address the issues of resources and the use of those resources in the delivery of health resources in a rather special and.unified-way. This council and the activities which it supports are very pertinent to those concepts. It is noticeable in fact, as you look at the introduction of major legislation and particularly as you follow the introduction of legisla- tion national health insuri@-ice'and the debates on it, that 7 they tend to divide into two major portions: one of them representing the processes of reimbursement; and the other representing the processes by which reimbursement leads to effective and acceptable services. And, in fact, one of the legislative proposals, the Kennedy-Ilills bill, goes far enough as to identify these as separate responsibilities, placing the payment mechanisms in one type or form of structure, and the health resources in'another. So that I think the philosophy and the dynamics are fairly convincing, that if one is to set about paying for! services as a general national responsibility, one must also set about the business of finding out whether those payments lead to effective services available to all of a reasonable quality in a manner which is economical efficient and able to contain costs. That is -- the latter part is where IIRA is. Ilow, it would be exaggerating things to suggest that HRA represents all of the-capacity in the country to deal with: health resources. On the-contrary,, the capacity for meeting health needs in this country remains essentially ovenqhelningl a private function of the private delivery system,, and there is even,- intent that it remain there for whatever period of time is necessary to have the job done, hopefully forever. There is, however, in IIRA, Ilealth Resources Administ!ra- tion a collection of activities.which is sensitive, critic.@-, and, in the course of events, could make most of the difference between a different and an excellent result as we continue with our efforts to utilize federal resources for general benefit. If you look at the structure, you will find that the three bureaus contained in any particular order you wish to take, the resources or the capacities necessary to develop data statistics or, in a broad sense, the intelligence required to understand what is going on and what needs to be done in the health delivery system, and this is largely in the national Center for Ilealth Statistics. It contains a significant part of the federal effort and in some ways the leading edge of health services research which will assist the country in understanding ho@i better to do what it is attempting to do in the delivery of medical care. This includes economic analyses questions, the quality of medical care, the development of new kinds of systems, better types of communication and recording, et cetera. And in the third bureau, which is represented by the; other people at the table here, those activities which have to do with the supportive institutions which produce the health manpower and with other.aspects of effective uses of health manpower. 9 es which have to do with the federal Those activiti interest in developing health care facilities., hospitals.- nursing homes, and so forth, and the planning elements which are probably, along with the intelligence elements,, th- key contributions which IIRA can make to a better understanding. and a better delivery,of health services, now, and even more so in the future, with national health insurance. We have been trying to integrate these activities so they represent a common kind of a function. It is not difficult for me as an individual having coming from the RMP to move strongly in the direction of an effective planning activity and to recognize the relationship between what this council does and effective planning. I was pleased not long ago, because this kind of recognition comes rarely, when someone gave me a certificate which is based upon the contributions I had made to compre- hensive health planning. I have been trying to do that since I came to RMP. The first statement I made when I came to Regional Medical Programs was that this program, RMP, must be dependent upon an effective planning process which, at that time and at the present time, is comprehensive health planning. That confused people initially, but I think in the course of time most people became dedicated to the concept that there is an interrelationship beti-ieen the tv7o; but that lo I a planless system is an undesirable system,, and that therefore effective planning was critical to effective use of always limited resources. So HRA is moving along, but still facing some real problems. Its problems are those which are familiar and which seem agonizing to visitors to Washington, they seem agonizing to those of us who live here as well, when we get to mid-June and we have no legislation which authorizes us to stay in business and no appropriations to pay for us if we did stay in business. That's- not really too remarkable. It merely has to do with the pressures of other events in Congress and in the Administration. And there will be legislation which will extend those in a variety of ways, and there will be appropriations which'will probably come in varying periods of time, some of them soon enough, some later than they ought to. Of most interest to us h'ere is what may appear in the form of new legislation which extends the activities of RMP,, CHP,, flill-Burton, and-so forth and I,will comment on that in just a moment. Ile will almost certainly have, without much difficulty, an extension of the legislation for what was the National Center for Ilealth Services Research and Development, now it's the Bureau of Ilealth Service Research. That will,, I think, pass without much difficulty or delay. The same thiAg is true for the National Center for Health Statistics. My own personal concern, and I think the concern of the agency in this particular context is to give very high priority to the development of an enhanced and growing capacity in the National Center for Health Statistics, @o develop an intelligent base, a source of knowledge and information, and analytical capacity which we do not have in this country anywhere at any level, and to do it in such a way that it's useful at the national level, at the State level, at the urban, the inter-urban level. So that when people attempt to get something done, they know what their base is that they begin from, where they are going and what needs to be done. This is clearly top-level priority in this agency, along with an effective companion planning activity, to make sense. The passage of the legislation, therefore, for thOSE two activities is important, but the sense of Congress which goes into whatever they propose is even more important. Ilealth manpower legislation is highly uncertain at the presen time. The bills which have been introduced are variable. The Adriinistration's.bill moves in one direction, the lIouse bill in another, and the Senate bill in a third. There are points of agreement, and many points of 12 great disagreement. What will happen with what has been known as the Ifill-Burto,.'l legislation is also uncertain, because the Adrqinistration-does not propose to extend the traditional Ifill-Burton program. The Senate and the Ilouse have other versions, and that will make a considerable amount of difference. As I am sure you know, a planning bill which is to extend, as I indicated a moment ago,, CIIP,, Ilill-Burton, IUIIP and some specific activities like area health education centers far has not yet been reported out; but it has gone enough so that one has reason to feel secure in what it will produce, what kind of a bill we will have. And I think there is reasonable optimism now about the passage of new legislation in the fairly near future. In any case, Mr. Rubel and his staff and the staffs of HRA have been working assiduously and I think rather remarkably to anticipate the passage of new legislation;, have actually been looking at multi-ple possibilities and so are prepared to move in whatever direction Congress and the. succeeding regulations require they move. I think the transition will be much less difficult because of that kind of effort, than it might have been had we merely waited for the events to catch up with us. I think vihat we shall probably see in the new planning legislation is a combination of the Administration's 13 bill and the Rogers bill and rather than using those names.; let me tell you essentially what would be contained in the activities. There will be legislation to support within States I a planning activity which is essentially designed around a combination of public and private interests which act together, the planning agents will be private, non-profit in character, and they will depend heavily upon an interrelationship between what needs to be done and the capacity of the market and the professional and public leadership to respond to sensible planning activities There willo in all likelihood, be an associated agency established at the State level to coordinate, review, approve those kinds of plans and to make sure that there is a balance in those kinds of authorities. There will, in all likelihood be a separation between planning functions and regulatory functions,, but the y will be -- certainly the regulatory functions will remain the State's responsibility, like those that are associated with Section 1122 of the Social Security Act, which is concerned with the construction of new facilities, the addition of new beds,, et cetera; the kind of certificate-of-need legislation. That kind of planning authority would be an improvement on an extension of comprehensive health nianning. It would contain a modest amount, I suspect, of developmental 14 funds in order to make things happen which might not otherwise happen, but primarily as a kind of stimulating or coordinating or catalyzing activity, rather than having a large outfloVT of funds to dov7hat appears to be desirable at the local level. If this is done so that the legislation makes good sense and is manageable, and if it represents, as many of us suspect it does, a modification in planning understanding t at a time when people have begun to appreciate more fully the importance of planning, in fact the essential character of it, and with the high likelihood that we will have nat ional health insurance in the fairly near future, we will have a combination of better legislation, strong federal support,, better State understanding and a new zeal, I believe, to put some rationality into the system. I can imagine no way in which any kind of legisla- tion will prove effective if the decision makers of the country have not reached the conclusion that it is better to do it sensibly than by guess and by chance; and I think we probably have reached that point, although not consistently throughout the country. T@ere it has been inconsistent, I am sure that Mr. Rubel will help to make it more consistent. That will be an Interesting activity. This council now, in reference to that kind of legislation, has a heavy kind of concern, and I would like 15 to make a particular pointin reminding you of what this counc,. is and does and should do. It's a rather remarkable arrangement. The National Advisory Council was created by Congress, saying to the nation and to you members of this council that you are to be depended upon to carry out the will of Congress in ways which combine your understanding of the legislation, your concern of the Public welfaret and your various kinds of professional skills. This council is unusual in that it is given more authority for the approval of g@ant awards than are councils generally in this government. You are told that you will be given some applica- tions which have been carefully reviewed and which have been put in a form of presentation which you can understand, and understand quite readily. And that you will make recommendations to the Administration, without which grant awards cannot be made, but which do not necessarily represent the amount of the award that will be made. In other words, you have a veto power and you have an approval power. If,, howevere the approvals which you provide exceed the funds that are available, quite clearly there are adjustments which have to be made. The forms in which you make your actions, the comments 16 which you make represent the distillation of public interest representing Congressional action and your final move in the direction of public welfare. It is a heavy responsibility, and one which requires your greatest possible attention. It becomes especially difficult how* because you are encumbered by a rather chaotic history of IUI.Pls, certainly in the last eighteen months. You enter into-it in what are administratively and ethically perilous times# so that you need to pay close attention to what you consider to be right and wrong. And you are also looking at a set of activities determined.by a court order which at the same time move in the direction, we are certain, of new legislation before-many of these activities are well launched. You will therefore have to express some judgment about how these activities need best be carried out. It seems highly likely that before the funds which you are going to be looking have been provided for Rr4P'S, and certainly before they have been formally expended, there will have been new legislation, new considerations, and new activities facing those organizations which receive these grant awards. As a consequence, you must keep open the likelihood that there Still be a new set of pressures on institutions here 17 and elsewhere throughout the country which may determine the best possible use of these funds. I think these ideas need to be set well aside zrom your basic concern, fror-.i the fact that you are operating under a congressional Act, which has not been changed, under court orders which are quite clear, and under a public purpo.sq which you are the best individuals available to determine. Now, finally, let me say in that regard, and asa special note again, taking advantage of an opportunity to be personalized, that those of you who have served on the council before, and many who have not, are fully aware of the tremendous workload which is involved in bringing to you grant applications which have been reviewed, given the best possible consideration to be put in form for you to act upon. In past years this was done by a large staff, and it was hard work. This time it was done by a much smaller staff over a shorter period of time under extraordinary difficulties. It is customary to give thanks to a staff which has operated in these circumstances. This is no customary comment. This has been an unbelievable undertaking by tho-- who are dedicated and who care and who have done what they have done because they believe it needs to be done. They have done it in circumstances where their e.-,.istciice is threatened, where their jobs are unsure, wher e 18 their future is unknown, and where they have been given.dam little encouragement from any source at any level. And this goes, certainly, probably several times over for Dr. Pahl, and down on through the entire organization, It has been remarkable. There is no kind of award, there is no kind of statement, there is no measure that I know of that can fully recognize what difficult times these haVe been.. I remain astonished that people will'work that hard, with that much vigor and that much honesty, in the circumstances in which they have been placed. And I am very, very grateful to them, and I am sure you will be before you are through with this council. Nowt if there are any questions that I can answer, after what has been about as long as I-expected to talk, I will be glad to respond. DR. PAIIL: On behalf of the staff and myself, Ilarold, thank you very much for those comments. I think we do indeed appreciate that commendation. Are there any points -- I believe you can stay a few minutes longer, but perhaps you had better nab Dr. Margulies while you have him. If you need anything else from that agency point of view on the tenth floor. I should add here I am glad Dr. Margulies charged 1.1r. Rubel with bringing consistency into government, and we 19 will be working toward that end, too. Well, perhaps we might move on to the next speaker,, and I am particularly delighted to bring to you Dr. Greene, to discuss again matters of importance to the council from the Bureau of Health Resources Development. RMP has been located now in three agencies since its history. It started off with the 14ational Institutes of Health as a home; it was then moved to the Health Services and Ilental Health Administration, and when that was organized last July 1, we moved him to the lIealth Resources Administra- tion. Since last July we have been in two bureaus of the three bureaus of that aaency, and I am particularly delighted to state that we are presently under formal consideration for inclusion in only one bureau, and it is Dr. Greene's Bureau of Health Resources Development. DR. GREE@TE: Thank you very much, Herb. I do appreciate the opportunity to meet with the council. It's my first opportunity to do so. In looking at the agenda, I have just noticed that it's a morning filled with remarks, and I guess tl-Lat's kind of a remarkable morning if you turn it around the other way. I will keep mine very brief, so you can get on with the rather full agenda that you have. And I know, since it is scheduled on here, that you 20 might be working on Saturday, I am sure that you are anxious to keep things short at this end so you can riavbe get out of here, so you don't have to,worl-, through the weekend. So I will try to help you in that regard. It is a pleasure to follow Dr. Margulies, and to echo some of the comments that he made very briefly about the adverse situation under which the staff has been working here in relation to the Regional Medical Programs and in relation to all of Health Resources planning. And the outstanding dedication and work they have done, as I am sure you will recognize as you work through this council session. But I will let it go at that and add an "amen" to what Dr. Ilargulies has said; and I an, very grateful to them, .as I an sure you will be, too. I would also like to congratulate you as the council and the Regional liedical Programs in general, for the work that has been done and the-work that vou are doing, and the perseverance of the people who have been dedicated tol Regional Medical Programs through some rather adverse and difficult tines. The fact that you're continuing to carry out the purposes that Dr. Margulies outlined on Regional Medical Programs in the interest of the public and public concern, and congratulate you for it, and I want to express my 21 appreciation to you and to the Regional liedical Prograrrsin general for that effort. Dr. Pahl mentioned that the Regional Medical Programs now scheduled to formally move into the Bureau of Health Resources Development, and there is a formal request to make that formal, although we have been operating this way since last February; that there is a request now to make this A formal transfer. We have not a formal, official reply to that, making it official, but it is expected to come at an early date. 14ow,,.Dr. Margulies indicated that the Bureau of Health Resources Development, into which Regional Medical Programs is moving, included the comprehensive health plannind,- Ifill-Burton program, as well as the old Bureau of Health Manpower Education, which has, as its legislative base, four pieces of manpower legislation: the Comprehensive Health Manpower Training Act of 1971; the Nurse Training Act; the Allied Health Act; and the Act that covers Public Health. Now, all of these pieces of legislation affecting manpower expire at the end of this month, and we have been .quite busy on the Hill and within the Department, trying to help fashion a new piece of manpower legislation. I thought I might just comment on that for a few minutes, because I know Regional Medical Programs have been quite busy and active in the manpower area, and I thougl-4- ,I, you. 22 would be interested a little bit,as to what the current scenel is and what might come out of it; and I will try to make this brief. But, as you probably know, the Congress is -- the Congress and the Department and the general area of manpower and education are more concerned now about the type and location and utilization of manpower than the total numbers of manpower as had occupied the scene most since the Health Professions Educational Assistance Act started in 1973. The focus up until this time has been largely on shortages and trying to increase output, of number of health professions of all types. As we move into considering what is needed over the next three years or the next legislative cycle, the emphasis has shifted away from a focus on continuing massive increases in output and has shifted to greater focus on other problems problems more of location of people, geographic location of people to deliver services; the types of people; the specialty distribution question; the problem within medicine. The greater emphasis on trying to increase productivity of health workers of all types, with great concern I about the continuing qualifications of people after they are out in the marketplace, and out delivering services. Now,, as to how this all will come out is anyonets guess at the moment, but let me just run down some of the 23 provisions,, some of the kinds of things that are being given attention a little more specificity than what I've just mentioned. I-Ihile there is less emphasis on continuing to stimulate increased output, there'is general interest and concern about the stability of the institutions that do provide manpower. This interest and concern is expressed in different ways, in different pieces of legislation those of the Administration,those of ilembers of Congress. As you are probably aware,, the Institute of Medicine study which recommended a certain level of capitation.. The Congress has been quite interested in that study, and the recomenda- tions made by it, and are likely to latch onto those recommendations in their committees. That is, in my estima- tion. Ilo@.;ever,, the Depart,,nant is reconiending lower levels of capitation to maintain stability of the institutions than was recommended by the Institute of Medicine study. But in all likelihood there will be continued levels of support for the health professions' institutions. 1401.1,, it also -- there also is a lot of interest in exacting something in return for that front-end money or basic support. As a minimum it seems that there will come out of this a requirement that the institutions at least maintain the current output or current enrollment of matters 2 4 of people within their school. I think that's a riinimum.. Now, it goes on from there in some of the proposals in Congress to require such things as having to be eligible for such capitation support that all students within the school would either agree to serve in the national Ilealtli Center service corps or serve in some shortage area or shortage profession within the country. This is in the Kennedy bill, and this is an extreme at one end as to the kinds of requirements that mav be placed or could be placed on capitation support. It ist I think, unlikely that what will come out of Congress will be to that extreme. I do think the Congress will ask for more assurance, that the institutions will be addressing the problems of geographic distribution and the problems of specialty distribution than they have in the past. The question of specialty distribution, the major concern is the growing shortage of persons to deliver primary-care services,, and I think-we can expect out of the legislation much more emphasis on getting involved and the whole area of graduate medical education to assure that there is a turnaround and a drift towards an increased output of persons prepared, specially prepared to deliver primary care. @d, again, the proposals to Congress vary in the strength of the leverage that they would apply to accomplish this. Some are quite direct, and others are more indirect. 25 I think it's very likely that we would have some- thing fairly strong in this area, because of the general concern, I mention again the question of geographic distribution and what is likely to come out there. We have been, I thinkf essentially unsuccessful so far in materially affecting the geographic distribution or- health resources -- of manpower resources, and because of the very general and ser,)ous concern over this issue, I think we may see fairly strong language and fairly.strong provisions in here on this issue. And this becomes an area of particular concern to you, because you've been trying to do something about this in the past. It becomes an area of concern to the whole Ifealth Resources Planning,, because this is an area that must be addressed to the development and distribution of manpower to serve the country in the future. There will be greater emphasis on productivity and greater emphasis on the development of health professionals who can work together and, in a team concept, utilizing para- professionals to their maximum to deliver the most quality services at the least cost. The committee in the lIouse is novi in the process of rqarking up a committee bill this week. There will be Senate hearings, or they are scheduled now to be held on June 24th. 13ecause hearinas have not been held in the flouse 26 to this date, it's highly-unlikelv that we will have anything to work with, a new bi'll to work with by the end of this fiscal year. It will probably be a few months yet, in my estimation,, before we're ready to implement the new manpower, the new piece of manpower legislation. One other element in the new legislation is likeIly to be, instead of having the four pieces of authority, we are likely to end-up with two instead of four. And one would be- for nursing, preparation of nurses; and the other would cover all of the other health professions, most likely it will come out this way. I will stop here now. DR. PAHL: Thank you, John. Perhaps you'd be responsive to questions. Dr. Haber? DR. HABER: Dr. Greene, in the move towards greater provision of primary care it seems to me there are a couple of ontions on a national basis, and I wonder if you could enlighten us as to what congressional thinking, as to which option seems to be most in their thinking, or are they equally concerned with all of them? I am tallting now about the move to increase the scope and number of allied health professionals, particularly surrogates for primary care, in the nurse clinicians, pl-.ysici,---i 4 assistants, or are they more Lkely to try to remal:e medical education so that more physicians go into primary care? or are all of these options equally significant? DR. GREENE: The primary attention in the discussion so far in the Congress has been more towards redirecting graduate medical education. Hoiiever, there is interest on the other option that you talked about as well, and likely the legislation will provide authority to pursue both. And in my opinion both need to be pursued, and I thin]-,.there i-iill be legislative authority that will enable us to do that. But most of the discussion has centered around attempts to shift graduate medical education or primary-care specialists. DR. PAIIL: Are there other questions or comments by the council? Dr. Jane@.7ay? DR. JAITEI-IAY: Do you think, Dr. Greene, that two bills will come out of the House Subcommittee oii Health, or just one? DR. GREENE: I-Ihen it first started, I thought there would be only one. The reason I say it now, and I had not said it at first, I think there might be two is because the Roy provisions have now been picked up in the Kennedy bill and will have to be talzen seriously no-.,,,, I 2 8 And Mr. Rogers nay hold out and not want that in his bill that he participates in, and other members of the committee may decide that they want to follow more down the line of the Roy provision, and may come out with two bills. It s hard to tell yet, since they are just starting. They may come out wi th two instead of one. DR. PAIIL: Dr. Janeway, would you care to give your assessment? DR. JANEWAY: No. DR. GREENE: I'm just reaching out for that one at the moment. They are going to make -- they are making an i attempt right nowt they are in session today to try to compromise and try to come to one bill. But I do think the Roy provisions have to be taken I seriously, more so than a lot of people thought earlier, at the beginning. DR. PAIIL: Are there further comments or discussions? If not, I thank you, John, and hope you can stay as long as possible, or drop in if your schedule permits. I would like now -- we have not forgotten coffee, for those of you who didn't find a cafeteria earlier this morning; but I think we might wait for that until we have had the remarks by Mr. Rubel, because I really do feel that this package of presentations will give you a perspective 29 that's most important to have at this particular time. And I am very pleased to have llr. Rubel be able to come this morning, again it's a very busy schedule, so the fact that he's here today is somewhat fortunate for us because Mr. Rubel is intimately involved in the development.of the Administration's point of view of the new legislation; andt as Dr. Greene indicated, since about January or February of this year the P14P program has been working closely with flr. Rubel, who does have responsibilities for coordinating internally our several activities under CIIP, RMP and the Ilealth Facilities Program. So, without further comment, Gene, will you take whatever time you feel you need to bring all the information to us. MR. RUBEL: I will try not to be too remarkable. First of all, in the context of manpower debate,, I would suggest to you an article appearing in this t,7eeklg National Journal Reports on Manpooier Legislation. I think it is remarkably putp the-presentation of the problems as well as the politics, and.there are a lot of politics. I will try to be a little more down to dealing with the nitty-gritty things. I met with some of you back in February, and I am not sure I knew then what I was getting into; but we did discuss at that time what the Departrqent's plans were for 30 spending RMP funds. This was almost immediately after the court had entered its order on February 7, Dr. Pahl, in his letter to you did summarize the situation as it existed early last week. It keeps changing. You may remember that back in February we discussed the possibility or, as we saw it, the fact that Section 910 of the Public Health Service Act was in the law and still is in the law, and I believe I indicated that the Department was very much interested in utilizing some part of the money that had been appropriated under Section 910, which is an authority we can use to do some things outside the scope of the individual regional medical programs The Department, through its representatives in the Justice Department, did propose an amendment to the court order, and we have gone throuah.several months of motions and counter-motions, and all kinds of gyrations, including a lot .of time spent answering questions and the like. We have reached a settlement with the plaintiffs in the case, the national Association of Regional 14edical Programs, under which we would be able to use up to file million dollars of Fiscal 173 funds under Section 910. 1,7e have made it clear that those funds will not be used to support any.kind of State activities in attempting to plan for future regulatory rules. Some of you have been very much involved in this, ar-,c. 31 I won't take'a lot of time to go through this. One thing is very clear, that the Department wants to put this litigation -)eh-ind us. Vle are interested in administering the laws that we have today as well as anticipating what is coming in the future, and we don't see any great benefit in continuing to litigate here. As I understand it, the judge signed an order on Friday, in which he requested each of several Regional Medical Programs to comment on the settlement, and each of the W4P's has, I believe, thirty days to do that, to the extent that there is no comment, the final order will be entered; to the extent that there are, he hfts indicated that he will deal with them very expeditiousl y So that I would hope sometime in the middle of Julyl this litigation will finally be.concluded. In terms of legislation, you have heard a summary of i-ihat's happening. The Ilouse Subcommittee did spend Monday,' Tuesday, and yesterda,, morning del5ating the questions of health planning, as they call it. They are kind of I following an unusual pattern. The purpose of those two and a half days of discussion was to provide guidance to the staf in order for them to produce a clean bill, a new bill. The Subcommittee then intends to take that bill and actually mark it up, go through it page by page and line by line. But I think, after the two and a half days,, the 32 Subcommittee did give pretty much of an idea, understanding 0-1 what it wants; and I don't think the mark-up that is going to have to come next will take a great deal of time. It -is remarkable that we had so many members of the Subcommittee spend so much time. it is obvious that they; are concerned and interested; both sides, from both political! parties, young and old alike. I would have to say in very general terms that the kind of thing you're talking -- we are talking about, is best embodied in H. R. 13995, which was introduced by most of the members of the Subcommittee in general, to look at all the pieces of legislation. They are very similar, and I don't believe we heard a great deal in those two and a half days that is different from what was in those bills, with perhaps one exception. It appears to me, and I never said it explicitly, that the Subcommittee is interested in including a large relatively large -- pot of money at the State level for the State government to somehow continue on, or with some kind of variation itys very difficult to know exactly what -- of the facility construction program, the Hill-Burton program. That was not in any of the bills recently proposed in any case. Exactly what it's going to say and how it's going to work, I don't know. It beats me how that staff is,going to wr-'@te some- thing; but they always manage. In general terms, we have what we call a health systems agency at the local level, non-profit, private organizations, and the committee was very firm on that, with,, by and large, a larger geographic area or population base than we have in CIIP agencies today. They cane down firmly. on a minimum figure of 500,000 people, but which could be waived by the Secretary down to 200,000 if he-found it to be- necessary or desirable. This agency would be responsible for doing the planning for its area. It would also have some relatively small pot of money available for developmental activities. There would be at the State level a State planning council whose members would largely come from representatives of the local health systems agencies, with additional members appointed by the Governor, and it would be that council that would approve the individual plans proposed by the local agencies, as well as using State governmental support,, filling in the chunks and making sure that a highway doesn't stop on this county line and here and start on the next one two miles away. The State would be responsible for whatever kind of regulatory features are going to be in the bill, and the're was an awful lot of discussion of what anybody means by regulation. As you may or may not know, there are so@-e 3 4 members of the subcornittee that are very adamantly against i regulation, although everybody agrees that something like 1122's view of capital expenditure, certification of need is important and desirable. The staff was instructed to draft provisions that would allow, that would provide federal support on an optional basis with -- for any State that wanted to get into rate review activities,, and that was further than a lot of people anticipated they would go. You may know that Mr. Roy is very much in favor of a mandatory review kind of role, but he was very happy with an option, which of course is what the Administration propose also. I would be delighted to respond to any questions either here or privately about features of the bill. The liouse Committee has prepared a very,, very exhaustive analysis of the various proposals that are pendil.lj.. Unfortunately, it's either in -- being printed right now or on its way some place or other. I am trying to get copies 'For, you, either today or tomorrow. I am not sure that I am going to be successful. In any case, if you want copies, you can write to the Committee on Interstate and Foreign Commerce, and I am sure that they will supply one for you. Unfortunately, it does not have a number,, except a little thing.on the side here, and I don't know what that means, but, for what it's worth, 32-84. This is Pn analysis of all the bills that are currently pending before the Congress. The Senate has not taken any formal action yet, although it's my understanding that this is a Commit tee Print about to descend from some place. In terms of a timetable, much like the manpower legislation, som e optimists hope we will have legislation enacted in August. of course, there are a lot of other things going on', on the IIill. There is an election to be run in November. And we just don't know. A week ago I was a lot more pessimistic than I am today. I think the action that the Subcommittee has taken has moved a very, very long wav down the road, and the staff is talking about working on Saturdays and Sundays; so that's the kind of pressure they're under from the members. Enough about the status of legislation. Let me turn to problems of transition -- to what, we know not yet. Ile made a decision back in January, that we talked about in February -- we have three separate divisions i operating here: one for comprehensive health planning; one for H4-11-nurton; and one for P@IP, and that is going to 36 continue until Congress enacts new legislation. That has caused some problems, but I think, by and large, we have been able to continue operating as well as trying to work together anticipating what is coming in the future. We have had a series of grouses working together,, trying to plan for the future. We have had a group working on possible organizations and another group trying to plan on-, how we go about the area designation process; how do you take into account sub State planning districts,, PSROareas, current:, CIIP patterns,, standard metropolitan statistical areas and the like. Vle are in the process of producing a series of maps for every State in the country, and you see lots of lines intersecting. How you make some kind of rational health planning -areas out of them is a major challenge. I think we have come a long way toward understanding hotel that process might work. And many other groups, as we anticipate what is coming. Just as soon as-legislation is enacted,, we intend to involve in our planning process representatives from all sorts of organizations, professional organizations at the national level, representatives from each of the components that are going to be into this scene. Ile don't feel, however, that now is really the time 37 to do thatp with all the uncertainties as to what may come. I would like to make one plea. late have had a fair amount of quibbling, fighting, figuring out whose turf is iihose, over the years. I thin]-. that is one of the key problems that the Congress is attempting to deal with. Ile have had a difficult process even during this review cycle in how CHP agencies relate to P24P's. Frankly, from my point of viewt I am surprised how well things are going and how much cooperation and coordination there really is. I don't believe it is to anybody's advantage to continue and perpetuate those kinds of arguments and discussions at this point. 1-7e've tried to get along as best we can. It's obvious that if progress were to continue both programs as they currently exist,, I think we would have to do a lot of work, because I'm not satisfied with the relationships we have today. But I don't believe that Congress is going to continue the current lawl.so let's devote our energies to how we can improve things in the future, rather than arguing about how poorly they've been done in the past. In terms of a transition, we have worked very hard to insure that the agencies, organizations that are funded now will be funded through some transition period. Ile don't 38 believe it's'to anybody's benefit to stop everything now and then try to start it all over again next year. Most RMP's will be funded through Fiscal '75. The 314(b) agencies, the local agencies, will be funded through April of Fiscal 175. We have a very real and big problem with the State agencies. Mr. Milliken works for one, where, as it was described in a hearing, "we fall off a cliff on July 1.11 I think we can figure out a way to handle that with some I help in the Congress, as part of the continuing resolution, In any case, we have tried very hard to find -- to insure that there be some kind of orderly transition. I think that's something that everybody agrees is very necessa ry. The question has come up, and you are going to have to face,, during these next few days, to what extent there are organizations that perhaps should not be continued during that transition. And that's something you are going to have.to deal with on a case-by-case basis.-- I would just like to give you my observation. That I think you have to decide is something marginal, you know, is it doubtful. We've been carrying something along for a long time in a certain kind of situation, and if that's the conclusion you come to, my recommendation would be to let' s keep going. Why do we want to change things now when a vear frori 39 now we are going t o have a very natural kind of resolution. On the other hand, to the extent of organizations that have no capacity, that are not doing things useful in their communities, I think we have an obligation and you have an obligation to conclude that federal funds will be wasted on that kind of situation, and to act accordingly. Finally, I have tried to make a plea for many months, and that is that we don't want to see ma .or organizational - 3 changes made at this point in time. I have told -- perhaps some of you have heard this story, but last October Congressman Roy spoke before the American Association of Comprehensive Health Planners and talked about his concept of a Regional Health Authority, and that evening someone came over to me and said,, "TIhere do I submit my application?" And I tried to say, 1-7ell, that's just one Concrress- mants idea. Ile had people at that point that were prepared to make all kinds of changes in orde'r' to accommodate an idea that someone had proposed. Well, if that had happened, they would be in ve ry -sad shape today because all of the concepts and ieleas that Congressman Roy advanced have not been accepted, and I think the same thing is true today. We still don't know how this is going to work out. And I don't believe it's in anybody's interest to 4 0 actually make changes. On the other hand, all of us are planning and trying to come up with contingency plans; and that is very proper. But let's wait until the Congress acts before vie make any kind of permanent changes, because we may have to make them all over again. Finally, I would like to echo Dr. Margulies' point,- you are going to have some very difficult decisions to make here. I think we have to hit the hard issues hard. There is no point in trying to gloss over things. I think the staff has done a very good job, and the review committees have done a very good job of raising the problems. And they are going to be difficult to deal with in some cases, I suggest that we try to make difficult decisions. 'This is a time that many people are questioning whether the government can function at alf-, let alone function effectively. Let's see if we can demonstrate that as servants of the people, really, that we can,do the job e f fe cti ve ly. DR. P2UIL: Thank you very much, Mr. Rubel. Are there questions or comments by the council on any of the matters touched upon, or just perhaps glossed over,, in view of the vast amount of activity that's going on at 41 this time that you would like a little further clarification or amplifaction? Dr. Merrill? DR. MERRILL: I have realized, from what you and previous speakers have said, that no one has the answer; but what I would like is perhaps an educated,guess,, so that I can respond to people who ask me such questions. One which I hear most frequently is the following:- Let's assune the transition period works and all the contingency plans are fine. If funding for luIP is continued, in what form, unde@ what authority will that be? f@IR. RUBEL: I can see about a 99.5 percent probability that funding for JU4P, as such, will not be continued. I spent two and a half days before the Subcoruiittee and I did not hear a single member even once raise that as an option. It is conceivable that it will be done on the Floor of either lIouse, or yet within the-Subcommittee or Comittees;@ but they clearly are looking to set up a new kind of arrangement. Now, on the other hand, it is also very clear that they intend to build on the structures and the people that we have working in the CIIP agencies and in the RIIP agencies. I can see many RIIP'S, as we know them today, with or without changes, becoming very much a part, becoming health systems 42 agencies in many places, and that kind of thing. I don't know if that answers it. DR. 14ARGULIES: John, can I pick up that five- tenths percent, because you and I are physicians and understand about that. There is, up to the present time, no planning bill 'i which has even reached the IIouse, and we have seen many misfalls in legislation. On that five-tenths percent basest what could happen is a matter of technical process. It is a continuing resolution and an extension of legislation in its present form. Ile will certainly enter the:, next fiscal year in some of our programs on that kind of a basis, and you realize -- well',, I'm not so sure you realize, !r a lot of people don't seem to realize, even at high levels in@ government -- that when there is a continuing resolution, which says that the appropriations will continue into the next fiscal vear, that also extends the authorizations to which those appropriations are attached. So that possibility could exist. That would immediately be negated with the passage of legislation which would replace the Rt.IP,, CIIP, flill-Burton,, et cetera,, with a ne@-,, kind of planning legislation. MR. RUBEL: Or b' passage of an appropriations y Act. I Ilo@\r, to be very candid, Dr. Ilargulies and I were a@ 4 3 an Appropriations Subcommittee hearing not long ago, we were told by -- we were asked, the Administration was asked: You're proposing to eliminate the MIP program and then we were told not to hold our breath. So, you know, there are a lot of things that are I possible, but I can report to you that in two and a half days.i before, you know, eight of the eleven members of the liouse Subcom,nittee there was not one mention made of continuing any of the current programs in their current form. DR. 14ERRILL: I think the thing that's been confusing to many people, including nlrself,, is the kind of thing that you state, and what I've heard repeatedly,, and that is: Let's keeo things going the way they are. And,, on the other hand, the statement that theress 99.5 percent chance that things will not be kept going the way they are. I realize there's probably no other alternative, and I certainly don't have one. But -- I think you have defined those difficulties. DR. GREE'-TE: With the councils permission and because of the importance of the topic, I would like to recognize Dr. Donald Sparkman in the audience, who is the chairman of the national steering committee of RriP Coordinators, who would like to make a statement on this point. 7 4 4 DR.-SPARI,',IW4: Clearly,, Doctor, Mr. Rubel is n ch u closer to the legislative situation, and Dr. Margulies, than I an; but from other sources from which I learn information about this, it is not quite 99.5 percent sure that there will be no IU-IP. There is a consideration of this, and I would remind you that as of a year ago the Administration said there is going to be no RRIP as of June 1973, and the Administration officials, Mr. Rubel and others, clearly said that. And beyond that time P14P probably will not survive, and the Secretarv and others took steps to make it as difficult as possible to survive. We are still in business. I think there is at least a reasonable possibility that some modification of the existing PIIP concept and function will continue, and I find it difficult to accept his statement. DR. 14ARCULIES: John, may I pick up on that, because I think our point is an y important one. Partly because it provides us the opportunity to separate the rather restricted federal view of affairs fr%JILL the much more mobile and flexible view at State and local levels. Let me go back to what I said earlier to this council. You are operating under existing legislation, and there is not much reason for you to speculate about what new 45 legislation 'Will do. You are also operating under a court order, and it's quite clear what Congress intended, and Congress has not changed its mind. In fact, this IUIP will continue, as does any other program, unless Congress specifically rescinds Title which is the basis for the legislation. But beyond that these comments are, in a sense, specious or irrelevant, at least; because if there is to be,- with or without legislation, an effective amalgamation of the programs we have under discussion, it will be because of the efforts of people at State and local levels. The wisest thing that we could do with this council activity is to encourage and support the Rt4P's to function in the most material manner possible, and the wisest thing they could do is to combine with their CIIP colleagues and other appropriate agencies in the State to talk with one another now about how better to function at the State level, regardless of what ha@pens. I don't think there is the slightest doubt about the need for that to occur, whether the legislation is passed or whether it stays the same. In fact, if the States could deal effectively with the elements within their boundaries, which we are dealing with at a distance, they could do whatever is proposed in upcoming legislation without any new legislation being passer-., 46 The fact that they have found that difficult to do has encouraged Congress and the Administration to alter the forms in which they function; but the best thincT we could hope for is for people to act together in a common interest within the State, knowing more about what's goin 9 on than anyone else does. And I would add to that, Don, and I know you would agrees because we talked about this before, that the time has-;, passed for us to concentrate too heavily on two programs which happen to have been passed about the same time and have somewhat similar interests. V?hen we are talking about planning for a State in the field of health that involves a wide range of institutions and-activities in which the CHP represents the major, and from the federal point of view, the critical planning force; but it has to deal with maternal and child health services, mental health services,, hospitals, nursing homes, payment Mechanisms, the whole gamut, not just two programs. And-if we can get a little further toward that understanding, I think, regardless of the legislation, we are going to be better off. DR. GREENE: Thank you. Are there other comments? DR. 1172UUIOCK: I would like to echo that feeling, because of being involved in that situation of getting the States involved, to accept @.;hat's going on as a cooperative effort, and I think that some effort has been made in that direction in some areas to do that very thing. Because ywu have got six different roads or detours going off doing different things. And I heartily echo that situation, regardless of what happens to PJIP,, because there are things in here that are salvagable and worthwhile to be used in the future. And if we can combine these with the efforts that the State level is trying to do, I think we are going to be better off. MR. MILLIKEN: To this end, I think there is a need right now. A good demonstration of the need for pulling this together, to have an effective activity. I don't know about the rest of the country, but Region 5 and Region 3, IIEI@7 regional offices,, are in a kind of a problem of working with States who are tending to pull back even,,-thing to within their State boundaries. Now, between Indiana, Kentucky and Ohio, there has been, for a long time, a very significant cooperative program where both PI.IP and CIIP are in interstate health trade regional activities. And there is an urgent meeting called next week in Louisville to bring regional offices, States and local areas together to see what can be done to continue this kind of cooperation. Nov7,, the IIUD program and other kinds of government planning are not unrelated to this, and it does begin to put 4 8 us into,, you ]-,now,, if we can'thave a strong front here, in view of the need fok keeping these @-ind of trade area voluntary coordinated kinds of programs, then I think we f ace a very serious problem. DR. IIARGULIES: I think one of the reasons that there was and is a heavy commitment to the private,,' non-pifofit approach to thing is because it does lessen the likelihood I that the artifacts of political boundaries will be too constricting. On the other hand, you've been on this council long enough to know that at the State' level that artifact is a very po,..7erful one. After all, funds flow into States on a geopolitical basis around those boundaries. But I feel reasonably heartened, as I would think you would, over the very successes that you pointed to, like that tri-State arrangement with both IZZIP and CIIP that you've had down there, that peoiole have managed. And I think it's much more likely from our experience that that coulA be worked out between the people there than for us to do anything certainly dictatorial at this end. It just won't come out that way at all well. MR. RU13EL: I can report to you that the Subcommittee very firmly stated it is in favor of interstate areas,, and for that reason decided not to allow the Governors to make the final decisions an area designations. Certainly the Administration bill would advocate 49 interstate areas. It's a very-complicated kind of problem, we tried to get into it, there are some 17 interstate CIIP areas today, but there are 37 interstate Standard Metropolitai Statistical areas. Now, some of them we have irTterstate, some of them we don't. The political processes are quite apart from any kind of knowledge about the medical trad@- area and what service patterns are, are very difficu-J!-t to deal with. But it was something that the Subcommi.ttee did deal with very explicitly, and you may know that Senator Kennedy's bill provides for areas wholly within @e boundaries of States. So we will see how it comes aut. DR. IIILLIKEN: One more quiak question. The net., legislation on the relation of PSRO,. was that left in? MR. RUBEL: It was brought up before the Subcommittee. The question was asked: Well, should there be the same boundaries or not, and I think there pretty general feeling that some of the P-SRO boundaries don't make much sense. And the Subcomittee finally decided to tell the staff,to use some vague language about the need to coordinate with various kinds of things, like PSRO boundaries, sub- State planning districts, and the lilze-@, without any mandate that you must follow. DR. PAIIL: Thank you, G@e. 50 Are there any otLier comments or points to be made by the council? If not, I would like to thank you for the remarks and say that llr. Rubel has indicated he will be here for the better part of the day, and there will be various points,.I--, am sure, you may wish to interact with him as we come to other topics. Now, looking at the clock, I would like to ask your indulgence for one more thing, because I see that Dr. Goodman has come into the room, and I know from earlier conversation that his schedule is very tight today,, and therefore I would like, before we break for coffee, to have his few remarks to you, because he will have to leave for another meeting. I would like to go to Item 6 on our agenda and introduce to you Dr. Alvin I. Goodman, who is the Prog.LC"ti Coordinator for the End Stage Renal Disease Program for the Bureau of Quality Assurance of our sister aqencv, the Self Health Services Administration. They too are located in the Parklawn Building with us. We are, as you know, as an Pd4P program,heavil,, involved in a kidney program, and those of you who have been on the council have witnessed the development and establish- ment of dialysis and transplantation centers as a result of the activities of luIP's. 5 1 Because of the Social Securi-@i7 ariendments of l-q72 anci tne-pavnents that are noi7 possible to Y--,atie4-its uno..2r lios eamendments for tro-,:itrent i,it@ll dialysis and transiolanta- tion, the End Stage Ronal Disease Proqram has )Dccn Dr. Goodrtan is the director and his asl-.cd, ovl-r rc-ccnt for the assistance of Rec .Tior.al !Iedical ProcTrEms in hclpi-nc, to inplcirent in the in-L -L-ial stages the activities which required to establish and administer. So I would like to have him address you and stay for whatever length of time is possible,- but I know it will be brief, because he has, as I say, another meeting. I think it's important that you hear the message from Dr. Goodman. DR. GOOD14AI4: Thank you, Dr. Pahl. 14embers of the council, as most of @,ou, I ar, sure, are well aware, in OctolDer 1972 as part of Public Law 92-GO3,! Section 299(i) addressing chronic renal disease as considered to constitute a disability,, was IS-assed by the Congress. This legislation went into effect as of July lst, 1973; as part of the mandate of the legislation, there @:erc. various requirorents, including a specific one for riedical review boards. As@yet these medical review boards have not been constituted nor established in the field. During the inter,---, period, an interim policy @.,as enunciated in june of 197'j. Since then, in April of tl@'. -ir, 52 1974, final policies for the End Stage Renal Disp-,isc, of Medicare were announced by the Secretarl7. For those the do not have copies of those final policies, I am leaving serve on the desl-, here. These final -,3olic4-s reflect the inniit of ranv professional organizations associated with d-@livery of End Stage Renal Disease Care, including professional iii-,:;tit from the Pj4P office. The major aspects and issues to address at this moment is tlie fact that there will be finally what IU.IP's have been working on for years, a development of a network approach for End Stage Renal Disease Programs, in that the broad array of professional skills and facilities required for the treatment of such patients requires such a coordination of effort and that facilities will be organized in regions on such a network approach. And perhaps at the apex of the netqork will rest a medical review board to screen'-appropriateness of care,'to screen quality of care, and to assist with other organizations in facility planning. lqe are in and in-between phase. This was quite discerniblewhen I arrived. On the one hand, those local bodies, PJIP's %.!ho have had expertise in these are.Ds and plans which, to a lessor or areatcr degree, were being implemented often, unfortunately, to a lesser deQree -- their 5 3 was threatened as was discuss(-,d +--@lis r,,iorni-ng. On tl-i@ other hand, the groul-)s were quite, and still are, in their -i.iifanc@,, so i@l, )-)ccc@-@ a questio.'l c-@- how does one, as rapidly as possible-, esta,')li@,",l these nct,,.,or'rzs, establiF-,Ii these medical !,,,-),7,-ds @,7itho-,it going the loiig,laborious history t:-iat t"l,-It are establishing PSRO'S. In discussions with members of PI-IP heret it became clear tlaat it might be possible, i-7itl-i the willingness 11 and cooperative approach of various M.IP offices across the country that we can initiate the program and implement the program through these PI-T offices, and see what develops in terms of what their future history is, and what the PSPO history is in trying to phase in appropriately this program and then phase in eventually perhaps, with PSRO. This program will be.adriinistered through the Regional Ilealtli Administrator's office. It is readily recognize that the RIIA's andtl-ieir offices n'either have the e.%pericncc nor the on-board c.-nertise from the Professional Point of view and from the plannin.g point of view tocasily implement this program, yet virtually everv community across the countz)- every region across the country still has an existing P"4'P office in which there resi0e@, such e>:r)ertise ind much plannin(T in terms ol' renal disease. So %,That is hopeC. -@c)r, i,-i essence, is that var4- C) 5 4 Government agencies and authorities in the given regic,,-is will be able to associate themselves together, some londiiia forth the organizational c;truc+.-tire, the federal structurL-, the regional health offices and o-Lj'-.Iers aivirig their e.,@pertise in rei.---.1 p rc in g to@@c-.rd the raniCi implementation of the net@.7or"@ concc-@l-;t, the affiliation of institutions in @i given region, and a development of local medical review boards appropriately to work out in the initia@ difficult phases this type of planning and this type of logistical and administrative support. Tliis,is sort of quite compatible with the statement made within the program of trying to use that type of programming and expertise still inherent in @IP in facilitating new programs and new plans as they come about. Ile hope that we are able to develop this cooperative approach. I still have plenty of time for questions here. DR. PAIIL.- Okay, thank you. I think we are interested in bringing this message to you at this time, because this is one of the instances in which the existing organizations kno-,@n as PiIIpls are finding themselves to be of great importance to another administra- tion's program,, in fact another agency's program, and we are delighted to be cooperative and helpful with Dr. Goodman. And tJiere will be official materials developed and sent out to all PJIP's shortl,,,, about ti-iis-. liu4-- +--here has been a lot 04, 5 7 We estimate that percent o--F all renal dial-,,si-@ currently nerforr.@,cd in this co=trv is perforr,.cd by the Vc-i4-er-ans -\f2 have an e -cf ect4 ve arrangement unde.- which a small. L-u@- growing nuipber of non- 'in our veterans cai-, ')e di,)!@ize-11. eLcility t7nrc)u-Th sha-r-,i-ic@ arrangement. Tli erationale for this being that we will dialyze non-veterans in exchange for comparable services for veterans by whatever hospital or medical school we have such a sharing agreement with. This@is entirely consonant with our basic mission of providing care'for veterans. This effective arrangement of limiting unnecessary duplicat ion of scarce resources is threatened by a legalistic argument as to whether or not the Social Security Administra- tion can reimburse third-party payers, who in turn reimburse the medical schools with which we have these sharing arrangements. T@io issues are at stake. One is the legalistic argument I mentioned, whi.ch I hope can be r-eso'Lved; I feel fairly confident.it can be. The othe@, which I an almost certain can b6 resolved, is the question of ncdical standardization. And we are in entire symnathy and support with Dr. C-,oodman's contention that one standard for renal dialysis should prevail throughout 5 13 the couti"-ry, since most of the people in the VA -- I'm i talking about physician providers no-@.; -- who are involved in this are peonle who are emploved on a part-tine basis with the %7A and they are also emnloyed at the schools of medicine and so forth. So we feel reasonably sure that this 'viill. be consonant our Fission. Sil,ectness and lighk-- will prevail DR. 'Thank you very much,, Dr. flaber. Dr. Merrill, did you have any questions or col@'Liii@,i L@ r! 7uiyone.,,on the council? Mr. Milliken. MR. MILLII.'.EN: Well, I think I have spent more time in the last month on the renal thing, the renal problems than I have time for, or intended to. Because of the lack of coordinated concept at the present time, of who is already in the act and who is getting! into it, and what the process, indeed, is. It's n,@i, understanding ih our region, for example,, that the Social Secur-@ty office in Chicago receives applications for renal proarams. They then forward these applications to the A agencies, who then submits it to the B agencies for review and comment. Ilo@-7. at the present tine, in Ohio there was a very good active proara.,ii initiated through Ri-@IP, which sort of extended itsel@' into a Stat-Ei,.,,,-i.d.,-- renal idvison,- corLmiL'tc-c..- 59 and the-"e was some unfort-Li i-i a4k--e le;clz of cc)rp,,uniccitions I)e-i-@,cen that committee and @-pplicants, and the confusion on what the proc.-E.,ss @,.s for submitting @-r)tD!ic.@,ti-cns ai cTL--tting clearance. I-v'e had one case in Co',-i:.--@I)as a New JerFev fir-,7, has coi-,c in @-id set up a ---,rocTrl-@n, ind z,.t the -rcz--.c,,njL- tir,,,2 they iia-,,c-- been unable to b@-.ick-ur) arrangerien-l- froin the ri@cd4Cal center a- the uni-@,@erEi--V. So the whole thing is stym4-ed and bogged down right now because of the fact that the Social Securitv office in Chicago is not able to get the kinds of clearance from the B agency and the A agency necessary to recommend and approve that program operating in that city. It's being straightened out, and it will be. It's well on the way, and we're having good cooperation. I3ut the man-hours lost and running down these le-ads and problems and getting the right peoDle together and finding out who is doing what is absolutely amazing. DR. PAIIL: Dr. flerrill?'- DR. @IIEPRILL: I night, perhaps, in view of fir. ililliken's comment, ask Dr. Goodman a questions As I understand it, what lir. hiilliken said is that there are problems with new facilities. Do you see th:is' as more of a major nroblem that coorai.nition oil e.--i@- ti-ncT facilities, or are both equally i-r,-Dortant? DR. GOOD,-"@ltl,": is a ve- clear GO There is an allocation of res-r,,onsihilit-,7 I:)etwe(,r the ,7e z,. t -,ocial @c-curity ag,@:,.cy, Ind are the stz-,ge now, we have the P--rof@Assio-,,nal input into the program E,,.ncl. ii@ipler,,,.c-,ntin4 ,7j pro-@cs.----,o,,Iil aspe--ts of --he The Socin-1 Securit,,, office for a@Irrini-stratLve purposes anC, ease of administration receives the aT)nlicatic)n. C@IIP, which coul--', no'L -ind shc)lald be ign,)red, is sunp-@scd t.@ ascertain need on a local basis and on a State basis, to th-3- extent that t--@lev are capable of doing so and do a good job. U'his facilitates.the flow of the applications and it facilitates the- movement and their final adjudication. Dr. Rubel and I are aware of the problem that certain areas have. The CHP'S, in some areas they do a beautiful job, they come out with beautiful plans, as .have Pl,'iP's in some areas. And in some areas, as have some Rt4P's, they have not--, and many more CTIP's have not addressed these issues. To the extent that they--don't, that means the regional office then receives the application, the health officer attempts to -- to the extent tl-iit they do not have the expertise within that of-@gice,, we do here. We pretend we do have the expertise, and we riake decisions, Now, we have received about a hundred applications, we have approved Iv)out fitlr to date, since the program was on. Ile have referred others. 62 Anv other co,-,jnents? T.Ll I! 1 wou'Q jusz indicate @at I guess iast i month, early last month,, Dr. Gooclman did meet with a number of coordinators with the stecrinc, committee, and we ;@-cili:ed abou4,- the details of how the PJ@iP's could be of practical hold I in initia4--ina this thrust. And, as I sa@.,, materials will-1.)'e II coTi@-ng fort-l-i to 7Lhe council, ou- re@,4 or-i-iil-tee, and also el-7 C PIIP I s in the near future. I would like to call a break at this point, and thank Dr. Goodman for bringing the comments. And rtiay I suggest that we-reconvene at as close to 11:15 as possible. Perhaps you would care for some coffee, soft drinks, and so forth; and the staff and others can guide the new members to our cafeteria for some refreshment. [Short recess.] 1-I.-20am DR. PAIIL: Hill the council please come to order. As we reconvene,. I find myself being bumped to lower and lower on the agenda, and-about this time I have decided you won't need a report from Pie. But I am delighted to yield to the gentleman the Health Services Ad@-iinis 4--ra-I tion, who is sitting on my left, v7ho is I!lr. John Reardon, Acting Deputy Director of the Division of Emergency 14edical Services in the Bureau of _,-Iedical Services, Iiealth Services Administration -- and that long title will be found under 7 on your agenda. 6 3 The rt-,P@,on I I-a-%re asked John to core and speak for a few minutes @,7itli ,ou and again. be responsive to quest4-ons -Z and inquiries, is because lie is in cliarqc@@- of the Emergency medical Services over-all program and is responsible for coordinating our activities in the T,,!,'-S area with thosc- of t:-i-- Dcpartmen4l-- --f '-T'rt@,,n@-riortation, IT,ezlth Services, and otl-iers. I have asl@ed him to please give you a perspective of the total E.'L'IS activity, with special empl-iasis on how the Regional Medical Program activiti'es'fit in, and the kind of cooperation which we have been experiencing together over these'rnany months, and particularly this last week when there was a meeting, which he will surunarize for yout and in which all of the projects from our regions which will be appearing before vou today and tomorrow were discussed and put into a total framework. I John, would you care to give whatever comments, and then be responsive to questions, please. MR. RT',j%RDOIV': Thank Fou. .2 Members of the council: I t)-iinl-. th-;-s council has been involved for a num'er of years in Emergency I-ledical Service type problems, and you have funded a number of activities which, in the past two or three years, I 'Derscrially have followed with interest, and nanv of @.ihich T have been out to see, have been involved in, and an ve@l happy to report that they have 6 4 developed into the magnitude of systems effort which no@j W-.!L,Llll.Lil Uur li@lw law. In terms of programs, the 1.@ledical Servicc-2 j@rograi@-@, \;Iiich I art involved in, this began about two years ago ,ihen i-7e awarded demonstration contracts. These are now in their second year of three. We have had succe sses i and failures, but I think that's pa-"t of der,,onstrat4@ons. I think we have demonstrated that the systems approach to the delivery of emergenm, medical services is not only feasible but is a practical and economic approach to solving the problem, We have full Emergency Medical Service systems on the street, taking care of people on a regional basis, and these systems are approaching self-support levels. With that much of introduction and passage, if you will, of our demonstration activities, as you recall', last November the Emergency Medical Service System AcL@. of lc,'73, Public Law 93-154,, was passed b@,, the Congress, signed by the President, and we had funds in the amount of $27 million provided under the Pirst Supplemental to the FY74 budget. The funds basically are three and a third million dollars. This year it has @one, been appropriated for research which is being handled by the Bureau of Ileal-,"-h Services Research in Health Resources z-dni-nisti,-,:ition. The traini_i-iq 6 6 Ile did receive $54 million %icrth of applications, e'l '7 I V",C)r@l C).r Y"ol L-1 L JE:y S O,-Ie o fthose we have not been through. Sone of there atrocious. 1,@Te received few cood ones, and those that were good have a high probi'bi-Lit-@y of success. We will f ul-id. As r)art of this I t_h 4 Lnil@ itts important that i@e come back to your interest in the Regional Medical Programs. We are concerned with a total system which, in my definition, contains three major components. The professional services, of surgical, medical and rqental health services. It contains all the functional components of transportation, copununica@ tion, training, consumer education, information type programs. These are the kinds of things that people routinely associate with emergency services. Ile also have to pay particular attention to how these services and the components are amalgamated in the rural and the urban setting. Ilow-you put them together in the total systems anproach is significantly different in the two types of environmental settinas. We are concerned, though, that we develop total systems. That is the charter of our law. And the number of applications we did receive were for categorical requests. They wanted to buv an a,,@l ulincc!. ',7e turned them doxin,, because that. is no@- by c)ur a--id other funes -ire 6 7 available. In the rc-,-Por4@- hot-II f rc)m the ITou,-e and Ser,,ite, thc-@ language of the rerc)r'@ 'Very clc-@xrly sets forth the intent o4 Congress, and this particular.Act was to support total systems. '!'lie see!,, categorical f-@,,nds sh@,-)uld go to otlier proc tvT)es of funds. ..Trai-i.s for those Nov7t as far as our working witJi other nrcgrai7ist think we have perhaps set the ground rules way back i@ilien we were working with demonstrations,. We just finished this week a national review of the regional recommendations. 1-7e had representatives there from CIIP,, Pd,4P, the Departrient of Transportation. T understand ll,, as you recall, has been ve-rv active in training, communications, transportation. Ile brought in Health Service, we brought in other people like this who t-7ere spending money on categorical components of a'total system. We worked very diligently with these people over the months, to be sure that we were not only concerned about the f-unds but also that we use their technical expertise to make it available to,the community in terr@is of technical assistance outreach programs, so the. can be part of the 'total system. I,.le have cro.-,s-exch,-il-i(jt--d financial information in terms of potential errant aboard n--ogra,,is, %@7here moi-ic-@y 'is J@-4 nr-j s-@-nt, %7here it's being reconnn-nCed to he spent, to be sur-@, G 8 that there is no duplication of funds, to make sure that our f unds are complementary. I am also lianry to report that within the two or th ree regional medical programs that are fairly large, that you have been involved in. over the list couple of @7 @i r s those progr@-ims have mide application and they have progressed.!! I in their'dc--velor-)ment to a point %.,,here they are now readv. There are others approaching the level of beginning full system implementation, and @,,,e are very receptive to those. I should mention, if you don't already recognize it that i-iithin our law there is one part, Section 1207, which says, in effect, that other funds of the PIIS Act, other than the ETIS funds, cannot be used to support full EMS systems; and that'is a restriction which the Congress has placed upon your deliberations. However, Dr. Pahl, our general counsel and mvself in the EMS program have N-iorked on this, and we have no problem with the recommendations that will be presented to you in your current meeting. Ile feel that these are not in opposition to the intent of Congress, and that they complement our program and they do not conflict with our program. lqe have also revi'e%ied these againstihe applications that we have been reviewing in the past few days, ancl we haNre no problems with this, 70 are i.,ori-ing with the vc--eran-- Ad,,ri@iistrat-'c)n,i L the Depar'-ment of Lal.)or,, in terms Of inclusion. of the returning -,,reterans in traini7-i7, pr-ogrz,.r-s, g--ttinc-, them involved in some of the paramedic type activities. i,; I thinl-l k.,-e have a v@a.,@\, exci-ti..riy proarai-,, a-, I c-',s c T)rograi-i that has in effect been in being for a couple O., years, but has now new legislation, and we are on the thresholds Dlext year the Administration has requested a budget for PY75 of $27 million. Again we look forward to our 176.pla,-,, we have already prepared the papers requesting somewhere on the order of the full authorization of 75 million. So we are looking toward building the-proqran. We will stress funding of quality projects. I will say that the one efficient thing we have found in many applications, and I think it is not due to the applicant's fault, it's more due to the federal gove@rnment's fault, this year is that we liacl many local communities, coun,--v, citv. metropolitan community applv. This is fine. It fulfills the letter of the law. IloT,..7ever, what we're trying to do is to develop regional comprehensive systems which pull together and make best use of the J-n,,7estnie,-t: ,into -,--csourcc- that the community has. I thin!,, we will see, tl,,rough our technical ass-LS4@-ailce 7 e cc)r,.,t-r@g program and through the funds %@@e have spent in tli year that there is a growing interec@,t.in this regional approz,-ch. lqe know it can work. will bo very to ans,@.,,er any q,,ie!7@tions ti t ,anyone r,,,av ha-,re about this program, or anything that ri(-4h-' be related to your discussions A4--odEiv, DR. PAIIL: Thank you. Dr. Janeway? DR. JANET-,IAY: @Ir. Reardon, I can understand your rationale for this short tir.@eframe perhaps, because I happen to know of one area that did not submit a request because it thought it could not develop one of high enough aualitv. On the other hand,, the EMS research, I find, have a four times application cycle,, and the EMS training, I guess, will have one. Is it your guess that with an appropriation for FY75 that you will have four cycles for applications, or iust one as you had this time? MR. REAIZDO',-4: That's an issue which we are currently -- currently have our grips on. I doubt very much there will ever be four cycles. If we're looking at cycles at all-,, we will be loo@-.ing,probabl@y, at one or two cycles. I would like to have a continuous cycle. I th,"@k any time a community has developed a meaningful applica-k-i-on. 72 and has it ready, it should cor.,,e ii,,to our Consideration so that we can immediately review it and start to critique 4-t. is guc,@s as to the probability of having continuous, DT,,@Dlica@-ions? I'N-rARD@@T the a@@pro-),. -a@ tions c,,7c2.2, I t ii,,echan,@sm in -hinlc teats erms a Continuous cicle For example, we could be aLle to receive appliCa4-japiS in July, August or Septenbere but we won't know what our appropriation is until probably October, Nove@er or December. And it I-;ill be very difficult to make the busr_ f investment with those moneys in July or August, although I think we can review those, and we would hope to work @,744- @le h communities to -- to work with them to approve a good application, to the point where it should be- funded 'when the funds @bo-cone available. I think there is a backlash, of course, on the continuous cycle# and I think communities tend to res,,-cid to a stimulation. If we say it's got to be due bv a certain date, they tend to get things ready. If they are provided an adequate period of time, sixty to ninety daysf notice, we say itfs continuous, continuous in our reinforcement that" we are receiving applications, tllat cori-littees will cTo..baclil-, to sleet) and they won't stbq4-,@- the-,,. And they lose I opporturii t% .1is a dilemria. 73 DR. PAIIL: Dr. I'latkins. Did I misuii@lc-,rstand you on when you said ould avoid and tic--dicare, and y obviousi,7 1411I. Are you then goina to depend on PI-!P and one other source? I i7asn't sure about that, I.IR. l@rAi'DO"I': I-hcii-- I said i,7as that as we begin i to develop and implement the local communities develop and implement and put on the street total emergency medical systems, service systems v7hich are defined in our law, we are going to have to look for improved coverage and reimburse- nent in the area of Medicaid and Medicare to reimburse the provider of that service at the local community level for the services that are provided. Ricrht now, as an,example, it's not unusual for Social Security Administration to be paying ten dollars for an ambulance call. Well, that's all right if you have-the vertical or the horizontal taxi 'delivery, that covers the cost of the transportation and oxygen; but in terms of the- quality service, which is_ supported with ceXitral communication well-trained people on board who can do El%G. telemetry, treat trauma, stabilize trauma, ten dollars is a ridiculous fee to he paying for this type of service. And we must obtain an equitable reimbursement. Ile are i@Torking wit!,, SSA Dnd ST,,S to ir-tprove their 74 coverage and rei,-.@)ursement necl-i@,ni.sms in this irea,. "L"his has 'to go along i..--Lth our national ,Iic--,iltli insurance proposals and PSPO and 111110 and some of the other mechanisms that are also being Oc-,voloped. DR. i-7AMi'.IOCI,': Are thesis Peonle going to c"assi-pic-,-' as phvsician's assistants and El,D's, or what, if you're tall,.ii-Lg about o-Li-I)oard assistants and physician's assistants and so fortli? MR. REARDON: I can't reallv answer that because one of the things we were chartered to do and reported to the Congress this year is a legal barrier study. There is a great controversy and in some cases absence of legal coverage, if you will, were whether it's permissive or restrictive in the States. DR. 1-12UId-IOCK: I am just asking for information to clarify it in my own mind. MR. RFARDON: I think what we're finding right now is that a few States do have ermissive legislation that p allows these people to perform these services, and I would say more comunities --t--e_operating under tl@e remote direction of the attending physician. DR. PAIIL: Is there further discussion on any of these noints, or other,-; -that liz,,ve not I-)een sufficiently covered? If not, thank vou vci-.1 much, John. lle appreciate I 75 that,, and we will let you esccz@ne. l@7e will now get to the important part of the meeting, The advantage of having so many speakers precede you gets it N7hittled do,..7n to %%,here I thin]-. it -@von't take so very long, @,,,hich I think is good, because one of the r@io@e important aspects we have coming up this morning is Dr. John Grarqlich, who will be reporting to you about matters x,xhich are of importance on the review of arthritis applica- tions. So,, as a preliminary to that, I would just like to make a few comments on a point or two, to make sure that we try to keep all of you up to date with some of the activities that have been going on. As you know, the council met last on February 12. Much has transpired, and that has been reviewed pretty by the preceding speakers. However, we did develop a letter to you just last week which tried to bring @ou uD to date on matters, and I believe, Ken, that that has been handed out,at the table,, in case you did not receive it in the mail. If vou ilave been following the Washington Post stories about the U. S. Post--a! Service, we felt it to Xerox another copy and give it to you at the table also. In that report I believe that we have covered i-,osL@- of matters. You j'-.now that the E)ecrctLir, did au--i-iorizc-, individuals so that, had all accepted, we would be fully auc ,fniented at -LL'i-s There i.,rere a couple of noxi-acceptances, for venr valid reasoi-is, and vie regret that,,- but we are.verv pleased. 1%14-tll tJ-1e. fact x,7e have so inann,., new members herc... In,order to make this initial experience for the new members of the council perhaps more meaningful and rewarding, both to them and to the work that has to be done he ret.we held an orientation meeting for the new members of the council and any other past members who felt t]-iey would like to attend on May 31, and this was a very busy day. I will just briefly indicate that we tried to bring ti-iis group of people into full knowledge of something concerning the history of their program, the major' areas of activity over the early years, the various earmarked progran@,iatice activities of 910, kidney, EMS, ILMO instructioiit arthritis activities, and so forth. TV6. tr ied to indicate something about the review mechanism that we II-ad established and followed earlier concerning the review crit6rici ratings, the development of our mission s t,-itentent, how this had been developed and a-Dplic-c3.- Ile spent some time on the phase-out and extension i the program and that had -done what obligations @nd 77 res,@onsil-,ilities I-,,ciC,, I)een pl,3.cx-td Unr reg i o@-s, ).rl 1 C) Cl 1 h c -Locai regions nad indeed responded and survived 0 ver i this last vear. And we got into the cl.a,-@s action lawsuit and gave them the current status and what seemed to be the direction we were heading %.;jth And you hivc heard frori,. tlr. Ilu'@)el t-n-is morning tic latest on that item. @.7e. dealt with what we saw to be the transition period that we are now in, and @,7en@ into tJie current advisory structure apparatus that we now have with the ad hoc PIIP review committee and the ad hoc arthritis review committee, what they had done just the week before, and what this council, at both this meeting and its ne,%t meeting in August, will be called upon to do. We went into what regions are exnected to accomplish through their local review processes, our management assessment visi-Es'ahd so forth. We talked about available funds. We discussed our organizational and staffing position and posture, what it had been,, ho,,; it had undergone changes, and what the current status is. And we went into such matters of interest as the Federal Advisory Committee Act on confidentiali@- , conflict of interest, open and closed y sessions of the council, At least fror@i staf@Ll-- point of v-Le,.7,, I would 1-i'r-@e 75 to thank those i.:Iio tooJ-. @-hi-s e@-,trEi tir-,e to' come to @le found it very rewarding I-le kno@@., we provided too much @T material in too short C-1 time, but we hope that Maybe sc;r.-Ile of it will make this meeting a little bit more helpful; irdeeO felt @t t to Lc, ave-r-lxo i,,?ort"h@..@hile t,,iir,g we have that opportunity prior to coming toaether in a large group. 17ith respect to our review activities, of course the major part of this meeting will deal witli the results of those activities, and Mrs. Silsbee, at an appropriate point will discuss some details. But I would like to say that we did feel pleased that the Secretary of HEV,7 did establish, permit to be established two ad hoc review committees for the work that we had t carry out. The first of these was the ad hoc P-@,IP review committee, and I believe you have at your table a membership listing for both that committee and the ad 1-10C arthritis review committee, i-7hich'-was also established under' the Secretary's authority. These t@qo cor,..irqittees each net for, three days. The one on 22,, 23 and 24 to review the J?J,!P applications from all 53 regions'. Mr. Petersen and air. chambliss chaired the individual sessions the review of the applications occurred; I chaired the opening session and the closin-a session, the full corii,,iittee met, in the lattLr instance 79 to review the recom-iendriti..ons (-,--F the ti-7o separate p @,n c, -'t S I Cli L ;J J- '-nce. L3 L-1 -L U I think I should just too one rioment and express, as t,ie l@@@-tinci Director of the r-,v -ai@.)reciatioii t--O I-rs F,ilsk)ee for the vast amount of @-iors: that she and her total. staf-@ did prior to this we,@tin(7, and again. there is no point in !)elaLori-ng it, bu-@- it @,z@-is tre,-,'endou,s -imou@-it o work under the most stringent conditions of personnel, time deadlines, and so forth. I thin]-, that again you will get an impression out of this when you see the applications on the front table and note we are down in our staffing to one-third of what we used to be. In this connection I would like to also thanltz Dr. Endicott, who is not here, but who did support his commitment made before this council in February, when he said he would try to make available to our programs the agency's resources to help carry out the.worl-,load that.we had. And in fact we were able to call upon, I believe it i7as finally seven - i.,7ere former PIIPS staff rl,--r.@'oers' wlio/ver,,7 experienced with the review process to return from tf-ieik job@@in other parts of this age.-.cy, during the month of Ilay,, to- 'g v'e us assistance. And some of them are here, but all of tl-- m I thanl@ hoth them anO 'their supervisors,, because are not; three did help us -,.ateriall,, n cjcL--L-4-ncT the m,.ito-rials for -i.e review committees r'Lho- second review committee, the ad hoc arthritis corirl,-Lttee, met on Mal, 23, 24, and -@15. Dr. Gramlicl-i served as our ex offici-o liaison council Mercer to that committee and sat in an the discussions, and shortly will be giving a report to k,ou. I.-Ir. SDf-zar, our staff person for this activit7 has worked long hours and, as with Mrs. Silsbee, deserves a special note of commendation for the tremendous amount Of work well done-in, again, a short time period from the inception of this program, when we first brought it to your attention at the February council, to this noint where you have recommendations on a number of applications. That committee was chaired by Dr. Roger Mas on of the Nebraska IU.!P, who didan outstanding job as chairman, and we had hoped to have him also here'to present a report to you, but a prior commitment made that impossible. But I do want to note that for the reco-rd, our appreciation to him. Turning to another point, our o@qn organization and staffing, to just merely @tate that voii havp heard from Dr. Greene that we still functionally are within the Bureau of Health Resources Development, and that there has been submitted to the aaencv a formal request that we be in that Bureau organizationally, whereas as of the moment we still officially are in the @-ureau of llp-,-.lth Services Pesearch 8.1 Our personnel ric)@,7 nui-,!)cr al)out one-third of we riaa DeT-ore, i i-,(-.I:Leve you @,iiii see from the woi.-k tlial- is coming to -vou that there are still. many peo,,-)le who z,-rc., committed and dedicated to this activity, and have done excellent work, but, nonc-th(@1css, we have lost r-,an@, cl;corl people; and, nonetheless, I believe we are mz-,ii,-iging reasonably well. Attrition continues of our staff, and this hurts particularly in the office of, or Division of Operations that Mrs. Silsbee heads, and as people depart from that office, why, vip particularly feel the attrition. 1-7e did meet with the national steering committee of RMP coordinators in May and had a very fruitful day. Part of-th.at discussion was related to the cooperation with Dr. Goodman and the End Stage Renal Disease Program. I%le also had a presentation from Mrs. Bernice Harper,, who,is the Acting Director of the Division of Long-Term Care, because there are program interests between that division and this agency and the R-7-IP program, where perhaps cooperation bet@,7E-,en the ti-7o areas can -Lrurl--hpr enhance the responsibilities of both. I would like to make two announcements to the council I am both pleased and --egret to announce two of our senio-- peonle will Ile ci@.7a -For short -r)eriods of t4-rq y I regret that announcement because this is our busy sea 82 J.] 0- but I am pleased to canrounce it 1)(-@cF,,use I taiiril,- that t' (-)pl)ur-Lui@ities that each will have in the nc:,.t few %.,c-E@lcs be very nice for them, and will certainly make their o@,-,Tn growth and Oevelo,)me;-it -- will advance their @,rowth anC, develo.3rient and also bring I-)a@, to the <-icje-ncv a b.-cadenco outlook on matters which are of interest not only to @,!P but to the a@-ency. Mr. Roland Petersen will be gone for the next two weeks to attend a health executive development program at Cornell, at Ithaca; and I guess will be leaving this weekend. The other item is that Mr. Chambliss will be gone for six weeks attending a program for health systems management at Harvard University..Graduate School of Business Administration, and will be returning the end of July. I think we will certainly be looking forward to the return of both he and Bob. Iqe have been operating, back to our general staff picture, under a postulated decentralization of Regional Medical Prograr.1 functions to HETI regional offices. I am happy to say that after a-reasonable amount,of discussion internally that ti,-cit decentralization plan has not been implemented as of novel and in fact I think, through the offices of Rubel and others, it has beco,,ic possible,, for thp Under Secretary of liE-1-i to ,314--ato that no determination has been made about such decen4,-,--al.iz@ition, and no deterT,@.inz-,Lt-@'ull G. TI 8 3 this point @,,,ill ',-)e -iide at least after legislzi4L-ion is K)assed. No;ietlieless, ha@7i-n7,, c;r.4-O.. t:,i,-it, Ivou will appreciate the corLr@,ent that Dr. Margulies made earlier, tJiat job uncerti4-t,r cont,@rii,-s to fac,@ our henc;e tlie F@t-@.rition; .2 yet we are hanpy @,-e can pi-ace our cm-,)lo-,7ees in Derhans more viable jobs, although i.@e are, sorry to see them 6epar4l- the program, particularly when they have had several of experience. I tliirLIc,, for the most part, they still enjoy what they are attempting to accomplish. Our current funding situation I think will become clear as we go through it today, but in general it's some- thing on the order of 110 to 115 million dollars to provide support for the Regional Medical Programs out of both this council and the August council. During our closed session, you will be reviewing the-recommendations of individual applications, and I am certain that by the time the council meets in August we will have an exact figure- for you, as a result of @-he time- table, with the conclusion of this much extended lil--igi@-ion. But at this time, the best i can do is to give you a $5 millio a 4- range under which @.7e're operating, and I thi-iilz tl-iat's prct,.y good, from th'e T)oint that we've been a-t sorie time in recent months. 8 4 ail lir. Rul)el and others have gone over in so.-ie det L'= @l ZD -LCL " "-)!-L s -La LLI@ (,)f that, and i -feel that L don; t xiant to comment further and take your time on that, Ilith respect to the over-all prograri for the council today and tomorroi,.,, I @,,,ould like to i ay that we I will have a report by Dr. Gramlich, @,71-iich Ibelieve is of general interest to the open session, about the arthritis activity. And we have the other items shown on the agenda. And one or two items of business, which will come ,I both at the tir,.ie,i,7hen the public comments are in order andI under Otl-ier Bus@iness. Then we will go into a closed session of the council, at which time we will treat in detail the review of the applicFtions, and staff will be present to add comments, and there are a number of people from the regional offices and other federal agencies, and they are invited to attend . Members of the public may not attend. The closed portion of th-e meeting is under the restrictions of confidentiality and conflict of interest, and I believe we brought that to your attention,rout-inely in certainly the orientation meeting and I believe the statements in the package of materials given to you. During this oren session of the meeting, horv,,ever, the information is open to everyone, and I tlierefore'caution speal,.ers or others not to into specifics of applicaL-IO-QS,1 technical review'., Cor',@,@ @it4-e(-, :-ipproac---, 1-!I,,en i 4@- me t on 2'@Ird @L-(.) th c- 25@-1 of Ilay. All t" 0 mf%'!,')Grs were c)r@,sc.-n@ The -funding there @,7as, -is a-Tn sure you knov7, in the n@i(:Thli)c,-Iic-(7. o;: $4f@-'S,O'OC" -vz',il @,71 ic"i the Cori-@mittc,,-- haci 'le- prc)l)l-@-n aching on an.. of r)roperly appro over-all viei-7 someth-Lnc@, over @15 million in c;rant re,-Ti-, ests. -iere there 43 applications involved.-in these gran- requests. I TI Interestingly, ten regions had not submitted requests for a varietir of reasons. It was immediately apparent that this was a unique P14P function, on a pilot basis, one-time-onlyt and some of the aspects of the uniqueness of t-hi-a particul-arprol"lem were well exposed by Dr. Pahl and by others, in that these were funds that would be supervised by individual IU@LP's, that there were no specific legislative constraints. This funding oDerationg in toto had been somewhat interesting in its ince-o-Linn, -but at the s--M-- 4@-..@-Le L@H-LS !'!as a truly pilot type program, the development of i%,hich,, -iiid the i philosophy, micTht @,7ell have profound influence on programmatic' thrusts and such even more remote aspects as the effects on future legislative'action. One of ccrlxiittee r.,.err-',)ers promptly pointed out that the @-IIP had Lreque,ntl,,, led ;'_he wav in such cr-Lti-czl matters, and used the of the kidney dialysis and 8 7 transplant Program @.i@tli pilot stu(,,-@.ies and establis'l-@irq policy @nd networks leading to tJie Ul-4 P)ate adequate legislative funding, aiid he hoped tliaz-_ such a situation -igh-L. 1 develop with arthritis; an,d it might. And to 1-uoll-e '@his particular comm4-t-l@-ce Iie said that tells arthritis p@-ocTram riay he a unicTue oppc)rt,,ir,--tv to make amajo-- impact. Now, the committee had the benefit of staff review, and although Dr. P-largulies and Dr.@Palil have very properly lauded Mr. Spear and members of his supporting team, I think the highest compliment that I could pay them as an observer at this-committee meeting was that the staff work was good. The requests were noted to have sc,,mral corir,,cn characteristics?in the patient care area, there were many elements aimed at the development or enhancement of inpatient or other central facility care, leading in turn to satellite clinics for arthritis.care. e-lucat@ Many of the requests had str ng pc,-"-en4L. L 0 171 components and public education components, and here an interesting linkage with -the arthritis foundation developed, which was that the Arthritis Foundation was involved in many other grant request s. There were some specialized programs to develop,. --For instance, juvenile artlirit-"-'F, programs, arthritis care programs, gout-. was in a lot of t-l-ie grant requests, and there were program elements that were quite common to most of the requests also, such as ma,@or eqtiil,)rent acqtiisition, purchase of vans, de%,elopment of r;@oec-'--alized laboratories, enhancorqent of existing equipment, audio-%7isual. Some grant rec.@,@c@,sts h,-.,@' consider@-31c facts hoped for in -Le -ms of research, includinc,- epidemioloq z-,.n-' tonoc-Trr-,phy as well as patient care and basic research. Some grant requests were looking towards specializes' units in hospitals, arthritis and rheumatism units some.@,71iat similar to intensive care or coronary care units. After the assessment of the over-all view of the many requests, Dr. Pahl very kindly discussed some of the committee's policy chargesi and this was an enormous asset to the committee in its functioning and future thinking. Ile first noted that it was important that this was to be a national program, not a series of small isolated prO3ects,, but that its impact would be significant if the committee sticceede-(l in putting it all to-etlaer, and that this aspect should be seriously kept in mind during its deliberations. The essential elements of the one-year program were outlined and in this regard there was some effort made to devise the appropriate direction of appropriations ol. of activities in @ic areas of +--.lie Triorc- sophisticated art@ri,--,@t units already in existence-,, or in those with minimal or 09 widely sz)read caT3ebilities. Tlle pilot aspect was emphasized as was tl-ie necessity for some measurement of the one-@rear outcol7lil@s for the benefit of the ongoing legislation prograr.,t, The appropriate role of a local arthritis cil-)- ap was discussed at some length, as was the foas4-bilit,,7 of proposals that carie through the arthritis chaDL--ers. There was considerable direction toward the desirability of giving addit ional weight to program elements such as outreach in response to special population needs. Pati'ent-focuing rather than general public-focusing prograns, and the basis for the continuing deliberations of the committee was clearly established. After the summary of the staff review, the public comments were called for? and then the committee went into full session. Now, this signaled the beginning of a full day's deliberat;Lon'in closed session as to the guidelines, the appropriate guidelines for assessing equally and in-depth and' impartially all of the grant applications. And the committee did give a great deal of thought and effort to establishing the appropriate guides by which the evaluation and recomenda- tions for funding could be made for each individual aDDlica- tion that was being processed. The first plan t2iat was i-iorl-.ed out is a brief go surinarv which discussed about nine or ten areas of policy significance. The corArrehensive health care for patient-- group@, that is the ele,-ients of coordinated care, @..,as discussed at some length.' The matter of professional education of people,n@viding-care, including the cutr ach area, the concept of "train the team" and including I techniques O.L reaching or training the patient, was a MaD,or consideration. Quedstions as to what niiqht.be the best module for delivering caret the kinds of provider roles, the different kind!§'of patients, coordination of communication took the attention of the committee for a considerable period of time. The matter of the delivery team, how best it could be managed, facilitated, what the range of its functions might be' was considered -is an element important in the assessment. Rbsearch and evaluation was an obvious need which was considered by the committee, as were the problems of needs, assessment and quality control. Then the matter of funding ongoing existing programs, as opposed to new stcirt-ups,, was considered at lenath by the committee, and finally the matter of needs for future funding after the expiration of the one-year RDIP grant was a major concern. These were just broad guide lines that were then 91 distilled into the resolutions and guides i,.fhich you have in front of you in the minutes, and which I won't need to detc-3.il. particularly. I would emphasize that throughout all its deliberations t)e con,@i'-tee l@@6p@ in mind the need for a degree of cohesiveness on a national basis, and a-L. the scim,@- time maintaining an objectivity in the assessment of each of the individual grants. The Guidelines that you leave in front of you emphasize the importance of outreach, and this was a major consideration as the main thrust of the programs to be approved and funded in the opinion of the technical review committee. There were some negative aspects, and the committee felt strongly that data banks and registries, per se, should not be funded. At the same tine it felt that these were not appropriate funds to spend on expensive hardware, particularly complex audi-o-NTisual, televisi-1-1- -F41m ventures that would have..-very short-term, if any, payoff. The coi-T@ittee did feel, however, 'that if -there were demonstrated needs and usefulness for audio-visual materials, using video tapes as an example, there were certain areas in the country of expertise @,ihcre , on a loan basis, widespread distribution night be obtai'-@ied of rlateriils on a some-v;,!-iat more centralized basis than if each unit went about establish'@@rici 92 its oxen, In the matter of public education, the problem caTiel up sev e-ral times of pul:)Iic pro7,ra@is -iimcd -it fund .-ais)'-n-,,, and of course it was immediately apparent that this is prohil),L.ted b,,,, federal recTti Vt@l-iicles were mentioned several ties in parL--Lcula'r grant rc,,Iuests, and it ;.7as felt again in general by the reviei.@7 committee that it x-ias important that large amounts of funds not be spent individually on.equiprqen+-- that might have very little long-range use, and might be unsupportable by future funding. So that there was definite concern about large amounts of funding for hardware. The final negative guideline was in relationship to professional training, since a number of applications had requests for funding residency programs and degree granting directions for 'personnel. The IU.IP policy was such that the residency programs in general could not be approved. Ilo,vi, this sou,-icls a little negative. It is not,, actually, because you will find v,-hen vou start going through the applications that the matter of positive effect in terms of outreach, and the various principles involved in the solution to the problems of the pilot program were carefully dealt with and the discussion we.,-it on in depth and was not 3 pressured at all. @il)p-llcaLlons,, each application was rc-v-e-,.ied i,%-i depth the entire committee and L-hc: o@?cr-all national N,?as 1-@o-pt strongl@-, in mind in the assessment of e@@ The individual aopi.ic@i-"ion was assessed It, was sometimes modified. It wac3 ci v,--n a ranlzing score. And a-"rt--,r this the committee discussed D,rogram coordination and outcoi@.1 And this, I think, merits a quote. The notion that communication and evaluation of this program pervaded the entire technical review conruttee's deliberation. The committee felt strongly that the development of experiences and innovative activities -- and I am quoting now -- "conducted under the pilot arthritis program should 'lar be widely publicized, that a periodic newsletter or simi communication about development of supportive programs should be supported by BTIRD, to increase shared experiences and to avoid duplication of effort." The committee suggested, if possible programs should! make quarterly renorts, and that there should be enough action on the part of the individual recipients that sta@f he well underway at @iL- end of three months and that per@onn'el and organization be completed and in operation at the six months. In oil evalu@,,%--ion, the committee requested, if possible, that there should JI)c conference in Siy, jr-onti c, r IS some reasonaiDie period,, at -which tir.-te they would see- tliev or the committee woul.@- see was going on in tlie funding proc-ram, to maintain cc).,itl-'L.,-.uitv. reCol-@. was respccL'-f-u -y 1 twas requested I)v the technical rc@, -nT,@ committee that the actions of this council, the advisory council, be made reasonably available then, so they could appreciate and evaluate the benefits of their i,7ork, This committee was a distinguished committee, as Dr. Pahl has mentioned it was chaired by Dr. Mason from Nebraska, and I will briefly tell you who was on the committee -- not for subjective reasons, but because it will perhaps help in future deliberations this afternoon on the grants themselves, about the membership of the committee which included a Mrs. Annette from California, a nurse; Dr. Baily, an arthrologist from Georgia; Dr. Donaldson, an orthopedist.from Pittsburgh; Dr. f@ngleman, a rheumatologist from San Francisco,- Dr. Pfeiffer, an orthopedist from TIashing- ton, D. C.; Dr. IIastirgs, a podiatrist fron,l.-7ashington; Joi-in Poleski; Dr. Larsen, an orthopedist from loiia City; Pranli: Schmidt, an arthrologist fro,-Li Chicago; Dr. Schulman,, arthrologist @.-o,-n Johns Ilopi zins; llrs. Silverstein, occupational therapist f,--cri Balti-iore; I-I,rs, 1--,Iilso,.i, a social workc@r r (N-"l California; lirs. '.Jarl.)orougli, i-7ho is a physical theraois,4t-- from r Georgia. I served as a swaying L)a7idge from the technicc--,l cor.-.niittee on one side to nat-L; i a 1 -7,dvisorv- council- on the other, over the si%--@@Lam of action that t-I i o- review c(-,:n,-@:iittee float---'-.-i7, Tlc-comin,-ttee o:or@:cO. Ionic and hard. In fact, a -Lc c-- r a day and a half of establ.irhincT guidelines for fair assessments of the applications, the!i took another day and a half to review individually and collectively each application. This' was not the easiest occupation, since, I believe, there was a little trouble getting the PtLrl-,la@@in Building to keep the air-conditioning working Saturdav; but they persevered and adjourned in the afternoon on the third day with a self-laudatorv comment which I-latt Spear hae- included in the minutes presented to you, They said that the-efforts of this committee have been exemplary fa as r as acting to the best interests adhering tc the guidelines proposed. We conside- this to be a very rqeager effort to,.,,,ard a tremendous Problem, and it in no way begins to provide a solution of any definitive kind. No@..-, t-ley E-,lso made one very important point.. The additional funding to -Lnclude many of the projects t-l-i.at N@iere rejected, as wo'L'L as L-ho- bulk of other projecL--i 9 6 which should have submitted but @7ere nc-,t su.rr..it,L-.ec7i -lecause-ti-ic guidelines provided by the legislation or b-v the constraints of t4-.ri-a should be considered when stic-la n-@ncyL, @@.,ould become available. In other N,7ords, the. committee really loolze@ upon itself as a x-.,a,,,station in a truly pilot program that has national'implicatioiis and should have a long-term payoj-.L. I think that there is one other comment that is wc>r@i making, and that is that it is typical of IVIP flexibilia- ,-y and viability in that this program could be thrust upon on a crisi-,.oriented' basis and that the staff could come up with a proper Administratioh to bffectively,get th'e-p!r@g@am 'to' tlle'sthLte:,it!nQw, is -'in'a very short.period of time. A great deal of credit is due Mr. Spear, Dr. Pahl, and the entire staff. DR. PAHL: Thank you very much, Dr. Gramlich. Are there questions for Dr. Gramlich on this rather brief survey of what was intensive effort of the arthritis center programs? The minutes pf -tli'lat meeting,, that; have been distributed to you, as Dr. Grainlich stated, are quite important because they contain the resolutions and guides, that is, the prenises upon which the committee later evaluates the application; and also there is in that document recommendation for follow-ul) by the Division of Regional '%iedical Prc)gra...S, 9 7 so as to try to make it an effective. national Drograi,-,, even thouah it be a one-year effort, as John has stated. And 1 @!ii-nk it ",ould either be @ip.@nror)riatc now or at a later point in -the meeting, if you have not had time to read those minutes, to have a formal council adop,"@ion or endorsc,-en4@- of those resolutions and guidelines, @is well as 'the recoz-,,,i,,enLla-'i tions to our agency in program, for an appropriate kind of program involvement following.tbe awards for the approved programs And if--it is the councils wish, this could be done at a later stage. But I think it would be well for us to have that formal endorsement of the committee's proces ses and basic-underlying premises, because this is an initial thrust, and we believe the committee not only did an out- standing job,, but they set'for themselves certain rules and procedures so as to try to carry out, to the best of their understanding, the mandate that was given to us.- I dont know to what extent you have had an odnor- tunity to read these materials that Matt has. These materials are at the desk today? MR. SPEAR: The riinutes aren't here, unless they have been distributed. They were nailed out. DR. PAIIL.- O'@cl-.y, they were mailed out to you. If you have had an opportunity, perhaps you would care to discuss that 'or, if not, that could be lef t we nc,-e(i 9 8 not s ome e:c4t--ra co.pies, @,,hicii j..-ielic..i;'_es to me tha' tiis is the appropriate time, then, to -@l:al@e an@,- action. I x7oul.cl su@c-fest ti-,at -..,e c-,c, extra conics and fet sor give them to ou, and -oerlici-L)s later todciv, or at such a time y as x.@,e ti.-.l':e ul? t'i'le z,,,@.'@hr-Ltis these couIC, be gone over and that action ins-t4Ltutecl. Are there anv points of discussion for either Dr. Gramlich or Mr. Spear at this time on the arthritis activity? Ilell @hank you, John,. very much for your report, and we will be getting into the detail matters early this afternoon. I would like now to take up one or two it.--ris of usual business before the council, and that is to ask for a consideration of the minutes of the last meeting of the council, the February 12th minutes. If there are any changes or amendments? I= 'fair would entertain a mo4-i-- for -L not, the C. adoption of the minutes. MRS. I-IARS: ' I S-0 move. MRS. MORG-Al-7: I second. DR. PAIIL: It has been moved and seconded. All in favor say "aye". [Chorus of "ayes".] Dr. P'kllL: Opposcd? 9 [@To response.) DR. PA','lL: So moved. the-.i also to c,--l", to -,Our -ittention ti-i.-t next meetLng dates for the council are August Sth and 9-t"-h, and t-h St4 I wo-Lil d h op c tli,-i4@ -7, schc-(Iiiled mc-etincT is 4 appropriate for you. Ii-- has been very Oi'Lficult to arrana.& meeting in ilugust, and we do urge all of-you, and those W'@k I 0 are not present this morning, of course, to make that appl4 meeting, because at that time there will be i-cations from 43 regions or so, requesting something in the neighborhood of $42 millions. So there is a reasonable set of responsibilities involved in that statement, so we would hope that all of you would try to make that August 8th and 9th meeting. At this time we are not attempting to establish a meeting date beyond that, because, very frankly,, we would not know what date to suggest or what the needs and responsibilities are,-so if you w@ill bear with us until August 8th and 9th we will bring in a large calendar and see what we need to do at tha'@- time. Before we get into the last item of business, I would ask for any public comments or comments by members Of the Dublic on anv of the .-la@--ters that have been brought up today by us or otlier matter,-; relevant to the council consideration that you care to make. lo o If there are individuals @-,,ho care to make or conr@,,o@hts, I would asic ,,ou %to i-d-2nt4-fy yotirE:el.@ -for the record, and if you are representing an organization that a.s, someone other than yourself, please identify whom you are representing. So the floor is open at the rqoment -for anyone who feels so inclined to make any general statement or cor.%-,,c-nt upon what has transpired so.far. MR. POPPER: Ily name is Robert Popper, and I have been on the Now York Regional ?.Iedical Program almost since its beginning. And for the past three years, or something like that, I have been chairman.of the IUIP. Noii,, I have watched PIT as a concerned interested citizen, because I an, a volunteer. Nobody pays me anything any more. And also as a taxpayer. Now, I take tl-iat responsibility very seriously. Considering the alternatives, I would rather pay taxes than not, but I do want to a-et my money's worth. I have watched R:',P over these years and have watched some of the.things it does, particularly in our city, that I have never seen done before. It has managed to convene some people who never before could have believed that today was Thursday, and I have managed to get these people, to sit them down in,a room, to establish prior;illics and implement programs; and it has baen really quite a 101 .remarkable thing, A lot of these people have nothing to gain from RMP,, they are not people who submit grants, they are just people who think that RMP is worth something.. I think this is good, and I think it's important. Now,, I come to you particularly with an unusual problem with New York. I hate to bore you with statistics, but the fact is that I memorized them on the plane coming down, and I'll be damned if they're going to go to waste. We have ten million people, nine counties, twenty- one congressional districts.,, two hundred hospitals,, and,, so help me, seven medical schools. Now, if you think that that's an easy group to get going on anything -- you are quite right; it is extremely difficult. In December of 1972, when we had our site visit, our director had just resigned, our grantee was asking permission to withdraw the PJIE was acting under wraps because we never knew from day to day what our powers were, and I can assure you when I cross Fifth Avenue the cops didn't stop traffic for-me. Today this is all different. We have a grantee who is responsible, respectable, and who cooperates,, but does not interfere. Ile have relationships with our comprehensive health 102 planning agencies and other planning agencies in town that have never been better, with a good deal of cross-federaliza- tion and a great deal of conversation, particularly with CHP, we are in good shape. We have a staff that'-s absolutely devoted and competent, and works just as hard as the staff down here, and we have a strong and vigorous PJIE which attends meetings" and which deliberates and which does everything it has to. Now, I'm not going to go into all the projects You have them here. I merely want to say that if you think all urban areas have problems, we, with our ten million people and seven medical schools, have ever so many more problems than anybody. But we have the solutions to solve those problems, and all we ask from you is consideration of money. We are five percent of the population of the country, we are putting in an application for roughly five percent of the impounded funds. Anything you give us will be deeply gratifying, and if you give us more, that's even better. Thank you very much. DR. PAHL: Thank you, Mr. Popper. I am glad we received those statistics also into the record. Are there other members of the public, or are there comments by the council at this time relative to this statement? 10 3 If,not* are there other general statements to be made before we go into the last item of business I have in the open session? I would like to have you turn your attention, then, if you would -- I am not sure in what form this was given to them, Ken, is it in the agenda package? In the material which contains your agenda, the last two sheets,, there are two staements there which the ad hoc review committee for the RMP applications formulated and addressed to the council for their consideration,, and I would like to, at this point, have you consider them in this open meeting because they are not related to any individual'application or the review of any individual application, but rather are matters of general interest to the review committee and to this council. The first statement I have is the CHP review and comment. Do you all have that statement in front of you? MRS. MARS: Who drew -this up, Dr. Pahl? What is it? DR. PAHL: This statement was drafted by Dr. Teshan, who was sitting on the review committee, but I believe that there were several. He's the one who presented it to the full review committee. The full review committee considered this statement and passed favorably upon it for submission to an action by 10 4 this council. So this is a proposal to you to consider and adopt it, amend its or not act upon it at all, but it is brought to you from the review committee, and we are serving in that capacity. In introducing to you this statement,, you should be aware of the fact, and this is particularly addressed to' new members of the council, that there is a procedure within the RMP guidelines and policies whereby applications from the local P14P are submitted to the local CHP agency for review and comment,, and that these comments by the CHP agency are returned to the local RMP,, where the comments are to be considered by the regional advisory group and the RTIP,, and some kind of positive response made, That does not mean that the advice by the CHP agency has to be adopted in all cases, but the comments have to be seriously considered and an appropriate kind of action taken following the RAG consideration of the comments.' In some areas I think it is fair to say that there has been very good-close working relationships,, and I think we just heard a statement from Metropolitan New York RMP,, where such activities seem to be working out very well. In other areas of the country I am afraid things perhaps have not always been as smooth. Consequently, there has been a spectrum of both the kinds of advice given IU4P's from the CHP B agencies as 105 well as the kinds of responses that RMP agencies have made to such review and comments from the CHP B agencies. As Dr. Margulies and Mr. Rubel have already stated this morning, much of this is past history, because we are moving into a new direction, and I believe that the sources of friction are much less-widespread than rumor - would have it. In many places.things are proceeding very well. Many of you who have sat on the council know that the local P14P's@have done much in the past to staff and help establish the local CHP.B agencies, They are sitting on the RAG's and on the CliP B. agency councils and boards, people from the other agencies; so there is good collaboration and cooperation in many quarters,, but it is not uniform. As a result of still this divergency of interest and activities,this statement was drafted by the review committee for your consideration and I would like to read it into the record, and then you may take whatever action, following discussion,, that you care to. Mr. Rubel is heret and I think this is appropriate, because he has these two sets of responsibilities.. and that is not only as Acting Director of the CIIP Program, he is interested in such activities,, but in his more major role,,'ane that is the Associate Director for the Health Resources 10 6 Planning. It is his reponsibility to try to make a more effective program both internally and externally,, between the CHP and RMP functions. So I would like to read this review'committee recommendation for your consideration into the record. OCIIP Review and Comment. 'Re.commenation for Council Policy and Request to Health Resources Administration: 'While recognizing legislative mandate and Division of Regional Medical Program regulations regarding RMP-CHP relationships,' Council requests that the national CHP leadership transmit to Areawide CHP(B) agencies nationally the mandate for fully reciprocal relationships with RMPS,, 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 RMP Review Committee and Staff to set aside any influ6nce of negative CHP comments upon an P14P application unless the commenting CHP(B) agency has provided the RT-IP with (1) the criteria and a description of the b-agency review-and-comment process and (2) a list of the b-agency objectives and priorities upon which at least a part of the P14P response should be focused." Perhaps it might be appropriate, since Mr. Rubel is here and has already treated this, in a sense, in his 107 earlier statement, to first make a co=nent or two which I think may be helpful and then ask for council discussion. Gene. MR. RUBEL: As I tried to say before, it seems to me this statement is an attempt at raising issues that have been very bothersome and troublesome in the past,, and,, very frankly, I don't see it as providing any positive effe@t for the future. There is no question that there has been an awful lot of each agency trying to further its own means within the RMP world.: There has been the question of "who sent you out to be our master' kind of a feeling, and it is certainly evident in the discussion of the review council, that that was a major one of the problems. .@""We don't respect you, anyway; we know what we're doing, and who the hell are you to tell us what vie should do?" That has been the attitude in many places. on the other hand, there has been an attitude on the part of many CHP people, one of, in many cases, jealousy, envy, 'you have all the bucks and we*re struggling; and weire going to sabotage what you're doing.' A lot of that has occurred as well. I think the Congress is in the process now of tryinc to reconcile the problems that we've had in the past. We certainly, I would say, over the last three months, four 10 8 months, have tried to do it here as well. When the applications went out to the RMP's back in February, we sent copies of them to the CHP agencies as well. The first time that had ever been done. We tried to explain what the rules are, where we also try to lay out some priorities,, as we saw them, where they could be working together. As I travel around the country,, I have found an amazing amount of interaction that people are trying to work together. I think perhaps some people feel the problem we have as bigger than what really is there. There is no question in the context -- the first part of the statment, I am not sure I know what it means; but in terms of reciprocity I think that is happening, people are talking to each.-other.. And I am not sure what making that statement really means. Well,, let me@stop-there, and I will certainly be glad to respond to any comments-you have. MRS. MARS: Personally I don't think this is a responsibility of the council, and I don't think it comes under our prerogative to try to settle internal politics,, so to speak, in that this is more or less a political issue. And I would be very much against recommending it. DR. PAIIL: Dr. Merrill, DR. MERRILL@:; I agree with both those comments. 109 Since I have read this thing, I wondered where the other eight commandments were. I think it's calculated to raise the hackles of the people wlio receive this. It's extremely High-handed,, and I think the issues which are involved, which are.much dealt with by a soft sell rather than an extremely hard and irritating sell such as this one. DR. JAN@IAY: John, on those two commandments hang all the Laws and Prophets. DR. PAHL: Mrs. Flood? MRS.'FLOOD: I would inquire as to the interpretation of the OIP(B) agency by the wording of this comment. Would this encompass also,the areawide.planning agencies that are unfunded, that are strictly voluntary and functioning in areawide health planning without any federal or State support, but who fill the role of review and comment for these levels? MR. RUBEL: Under current Department policyp there is only a requirement to get review and comment from those agencies that are funded by the federal government. I think in practice it has turned out that there are many other agencies involved as well. Hopefully, in the relatively near future we are not going to have that difference, we are going to have planning agencies covering the entire country; but there is 110 no way, there is no requirement that an RMIP get comments from anybody other than a federally recognized and funded areawide planning agency. MRS. FLOOD: But in reality they do,,' they go to the areawide planning agency, recognized though unfunded, that does fulfill this role. So my question would then lead to: If this policy statement should be adopted, would it be forwarded by your office, Mr.,Rubel, to these unfunded yet - functioning areawide groups? Through the (a) agency,, perhaps, if you use that mechanism for dispersing information. MR. RUBEL: Well,, we. certainly would be telling it to the (a) agency people. We have no formal communication channel to the unfunded areaviide agencies. MRS. FLOOD: Well, that is an interesting fact when you consider that the regional offices would require a review ad comment from even the unfunded agencies before they consider applications that are.not directly related necessarily-to RMP but to other funding sources. In light of the fact that this particular policy statement then perhaps dispersed through the (a) agencies would reach even thse unfunded agencies, I would also feel that it is a high-handed approach and would cause many cl@ problems for Regional Medical Programs. Thank you. DR. PAHL: Thank you. Dr. Gramlich. DR. GR2U4LICH: Dr. Pahl, a question of information. Is there anything in DRMP regulations which requires that DRMP s-Eaff and council not fund an otherwise Appropriate pro3ect which has received a negative comment? DR. PAHL: No,, the regulations, policies merel-i.- require that the applications before being considered have gone to the CHP(B) agencies for review and comment, and that such comments be received,, considered and in some way disposed of, affirmatively or negatively; but beyond that there is no requirement. And I should say, and this will come up as we go through our RMP applications, we made a very-strong effort, as we have in the past, to make sure that despite the short- time periods for the present applications, that our applications did go and be reviewed by CHP(B) agencies, and this placed a very heavy burden on the (b) agencies. The time requirements Were very,, very strict. We have received the comments from the P14P's about the (b) agency comments and what their actions are., and I think we have tabulated these, and both Mr. Rubel and I are quite satisfied that everything that could be done in the periods that everyone had available has been done and it has been really a remarkable performance by both the CHP(b)ls and the Pl@ip , S. 112 That is not to say sweetness and. light exists in all quarters,, but it is far less than whatpeople believe. And, as with most things, a few cases of dissention seem to color what is not truly a generalized situation. MRS. SILSBEE: Well, in practice, some of the (b) agencies did have difficulty because they have such a tremendous load on -- and have been sending in comments that to Mr. Rubel and copies to us and to the Regional Medical Programs. In some cases the review committee had those late- comers, In every instance we felt that the information would be accepted, but the real forum for discussion was back at the regional advisory group, and we have been trying to get information about what the process is that is going on locally. DR. PAJIL: Thank you, Mrs. Silsbee. Dr. Sparkman. DR. SPARKMAN: I'm @ohn Sparkman. I am Director of the Washington last-guard unit, chairman of the steering committee coordinator; I can't speak for them, but I think I reflect their views, and I would like to take a different approach. It seems to me that the approach so farbas been to tell RMP'S, you just must abide by CIIP review and comment, and we have had this mandate laid on us. 113 On the other hand, I think what the authors of this particular statement had in mind was that the CHP should at the same time be told, Yes, you have a mandate to cooperate with RMP'S. I would agree with what Herb has said, or what Mr. Rubel has said relative to the fact that in general relation- ships between CHP's and RMP's are good,, and they are better than the general rumor has it. I agree further with what Mr. Rubel has said, that there is no point in looking back and having recriminations, when we should be looking forward. But the fact remains that everything that has come out of the central office'has not seemed to be to this effect,, and I don't have specific comments,, but I know from sp eaking to my fellow RMP coordinators that they feel that Mr. Rubel doesn't quite reflect to his colleagues in CHP what he says here to us. Now, I don't question h'is honesty, but this is the feeling that still exists, and it seems to me that the first part of this,, down -to "furthermore agrees and instructs" does in fact include a positive recommendation to say: All right, P14P is going to cooperate CHP's are going to do likewise. But I think I would agree with the scratching of an ad hoc PIIP review committee and stafft to set aside any 114 influence of negative CHP comments. But then I would think it is reasonable to ask the cHP agencies to describe the criterion and description of the review and comment process,,.and to list the -(b) agency's objectives and the' priorities,, and the basis on which their judgment was made. I know from the facts that,our own'region,, but I don't know on what basis a judgment was madep and I clearly think they should be told this, and I see no objection to this. It seems to me this is a positive thing to do, and not a negative thing. And I further think that it is the responsibility-of this council to look at this and act-on it. Let me say that the coordinators hold this distinguished group in great respect. We recognize that from the beginning the national advisory council have played an exceedingly important role in PI.IP and detrmining policy and quality by actually setting policy, and I see this as a policy, and also by the careful review of applications which we are all going to do, which is an important part of determining quality. So I see this as a positive thing, and I see it as your responsibility. DR. PAHL: Thank you, Dr. Sparkman. Are there other comments? Dr. Merrill. DR. t@'M-RRILL: I would just like to reply to that. 115 In my comments I did not mean that I didn't think this was at all a fine thing to do', but I think this is entirely the wrong way to do it. What this proposes is that this council formally request that the national CHP leadership transmit; now I have a very strong feeling, perhaps shared by other members of the council, that it will never get any further than that and might simply irritate people. I think there are other ways of effecting the kind of thing that is intended here, and I think this might be done without a-formal statement.from the national advisory council of P14P. I would suggest perhaps that it might be done on a personal basis, or a man-to-man basis. I think you're quite right, it would be nice for a local RMP to know the (b) agency objectives and priorities; but I think for the (b) agency to transmit these to the local MIP by reason of a request from the national advis-ory council, coming from national CHP, has the effect of making more of an issue out of it, I think,, than is warranted. DR. WAMMOCK: You're talking about that local people make this comment rather than the national level, is that right.> DR. MERRILL: Well, I would suggest in this stage that the national T4P people and the national CHP people get 116 together at the request, when and if it originates and I think it's reasonable -- should come from the national CHP without the tag of the RMP, which would only serve to be a sting. MR. RUBEL: If I could just make several comments. First of all,, in terms of our attempts at suggesting that @IP's and CFIP's work together, I would point to the covering letters that went to both organizations when this funding cycle first began, and I will leave that for the record to judge whether we have or have not attempted to suggest that there are very meaningful relationships to be carried out. The second point, the very essence of the planning process, within a comprehensive health planning organization, is its openness and the ability of virtually anybody to participate in that process. If we have to have a mandate from Washington that tells people,, Well, we've alread7y told them what they have to do, it's very much in the open, to open it up some more,, then we have failed even more than some of us here think we have. It is very true that there are many planning agencies that have not articulated very clear objectives, but that same thing is very true of RMP'S. It is very clear that we have CHP agencies that have 117 not responded very well with specific comments to a proposed project, but it is also true that many RMP's have not justified a project in a way that a CHP agency could respond. Wh at I am trying to say is we have a lot of problems. To the extent that you ask,us to communicate with CHP agencies, I promise you we will so communicate. My own personal-conviction is that all it will do is exascerbate problems that we have,, and it will not be a positive influence. Let's face it. The July applications are just about on the way. Who are we telling, you know, you've got to communicate before you submit applications. For what purpose are we doing that? I would wholeheartedly agree,, to the extent the current legislation will continue, that we need to find better ways of communicating with each other,, and if I have anything to do with it, if concurrent legislation were to continue, we would seek to do that. But, in light of where we are, I think it's a little meaningless to try to start doing that from this point on. MRS. MORGAN: I don't believe we as a national advisory council have any control over CHP agencies at the present time to demand what they should do. Ile can over 118 RMP's groups, but we certainly cannot over CHP(B) agencies. DR. PAHL: Mrs. Mars? MRS. MARS: I would like to make a motion that we do not adopt such a resolution as being inappropriate for'the council,, and perhaps along with that,, however, adding a directive, such as Dr. Merrill stated, perhaps you would like to phrase that a letter be sent or something.in so@ter termst rather than adopting such a motion. Would you like to add an amendment to that? DR. MERRILL: No.. I think th at the thrust of what we all are thinking is very clear to Mr. Rubel and Dr. Pahl, ad I don't think it really needs to be put into writing. I am sure they could follow our wishes, MRS. MARS: Well, leave it then just as a motion to not adopt such a resolution as being inappropriate on the part of the council. DRo MERRILL; I second it. DR. PAHL: It has been moved and seconded to not adopt the proposed resolution. Is there further discussion by the council? [The question was called for.] DR. PAHL: All in favor say "aye'. [Chorus of 'ayes".] DR. PAHL: Opposed? [No response.]. 119 DR. PAIIL: So moved. The second statement,, which I believe is one that the review committee was very interested'in bringing to your attention, I think is fairly obvious, particularly from this morning's presentations by all of the speakers,, namely, we know we are in a transition period. Each speaker has indicated that it is necessary, essential, highly desirable' for the local RMP's to order their own affairs, and seek closer, more effective relationships with those groups in their own regions, be they governmental or non-governmental, so as to look in a positive way to the future developments as we perceive them at this time. And this recommendation by the review committee, I think addresses itself to that statement. I would like to read it into the record, and then have the council consider this. "Action to preserve PkiP Experience and Relationships" "Recommendation for Council Policy: "In view of legislative developments now underway for further evolution of-RMP, in association with the CIIP and Hill-Burton programs, in the interests of national health planning, Council encourages RMP's to develop organizational readiness and any remaining regional relationships which are appropriate to lead,'participate in and accommodate the anticipated new operating structuns and requirements. 120 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 RMP experience e@ted." has cr I believe I should convey to you the committee's intent here when they say 'organizational readiness", that they are stating that the local P14P's should look to'their own internal staffing patterns and structures so as to be in a better position to be responsive to both the regio nal needs and the developing legislation as we all see it. So this is not encouraging, by any means, RMP's to adopt different forms of grantee organization, but rather to look internally to their own staffing structural patterns. Now,, with that as background, I would like to invite councils attention to this recommendation. DR. JANEWAY: I believe that this is anticipatory of'federal legislation, and one cannot read the intent of people who propose this to council, and I think it's open to a variety of interpretations, and in its present form I could not support it, a resolution such as this. DR. PAHL: Mrs. Mars. MRS. MARS: I would just reiterate what Dr. Janeway has said. I feel the same way about it. DR. PAIIL: Dr. Watkins? 121 DR. WATKINS: I believe -- I was going to say that I don't even believe that we should have the responsibility of voting on either of these things that came up today; we should have returned them to them with the comments that were made,, without a vote at all. Because we are negating something that we're not responsible for. DR. PAHL: Dr. Schreiner? DR. SCHREINER: This reminds me of a story about a Czechoslovakian sheriff in Colorado, and due to local budgetary difficulties they had gotten down to one deputy, and they had a gang of about thirty outlaws holed up in a shack, and the sheriff said, "Well, men, since we're out- numbered,, I suggest we split up in groups and.surround them." (Laughter.] I think the P14P's that have lost a lot of staff know that they are in trouble and are trying hard. I don't think they are going to be helped by this kind of a resolution. I think the ones that have the staffs, the reason they have good staffs is-because they know this is a problem, and they are getting ready for possible future legislation. I don't see that anything is going to be accomplished by this type of resolution. DR. PAHL: Well, I think, unless there is further discussion,, the Chair understands the sense of the council, 122 and we will transmit such discussion back to the.review committee,, so that they will know the disposition of these, Before we break for lunch, I would ask once again whether there are any further points to be made by council members or the public on any of the matters we have discussed this morning. Dr. Haber? DR. ABER: Yes,, I would like to comment at this meeting about the proposed outreach of the arthritis proposal. I construe this as being very important and possibly a mechanism in which the treatment of arthritis can escalate and elevate itself up to a much higher plateau. The reason for this is that most arthritis is not treated in hospitals, it's treated on an outpatient basis by a variety of practitioners, some of whom may not be qualified. And I think if I sense the meaning of outreach here, there will be an opportunity for physicians who are a tertian kind of physician, who are involved with research and teaching and so on# to be able to relate much more closely to the primary-care physicians. That is to say, the resources of the hospital, the school of medicine, and all the rest which have been devoted 123 largely to life-threatening diseases on an inpatient basis,, will now be turned toward this very important area of arthritis. I would commend you for this, Dr. Gramlich, and I think it's a very important step which could raise the whole complexion of arthritis treatment in this country. DR. PAHL: Thank you very much, Dr. Haber. Are there further comments by the council? Mr. Rubel, -1 believe, had a statement.' MR. RUBEL: One further thought. I mentioned before that we have reached a settlement or at least there is a proposed settlement of litigation, and that we have agreed at least that unless any RMP objects, that $5 million will be used under Section 910. It is our current intention to spend all of that money,, using the contract authority, and that would therefore not require review by this council. On the other hand, by the time we meet in August, we have to have our plans,, very hopefully,, firmed up and I anticipate that.we will be discussing with you how we intend to use that money, The thrust of that effort is to help us do research into the technology of planning, as I call it, the methodologies to be used, I believe the coordinator says,, with major emphasis on criteria and standards for expensive 124 services like open-heart surgery and the like. But we will have a very complete plan worked out by the August 8 session,'and we do want to share it with you,, and get your -- whatever suggestions you have 'for us. We are going to be a little bit in the middle of a -- we can't go ahead until we get the court order signed.' I am 'not sure exactly where we are going to be on August 8th.. Wherever we are, it's my intention to fully report to you exactly where we are with regard to that $5 million. DR. PAIIL: Thank your Gene. Mr. Rubel has just distributed to you, because it will be important to take this up in a closed session, which we will convene following luncht the minutes of the ad hoc arthritis review committee, wherein you will,find the premises, guides, resolutions and recommendations for follow-up by this agency in the arthritis program. And if you should have a few minutes that you could look at those, I think our discussion and adoption of these would be more meaningful following lunch. I would like to also thank Mr. Robert Tarr# the the HEli Committee Management Officer, and Mrs. Robert Skinner who was our agency Committee Management Officers who is attending this morning, and just state again that we could not be-here and have the paperwork done that is before you 125 without really the great help and assistance that they have given to us in establishing and moving forward through a rather complicated complex process. The papers for the establishment of these two committees that we have been reviewing this morning,, and thank you for attending; it's nice to have you here. With that, I will adjourn the rqeeting for lunch, and suggest-that we be back at five after two. tilhereupbn, at 1:05-o'clock, p.m., the committee recessed, to reconvene at-2:05 o'clock, P.M.,, the same day.] end em WD fls WHD-PM-1 AFTERNOON SESSION 2:15 P.M. DOCTOR PAHL: The Council-will please reconvenes, now that the Acting Director is here. I apologize for being a few minutes late. We continue to get communications from Regions; we -do like to have the 'latest information as we go into the review cycle, but I think we have to call a halt to it @t this point and get to the.-business at hand. I think that -- Judy, just let me ask whether you would,prefer to-give your general comments now, or after Doctor Gramlich treats the arthritis program? .-think it would be simpler ifus just MRS. SILSBEE: I'-- concentrated on the arthritis. DOCTOR PAHL: Because of the schedule, which permits Doctor Gramlich to be here today but not tomorrow, we have decided to ask him at this time, again, to present now in this closed session, the Arthritis Review Committee's consider-- ations, together with a specific recommendation on the appli- cations, and to give you a full picture of those events, and then to ask Council to take appropriate action. Now, in opening this meeting, I would again remind you that the proceedings from this point on are confidential, both the materials that you receive as well as the discussions that will ensue, so we ask that you keep that in mind, and also, should any application, either within the arthritis HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 WliD-2 127 program or within the Regional Medical Program, be discussed from the area from which you come, or if you know of some other conflict of interest as a result of your own involve- ments in consultantships and so forth, please'excuse your- self from the room during the discussion' of that'specific Region's application. Are there any members of the public who are here, because if so, I will have to ask you to leave the proceed- ings at this point. Doctor Gramlich, will you please proceed with your discussion, and in that connection, I have been requested to announce that because of the low ceiling and the aircondi- tioning, it is hard for the Reporter and the staff to hear the comments, so please use the,-microphones when you have occasion to make comments or address the Council., DOCTOR GRAMLICH: I think there are several things that merit emphasis that I didn't pressure quite enough this morning, in terms of discussion.time limitations. First off, just a small subjective observation, which, in addition to the listing of the Technical Review Committee members, which I described this morning, I would simply comment that this wa s a very hard-working, extremely conscientious group of people. DOCTOR PAHL: Pardon me, Doctor Gramlich; can you put the microphone a little bit closer? I am afraid the air- 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 WlID3 128 conditioning unitsat this end are makkng it-difficult to hear you. DOCTOR GRAMLICH: Is that any better? DOCTOR PAHL: Yes, thank you. DOCTOR GRAMLICH: This Committee was an able group which devoted a great deal of attention to the problem, as witness they.went to work at 8:00 o'clock in the morning none of this'9:00 o'clock business, and on a couple of occasions worked until 8:30 or 9:00 o'clock at.night, or on one occasion they worked that late. The Saturday morning -- or the Saturday session -- lasted until mid-afternoon, so in effect they put in three days of hard work in reaching the conclusions that they did. That's a small personal aside. I was there as an observer. I have been credited with the good work they have done, which I would like to assume the responsibility for, but my position merelyuas that of, hopefully, a bridge.between them and the National Advisory Council. I did not contribute because I have no acpertise in arthritis or rheumatology. Now, down to the work. I think it is extremely important that the Council is quite cognizant of the guide- lines that this Technical Review Committee developed, because it was the basis on which they made their ob ective decisions i as to which grant applications should be funded, which should HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202)546-6666 129 WHD-4 be disapprovedi,,and the,numerical ratings and prioritization of the ones that were approved. The purpose of using this format was to make it considerably easier, hopefully, for the Council to do its own job. Now, I have very summarily named off and listed, briefly, the guidelines that they came up with. But you have only just recently received an opportunity to read them in detail. I would first off ask Council whether they would like to discuss these in detail, or whether they feel satis- fied and'comfortable with -be guidelines as they have been given to you on the written sheets that you have? If you want to discuss them, I will be very happy to do so; iE you think that there is no need to waste time on that,'that is agreeable to me. DOCTOR PAHL: Is there any comment by Council as to whether we can proceed? Have you had an opportunity to review these, either prior to or over the lunch hour? I think, Doctor Gramlich, we might assume then that they are in agreement with the understandings reached by the Review Committee, and you might proceed with the report. DOCTOR GRAMLICH: If that is true, then I would suggest, as a matter of-the least confusion, that it might be HOOVER REPORIING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 :WHD-5 appropriate for mO-'tb move that Council accept the report listing the guidelines. DOCTOR PAHL: Is there a second to this motion? DOCTOR WAMMOCK: Second. DOCTOR PAHL: It has been moved and seconded for the Council to accept the-report of the Review Committee in which these guidelines and recommendations are given-in detail. -Is there discussion about any of -- Doctor Merrill? DOCTOR MERRILL: Yes. I have one rhetorical ques- tion which I have asked Doctor Gramlich before; I know the answer to it but I'd like to have it for the record. I assume that there were no sticky points in any of these recommendations you made which you felt needed the advice and concern of the Council? There were no problems which you felt should be dealt with at this level? DOCTOR GRAMLICH: I recall none. Matt, were there any that came up? DOCTOR PAHL: Mr. Spear, would you please comment? MR. SPEAR: 11 can't recall any. There were specific cases having established these specific guidelines, there were specific cases I think the best answer, if I interpret your question correctly, Doctor, is that the recom- mendations and guidelines that the Committee adopted for its own guidance were done so with a recognition on their own part 320 Massachusetts Avenue, N.E Washington, D.C. 20002 (202) 546-6666 WED-6 that these were not carved in stone, and if there were a reasonable basis.to violate them, they would do so, and at the moment,,off the top of my head, I'm aware that they did so in only one case. DOCTOR PAHL: I think it should also be perhaps noted for the record that the guides and resolutions, in part, form the basis for the recommendations for follow-up by this Agency, and in that sense there would be continuing involve-T ment by St aff to help make effective the recommendations of te Committee, insofar as these guidelines were utilized during discussion of any specific application. So the two together are the package, the recommenda- tions of the -- to the Agency, as well as the premises on which they discussed the individual applications. Is there further discussion by the Council? If not, I would ask the question; it has been moved and seconded to accept this report. All in favor? (Chorus of "Aye") Opposed? (No response) So moved. Doctor Gramlich? DOCTOR GRAMLICH: I would then think that perhaps the next step would be the assessment of the list of the"' HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 132 recommended disapproved and approved grants, and the allowance therefor. In the sheet -- or, in the folder which has been titled 'Arthritis," which has been just recently handed to you Now, you will note these are alphabetized that there were --.You'll note several things first off. There were grant requests totalling $15,866,581, for the payable funds $4,275,000, but the Committee, of course, was always cognizant of the need to keep the approvals and the funds recommended within the $4,725,000 figure I'm sorry -- the $4,275,000 figure. Therefore, they went through the grant requests one by one, with a primary reviewer reporting on his or her objective observations, and a secondary reviewer either con- firming, denying or altering the review of the primary reviewer, In each instance, when each grant request was con- sidered, this process was followed by total discussion by the entire Committee. That is one of the reasons it took three days. There is the recommended funding for those approved programs came out surprisingly close to the amount that was available. They didn't realize at the time this was being done whether it was going to come out close, below or above, so they took the obvious route of prioritizing them, HOMR REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666.I 133 WHD-8 and ranking the score, giving them a numerical rating as well as the eollar figure. Out of the 43 applications that were considered, 12 were disapproved en toto; the remaining 31'were ranked, and the recommended funding not ed. I have just discovered a minor discrepancy, I'm afraid, in that on the first page of my listing of the Committee's recommendations, the rank score has been left out. Does yours have the numbers on it? MR. SPEAR: We didn't put it on the first page, Doctor. DOCTOR GRAMLICH: Oh,, okay; very good. So what you see there, then, is on the basis of zero to 100, the Committee's estimate of the qua3ity of the grant request -- on the second page, now -- the total amount requested and the total amount recommended by the Committee. I would MR. SPEAR: If I could inject one comment, Doctor, the rank score is a ranking after the application had been modified by the Committee. DOCTOR PAHL: Thank you very much, Doctoi Gramlich. I think this give you a picture of the recommendations that is, the final dollar recommendations for the approved programs, and before asking for any action on this, I would HOOVER REPORTING Co, INC. 32OMittachusettsAvenue,N.E. Washington, D.C. 20002 (202)546-6666 TtIliD-9 134 indicate to you that the earmarked funds for this program are $4.275 million, and the approved programs exceed that amount. What we would intend to do, following Council action on approved and- disapproved programs, is to notify those Regions that have had programs approved that we are also sending some dollars with that notification, to the extent that we can, but for those programs that were approved by the Review Committee but which go beyond thelactual earmarked funds available, we would indicate that the Region may,? at its discretion, use its RMP funds from the June and August Council awards if it is in their best interests to do so to fund the programs. In other words, we would assume that they could incorporate that-into their total consideration of priority listings as to how to use the ILMP funds that we are making available to them through this next June 30th. Those programs that have been recommended for dis- approval by this Council would r4ceive a letter stating that their application has been recommended for disapproval, and therefore they may not Use PIAP funds for the support of that program, and that the application basically is ended from that point of view. So, with that, John would you care to introduce a motion for the Council to consider? DOCTOR GRAMLICH: It would seem to me the-easiest HOOVER REPORTING CO, INC. 320 NT@isachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 135 WHD-10 way to solve this problem, if the Council is comfortable in so doing, would be to accept the list as prioritized, and suggest to the @iP's that those programs.that fall within the-total f3inding, starting from the top and working down of $4,275,000 be approved en bloc. Now, that leaves a question about the ones that, were approved but ranked low - and therefore do not fall within the funding purview of the amount available. If you look at the list on the second page, the gross total after Albany sixth from the top -- comes close to the funds available. That figure is $4,239,750. After Albany, and before Puerto Rico. You probably also have noted that Puerto Rico has the same score-'rank as Albany. This poses a minor problem, in that if Albany is accepted and funded, we stay within the $4,275,000, but Puerto Rico has the same rank, according to the Committee's deliberations. So there is an element of unfairness to that. If Puerto Rico is added to the list, the figure that then totals out for the funds to be allocated is $4,332,950, which is about $60,000 over the allotted $4,275,OOC I would suggest -- and this is an independent suggestion, that if we deem it possible -- if Council approves -- that an additional $60,000 might be found somewhere which ,would allow Puerto Rico as well as Albany to be funded, and HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 136 WRD-ll therefore would make the following-motion.. That Council approve the funding of the arthritis grant requests within ranking limits, and if all Regions -- all RMP s, including Albany and Puertm Rico accept the recommendations of the Technical Review Committee and Council, that additional funding to include Puerto Rico be found, if possible, from other sources, so that it also would be included in the approved and.funded list. That's long and complicated. DOCTOR PAHL: I think the Council has the sense of your discussion, though, and I would ask if there is a second to this motion? MRS. FLOOD: Second. DOCTOR PAHL: It has been moved and seconded. Is there further discussion.> Mrs. Mars? MRS. MARS:. How does the incidence of arthritis in Puerto Rico compare withalbzfny, and what is the compari- son between population figures? That in fact might be a very decisive factor. MR. SPEAR: That -- we don't know. To the first part of your question, Mrs. Mars, no one knows, other than' that there is a higher incidence in deprived areas and in areas in which family income is below $5,000 a year. MRS. MARS: Yes, but the climate also has a great 320 M-assachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 137 WHD-12 deal to do with it. MR. SPEAR: The field discourages that. They do not believe that that is true, accordingto present thinking. With regard to present thinking, regret to say we do not have those figures. MRS. MARS: Well then,, how can you base it as being equal,, so to speak' that one should have as much money as the other? DOCTOR PAHL: Well, there were a number of elements that went into the consideration of the review, which ulti- mately led to the ranking priority of 40. it is just coinci- dental that it comes out with Albany in the ranking. MRS. MARS: I meant to say in rank, rather than money. DOCTOR PAHL: Surely. MRS. MORGAN: Can we really give them more money than what has been appropriated? DOCTOR PAHL: I thin@ the sense of the recommenda- tion -- or, the motion- that is before us, is to fund througl-. Albany, and if it is possible for the Administration to find f additional funds, to fund Puerto Rico. That is the sense of the motion, and this merely gives us guidance as to what the Council wishes to do, and we will attempt to carry out this request if that motion is carried. If it is not possible for us to do this, obviously I(OOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 1202)546-6666 138 WHD-13 we will then fund as far down the list as possible. It also could be that one Region or another would find it inappropriate to accept their award because of the modifications that have come about as a resul-E of the Review Committee deliberations, and thus we are not certain that these will be the final ultimate ones in all cases that would be the approved, funded projects. That is why we have a slightly longer list to tako care of, which must.be the result of negotiation following Council -- Doctor Merrill? DOCTOR MERRILL: Because perhaps Puerto Rico is a favorite of mine, but would it be feasible, let's say, instead of dropping Puerto Rico entirely, in the event that you can not find $60,000, to take $2,530 from each of the 24 above it and allot it to Puerto Rico? It's not a lot to take away, and yet it would assure that Puerto Rico was funded. DOCTOR PAHL: I think Staff has the flexibility for negotiating within this rather strange dollar figure as a ceiling amount, and I believe we can receive the guidance of the Council and fe el reasonably sure that there is a possi- bility of funding Puerto Rico without actually being able to commit to you definitely, sitting here at the table today. MRS. FLOOD: Also, Puerto Rico is a favorite of mine, but also with a concern for equal ranking, and an arbi- trary line drawn for equal ranking, may I ask -- I would doubt, HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 139 WHD-14 that any Region would turn down any funds that might be offered, even though I find it interesting that Ohio Valley, for example, with a request of $711,000,.receives a recomnen- dation for $46,500, and another marked one, although perhaps not quite as large, would be WisconAin, with $267,800 and a recommendation at $62,000. May I -- there is one other here DOCTOR MERRILL: Look at Iowa right below it. Compare Iowa and Ohio Valley. MRS. FLOOD: Yes. Then there is Mississippi. Might I ask of Doctor Gramlich, how would -- with such extremely high ratings of.these regions above could their funding recommendation be so starkedly lowered? MR. SPEAR: There are many reasons, and I will try to recall some of these to you. Many of the Regions went the usual RMP route, in which they came in on their applications with a full-fledged, Region-wide care-delivery kind 'of,.program, and we had tried to make that clearin the guidelines that @ limited funds, and with the language in the Congressional authority, this was not what we were after; that we looked for pilot efforts. And one of the reasons in some of these where you see such a stark distinction is where there was a very sharp cutback to just a pilot activity. For instance, in a number of states where they had IAQQVER REPORTING GO, INC. 320 WAssachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 140 WHD-15 divided their states up into a number of various areas, and then down into sub-organizations of other kinds, and they had pooled people, activi@s, in all areas of the states, the Committee said: only go for one or two of those and try it out, and see if it workst and provide yourself a working basis which is demonstrated and proved. That happened. Some of them had very large requests for things that by resolution the Committee had decided not to -- film-making, videotape-making, development of publications, and the print- ing of them. Large computer data operations, patient registries all these are much needed in the country, but this is not the program to support those kinds of things. I know there are two or three other reasons; they'll come to me. Maybe if we take a case MRS. FLOOD: Choose Mississippi. MR. SPEAR: Choose MissiAAippi? Let me think about Mississippi has a ver 'fine, very gorgeous hospital y being built in the state, I believe in Jackson, and the application surrounded that installation,,that facility, and as the Committee looked at all the various components in that application, they came to the conclusion that what the program was really being asked to do was to underwrite the first year's operation of that institution. And they said: "Thanks, but no thanks. What we will HOBVFR REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 141 WHD-16 do, for those kinds Of very small but meaningful out- reach,activities you propose'to do with that institu- tion, we would like you to start them now and do them.' And that is what they funded. MRS. FLOOD: But you rated it 80. MR. SPEAR: We rated it 80 with that modification. Without the modification, they would have turned-it down. These rankings are with -- at the lower recommended amoun t, the ranking relates to that, and not to the request. MR. BAUM: Matt, there was also in that one, as, part of an example, a request for something like $385,000 for making motion pictures related to arthritis, and that 'is one of the reasons for the sharp drop in money, since that was completely chopped out of the approved project. DOCTOR PAHL: Thank you, Mr..Spear and Mr. Baum. Doctor Haber? DOCTOR HABER: The same question was bothering me; here comes Iowa, way down the list with 97 percent of what they requested. But I think the explanation is clear, that e '@o the excellence of a particular part the rank-score r lates of the project, and the total sum may be unrelated to what -- DOCTOR PAHL: Mr. Spear? MR. SPEAR: Just an idea, there. You see, you have -- like yourselves -- many people sitting together makiV these kinds of determinations, and it 320 kissachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 WHD-17 142 is hard to tell on what basis a particular reviewer will make his ratings. Sometimes it was the excellence of people who were underwri ting a program. Sometimes it was the'excellence of planning; sometimes it was the specifics of what they were trying to do, in which they knew, by similar activities, or for some other reason, that this was going to be a go ing cbn- cern. All of these things came into it,,and we are not quite sure in some cases what was the balancing factor. DOCTOR PAHL: Is there further discussion on the motion? MR. HIROTO: One. DOCTOR PAHL: Yes, Mr. Hiroto? MR. HIROTO: Does the,RMP plans which were dis- approved were they primarily disapproved because they fit into the resolutions of 'non-activity'? DOCTOR GRAMLICH: They-were disapproved on a multi- plicity of bases. Some were disapproved because the program that was recommended was ent@rely outside the guidelines; other were that it was felt that the personnel involved were not capable of doing what they claimed to do. I think in this guise it is important to emphasize once again a point that Doctor Pahl has made, and so has I-latt HDOV-ER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 WHD-18 143 Spear, that of the approved programs, if there are other RMP funds available, too, the Council says in effect it is all right; if you can find the money someplace else, go ahead with the part of the arthritis program that is not funded. For the disapproved programs, as Doctor Pahl has pointed out before, no RMP funds of any sort can be used -- should be used for that particular program. DOCTOR PAHL: Is there further discussion, comments, questions? MRS. 14ORGAN: I don't know whether I understand or not, when you say that they may use other RMP funds. You're not saying they can use other PI.IP funds for making movies and that sort of thing, are you? DOCTOR PAHL: No. It would be within the MRS. MORGAN: Within the guidelines? DOCTOR PAHL: Within the guidelines. I would like to act on this motion and the come back to that point, in view of Councills consideration last Fe.bruary. I would like to act on the motion to accept the Committee's rank-ordering and overall recommendations, together with funding through-the rank score of 4O.to the extent that Staff can negotiate this or obtain permission to exceed the earmarked level that has been given to us. If there is no further discussion, all in favor, please say "Aye." HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 WHD-19 144 (Chorus of "Aye") Opposed? (No response) cj So moved. Now, in connection with what I indicated to You before, as to our interest in sending letters to those Regions that did have approved applications, but are not.within that funding range, to provide them the opportunity to use their- own RMP funds to support the approved programs as,modified by the Committee, I have had my attention called by Mr. Baum to a resolution that the Council made in February, which I would like to read into the record, so that there is no misunderstan([- ing or conflict between the two Councils, particularly in view of the fact that we have a large membership. In February, the Council approved the following resolution in relation to the arthritis centers, and that is on page 6 of the minutes of the Council meeting. Quote: "Whereas the Congress has earmarked in connec- tion with Public Law 93-192 certain RMP funds for planninc and developmen t of"pilot arthritis programs, be it resolved that the National Advisory Council on Regional Medical Programs recommends that activities in the field of arthritis be recognized for support under Title 9 of the Public Health Service Act to the extent that funds have been appropriated for this function.' HOOVERREPORTINGCO,INC. 320 M-a'ssachusetts Avenue, N.E. Washington, D.C. 20002 (202)546-6666 WHD-20 145 Nowsp I believe it is fair to say that the spirit of that resolution would be contrary to what I have just indicated to you, and very frankly, in the press of things which I have been concerned with, I had forgotten that we had this, and so I am glad you reminded me so that we can bring it to the surface and ask this Council, now meeting in June, whether you would like to reaffirm, if you will, this resolution that was passed by the Council, which would limit then the funding of the total arthritis programs to those that can be fitted within the earmarked, or whether you wish to reconsider that, since it is the Councills resolution, and endorse the position which I indicated to you was my intent, and in all honesty, having forgotten the earlier resolution, for which I apologize to Council. MRS. MORGAN: Could we say, take two percent or one percat of all the others above and be able to fit Puerto Rico in? DOCTOR PAHL: I wasn't referring to Puerto Rico; I was referring to the fact that there are below that, four additional approved applications which obviously are beyond the earmarked. And so it is in the interests, I think, of this Council to consider whether it wishes to permit RMP's to use their RMP money, if-they see it to be their priority, in those app--oved @,egions, to support the pro grams, or whether you wish HOOVER REPORTING CO, INC. 32OMa3sachusettsAvenue,N.E. Washington, D.C. 20002 (202) 546-6666 146 WHD-21 not to make that opportunity available to those additional Regions. MRS. GORDON: Could you give up the rationale for this particular decision? DOCTOR PAHL: Well, I think the rationale -- I am trying to reconstruct; I am afraid our minutes are perhaps abbreviated here, but it would seem to me that that was the interpretation of what the earmarked meant at the time, and_ Also at that time, when the Committee met in February, we were very uncertain as to just what level of funding -- I am- sorry; when th e Council met in February,we were very uncertain as to just what funds we would have to su port the RMP program. p Having-the Court order before us, we felt we knew, but there was also some uncertainty because of various con- siderations that had come into play, and at one point in time a rather large sum was thought perhaps to be better used for other purposes, and I am making a report to you now that some- thing like $110-115 million wil@ be available to support pro- grams -- the regular programs of the RMP'S. So there is a ques@n here of whether the Council feels it important to permit RMP's to support programs approved arthritis programs beyond those which reach the ceiling mark or whether it is not. Doctor Merrill? DOCTOR MERRILL: I wonder whether the Council might HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 WHD-22 147 consider, in that light, modifying the February resolution to say that these other funds not now earmarked for arthritis might be utilized for this upon application to the Director, and with his approval in special instances? DOCTOR PAHL: Mrs. Silsbee? MRS. SILSBEE: Doctor Pahl, I think Councills resolution in February related to the earmarked and the way in which we administer the earmarked. Once those-funds are put out under the earmarked, the Region does not have flexibility. That money must be used for arthritis. DOCTOR PAHL: That's targeted. MRS. MARS. Well, I also think it was also to not dip into RMP funds at the time, to be used for the specific arthritis programs, that we felt that some had been allocated and was adequate and ample. And I think that the resolution should stand, even in view of the fact that we now do have further funds. DOCTOR PAHL: Al 1 right. Is there additional discussion on this,point? Mrs. Mars? MRS. MARS: Certainly there can be somewhat of a distribution of funds, as it stands now, and send it back to the Review Committee to see if they can reallocate. 320 Massachusetts Avenue, N.E. Wasfiington, D.C. 20002 (202) 546-6666 TIHD=23 148 DOCTOR PAHL: I am afraid we dc not.have the time available for us to obligate these -funds by June 30th. (Discussion off the record) DOCTOR PAHL: I think that obviously the Staff will do its best to negoatiate with Regions to fund as far down the'list as possible, but I think we need a clear statement from this Council as to the reaffirmation of the early resolll- tion, which is your point, or whether that resolution should not stand, because I have misinformed you, in a sense, quite out of ignorance, if you will, or of not remembering that earlier point. So let me suggest that, Mrs. Mars, you make it as a motion and let's test it. MRS. MARS: Very good. Yes; let the resolution stand as it was previously passed. DOCTOR PAHL: All right. The motion has been made that the February Council motion stand. Any second on the motion? Mr. Rubel? MR. RUBEL: i'would just like to ask if in 1971 or 172, if the Washington-Alaska RMP had put in its proposed project for $175,000 for this kind of activity, would that have been accepted -- acceptable at that point? Is this something that an RMP could have done? DOCTOR PAHL: -Under the original guidelines, yes. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 WHD-24 149 MR. RUBEL: Do we have-any other kind of quotas that we are using here for kinds of special projects? Have we said in here that we could only use I understood that the essence of the RMP philosophy was to allow a Region itself to determine what its priorities were. MRS. MARS;. I don't think that has anything to do with this at all. This was simply that we did not want to supplement this four million whatever it is -- and take it out of RMP funds. I don't think it interferes in the least with the idea of a legitimate project on the part of any RDIP, whether it concerns arthritis or anything else. DOCTOR MERRILL: Still, with the uncertainty that has prevailed, perhaps between the time of the original application, let's say, for other funds, and this arthritis application' priorities might have been reassessed, and if the total amount of money from out of our pocket was not changed, but simply an intramural reevaluation from one pocket to another, in light of changing priorities, if this had the approval of the Director with proper application, would it not be the prerogative of local PJIP rather than perhaps the Council to have a flat "No" to this kind of thing, without knowledge of the fact that priorities situations might have changed between the two applications. DOCTOR PA.HL: Is there further discussion by the HOOVER-REP@RTING CO,.INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 (202) 546-6666 WHD-25 150 Council on the motion? DOCIOR am not sure I understand the motion. Is that-- in effect saying that p7e can not support Puerto R4.z:o --cro-u fur.,@@,s other than this grant? Plr'%.@l-'LL: He 4-S saying that we would n ot supportl with fun4s beyond @,e earmarked any approved -- beyond e'armark,@ lvel, any of the approved appl.cations.% That is, we would not.be giving the right to Regions.to utilize their funds for the support of these applications. DOCTOR @G-@-ILICH: I put a little different reading, then, on this resolution in February. You know, it is easy to put all@ sorts of readings on-it, since I wasn't there ana on re,7t=-.- e-@ v;.tiat the Council had to saNr about it But it strikes me that the'Council, in its February action-,, wic-re it says: ... be recognized for support under Title 9 o @L -L"-h@ r-ubl@ic H@aitli @Dervice AL-t to the ex@Lent that funds@! ha-@c- bee.-,L. --F or this function." "we don'- know T,7-.;Iat Furds we is Let I s t'.-lese while are- to ha-,:--@ f-c)r. vi-e car-, wi-L-"L,@ut t i g a t eanything else,. out oz- monc--.,-@s going to get, and tha- perhaps ati w---@ -:Iu .7, PL 93-132 and the-mon(--%, WHD-2 that went with it under Title 9 iiithout considering any I SuDsequent possibilities. DOCTOR PAHL: lo'ell, I would suggest that since we are a full Council no,@v, that this Council act as to what it sees to be tl-@.e best interests of -Ehe program, because there is @L.ul-l- b-e'-'ore you as to our current situation and and the funding recommendations, and I. believe you have #the right, as the Council, to make whatever reaffirmation or change you wish from an earlier point. i-IR. MILLIKEN: This is going to be'an amendment; is that r4-ght? No? ltis a restatements 14RS. IIARS: NO, it's merely reaffirming the motion i,iadc- ir, Fehruary by the Council. Reaffirmation. DOCTOR PAHL: '4rs. Flood? 1-iRS. FLOOD: Perhaps being a little repetitive, but, let me --!.ear now in my mind we-are.saying that should'we overrule -ciie policy action of the February Council meeting, 0 s a newer, broader policy statdnien@, nonetheless, i-.-e would '.,'Ledical Pi--ocjral.n-.s to e.,-.pF-nd-Ltures o. c -c. s p @@us @.a4@r own -un" o the ca@-ego--ies o f act4@.v-'@t4@cs au-,rove-"" tile L-.ev-Le-,z in ,,,c 'id riot woui- to go a d a r, du@--@-- -hnr e-.,,@@-Pditures in an rL a r z s up to t,-,e level ',-,-ed hc:rc as 152 I-IliD-27 we would Q-ive them only the authoriz-@on to augr.-@nt t.,ii-mir wF--!!&, trey are above the cutoff. Let's tal@e S07,@on2 else. Lai.ces Area, for examples that is below the cutoff 14 ne. '-"hcv wood only bein a position to use $45,000'of -Lr u.-, d s I-@or that component part of their application. the -.r,,-.erp@4--ation I'm hearing? DOCTOR PAHL: Yes. MRS. FLOOD: Thank you.' DOCTOR PAHL: In other words, what we have is a preliminary review group that has looked at the technical me-i@ and has established guidelines for a national pilot arthr 4 tiS center program. In order not to abuse the whole! process, -we would appl,, t.@.e sar,@e restrictions on all a-pproved Regions so that tt-@y c o I d not do locally -.irha4.-- wasn't really approved otherwise, there would not have been much purpose in -,:o4.ng th@--ough a nalt--4-onal review process. as TL'tc- -uez;@-,7. --re is 4t--ha@- i-.-a will -cry through t-- n-@--t--i-ionz; 4ch have to 4 W 4 -.',le P-,c- g n z; ve ride a L_,a!_: C, @@ar dDwr, c-r@ s !-is as wc care @-.,i-th the full szr@e and dis- c) a o n .@..'.c-,thcr P,:ali'ions V,,ho --r t'@24r but ' , tf _.; 4 - -:7 ,_r, - 'a _2 i- LI J- - I 1 15 3 2 8 where there is insufficient money" whether they may use their o,@. P@-!P funds to support what we can't out of the ear- marked, and that-represents, I believe, the consideration that is before us. '-nd the motion, as I undertand it, that has been riade-and s-econ @-u, woul-"! be to limit the 53 IU-,IP's in the ilot art!-ir4-t4-s center program to those Regions' approved P applications to the point-- where the earmarked funds have run out, wierever that point happened to be. All in favor of the motion, please say "Aye." (Chorus of "Aie") Opposed? (Chorus of "D:,o'), Well, perhaps we might have a show of hands, if you will, please. All those in favor of, the motion, please raise your hands. (Sho-.@ of hands) Four hands. ol- an s' Th,,! motion is not-- carraed. N@.,,, we will entertain a di@rfarenl-- motion. to DCC@ i nake a motion that the @Lunds @z-,r arth--;@tis r,--oject -- that tL@Lcs@--, ar3 ,..Ot aviii-,aL,.Le -@@-om t,.,Lc WIID-29 arthritis Project be allowed within the limits of the recom- mended total, to apply other funds now in their possession to the arthriti-s-project, upon application to the Director of r,!,!P and subsequent to his approval. DOCTOR PX'll',L: All right'. Is there a second to' VOI%@-E: Second. DOCTOR PAIIL: All right, that motion has been made and seconded. For clarification, I believe, Doctor Merrill, you would want to state not necessarily the funds "now in their possession," but funds currently available to them or those Which are to be made available to them as a result of June and August Council decisions, whatever they may be., IT DO,--TC)R 1,@- RP, @L: Yes. Is -scussion on that motion? DOCTOR PAIIL: L there'di- ILTIS. !-,LEIN: M -@er Chairman, I didn't get that' limitation straight in m%r mind. is it a limitation on the aroun-L. ---LDP!4-cd -@or, or -Lhe a.-L o u.- itl-, a IL-- i, Tas granted, us,-- c 4-r ot'-----r funcls7 w- MR. The ariount that was granted, ric;"-A @i Is that w.@lat %,ou mean.@ funds that i,;ere granted. 4 s alD@, fC)r; granted a.-id D '-'C 'T of the Review 155 TET!ID - @IRS. KLEI' 7 Cll, l,liSte r Chairman, that, then, would lie an extremely limited motion, would it not, and would apply really to these last two applications, possibly, because --'Ls it,-,ny understanding that there arc sufficient ava--t-allll-e to fulfi-',-l a'LIL the other commitments? D@l-T,@--a P.--.-TiL: There are sufficient funds to pay all except perhaps -- $500,GOO total arwunt of recommended applications, so it only has impact-to that extent. It's irLiport@ to those regions. MRS. KLEIN: I see. Thank you. DOCTOR PAHL: Is there further discussion? no%--, all in favor of the motion say "Aye." (Chorus o "i%ye') opposed? (No res@onse) ried. The notion is car ;,,"Ll right. Doctor -@ramli-ch,. are there any comments YDu a v,-- or -@'.r. have on -.-le arthritis activity? I u d one comment, mLccli-,,iical r%cview Committee the activities, at intervals an-' a' --c o@ the grant year. T t"-at urc-,c: the Rh!P.Is to Io 41 t-.. S W; tlli- t' li,.i-S of - .-i 14 -- i carry -@' --- - 2 - i @, ;..Le r, @ I i i - II . i i I T-@ WlID31 feasibility. Does this require a vote? DOCTOR.P!!LIIL: @io, I think May I just please pass along the comment that it is -,ol@ for us tc cct a record of the meeting,wi-Eh mult-Lr-le g L-n in the room. It is just a poor ro37, for l@e acoust4-,cs, cr perhaps it's overly sensitive for acoustics, so please keep the individual conversatioas- down if you can so that we can get a record of the Council meeting.- Doctor @.-aml.ich, the Staff, I think, understands through the discussion of the Council and the acceptance of the minutes and so @@orL@h that the Council would wish us to engage 'n these activities that were recommended by the Co= 4 s , b,,, the Co=ittee the Council, which ttee, enaor c@- hopefully would lead 41--O an effective program over the year, i.,,hich would mean that we would be calling together the D4--rectors of these projects, as'@c3.ng_for periodic reports, and an@ give ass4st-nce to them in tho c-- to W s kA as call areas dal-- s-.7-z ten, sprovide assis@ ar,.ce i:i an@,-onr4La'L--e I 4-mited sources for --he production oi: auCiio-visu,-l a;---Is and th@ngs of th,-s nature. So I don't bal4-@vc wc ne@--J a fo.rmal Council action @-kat wa w-,ult'A it c,--rtu--Lnly zLs the Councills dezirc. I WIID-32 157 DOC.'TOR JilNE@",AY: I just wanted -- I'm new, and I would like to ask a question for information. Would.@,ou defi.-.e for me, to make me a little bit I rr. ore coilfc.-rta,')le, about the meaning of a priority score of 207. D 0 R P L I wou'Ld to ask either t@iatt or Doc-cr it's important DC@@TOR Because it's a little bit different!. then I'm used to hearing. ZIR. SPEA7.,": I am tryina to recall, Doctor Janeway, I ust what that meant, and it doesn't come to me at the moment. I can look up the records, if you want to take a few moments while I do that. DOCTOR No, no to I.,M. S'.O-rA@n,: But -- those Regions listed below PuerL- Rico have !-,ad successes, and lesser successes along the way. 1,@-.,iat the Cor,.i,.qi-t@@ce -L,;as looking at were in some cases F-:,.Li L-;,.ese -v,,,ere sozzie of t.iem, certainly in all cases to t:-i-- c ns -'-,h-aL ai c,--,+- s.--,ort to Dut these pro- na-i ly well set-fortii p-Laiis; the -",2 0 9." iz, a n,@ able, t--roucj.-i ir where d, w-@.r,-, no4.- 4@,-i the -u-;-Ii as an VnID-33 158 example, altHough I'm not sure it applies specifically to 4- cas@. -e there w@s an underlying feeling that there Whe@ were better resources there and a better capability than they @ere sec-irg, and it raised a' little question in their minds as to ti-.Ie real- intent and the real cor'r.-in4Ltment to what they i-7ere reading was in terms of carrying out -- insofar as carrying out those things the Committeewas willing to recom- mend. In some cases -- for instance, Puerto Ric6 would. which is a 40 -- in the area of known extreme needs @or this kind of t,%ing -- not that it doesn't have many, many other extreme needs, an-' it vias sort ol a joke among the Co=.Li@"t--e, because in @@he Ce-@-ral Ho-p4-"al of Puerto Rico, ii there are 14 rheu.-,,ato'logists, and there are JzL--ge areas up in.New England, for instance, that don't have that. And as they went through the rest of it, they sav:Lrg: "I -@q4-sh v-i-e could pass out spme of those rlieumatologist" n Puer4l--o R4.co. Bu@- @,,cu t'-n-,c-Lr P'La-,i %@-@-td us @.,ho x-xas 4S going to direct it, and tha. something that, going back I to there @-@is Councills a-ooroval, that is the f 4-rst thing we are going to ask your up tl-ierL-? L@ u t ',-,nci@,@n, thc-- 14 rheunatolog-ists and I L59 sc)r,@,e allied ,Iealth peoole the caT)abilitv was recognized @ii,:2re was s@i,2 outreach in it that-- loolzed like a good thing --o do. But they would have had a'.much higher score i-' '@h@--y had to'Ld us who was going to run it. c-c --For inz--ance,,,ou see, these kinds of things a being adequate for your question? C!12@1:3LISS: Maybe I can Ikelp just a bit there Doc4@-or Janeway. Ranlz-sco@-e is simply a technique that the'ad hoc Cor,-L-ni@@tee use,"' to sort out, and in its sorting out it assigned certain n-ar,Lers to each of them. some of the ones below had ran!:.-ings the 40, or below the 20, and it was just a way c@ 7av4ng oul 'Is work so we could establish a pay-line and '-@-etwac--i all the contracts. DO-@TOP, J-'-@"iE@-7,AY: I understand thatf but the intent o --F h q,-,ezticn @.,-as different than that. DC,%--TOR Pt@-IIL: I understand the intent of the ques -.-70 Lad ber-cre places the 4-F. r,2ach-4.ng on-a of those other action, -hey would have of reco ,,en -a'@at4o.-is established t,,e L-@e rccol-u--4@ons. S,3 o r a x -,le, de-@e."Lo-.n the @,@3t t woL,. I ',iavr-, to be wit", developed by the Committee, which is an answer in support or your question. -Ii conjunction with his quest' ,IRS. GCPDC:@@: 3.on, would tiis @@h2n be would your ranking be sort of'a combin- of an(-- Co.-,,@ittee's feel for their ability 4-0 -,La i-i@@ ? ould ti@.at be a combination DO'-r@7OR P@T: Yes,.I think those were essentially certainly elements that entered into t@e ranking score; yes. i-IRS. GORL'JO,@7,: You.could conceivably have a tremend- ous progra,--i, but yet you really didn't it as much in this area as positively as you did in another, and this then would give one with the greaL-.er need maybe a higher score or Co.-aoet@-ence o' staff to carry out the progran@L, thz abilities of the organization to supervise, to r,.a'f-le sure LI-liat.fur-ds were properly spent, and all these I v%rou'Ld .7h@ no@ k@ow ch element went i,@ t:,D ri c a t score 'u%-- @,,iosc were considcration,@- i c iv 4@ 1 a a.t- tcj Cou.. ta an"' cv@n@,,ia'ly ;,;e will re-@.- to at t.-ic- t- t-,e disposit- IIHD-36 We also will make Uic awards -'or the arthritis applications same official award statement, after applications, i i s%--o,-lncil, that we have for the regular R-14P so that on t'--.e one a-,qard statement there will be shown the 4- 31 4 u.-ids f or' vour ar.-h.-it4@s a@T i-cations and there will be I for that purpose se-:)ara@,a'L@.- 4L so it will be used witlin 4t- i I Again, we remind you that certainly the rankings and the dollar recommendations and actions are confidential and we will be iiorking with the Regions as soon as' we can to effect Councills decisions in this matter. Now, I would suggest that we just take a five- minute break -- Doctor Gramlich? DO,'-'TOR May I make a final comment? I, won"%-- delay the stretch more than 30 seconds. As an exercise in crisis management, this has been very interesting. You must remember the Congress only au@ior-@ ;-zed ti.iese funds last .'all. R:-JIP was -not even sure they were a,@a-@la'-la -anti' -zt-'d-'-Iarch, and -n that interval icj to ;De 4 C W - as ru-- to;@@"iar riave =u@able ir@i-pa:-'- o -I Caro o-@ tile @-.Le--ri-can But itoi7t! -L i-, aqa 4@ -',@,i:,,.ons.trates the p s am' tl-- a@i" of b a n d Wo'Ll-, thank you very much, Doc 4--or S-@)-:2ar, an@l let's take a 16 2 WIID-37 minutes to sL@-retch, and in five'ninutes come back and we w4@ll ge-- ,qi th s ('@,'iiere-upon a short recess was 't-a'-.en. 16 3 I'lliD-38 DOCTOR PAIIL: We arc going to reconvene now with some introductory from L.Irs. Silsbee, and then we mov@ into applications in general. I,,Te wished to take these up alphabetically, but because of the OIL some individuals, not only on the bu-@ arc- i-.-i the audience, an--' have something to con-@r4-'--u4--c, there @-:ill be some departures from that alp',ia-, betical arrangement. -1 am going @-o have to ask the head table particularly if they might wish to refrain'from smoking, because I have had-a request from one of the charring members here that this isn't conducive to '@-lir-king al@out all t-,iese complex resolu tio4-is Judi,,, fly dor.'-. you jus--- proceed now, if you will? -All -4-h- @'RS. SILSDE7: D4 ck, v;-ould you cc-.ie on up? This is the operations part of t-h,3'S@-aA':f that is ZL a eac, t-,- here, and peopi- tend to tal'z i-I zhDr--.".-@nd around .1@ro, anL4 ,cu hear --he name "Silsb-:-a@a' 4- -an@ -z-n and all o-' dzn'-L. s 11-jc mean collec4,-dN;@ -@eal-.zod @,,,e,were go 4-ng riav,@ t-.-!o o a list o-F people -h-@' 3 9 164 we could use in ad ho- review capacity, because as you recall,' I Council -lovelier ha@ to do this themselves, and in F@,br,,iar,, when ,they were faced with this Drospect, asked Doctor Endicott specifically for a first-level review to help tl-@em, so that C-o--".-.cil ccu'Ld concentrate on the policy. issues e And Doctor Endicott promised to do this, and we' were operating under two possibilities for quite awhile, But! in-contact the people we explained this-. it was importanr- ror this review to have people w@io knew something about Regiona 1 Medical Progr@-rs-and had had experience in either the Review Coi-L-tii@@tee at the national level, the Council, or in Regional i@.edical Programs. In the material behind your Agenda is alist of individuals.@-hat were contacted and i;ho are going to serve on the Review Committee, which as it turned out, did become a Co.-.mittee. Three of the members that were listed on there %,,,ere unaj'-,le to make it at the last.-minuL@.e, but we did have 23 reoplc- 19 c)-@ origi,-ial list, PI-us 0 rA e: r a r cn, a a iri@-,wer, L@o &@-al pr -@ra,7c amp lications, it b,@,came apparenl-- 4L--i t'lic three days -Great we lia@@ set aside that it coui-,! nof- as a tot'--al during that entire so t'Le fc-rr..ar- '.Iav@- c,-oen as a grou'@ 165 4 0 to discuss th.@ general policies under which they were going to' be o-erati@-,g, and we broke into two panels, with the Regio,.n.s that were served.bv the 5outh-CenL@-ral staffs and the id-Continent sL"afFs in'the one panel, and the Regions served m by the Eas'"-erii Opera@@-'Lons Staff and the @,7@-stern OlDerations Sta@L'I- in parc-.!. Ess@-lit-'-Ially, this was *ort of an even group. The first pa.-lel i..,as chaired by ?Sir.. Chambli@, and the second'by Ilr.-Peterson. Each of the applications had a thorough discussion by its respective panel. @Lhe applications have been sent to two reviewers, and they served as the principal spokesmen for the Region, but-- -the issues that were involved quickly beccx.,L,.= '@-he C@-IrLrLtil---Lee 4-s-@uas and were discussed, and each Region was discussed by panel. Then on th@ dav, one @anel ',-,ad chosen to go o7,.7er s r- i re of reco7-@-andations and make sure a i,, o a U,.-L-cre.--t J@ashion that t---.ey @c- t@,iiav c:te,', @n ci. for as C, z; c; Z. 'rie @@zer tiey c:---lai-giad e r bas@.-" c-l-. r f-- - t'- c @'i @,,)r-tor Pali' E-z anLi ,icam,- L@--te pane7 5' and their 166 WHD-411. At '.hat point the two panels recognized that one panel ha:l mad some recoi%-non-dations and they began to wonder if so@,.e of t'-.3se racions had been in their panel, whether the sa.-,,e .,;--uld have come out. But -in those an -.n--14-,.ri--Iual thou-,Tht there was some'discrep- P-n--Y, -:-ssues were discussed. m@he Cc=.,Littee as a whole did not make changes in the panel recoi-,inar,.dations, and I belie@e you have all 'received both the coiazosite reccrr.L-,endat;.on8 and the individual recon,- n@endations on each Region.. That constitutes a review process.! Noe7, this afternoon we originally were going to go '@hroug'.t Regions alpha"-e--ically. But because Doctor @--c with us to-lay, and Doctor Gramlich to-"lay, and @@or a cou--'-,-@ of other Regions that have people'here today' I we a@--e no@@ o us@- t'-,ia@- rel,hcdology. We will get through the ones tha-" Doctor I,,Ierrill i! and Dc--@@---: -@-t--a,.ilich rev4-e@,.ied; we oii-ll tl-ien include Inter- t Sou@.- C=rc'4na. @-h@a order in which we go.today: a C C7,,.rol in:-. 167 @-71ID-42 South Dal-ota; S. .'"7'@IS: T I uld you roind reheating those, please, R Judvl> i-lr%S. SILSBEE: California, Georgia, I;ucrto Rico liow, 'this is not alphabetical, because Doctor @lerril.1 isn't leaving alphabetically. %Iississippi, North Carolina, South Da.,-,ota, and South Carolina. just one general statement, now. In bo,@-h --he instructions that were..sen-t to the t ed.-cal Prograi,is and the instructions that were s n -giora' .@l to @l-e Cj=-: tC -_C, there were certain material@ that e ci 1-i i i a a n cl w@-, allied -L-he IZ---gions to nrovide information! a c c r- some 4u@--r@ent alon- thEi-@e lines, an@l w@- aslzc-,-' individuai - a rating sheec 4-0 give us bzisad o.-i cri't-eria. @z)intv-to rea(a oul@- the on each i.LC@-11, Lio 4 t-e important to 'I, - . . I ! i I i .I i . I .. - 4 3 you at this ?c)-Li-it: Progra.-,i leadership, Progr4@it staff, Regional li'@Avisory Group, c@ast @erio=,,aiice and accomplishments O.-jqc@-ives ar,,d'priorities as outlined in the appl!Lcat-Lon. Proposals. Feasibility. L4L'@-elihood tdiat these activities and projects can be successfully implemented with some results in the -4"- 4-me and proD--Sea. CHP relationships. And t.'.cn the overall assessments. No;;, our suggested -.@ay of moving today and it is up -@o Couricil as to you will procF-ed this way is of the i,@ e dto have some general statement on the Pcgior, aii,"7 C t L@-ee act-Lon, zi.-id because-the material i@c sen@- -to you s;---nt at 4-=u--h alate date, I will ask each a sta@--c-.qent on T,-i w ask re-@-'Lewe-- of Council L ght to Car--,, on t.@e I-SCUSS4zn, and i@ t,at 'orTiat s all ri -Z vou, 73 r C.) e u,@ -,14 Cali;.-c-,r. -a: '-r. R, us s;-@'i 169 .1',D-44 CO U'.ICIL O',.z REGIO:",U @IEDICINL PROG@!'@:- CALT FC)R"IA J.ZEVIEW 1,L@@ SS,--"T7r: Lc-l- the record short that -74r. Hiroto lias absented 'Lrc,.-,i the room. CorMM4 t tee on Reg California ional medic@-'L Procfra-.ns,as sho,.;n on the green sheet, was rated as above average. Regional lledical Programs. In all the areas that 1-irs. S2L@tsbee mentioned, %-.he program was rated from good to excellent--, Keith exception of the proposal, vrhich was Feas @l 'Y sa 4-i-s @Lac L--o"ry. Re 'L a kl- i o z-. p s CHr- average. The sk--aff is s@.ro.-.g, very active. The -Lsory Group is a stable group and -does -ecord regar-2@ng co tinua- T'-- a a q o track,-- n t4 San i@l: Da@, area.c-= a e,-, i't n 1-" with th@- Dapa@-y Direc,"-CZ7 j U -7 a these areas a --r abei rg aldre@-.,7,,@ r anci di-1--rcn- s. 171 which. are' critically important. All of these things are co.-i-.a4Lned in hei:e, a.@-id were really a trari-@ndoug helT), and I thin'-, the new system is going to facilitate certainly our wor.K. 're; oz: you -,ier-,ber the classic example of-Puerto as ce i.,,e principal reviei,7et of that, and r- .-ainl-.- or.@ 7za-,c-r, it 1-oo,-.ed just awful. When we went down and 4 found out what 't:-ie real storX was we found that it was a very. good proposal. I think the kind of thing I was looking f6r previous..y is all in here. as far as California goes, I have read it, I- havc @-lar'm-ed sor,,e questions, things that I thought were good and at I thought were bad. I did this before the other s h e L-- sar--4-ved, and 1 found that most of the things that I ',aad;i marked were in aureement :the other reviewers. Tileir overall program, re' ort, for those of you who p havoc-, t,,ie big -@.-@'-,iich begirs on,page 123, I think, explain@ 4- e7 'pla4 wha- Lns their structure, it for such thii-,as as ;D r o,-, r a i @7, siri Monitoring of op;-nret-Lons, and for review and Dro--@-ess c.' a@pi-ca@ion proposa's a view to -v c Qro ec t -p-cposals while th@@" o 'T.1 7@ c@; (D 7L qua@--- a L Ca 7 @,@r- -a, the record 172 @.47. of accomT-,lisl-'E-ien+--s, which is listed on 134, I think is very car! out, it-- see.-.ad to me, with some of the tons noted by the Reviewers, which I gather are being corrected. They've done a good job. --he P.-czosed Prograirs, which you will 'Lind on page 'L-@7, for o@ U W--io hav-e it, seemed to me quite reason- @-a%te, Lo -- instance --'well, before we get to that they have, for instance, emphasized the thing that we thin4l. is,so -@n@iDorL--ant, the continuation of project activities beyond the period of @.,IP support. S6 major project activities have terminated since I iu'Ly of '7"@, and of these Sr'i, 76 were designed as on-going I.-Aave '@-een continued by other sources of funding.1 T,.,-,at seems to nie a goo-4 tra-k record. T"4 regard Lo the4.r proposed programs, tiny seem 4- -L --ted to the a4-rs of ILNIP; one of them to m@e has to do w4@4--h manzowe@-, T not'-a, as again did the'--evie'wers ard you that I -this note- before t saw so -,7c cartaLini-y are in the sarc hair@- a 1 a 0- ,ncre a n a Tore @.han a hundred colleges an-.' universa'.- e s o,:-, d I'-' t-a s d c 1 i n c s a s -m s c f t h e c on s to Ol-,. --ional --,3u@-I a b c, r e s- -L:rc-, cci-.trol, L - 1 7 4 probabi-v R.-.ore ef=cctive than it was in the past, in terms-of ri of k--h@, activities. -iR". S7L@ IE: Doc-or !T-rrill has been -- has made a o i and it has been seconded, to the-effect that the D--2 approved at the level of $7,-353,OOC) ussion? e-a cast Just a simple question. I would like to find out how it is that California is in a seven million dollar bracket, and others are three million? I wonder if they had any inside information? MRS. S-LLSBEE: Historically, Doctor Watkins, the Cal-:uz----::nia nroc- s, -Ince it has about 18 or 19 percent of 'the' popul.a@@ion, has been @lun@--ed at a fairly high level. 4 S p.=Ir-";-cu'l@ar application represents continuation, Y. MR. That is correct. S- All of these Regions will be coming aD;)Iicat4-ons -o-- iL-,ore --Fu,-L-"-s at another -e s-c, on. e e is aconl-i,-iuci@icil qu 3 r uo 175 WLID-50 COLT@TC NATIO;@.AL ADVISORY IL 017 REGIONAL MEDICAL PROGRA@.!s VIER G E 0 P-, MRS. SILSBEE: The next Region will be Georgia. 1-ir. Van '.ink I e? @-7ell, I am only going to give a ze.. h @-c,,,, gh t--,. e-rs had nothing but good to sa- f or the y state of Georgia. The reviewers rated this' Region as a superior R-@egion; they gave it excellent remarks in terms of its experienced leadership, its strong Regional Advisory Group, its co@=LLittee structure. The same blessing was bestowed on their experienced progra-ii t@'Ley noted they had good CIIP working relation- s-,-,ips, and considered to be a'well-@-,ianaged and well- aa7Linisr-erc'" T-lel-cal r-l-ograr,' Georgia had reques@@ed $3,629,757, and did not pro- y pose o core in Ju'y 1 for any further,mone s. Tie Coimai -C- -co=e:l -a a-p-roval a the requested level. re Doc-a:: 'I-Tcrr4 a v that rczcr'-, 1.) ronc,@,- a 1 s I %;,as not vie ht,. prcci-zic,-., and possi'--ln- sa-,i-.,@ dcc-L--c cf their 4 to d@3-. to begin -z@, a -,roposal, 177 WIID-52 DOCTOP, 'IERRILL: But this Section D says: "It is anticipated that ten hospitals will be sel@e--'%--ed -@cor any requests to develop..." i@-IRS. SILSBEE: Mr. Jewell is the ODerations officer v;.,L-,o is for Region. I wonder if you could cive us sci@@.a -,rs-,ghk@- here? JE@-1-@LL: Doctor -.Ietrill, this morning in the mail we got some further amplification on this. Would you believe it? I have a letter dated June 4. 1 have it here, and I didn't want to load you up with anotner piece of paper, but here are the ten hospitals. They sent out this reques@- for proposals, and here is the list of going to fund these activities %--hro-@,-h pro@osed to furd t'L-Le@- activities through. D O'@' r-7,OR :,ZRTLL: Bu- nevertheless, what I am readings here is type@ u-p as a proposal from Gc-.rgia, not as a guide-,[ 11 'lir@e sent to Georgia. !,Tow s@-e a t-ne -reason t'--.y tal.',, about these e n hosDit+-@is, bu4@- s -Lil lea,@v-es four paragrai--',-is ivli i c h s @c as may wcll a v.--. "c e c u r i- n L, c o a r@ d ser@l- -the@L bac-- to you. you are Doctor, is pro- poz.;c!d 'by a V,7e d--n'.t ha-,7e any guid.olin-- on that pat4L4D.'.'C. care. DC;7,TC,7L -L J--. L Til-,.a'- is exactly %@iiat 1 am sayi,-,;j. 178 1-71ID-5 3 7,rught Lee was saying these were the guidelines They are guidelines that 0 o-,:, to @'ic providc.,zs within the State of Georc,-ia. S!Lc.BE@-': Doctor !.Ierrill, I think perhaps the i on the a?p lication frora Georgia might be cr6er. This,progran@ in order to get this application in, they -wanted to have a year in whicft to do things. It fics under-1 did'propose this umbrella operation, with the speci going review after we received the application. I-,,-.qat 24r. Jei.;ell has there are the specific areas in w.iich this ack@-ivity is to take place. DO,'-,.-,L'OR I.I@ERRI@WL: All right. @ie!'L, I will -L-he'n say only thal-- the coTu-,ients I have also to 4--he application '@Lor stro',@.e, cancer and ki(2@-@@-ay, ar.,"@ ga-@h@-r that this is the reason t'--.ey did, and yo-a@ are all sat--s=L4@ed they are coming in with good speci-@ tt c 1 d c r agree -c,'.ie recc,,@.-arda-ion. S. .forga"i, a that is you i-.Luri CTOo i: progr c-,7@r -"Iii-a and s7A-Laa@-z, I- second r r i s i-.o G y o,.ia c' a r. iD,@ -i ? r@a":c, a in io -a t t:-. -n ac 179 l@71ID-54 in the amount of $3-,62-9,757, which is the same as that .RS. .1 secon,4 this notion, and it is on the b,--s,-s that-k-.hey do noL-. come back in for our August meet- r, g 1-rore fu,-i@",s. T'@,.,is would carry them through. "Lha y h a v e a Ccordina-@Or v7.%o has been there for s@r-le time and is doing an excellent job, and I second it. I-IRS. SILSBEE: The motion has been made and seconded- that the Georgia application be ap'proved,at the level of $3,629,757. Is there any discussion from the Council? DP,. Gr@-IL-CH: Tei.%at is meant by "target figure" on the ycllo,@7 sheet? $@@,522,000. -or Gram"Lich, %,.-Zen we were sendirq. 71 ST@q-EE: Do'c4L. eSe inS4-rU-@ o u, t in March, it was thougl%-.t tD be import that g@ve t)..t some ballpark figi;re in which they might Li a-iply LO7-- .,u.nds. We too'jr, the 173 level, and I won't attempt c, r 7 e at Ga.-,@1611 could do t and t-i,,2 amount o@ Dase6 on Y, took lfivn t t' be sor4- o-c a targe s @u@@ a La! Doesn't ireai-i any- was T,l -%--nur ez--rlicr m i n,:7,1, voti sent us ISO hen the I,-,_Iical Progran and the panel and t" G@arzill asse-sr,.Cnt, and the Review committee re f the r e c c r. @l a to ,i sand t'-,.at reflected a percentage o request that was being sugges@,c---'. r e a-e se-,7;--ral in here thal- were called super i c. - a t Fre n(i L, loo pen.-cen-. of their requests.' Is thi-@ baca,-,se yGur revi-ew=rs may have been on the different teams, or is it for more specific reasons? L'-IRS. SILSBEE: I think- we'll have to talk in terms of the specific reasons. I think there is no overall prin- ciple you can derive from that. !:-i t'L-;.e case of Georgia, -,he reviewers one of thci,,l a,! be-@n on a visit to Georgia, so understood the whole o- @.ai- pro a:L- dev@ lo@i3rL i- gr i@iiic'--. has had a long history i-n ji ,-IS Oi- L-ne area f aci thought --he -programs te 047 t -nanagt--d, and in terms - ae criteria they were @,;as w@-11 L opc-rat ing acainst both o,-F @-A.Iought -@t was e:-.cellent, a 1 t'--a -L. 1n-s w tT4le 100 -Q--rcent figure came up@ -ou. L,SCUSEIOI-,. tn Aar All r i t a 'L, I@@n --'avcjr o-'-: @ie Lo approve aL Li7i- leve.'L, !;ay "!.re. _iorus or @le", 73 WIID-5u- "L'ne mi otion is carried. 182 'iL PROG@'U4S NATIO7.@,,,.-,, P-DVISORY COU,'iiCIL ON REGIONI@L MEDICI REVIEW IIRS. SILSBEL: The next one is Louisiana, and this 1 is Louisiana was an interesting one to r-.e, again not having read i k-- over without bene,fit V 4 e.U all@. bf '--he r-- the staff work, I thought it was rather a good program, and that it hit specifically at the areas in which Louisiana was weakest, and attempted to correct these, and it had some speci.-ic methods by which they proposed to co--rec-- @,zL@.,@-ch I thought were singularly appropriate, kno,@iina something about Louisiana. 1 do 'Lrom reviewing the previous II LUU--,Ls@ana r e a s -L"-.ere wc2--e some I--,ersoi-ta'L problems there ..@ere lcr.-.s -k"-ic:u".ar'l-y with integration in the Pr -,,-a O. sec@--or-4-nto P@l@ programs, and I donl.t see perh --@ca.L@y oncd here, -aps someone could co7,-,Ml@-lit g @7ou a Overview o'L group.-- :@a:. to C- n cazc ited y C Li a, a t o n u r i: Ca -a! irc, av-@rac,.@-, an@l vye o@,-ai %-3.ro- e en" WHD- 5 8 183 application and had graded it individually, and we-came up wit.@ a comoos4Lt-a-, score. Lou4-siana has never achieved'a triennial status, and ap-,oc-ars to 1,L-Lave content in past to apply for the lit t-,,@e oF crant c CeLord-na@or has L-eeii, up unt- 1 recently, serv T i@nq on an ---5 De-!--cant '--asis; as of July lst, he will b e r@ Increasing his to 50 percent. The Regional Advisory Group has several outstanding! rie.Tbers, particularly its Chairman, and its Evalua-Eion leadership. Its t-@aclz record in t@@le area of management of fu.-i@"@ has been goo@-, and ',ts unexpen-.1--d balances on previous grant awards have been rela-%---'-Ive'Ly nil. .Lhe grari--=-e 4---scl-f 4@s a not-ILor-p---cz-@ Jt-- organization -a-i hoo s, and its indirect costing has in con--rac4- to m @--cal sc bec-n The e;n-- s c n -@-hc. R@-vi@q --cra-i4-ttn-e approved the s t 0 C n e@,senc--.,_ pf 0- 7 r i r,:,- s-2r-,.@i c-@s @o -scope U 1-@ 4-0 4- prescrt t4-, d-n, 4- C. rill. -cu-- -d d T,T a@-c-ars to 4.@C -Lo bc the real St rength of that pro @n@, 4-nL-,o too o- --'.,cse things, they m-.d; cal education and physi- a L-i of 'Linding out with the r_c. t@niness s@ayed in Louisiana, whv they =r,:acialties they do, and how t' c. go in--O cy ni@ be persuaded to go into specialties which are more necl:i @C-d. And t:qat-- certainly is singularly appropriate for Louis4-ana. They Iiave a program on the assessment of quality medical care, which certainly -- and consultation service, W',,ch-certainly is because again, as pointed out h@-re, one of the reviewers suggests that L. e -,Ij, -Aav@- 4.-wo 'finds of care and t-,-.a-L- LI-he two don' t 1, Cj 0 -Cc @el--ha,@s LI@@ :Ls re@Lorring to the problem which brou;7-'-i'-- uz) ea--!-Ler; is correct-.-' @ec@-i done to y a lot rather have ",r. Zivlavsl:-.i Coulci y o,, i c a i4-@le mo i: r-, speci.- 'Lic? 185 I,IT.ID- 0 DOC@@ OR @'.ILPRILL: Yes. It was brought out a',-- one of the Council meetings -,,-,u.Ls.,Lana w as that there were two i,,iedic-.1 care; one for the indigent patient, and systcns 0- e-- r,@-iT, clinics for the more affluent t-l-ke o-i and %'-.iat t'i-Ae so-called.private doctor did not n; a c -z! r s e,@- eye to e-@e, and indeed tended to resent the activities of ICIP'S. i@-IR. ZIVLAVSKI: Several of these project activities here the new ones, specifically 55, the Earl K. Long Char-Lty Hospital this is one of the activities on-a new proposal; project 54 is a Charity Hospital of New Orleans y. Project--'5- agai.-i is Earl Long Charity @iospital- act v Pro4-c- 49 is tne La@a-,re-- and the main %@..-Arust@- for tne indigent in %--iie inner-cik--Y is La'Layette. In project-- 53,. @-hey are tu'Lizing abou,t.the inner-c-@.Z and t:ie d i g e 4--s 'D 0 a rt,e; -v.-hat- pa,.ics are these at-, us%-nq uiie pope n,@,,bers G.-,_ tl--@-- page c t YE@@L'!cw sh=-c-@. The s-@aL@rL s-c-,ra,,iary on h c @-e'Llow D 0 C'-,- Z 1 F, T L 1,4. a -4 's all r@@gh'L-; 4us-. i@.,ailte-d 186 !,IP. ZIVLAVSI@I: Looking at Louisianals history, these near proposals pro!Dably reflect a change in the leader- ship of the @-,6G Chairman, and more of an outreach in the rurali cor@jiuni44--ies o-' Louisiana, as well as some of the indigent the c-'_tj@-es. '-@hinl",, are some plus marks, w'.-iere previously.,, in zas@- liaver.' had a good track record in the cities, because of what your,-- DOC'"LOR L@IERRILL: 'Yeah; now, that is certainly one of the nlusse5, and I'll those that you have. I -L-.hirak-the Lafayette plan is particularly good. I th 4- rik tiie --'-.S, thc--'agii-risk neonates, the transportation s y s i for the ;-ndigeiik-- -- are all things v,-L-,Lich are eminently i approp--@--ai--e -Lor Lou4-,slana. .Du'- again, -xy concern are -L-v.:o groups 0- I p.-A y s i --'La,6-,s 4-ri Louis-@ana who do not see that these kinds of prograias are 4@ntporL@-an@@ for the ind--'Lgen4L-- of Louisiana? And c.,-)u'd I a bit c@-i this t c '@rA the r.@, i o--, th-2 Statc of Louisi,@,r,@-,. T:hi t @a k.-, i o a r-, a z a-r C p ZO, 1 Sys t C"Losc to 7@ @lcur 2..-i an cTerit poor zor carc, and I VC@ i c IL t,.D t.-i c s @D s 7, 187 .62 thrc,-,g"-Iout %--ha reviews of the Louisiana ar3pl.4cations by both the -w Corc-@,,,4 and C ui-i 4 Is, this has been hard-hit 0 C- T! overall pl,41ozonhy ol the state in having this as Fear as dual sys@-@,. a@ is iio-@ to say anything at all as far as to c 'I-.a r i L-Y s y s @-,m but to respond question: ha done an thing about sr, o ,ou- ve they th 4-!j a--re 'they doing anything about it? The ex-Surgeon General, who is living in Florida now, has been elected as @-h-c Chief of the D-cpartnent of Socia Services, wherein the new reorganization, the charity syEteri 'Li-t--s in. Specifically just v7here, and how far that would l@-aa into the -future is con ecture on our part at this time, but hon- th-4- an=7,7ers question. !,,'-@R.RT'L: We' I think and par@4cularly because of the thrust of the burdens of the new pro.-rams, and @-i-ons about L-.'ne pc--son,-iel, I would a,@ e al-'-Lho--l--'Xi no-L. as en---;-;.Usizi@-t--±r-ally as the others ar.,d a --ecc,:i,:-.enda@-i.c)n t-.-iat t IC @u?.-, e. d at the -Full @o,-n y ,c:4 I vcu a-,7e an S :r, 7L -L 0 C) r u i-@ o -ZD:- at zio. Tilc sarLe Ct'-,@s=ns Come to -)ctor --@u don't have a Ti-' ,air niin@l as d-c.@ to D, 6 vicia-tio@.-,i, or anvtlii-r,.-j I t i 188 V;IID-63 i'll.@S. -DTISBEE: t@To. DocL@or Schreiner? DOI.'TO-TZ I just wanted to make a comment that although those charity hospitals are separate, and they --usto.--tar.-L'@-y reaara a orivajL-e sector, they are very closely d ,Lxj u -'@ s -L a n a S@-ate Z..L@-dical School. was,jus- gone. to, saythat I am familiar with sote of the lateralization of the charity hospital systems, and 'this was originally-designed under state aegis to follow -he horizontal east-west main transit line across the roads, tl.-Lat tied trade areas together in Louisiana, from east to %rest and this h,3-=Pital -zyster.., ir@ile it's true it doesn't tie into thincs the C,-.;.-rer Clinic in -Lulane, it does tie in very C'@os ly to State schools, and there are rotating louse SL@a"@@Ls. -Iere are @u,@a@@4@na fu@LIL--Lir,-e @-acul@Ly members to Ln eac,']. so that b-yl coripar-@son, the t,-, are un--'@-r 'Louisiana S;@-atc- School, dc,--@ -c t i rik wouio s la,@- 7 er mu c 'II by comparison. -hans, some o' t"--7- L class arison, je@- e c zi C-1 C) @n e d c-- - T- a' @,self to r, 4@ia M.Z IT, c r L, poi-i,.t T 7 a Gcorge. -at ciie- o-c @'-c! z e @.i "-,a t2 s in -7" c, r o .7:" 4- c o is a E;ir..: ;qliD-G4 kind o@' torri,--o-@y, has been their enlistment of private S4CianS phy and private hospitals in cooperation with these other ];.inds o@' activities, and that, I think, has not been trLie of Loi-,- S 4 i L-- is pretty tough on the p 1 -@.ese peo,,)Iel.-are on the s -L--ate payroll, and tL'ie@v ar@-- on a 'Lull--time salaried basis in thd hospital. .-It would be pretty hard for a private doctor; most of L'.%.@-se doctors arc on a full-time salarv. SILSB"-E: Doctor Merrill, would you like for us to as)-, t'.ie Reg,-on to address itself more specifically to .L. Ln their Li'ul-%? application? In ho-4 they see this work--L ,i g out? I L: h4 since the question has D C. it been zL of times, I think it might be well to a.n4- T@ certF--@.-,ly ,,ould li',@e to know il,6 answer. I -v:hv the question has not been raised in g--.aat -@ervor, un until c. u i t c he answered. i don't '.'-C li-IaL,e a '@'LC) tC)n L r. e d s c o I 7 Z.1 tl,. -tee recc:z, n@ el:a C, r '-at 190 @FtID-65 !IRS. SILSBE7-7; The motion has been made and seconded. Is there any discussion? Al-, in -7z-.vor? 'Ch:)-----s "Aye") response) ,he motion is carried. 191 I-IliD-66 -1 VISCAY COU:CIL O,' r, T-'GIONIU @EDICi'@L PROGP@,!S -0 RICO P%EVIEW PUEPJ. 14RS. SILSB'@",E: 'he next one is Puerto Rico. L w7.lo is the Chief of the ',as b.ee-,ci called a;@:ay because c-@ his fa@.,--::'s ar,@ so 1 am going to wear that hat Zo-r I 4- a -,Linut--. -@But since Doctor i@,lerrill and tirs. Flood are much more expert on Puerto Rico, I am going to defer to Doctor r r "ERP DV-CTOR ;.,I I T L: 1, as you know, i.,-e site-visi ,-@d 1 Puerto Rico, following a very un.'avorable'review, simply a!-one. We T- ver,7 pi---asa-n+--ly surpr4--sed by the of the s+-a-Ff, bv t e -Y C.L the Di.re--tor, and. ri I par'--4-cul-ar'L-,,,r of --he Associ-al@-e Director, at that tire, and 4L-,qe lov-altv of the and particularly by the number and c @@ere in-c-rez+-,d in the progra-i. 1 are i@,k the f i too -- a s c. -L- h i s v zi z ac,,@, n, c-:-zac--ly -Lo th@ 'i@-@rds of things -.@.ere needed in P u e r 4L such a emergency health aric7i @tani-@o-,q@r evalu=- t.:L o n o-@ and thi:-iicis I a Service,, in WHD-67: 192 hospital health services, rather Ryder !.'Lemorial flospit@-a,!;, v7as asso@-ir,-,"-ed area government health center, and although two n@w hospitals were being built, they made every e.L.Lor;@- -n the instruction and olanning of the administration, to see --he:: no ciu@lica"-ion of services, and these s-cl-;,,,-'Le.:.,,ented each other. L- puts on paper soi-e Ess@-r@ s grant reques'L. of the things we saw at that time, and I am enthusiastic abou@ it. It apparently was called above-average by the reviewers, but it was recommended that it be.funded in full at the rate of $6,1@5i862, an-,A I would agree with that. I v:o u'- d to ki-i..3w if anybody could answer this CIU_S-"40n On S@a@@: or rio@ sci@ie of the staff people %,,7ho have I:-al-@t th@ cr-:,7@c back in an- cipation of @,s, or will come bac'tc? You rerie@.-c-7- iat one of the things that strucl. us was that alt'.-.ouc:h so;-,.-te o@L the sta-'f had wor;zed very hard on had -@;h e r, believed -"'-tat --Fl-,nding was not ze aae-4a-ze, @ai c-D:,,e into c)taer Doi)s in trie w r;,. -or hourz-, w 4- L u arci many c.L' them had tc; coi-,c ',--@ac:k @-u'L --tiTrte into the 3rogr i,, o micas any arsw@r to their-? 19 4 WIID-69 s a,.,7 t'@-@ 1 s a.3 ;ay o-F doing business in Puerto Rico, and did not, as perhaps i -a c i@., ot'-Ie@- similar situations wl--iere the have .'ad concerns of two kinds: sL@-a-'f, be--a-aso. they don't -- except for c) E. t a c c c.@,@ s c.-Jase red, write and blue dollars ubstantive concern. c ",!,a .@e ccr@-a@ril_y didn't have a concern that there was rIP-0 S a f' oriet4-;-tics had been -- also, but again, this is based o--i i.-I.lat I cfticil--ly recall from Bill Furman's review; he been there, ar,,d I have less Irnowledge than you and Gerry, bu@- h--ving c.-4aired the panel and listened closely, Bill @ias suci a forceful and picturesque r e,., e r -s. i-io-- @-Oo d-'_, '-'-@i-culi-- to recall so.L-,,e of ais co.T.- ----&4s -,oint specifically to this point, t-aa4-4on actually; R R L L lqell, I saiq that si as an ass--, iecause it meant L@.hat-thev @-iz--re available, and ID -cr --t d a bit t same prc@!,:,- i-I..c.:-.ber-@ c;2 s j@, az,,! x-7.-7is concerned al:)cu-,@ i- n z,-.id lo-rgo 1--h@ir sta@'@@ lias re-ola-_ccil I did t--,D 7 a i,, ci it c 195 @'ilD-70 I-IRS. SILSDEI": I,,Ir s. Flood? @,@@IPIS . FLOOD': I might add some explanation. They havo a 'Lang-L"'-iy li'.-,t of staff people in the application, and as 1:'.r. Cl-iambliss comriented, there are few faill4@.liar t.-.erc, but there are sorie new names, and. we -Y Coordinator.up there now. I,-,e dc) not av-z a Dar@--'-.4@rLe DeiDu4t- have a Ass4.si@-ant Coordinator, at least by virtue of this particular core-persorinel breakacwn. They certainly seem to have a full complement of staff, although they have a few positions vacant, and some are at tire health educating level, and one, a secondary associate coordinator s'LoL@. here, and perhaps that was where But L@-he-- ce---Lain'Ly see.-. to have more staff than li-.'r-.e to reiterate Doctor review. Thev are involved in concept develorjrti-@-@-i-c @-.-erer ana have 4 -0 L 1.7a@ sector E- ley hav. @;-,l c- a-- c- c al Prcc @L e- r as s s n -,ir co to c 1-i e v can t '@IIID-71 I would second the recommendation for the funding as recom.,oeiided by the Review Commit@-ee. ZIRS. SILS-@EE: '@ie motion has iDr-@en made and seconded 7 that the Puerto Rico application be approved at the requsted level o,-c 7'j 2 r, -2 discussion Al 1 k'Ci,,orus o'L' "Aye") Opposed? ('-@o res:Donse) The motion is carried. Doc;tor we appreciate your rapid-fire review@ t7,Aere; sorry you have to leave. WIID-72 NATION.!L L@-DVISC@n@y COU'@IC-'LL O@@'T RT-'GION@-L 1,1@DICI-@L P.-tZOGM@ix-IS 11-Tc-SISSrLPPI R-RVIEW IRS. S-L-BEE: Now, Doctor Gra'lich, we are goi + rri ng to put you on the grill. Van- I a-,-i sorry. Doctor Terrill could-, 7 t:l- 4 S 'd s" Region. stay @or or,@. a d -ViSi On@ o@L- the revie-@iers was a former site-visitor, and he was highly complimentary of MississlPP3-. -He felt they deserved.quite a few pats on the back. They were consi-dered'to be-an above-average to supe-r--.-Dr reg--on, program leadership was considered to he s-'--t--ong and viable; they have a c@7@petent leadership staff, i-,s progra-i @L'f, I -=hould sa y was and -ve -@el-t they were 0 goals an-' cb-:@ct4ves to supp a-ae prozosal as SUI@-rL4,t-'L di..@as to congruent a a -Program,-,,,. W@ A. r-roposa'L a-!- r ri a n OL ri ba@---d on a h a 4- 19 8 IIIID-7 3 --c reali-S'ically accompl;shcd in the tirefra,,ne remaining for pro@-air,. Mississippi requested $2,350,409; the Con,,.,nittee reco.-,-r,,iendation $2,200,000. Z 7-': D3--tor Gr a.-, 1 c h -,ld like to corL-iant, fir@-@- ha- 1 f4@,d 4r, @,ello-%@- -@ol(aer, which we received on of--' t arrival today, a transcript of the Review Committee's comments, which wou-@d have been very helpful had they been early enough, then I had had tire to read @Lhom. !IRS. SILS3@-E: Could I make a comment about those? '"Lhosze traz.sc,--4.,ots are put in the folder and we to get out of %the ou4---o@c this room. he hc-lnf,,ii; ,,,e would have liked to have sent there to yo,@l in ad-,zance, b@-,@L- because of tie confidential,-'.7r -oceedincrs, we chose %'-'his method. of the'p, But I agree; I wish we could have had them, too, bu-" l@-ecause the Co@.-Ii--L"tee di'n't @ow that they were going to be usc,-d. in we felt @.ta@ it was important tc, i,@st '@-ave r '-@.ere i.-n. t-@i-18 roo!n.. SUDP D R C-@- ose tlen as a corrollary tc.@ Wr,. I..7@ u 0 0 s 1. i you? I-ITE!ll, -s s 1- s s generically speaking, unfortun- at@'-@y, i iL t:,.at all o!- the- RecTions to wiicii T was assigned as ri o-r ci -,z a r rE, .i -r c 'superio or abo,.,,e Cie to SUE)C 199 w',.iich Tables --he job easier, of course, and I was interested :L-i---h,2 figure was reac'Liad, because I reached mine in a sor@-,.e-,,7iiat different way, in a more programmatic fashion. I looked in SO.1,,,C.detail at the projects request, a.,i,-@ rote-Ct for that there were several programs, as i;as cbsc--vcd b St:aff., that r ' lly raised a 1 0 ea y o@ qucs+--,:Lcns as t-o e L-Iher they we're R@,IP-oriented or not., For example, solid-i-7aste management training, which is a program i-7-@reby the State Board of Health or, through e State Board of Health, aims to train landfill operators, which seems to be pretty much a Public Health operation, rather a f lat-out RTILP plan. Z."ng a the yellow sheet, and the numb loo,' er o@i particular one -Ls C-137. C- 5 Is !.'ocd Sei-v-Lce Trainirig Program night more -h Service. approprizl --a 1. y be r@i 14.c ileal4t- Also in &the yellow sheet, in C-140 to 144, I had a spac-La'L observation about this, b ecause these four programs were canc@ar-re'L-at(r-,,,', but were all to be @-oanagea by the _a Corcc,-, y --aal pro@ an! a7-4--hough they small --mc.,,urts, it 's r u c.'@- me tha tl- perliar3s these were t,'---,4.- woui-t- -@a ]ust supplerqent4-nq things that e e r i c -a nCan--,er So,-, -ldy done -v lias airc- 'bi' 'Ar leave had sc-.-.a concern about R;"@ visi Lity,,and I r. c--, a dii"@ o pro'--rai.-,Ls, p--obabl@, erroneously, but I can @'i"IID-75 200 imagine the situation whereby the @IP would provide the funds and the Cancer Society would get the credit for it. Now that may be paranoid, or it may be realistic. V.iey were small amounts, I grant. I had sor-,-a_question about C-159, which called the Quality o@L Sarvice @or th,-- l.Lc-n-ally Retarded; it struck me @,is was an unusua'; request.. It didn't really lay out-any program at all. I had an equivalent question about C-162, which was a hypertension survey, Pearl River County Hypertension Siarvey, ,L: in which they proposed that the emergency room nurse would take blood pressures on all patients who came into the emer- gency room, and a -@l@ag went up that per'@-@.aos that nurse who takes the b'-ood pressures should take the blood DressurcS v.,.ae-.her she is being sup.@orted by P,-NL@ program or not. @Ln. a s d Ag@,' l' program $10,000 but it'di s t 1: a me as a little costl,,- 'o- the doi- -'a..routine dut r ,ig. of y '-!IC -,iurse should or--' i zi a r 4- do. a c--bl-c IZV proc7ra-,i @ror and I %Seoul(! L-e -,--::Z;4- to a.:i r-- ti-, a- T dcn un-,CzstaTi.-d it care- f7@-I or, t-,Dro,@hil but as I read the p--og--ani, 1 wonderc--" 4F p@.yo'-@ -,qaz rea'.7-y t -1,@ L- L: 4- '-,,a r a .-----7ical Costs at ficzlle. 1-1@ Is are 1 -Fur -i, T@; cir-c@-1-1-Y a :Ci-larc @ctic)i and aaain IoLir p u c I y - Q @l I'ater cysLe@ils; the . . , ;, I'@; i - . . , . . I v I; 201 @,lliD-7 6 nrogram soug'@@ to -jav for half tlle costs o@ installation o' flourida@-io-i ecuipiren'L-. T wonder if @,IP is interested in that sort of pro- ject? n wi-iic.i are the last several o s-.::uck b-,,, the la@-t four 0-36, 37, 38 to say:" and 3-@l, fcr appear to me these are some new projects that we think are pretty good; give us some $600,000, we'll spend it as we can develop the projects." It s.ounds good; the titles are fine, but this loo'--@led l@-':e abla,-i'.: checlj,-, sa@ring: "We are a goc4 outfit; give us the money and we s,-j@-rd i t-- wisel-,r. Noo.,, lust as a riatter o.@ philosophy and policy, if this i-@ an -,pn-cpria--e wav to go for P-IIP, fine, and there is no question but thaL. the titles of the projects are good, but @L-cre is -io substance behind the projects, in t@-ms of 0 nll 4 -la -ng an.d Drocess. MR. VA!i -@-ie application itself does addressli those, DOOL--or. Othcr C-ian @.his yelloi- sheet, t".iase four te ris are, %--he sar.-,a thing that you were looking at on t.-ie Georgia I., aiDt:14@catio,-i; tiiese are-w,-iore they had sefit out .;ritten requests @or proposals. Thr-@y do have the-' request in-house; they have 2()2 @YVIID- 7 7 many more requests than they have money to support. Now, at the tir@.ie that the decision is handed down by Council as to how much money they received, their RAG- will meet again in terms of their.priorities of what they can fund ;@74-thin -"nose general areas. l@ilov,, the primary reviewer raised the almost identi- .cal same questions on the same projects that you were men- tioning, and they did we do have a list of all of those. They will be communicated to :the ',Iississippi RMP. However, he did not c'---oose %to say'that "You can not fund this', fun'@- that, or fund theother." lIe said that he thinks they have a very low prior- ity, and felt that they should be allowed to determine within that unless it was against Counc@-". policv to decide. -IRS. SILSBEE:' 1-irs. Flood? I,IRS. FLOOD: 'Is this.an A-rated region with a tri- ennial status? 'IAN Yes, it is, or it was 'at the time that we doing that -Lvpe of --hing. Doctor, I might mention a!4o# that we in"Sta--F@L have raisc4- the same questions, almost to the letter, that you have. Ile need the he'L.z) of Council heria on the solid waste a,-id "Peter #'-Ile Pe'Lican" and '4-4 i so IL-.her b r o #--',i e r shere-, and to get your gu4-dance as t(:) whether we should sacc@ifically deal. 20 3 fill D- 7 8 i with so.-,ie of these projects on an individual basis, and seein that they are eliminated on the grounds that they do not fit within Historical @,IP operational activities. DO-,TOR Gi@-ILICII: Incidqntally, and somewhat tan-# gentially, for t..e bene@Lit of the Council's advice, Pierre the Peliczn a,-oears to be a how-to-raise-ciiildren program. That is correct. Now, back to the original point about the $450,00 0 re4@es@@. You said that information was available justifying these, but is it anywhere in these grants requests? Because I didn't seers to find it as I went through. -e point is that it made it hard for me Any-way, 4-, to sensibly review what npeared to be a blank check sort a.. of reques;-_ for funds. I realize-that in some Recjions, some Pi.IP's, that probably is a perfectly legitimate way to go,, 3ust to get the funds, but how.do we know that as we go through this? SIT@SL'-E: Well, I all revelers are -i.-,a on Ci concerned -"bouL-- just dc--pe-,ici e written and it I is '@-Iard to convey t;;-I.L s . unity, Doctor Gr Did you have an opport amlich, to talk i; h Doctor i,lerrill before he DO,'-'TOR G,:'@,ILICH: About Mississippi No. t via S . an sorry ha had to leavc, because he had been on a previous site-vi-sit, which *,a sa couple.Qf 204 lilID-79 years ago. You mentioned that you went through this program- matically. Did yau come up with any kind of a level of funding? DOCTO@'Z A f igure? It was interesting. There were son.,2 that I had question marks on a programmatic basis entirely, s-Dr.-e that I felt.-- like this cancer society I business here -- -,iaybe if you fund one or two of them you get'whatever little mileage there is to be gained from sayinal: "Yes, we are indeed in support of you, the Ariierican,Cancer Society." I scratched the ones that were obviously Public Health Service and should, in my opinion, be in that area, unless Council decides otherwise. There were some that I had so.-,e question about; I didn't di,-iinish on that basis. I think the four items that were $150,000 apiece,, the four projects, that Qn the basis that it w,-.s a suoer3.or diminished it by h@, subtrECcting the ones- that obviously should be in the Health Department, the one that was cable T@,' MRS. SILSBEE: What f icrure did you come up with,, Docto@-? DOCTOR GRA.".LICII-. I came up very close, within $200,000 of t.,ic s@-ne fLjure. IIRS. SILSBI"'E: Well, they may have very wal gone 205 ",MD - 0 -L..'L L;:ough the same process in their review. Do you feel that the $2,200,000 -- the concerns you have will be conveyed to the Region; there is no question about that. The figure I came to was $@,031,000, which was so close they should@'t worry Do you.want to do that in the form of a motion? DOCTOR GRa2,!LICH: Just to get out of Mississippi, I would move that we accept the figure of $2,200,000. MRS. SILSBEE: I would prefer the proviso. Do you want to word something in general terms, not specific projecu5 DOCTOR'GRA!,.ILICli: Let-.Is have a little discussion about it, and then make a separate motion. IIRS. SILSBEE: The motion has been made. MRS. FLOOD: My Fon,-nent would be that I think you are being a little generous. This is blatantly transfer of funds to Public liezLIt@: Service &@'s not just sort of obviously, and they are in small amounts, but this is trad-@tic>nal public health work, and! I don't see anything -A.nnovative about it. It certainly does not si'@OW wil develoo into any repu'--able state new 'ie way you are ss these programs, loc,"@ Ln goi27,g to addre that yo,, could use across the state. it f -,his has no i,-,nactua:l Erogram as such; I can ind any objec--4uves or goals listed in the application that this i addresses -;@r-se'L to. Food-hard-j'e'rs' classes? '-;Iy goodness. Li i -3 1 .WIID 2n6 Really, tha,--'s exactly what it is. MRS. SILS'"OEE: What action do you want to take 'th t;-is concern? wi @L,@,S. FLOOD: Well, I wasn't the primary reviewer or the secondary, so I didn't have an opportunity to look at 't.-le Forn-, 'L@j 's to see how many oil- these are.now. I hope all of them are new and that they haven't been continuing for some time. DOCTOP, GRA@ILICH: All of these are new. !.IRS. FL@CD: I would take a closer look, and it would -Lal@-e --,le a r,-LI-.-Liute to f igure out how much I would give them, L-ut'.rL certainly would de'Late the public health issues more than jusi@- to recommend to them that they do it. re DOCTO.@, '..@y don't vou list wiat they a so we w - "Invq? 'RS. E'LOOI'J: 137, I.-idustry employee, education; there's another one. Solid waste management, C-144. FLO-@D: C-14', 145. e DO','!()R GRI@ILICII-. C-@Go' is the Public Health on @.hen there's'anot-.,ier one-in there. the record.) (Discussion off DO%'-TOI-', C,!-'A-",'LLICII: 165, '-Iedical 'rosi@-er I-Iomes, is really PuL-'Lic -Health; that-is a welfare program. .DCCTO:L '"Ii@'L3 163? 207 :WliD-32 DOCTOR GRZ--'-'LLICII: 168 is flour4Ldation, another Public iiealti-i. That is roughly $80,000, iirs. Flood, which doesn't really MRS. FLOOD: I know; it doesn't really slap their DOCTOR G.L@MICII: I wonder if it would not be simpler ijl.,.-we accept the figure, vote on -that, and then dis- ,cussed the problem of reassignment of inappropriate areas, and too, the open-ended request, which I am not totally satis-I fied But there are ti-;o separate areas, and I think they might be senaraL@-e@-, and this might apply to other Regions*, MRS. SILc"'@-@-Z: Doctor For infoz-.,-,atio.-i, at the risk of exposing my ignorance, what is 'a "c-.rLloking Withdr&Lv.,al Clinic?" C-,_,@'j-37TSS: ".ayl)e I can answer '-hat there. So:-,e years ago, the smoki-,-ig an,,' her-@itli activity w---- an i.-,-L-egra"L part of our P,:IP's, because we Lelt we fell- h-:a-,@- @o it 'rori the @-tn--c- ----scase have funde--' --Ln yea--rs p n- s sroj'zi,,-ig and health activities under the aeg-!s o-F r This is s-'@-"nly athrowback, 1 would assume, to a ty, P-%!P in --h c a s and it is l@ sii,-,t@ly a o--F controlling the' as a-preventive 209 WliD-34 do Rev4ew Cora-,ittee work or do Regional Advisory Group work Doctor Gramlich has suggested that you'take a look at the funding level vraich he made a motion would be at the CoL-,n. i@L.@Lee recorx..iendatioii. DOC'-70R $2,200,000. MRS. SILSBEE: 'V'-Ihich is $2,200,000. -.-Now, there has been a motion made. DOCTOR 'YIAI@12-IOCK: I'll second it. MRS. SILSBEE: Do you,want to discuss that further? All in favor? (Chorus of "Aye") Opposed? Two Council members opposed. The T,-@'t-'Lon is carried. Now we have the sj4.r.1ple issue of the advisability O.r @'Regions pursuing this particular course, and I think you are really trying to get back to t.ie Region in terms of their'! i%M S RS: @id I assuiae those taree million dolla-@s they a,-re going to re-ue's-"@ in July and August'will be reviewed?, YIRS. SILSBEE: O"-Xr yes. IIRS. @@,@S: Because this is something, I think, znuz we should look at very carefully, this further rectuest. DOC@@@-R ZIay Iask, is it appropriate here,. to discuss the Principle involved in the las- four projects,, 210 whic'l were ,for $150,000 each, without particular justifica tion or,programmatic support?. Noa, this applies, perhaps, in this area, bu-t it may fell in other areas, and iL is a matter that came 7 up a couple o4r --"-.ies durincT the arthritis Technical Review meeting, i-7,liere a good strong PR-IP said: "Give us the money and we'll do the job," but they didn't exactly say what the job was. Maybe t-4s doesn't occur very often, but if it does,i we should have some guiding principle. YLRS., S'LLSBEE: 'LI-,ere is -an application that you will be considering later Texas @-at-brought ut) this very same issue and the Review Cortnittee told us to take a dif@Leren%@- kind o'L action,:waiting until they got'- the.particu- lars. So this is ICTI DOCTOR GP,@-M Does that solve the problem? I-!PS. SILSB-@@-: ,to, no+-- ag far as -Iississippi is concerned'. - I t.:-iink you have solved it, pro'---ably, in your IL LU:-,d -LI! reCOia@re,-2d C.'l . '@te P, IiL@ a--. is precisely what the Comni a @.p -c d --o ,'o to resolve i by t@'leir L@unding level. MRS. SILSBEE: Doctor Janeway? DO-'-'LOR JPj.'El--iAY: Just. an observation, that if one-. na?,es the assu,,-,pi--io-,i that the funding level, as recommended, 211 ID-@J6 dc!lei'-es theze programs speifically. That is his one set. If c.-i th,2 ot;-,er hand the funding level is set on the basis of certain other things having been deleted, and then one specifically proscribes the utilization of these --Fun,"-s, t.-.ese 'Lunds for Pu'@,"L4-'c Health purposes, then he --4L-h@n i-4.- i-vz-s ever, more 'La',--4--L-ude, i,,,ider lat-4-@-ul"e for -he use of non-prograr,---,iatic-orient .-h-3 use of in 4- ed funds. SI.,-USD-@E: Well, it seems to me you have a lever here that you would not ordinarily have, and.that is that they are coming in with a oroposal in July, and you could very well insist that you have, at the tire, specific -ie information aboul.- hc,@,q ti Regional Advisory Group has chosen,, @O Oa,--J-ay these fumds, v7ith advi-@e, in terms of the concern that you have, and you could look at the Region again. That is not an opportunity you have very often, in terms o this short tirief rame. DOCTOR GRA-I@,LICii: That solves one oz my concerns, iv).-,icb is si-ri-)Iy that it is entirely possible that the pro- gra:p. wi'-@ Ibe v@-ry good, exactly w."Ia-L- it should be, but since is t'-@@ c;Dcn-c-n-@'_L@-c-chnique, it rl= 4 -res -- very cult f r u I @.,oul-"! ha,--e to sa-.:,: you can't do it" because s .iot w'--a+- are sa-@.-ing a- all. I would like to not I- ia4- on.L y s e -@o,-@u st is I woul d like 4%-O -,,,-olvo a @j@--,y coL:'-, "Lc!ave t.,,.e respor.,se croen-,endecL. 213 f c t ti-,at we don'l@- have sufficient 't-Ino%.71ea-ge as to why y I t@ink you can d.Lrcct "-his bacli-@ to the Regionai Advisory Grouo, as to why they chose to,-- yo@ &re looking aL@- t'@-la qu@-lity@ o'L -E-ic decision-making there, and we could ask -'or additional information on that for you, too. DOCJIOR Pi-@IIL: I think we would like to go back o Mrs. -rlood's Pont, that a lot of their activities don't fit in with IL-heir own objectives and goals and programs, so that I don't like to have a policy that rules out.anything that smacks of public health. It may make sense for that Region if -Lt is part o@' their program, but in general, we are not designedtd take over'tho.se kinds of activity, and there are so many good uses for the funds that I would think the IUG could receive thit advise and perhaps act more appropriately. Certainly they.could look at @-heiA- objectives and progr@-r,.-,ia,--'Ic goals and how these @-ioule, fit into it. Tha-- 4-s -the thing that i@e are 4-n-Lerested in, but I pcrzonal d--n't believe we shoul-d have an abso'Lute rule ti-iat -public. health is -Ehere;@-c;re inapioro:)riate to, our f und- 4@n@-@. !:u-t it does have to a-,,-- carefully. I was -4us- wondering i@ we cxe @@ISS going. to as'.,@ the local t,, i c- r --ns,.Ner on k@. @-i ;-3? An- are r@e going 4L- q e t t b,@ 0 If t.;e rr,' L-- @T it b,r- la-uly ls-@, V.'C 214 "iiD-89 w,-ll be t 4@ thereafter, because t.icy do have to i allocate t-a@-se dollars, and we will get.that information. I D@"-'LO.'Z GrA:-ILICIII: And 'there is one other element iii @llis s-a!-,ie tsmanship.' ,@oblem thak-- relates.to gram It is entire!,., r-ozsible that these were in thei-I a.-,d --u-- 7D-ar-@ectly le itimate,,but the reporting 9 @--eceived was iisu--c@Licient-to &nable us to make a judgment. Now, I think this m6ssage might be conveyed, because if we misinterpret vlhat iqe read, it is either because we read it @,-rong or because it was written wrong. ',,'RS. SILSBEE: Is there any further discussion on Mississippi 215 r (7 1 rD: 7 L"EDICAL P OG M C 1- @'O." T.?, r@VIET-17 L'@IRS. SILSBEE: Okay; how do you feel about North Carolina, Doctor Gramlicli? Have I got some ideas about !4 or th o I In the 'L-'L--st place, that 'airplane. I am taking the p--ogra-7L-..iatic apart. It has a superb RAG, it is well staffed, it's a ood organizatbn and has done a good job. Its track record 9 is fine. $50,000 for air transportation. That is hard for us to see - 001, s@---cond ite7,-L. North Caro2L,:Lna ,.ias a lot of outreach clinicS throughou4L-. @,e st--ate, and it's a big state -- not as big w some otL'ters. They like to transport their residents, their nursing s-@aff and consultants to these various outreach programs b-,7 air, a,-id t'@iis ma'l-.es so.@ sense, but as I read the grant request--, it raised a question in iiy mind about Wi-&et'@-ier it was an or WI-ieth,:!r it could perf,.,a,:P@; L,,a s-co-,:>cr4k--ed year iiith the understanding that it is tl-ia- i T.,ortant, then the state leg-sia-ture of North Caroliiia oug,-.,'L-- @-o soo,,@.sor Tii@re is som@, n a!--ouk-- this in the grant reque answer as %,rc e r it was an opportunity' but r-iol- e. s@-,2c- 216 tL, u-l? i,@,Lis .Beat r-.@qht otierwiso not bc- tiicre. iL The oiily struck me significantly about k--arolinals prQqr--r.. was that they have their -- they are big on hvv-ertension, and beginning at 66-A through 66-L t,,,ey @ave a total of about a dozen programs all related to i'n tc-arr@,s ol"doll'ars they'represent $459,739.1 I realize -"hat North Carolina is a very good RI.IP I and 'they might be able to T3ull off all these various and sundry projects successfully, but it did strike me that that was a lot of expenditure for one particular disease, when most of it was related to screenina and education and develop- ment oil- service personnel. They have some very good programs. on the second page, again, there was a very large bloc.-,. of programs, s.%-.arti-n-7. at 67-A and ending at 67-G, on the providing of rural health care, and I like this general -h, and I think most of those were pretty good programs . a.@proa. L. II It see,-ie--l to be well integrated and- t4-e i,-ito'each other iriti,@ouil- a lo-L. of dupl4Lca-@i-on, w.-.ici-i ccLld.-i' a I., for sure a@out t,;l--- hypertension Tiere seeme,@7 to be some overlap in -@haL-. area. rL@ia rezq-- of -@.@-ion t-hc! @,.'IP se@amed to be t o D i t , and using a obscure, tecl,.ni;7,ue, came up with exactly the same -Fi-'ures. The was also quite 217 I-'*IID-') 2 the med;ca! air operations. They singled t tha,- out ift:,,iediately; they also were concerned about 63, which th@ considered, as near as th@y could determine from t'@,.e information provided, to be a pure PSRO, and thus con- S'Ide--ed i,nar,-Dro-,,-iate for funding by RIIIP. ,lan, I interrupt just one second?' 1: d-.dn"L- P-@ci'-. that up when I was reading it. 6 3 appears to overlap directly with 41-E, which is called "Area' Health Systems," but when you read the request, it is a PSRO training program. I-IR. V"l ii WI:ll',LE: They also expressed considerable concern about 69, Doctor, which was the university-linked hospital 14-braries. They thought this was completely over- a,-,ibit-Lous; @-iey didn'4.- feel there was any guarantee it would ever be continued, an.@@- more ar,-zropriately, they felt this l@as sorte;@-h4@ng -Eiat Liese hospitals should Iz doing anyway. hey sai-' libraries were nice, but they didn't really see that ti-.,is, -was going to have any great ef'@Oect on the system there. mha@ on@ toy had real concern wi-h; they also C,-i a-1 a t--n -@.-i 'that rur--l clinic, i an.-' they only Tade mention o-@r, i--,. Their concern wasn't.tha%@- grf,-at. T tliin,c the=-,,, much as you -',o a!Dcut 'that. They also exD--ezscl" some concern aL-out the fact RCS4 +-,hatt i s -on, in 45 nc-e projccts, ti-&ey were a b;_ @-h-4-r ability to c@rr@ t!7tem out, but th 218 wen- alonj @;4 Ih 4t base-! on their past performance. Pi-@S. SILSE-E'@: '.Ir. @!41!i.kc,-i t..-as the secondary reviewer. Did you have anything? I would agree with w.',iat's been said. I th4-,-i'-@ -,,ve coul,-' s4-:,-i@ly not go along with allowing these -Eo be not challenged. We should certainly ch-all@e.-ige @,,en in '-L.,e=,.,.s o-' allowing them to stay in. MRS. SIESBV.E: Doctor Wammock? DOCTOR It@l:,,IOCK: I would ask a question here which was raised in 63. This matter pops up at every turn, and I know that some way or an.toher we are going to have to address ourselves to this. MRS. SILSBEE: I,,Ie are trying to work with the PSRO staff to trv i@-0 get that resolved. DOCTOR @7@,%I:@-IOCK: I realize there are iriDlications, here, and I am asking for information as to -- well,-what is- the relationship, or i-That are -they endeavoring to accomplish? T mean, 1 sa".7 this i,,7-iti-i lots of reservation. I di,iil-' wai-. to 1),--irc, i- u-n bu- in my c@v-n particular mind, I i am well, I'rt for a r.-e"er -review svs-ce@-a, period. I'll say w-'@4L-.icul-- any rascrvaL-.ions whatever. S L t:e'Ll, as you inay recall, back in --te--ibor oF 173, the Rn c tc,!"' to CDT,-,c illi with re,-,ues'-s ti-ia't were con-@inou to f:-Ive d4--F-'crent areas, one of ior o tv, area'. a.-.otl- il-cia was hype-- 219 HD-',! 4 11 4 tension. So'som'e of these rings which you see in here we-r-@ direc-,ive, which has not been turned the result o'@ @hal- around. DC)C"LOR Putting it in PSRO? L: T7 I could, I have had some discussion IV, 4 h t h c e,:, ir- -a D: 2 -o a r n t responsible for PSRO, an-, therl-- is at least the possibility that some of the-specific applications here as well as some that might come in in the July cycld', at least to the near view, are an attempt a possible attenip-L-. -- an alleged Dossible attempt, at circum- ve-i,.ting the PSRO. rog@-am, and we are very much concernd with -P that. I doubt very much -that the Denartment would fund any. activity that would do that. We are in the process of working with the PSRO staff, look4na a-@'the specific applications here, to make sure that that doesn't happen. DO%"TOR I am in favor of this business of quality assurance, or whatever ygu are tallzing about here, because 1 r-,ean, gro- W4-th this problem everv day, the C@@L qucsti-@-i -r ou are going- to call it PSE. or wha4@-ever t -L S quali-@@ assurance or survival il-Li s . SI 7 -Dr, -E: -ir. Rubel tajks about-- trying to C.Lr- Cur.'.vent t L- th4Lng. is looking at it froze one point of y4 ng view, an--' I was tr to loolz a-. it fron, the -ooint-- of view t.L 'L -@e -'-,hal- @,e ga-@e last o--F the con @nu--t@,, o t. e- d-r@cl- 220 I do think that we both agree that we can't have this funded in two dif@'erent places with two different -sets of priorities. DOC-L v OCK: That was what I was thinking about. LI, l@T' SSjT @SB-@E: i%Lrs. Flood? Z-LOOD: ,Vell, I would just like to reinforce the Review CorL-aittee's statement about NtL-nber 69, which was the'network of hospital libraries throughout the state linked through the University Health Science Center tied with library resources. This is appropriately there was a tine when funding for this Las available through the National Library of Medicine in small 14b-a-v development resource grants, and ossibly so.-,ie oil that funding could be available, but it is p a massive un-@larta'jzing,- even at this funding, for a one-year developitient, and should not appropriately be addressed, becaus@ll indeed, this never finds continua@6 support if @.he hospitals have n@3- alrea:,ly S,-iown -t.= in-@rc-s@ to do i on t:--eir own. @US@ frCr,-, cc,-or Gramli-'@l, @S 11 you haxl arrived at the s a,-, r erelative figure that the had, and t c n I began to hear a lot of other concerns. 1,7.here. do we stand? I-i'C 1 1 ,tille- fu'L --rundincj w-as not -idzad bv tlic Co@@-. tc-,e; c -e redu-cd by something t'.1 -2y wcx 22 1 WIID-96 o,:,-,zz a L'.ol-lars, .,.,,iich s--2emcd reaso,-iable. @.Iiiat seemed reasonable. So I move '--hat we accept the Review Cor@,ittee's reconma@-i'@a4--ion of $2,375,522. DO'@TOR Second. All in favor? (@-horus of "Aye") Opposed? (No reply) Carried. icw-f we will get this back to the Region, your c@, cerns, to t.-.e Regional. Med4-'cal Prograri. 22 2 @N',ATIO, 14-:kL i@'-)V-@SORY COU.%CIL Ol,.' @-Z--GIONAL MEDICAL 1'ROGIW.IS SOU'Tll DAKOTA REVIEW M.11S. SILSBEE:' South ba'r@ota. Mike? IIR. POSTA: The South Dakota Regional Medical Progra.-,i request is $729,417, which,was aoproved in the total &-.iount requested. As some of you might r6call, South Dakota used to L be, several years back, associated with the Nebraska program. They got a divorce, and I think the separation has caused both progra-as to imp4Love tremendously. Because of the divorce, both South Dakota and Nabraslza have been among the most funded regions of the 53 that we have funded novi. For instance, the 12-Ttonth annualized current funding level- for Sout@-.!Li Da';:bza right now is $428,152. Although the Region has never attained triennial status, it lias been considered up until, if you remember the last Counciil-, as a olanning Region rather than one that has acn@ea o-.@ra-@ional- sta@-'-!Si, Tilie reviewers scored -lie Region as,an above-average a un4-ausliess o title South Dal-lo@-a programs is in the @t'.-la@- i'-- is t.-ie only one --'.,-.at I of %%TI-ic!reby the ciir,. -ounc4 1 an,: .-@G zL-c o-.i,-, @h@2 sar,,e. The do provide', y qrc-at st--engt-,i to @@hc stLate. V,'iiD-9 22 3 Program proposals were considered well defined and had Priorities well.-,mesiied in with the identified health needs of L@-he Reg4-on. All there is is a small staff that is being paid, by '-Iio- R:,!-:; are- many other consultants who ',lave given ad L@-.-'Lonal extra strength to t',ie program. I think -Liat would suffice as an opening. MRS. SILSBEE: Doctor Gramlich? DOCTO-@ GP@ILICH: This is going to be a very short report. I would make only one comment on the staff assessment and 'I--hat is the Region was assessed by reviewers as'not above- average but as superior. MR. POSTA: I stand corrected, sir. DOCTOR'C@-',-@I-@H:. I could find nothing Wrong, I have no cc.,@-nent; I move'that they be funded at the rate of $7@G9,417. This -Ls supplemented by a 17-page confidential report, @.:hich says e.@cactly the same-@Iiing. Tie transcript -o-7 i@- c-, revlic-..-c-L-s' coa@,e.-its, a l'i-page renort, ;that they couldn't -L aL S i c :z o ii g W -L i i t . I.ZZS. SILS!3'-7 7-@ l@irs. Flood? M:I.S. FLOOD: 1 1 ,I only ha-@ concern about one L prcgra--,i, and that was the project %'umber 12, %,;hich I felt ref7 CC,- I -e-L'L a. sort o-@ a r, i a ma@-.zigeriLn'-- in nurses C,,-- 13 a.-) c sr i e r @.ian anu r s s':: i 1 J- d,3velopn@enL'. in the 224, L'@'ZD9 9 I @r i3ro-rai-,i, but the newness of their independence, and w h their w@-11-@loclx.-te,-ited analysis of @-ieir objectives f or '@-'I-ie Region, xd the.--Fact that this might in truth be the cause of a tremendous nursing personnel turnover, I-would concede t:qa@- i-L- might --ossibly be an adequate manpower develor,- l@-ype o@L project, a,,i-'l I would accept the others recom-: r,,,c--nda@n. MRS. SILSBEE: Is that in th@ form of a second#, 14rs'. Flood? I.!PS. FLOOD: Yes. MRS. SILSBEE: Any discussion? All in favor? (%@-'horus of Aye VI) 1--@)posed? The notion @@s carried. All rig.-,t. The Reporter has asked for a short b- -!z, and we still have two Regions, and because i@. Sidel Recion or p-z---h=-Ps i'-Is -Doctor S'del; I don't kno,.,r 'll h-@e 4- o-, an-d ',"r. Pu':jel 11 not -be -here, ta4-n an@l @-ut- -C a recess was tall-Ic.,@.,-i.) 225 T@-71ID-10 0 't,,@@TIONAL ADVISORY COZ;'@@.CIL O'l- REGION.A@ ,'IEDIC-@L P,70GRIU-IS r-,"-VIEW riq.@.t, let's get started. been caught beti-,-epn a dilemma Mrs.' Mars and I a--id Rubel has given way, so we are going to L-ake up first. 7-50-@T.,N: Inter-.4ounfain. Th-a reviewers rated the Inter-!,Iountain program above-average. The program has good leadership, a talented staff,. and a most active Regional Advisory G--oup. The Co.@.-ittee recorLTnended funding in the amount of two -Liillion dollars, which was a substantial reduction below the $'-',O-d-9,425 requested. Suppcrt for tha reduction was based on, one: the relatively unexpended balancesin this Pegion over the past couple of years; -,uyo: the large amount of requested funds was ccns---re- -nverli, ai7@bitious, and an example of this was that 33 new pro-.osals are inclu@,ed in the particular applica- tion. I am sure ha t :,Irs. !Sears and I'lood.wi'Ll wish' to go on w-@th soue mo--e specifics of '-.he program, and perhaps -he-,7 T@it iit @;art 'to up -he @u--.diricj o@ the'l,-.calth Cor@ora!- 3 c -io- which had been brought up at the ii- -Hoc r.,---2eti7.tcT as a potential proble.-a., r c a 1 y a rather ince-,ised over the 226 'v7llD - 1 0 I- Cor-L,,iittec-,Is cutting this proara.-n down to 52 percent of tl,ieir requesL-.ec' This progra-rq have si'te-visited twice. The last time was ':.iot-7 -Lia:ay months ago, llike? POST--'@: it was January 15tli. @"IR-@. @:ARS: it was January of this year. The program,. is under new leadership, very capable ew leadership, and before I go further with it, I think that n to cut this program down to 52 percent is lainly a slap in p the face. I think it will absolutely kill all of their incentives. The program had a man running it previously who did un a very -4ght sh-p. Howeve-, he also did not get'much r done a-- far as outreach, and this was one of the recommenda- tions that tl--,-e sil@-e-vis;--i"- tea-ri made at that time. This was being corrected, -anu' of-course, par-tly $this HDSC does carry on that pi.-.i-losophy to a certain dearee. The outreach program is benefitt--ij-ig minority groUEt-, i:; add4-,-,-g itself is cacLd4-.-.cf Minorities to ;I the sta@@f. The ca'L-'L!,,,er that is required is @omeL-hiiig that is very to a.,@i area; ho@,iever, except for a are very- muc.q in --'w@-'Ll, the i percentage 4-s very s i.'. Z,'i 'L IL Site-V4_ -am recom- Ort@- of the tha it tc @.end-2d at a @c r r,4 @;7r@la between t'-i@. 227 T,IHD-'-')2 !.'Iountain States Regional "1.1edical Program, the Colorado- L Ily@. ing, and the In't-er-.'Iountain. This is being carried for- wal:-"4 , ai-"- t',,ic-y 'i-lave "icc-pt r,-te apprised o'L their activities. Th4-s was another thing that the site-visit team "d was very concerned about, this turf prQblen 1 'k--ha@- was as@-.ed bv the site-vis-L -. t e a.-,i has been met, and t.'-Le @,vhol-e '-Boeing here is, I agree the program has been-over- funded in the past -- I can't argue about that, but I think, ri under the new leadership, that this money will be expended and used very, very wisely. The HD.SC -- Heal@Lh 'Develop,,ment and Service Corpora- -profit independent corpora- tion, which should parallel a non tion, this 1.@'.'LP was developing as a project., and it.is going to be to-@ai'Lv sepa@-ak@-ed .@ron '--he !R:,IP, Which cerl--a4-nly should relieve some of the concerns that were expressed by the Research Adr.-,-Lnistra4;_-ion of the University. f see no' reason why this can not materialize. The ela@ r -icnship ti-iat @@-ie organization has now., T,.-il-h t.,ie' grantee c-@ga.n- 1- za@-i@n is a ve--y ruchlimdroved one, and ti-, IC they will worl%- very closely t@-oge-"@her to 'any problems and v. L to i--,L t@,e T-. @;S r,,-om rc-= 'I ly be-c;o.-.L4 rcj a support pro cc-' 0 a T ZT iz - -,aE: a -u-din,-,, --rorc@. c r sources,, anL', IL-.h hl-,-,7c r c e v ej a n c,, w d g e n a e-1, would receive, t': F i - !7.- so--, Th' 228 -ha+- continued fundin .ias succ@E-sf-:ul, so 4@ g of the projec,- IS assu-'e-u and shoul---' not require IE.-4P funds to support it. I to!,--'4 you the Tri-Regional Coordinators have met th@-@,, a new P,!iG Chairman i-;,io is one of the most me,-,'--ers of the public that I haVt co@-= is gi-vin,- more of.his time than any indivi- aual that@- I kno,,,i of that acts as a P.AG Chairman There has been a tremendous amount of rapport dcvelo@2d; the system now is very good,. this'is the assess'- ment of their pro4acts, and I simply feel that if we accept this degree of detrimental fun--4ing.here, it is just,-- the iev is simDly the whole program is going to fall apart,. be.@ause I @iscouraaer..ient is going 4--O 'De SO great. The doc@-or is a pediatrician, I believe, by profes- Sion, @as he no,@-,' v,-Ii-o is now the Coordinator? I,IT.1,S. SILSBEE: He is an orthopedic surgeon'. I' couldr.' t rerie.Tber what he was.. lie is giving so much of his time to the program now ne was not originally zL -f u'Ll-1--iTn.@ Coordinator, I believe-; L 4s t,'-,a correc@-.@ l@ tT -z-,e s A-JuL- he is g i vi rig more o --er da and il- is just a shame to to i--, da@, a'4 y do tkl4-, s to c-- ,Droc,-rali suc','l zi, s ti-iis. I w-ou'La cer L--ainly that ri unt 0 a,-,crecised a-L- lccic-: t to $--,,349,000, zL!r i,-ig a m -iere arc 229 W'.-ID-104 to this program that you can't so many things cii corci(-, in,- Tiiere.is a religious philosophy there.', The Church has dor-.-,i@.atEL: '-iie program until the last few years, and certaiz'Ly now, uL'-@r Doctor S4--ud'L--'s 'Leadership this is not true. have aga.L.-Lis,@- the Mormon faith; I th irk i t is a great faith. but it has dominated this entire area, and I think these are --hings the philosophy has also dominated the University. The grantee was milking the program at one -iis is no longer true, and the whole thing has point, but completely reversed itself, and I think they should be given a fair chai-ice to carry oil pro@am. L So I woulk--71 --ecorL%aend '@-@,849,425 against the but $3,P,49,,.'r25 that t@@-.=-y ha@" reauaste-d, taking a million off raising the level of funding tl,.ak@. the Committee has recom- mend@ad. Trd would sug4est that when they do abnly for t',i,',s extra we can look clrsE!lv aL. that, and if at i4- aiiv t4-r,,e we are qoing to de4y 'Lunc@il iig, thank should be I., 1, p- t t'--,- a t 0 t'.--an nc@:. so h s I s r, v MO -L- 'I Oll S s LOD" c- i on airfer in quite IS. RLCOD: v,:-,---ws of the T a f c@.@ r -a--. T@3 c c L@-s -.crc":7. wou'.---l agr@G With c r that the influence of the 230 1 0 5 Univ--Ir,3"-Ly O."c and by its very nature, that of the Mormo4. C@,,urc4li, parri@at t7.iis progr@ri, b it I 'can not speak as strongly to the facts as Mrs. Mars presents, that.that is no long true. I -feel that t'-,--re is still a strong controlling a@'-, @ude tha,-- only the things which 'emanate @Lropi Salt Lake City can be done in a quality manner. Doctor Studt, the Coordinator, is making an extreme i effort to bring this program away from that concept,. and move projects from the strict University base. There -Ls, though, a lack of professional capability in the Region to the degree that has been expressed in the past, !.)Otl@i @-Y 4L--he -@'.IP and ;_,-_s RAG, but not to the extent that e .-.ave been led to believe. W minority issues in 7Lie state have not been a-_4dressed. I do not feel that the are ad equately addressed y -et,, the addition ol one minority aartinis-rative staff Y p@-rson, an T--Ter;@can --Ioes not in any Jay solve the a'4-s4L-- c 7@c p c@ a@@-'@-adco @,o,,ard the r l@ r t ea s t,, are s e r -vre db I'll T- z, I t:l z C, z s v -li,. cri,-,aos rccor@wcnda- 1 --ght o' arsh, m-.- "C E2 r a 4 p-@c,--c-s a3@l ti- c.r s4- @,af fcosts t '00, 0"--lus, %-,shield, 231 "IID-106 ".Ould leave t'lem 10-ss than $3110,000 for new project start-ups! U- W;@k--h ar s But their request is excessive, even with the Skilled sta-@f that they have, in light of the fact that the ion still mztjor',-4--y of projects presented in the applicat are based the Salt Lake City area reaching outward, and not reflecting strong interest in developing their limited. capabilities of the Region to stand alone and develop its @;n expertise in attempting innovative projects on their own. This Region had d belief, whether erroneous or not, that Lee,, could only use the contract mecahnism to pro- -Z ide funding for projects in their Region and they never v I indeed o-F@Lered a full grant project fund to a proposer. The si-te-visitors reco'n.Lviended that their animist tion an-"! c c c s broadening @ie scope of thi and if have indeed done so, there is more potential at the local level tha t in e pas4- would a- a c r c 0 r, d a.0 n sof Comriittee 4-4- are -L.@io h-Frsh, bu'@'I @qould not grant the,--.i t.,ie $2,800,00@,-@ plus that '.',ars su..--4ges L--cd. T i,,,ould al-c-nz,,tel@. ol-rcr $2,300,000 plus the'odd cents and d@-Ilars, i @L --s a figure to gi-,-e the -at,-.abilit-,,, to,@dress soire of the Rec-,ioi-ilpriorl"-@ies. 232 WIID-1 07 a'Lso i.@,ust inquire, in Doctor Stud,@- s letter of ,--rars,-,tittal to Council, to @IPS here, hc- stated that I the R g'Lon.n-l C-@orc!4-nators -- the Tri@.Dlegional Coordintors would iiie-c44-- ti-ie L@irst ;3art of -'-Jay, and j'.@irs. - I.Iars tells us @@,i@y -save and ,.ou'Ld line to inquire for my information l.'L Doctor Curtis did -ndeed attend and participate in the Tri-Regi-onal Coordina-Lars' meeting? MRS. @IIARS: I do not believe he was there. Just a minute; I have the letter here: "On Friday, June 7, representatives of the Regional Advisory Groups' of the three luIP's serving the Inter-l.t-:.oun-,"-ain area met in Salt Lake City. In at@Landance were Mr. Thomas K. Young, RAG Chairman oil Colorado-;-Iyoming Regional Medical Program." -Liais is not what you are referring to. But however, they did meet--, tlie RAG's met. I have the othe- letter; I'll find it in a minute, so we might as well get on with this.' Sl@@SBEE: L.Irs. @lars, answer her question sp Lical--lv; DocL--.3r CurL@.4Lss was Dresei-it. PC;S---'A: the RAG Cliairi-z,-,eii ar+,! all the Coort--'iia-tors ..;ere th,@--re. 'Lhis meeting tias purely the three RA@'s f rom the vzLr4-ous '-Re,,j-Lon3, an-i there were represcnL@-atives o@ d ail xose. iae I-eczing wasa if-- include, an ouroviae a- tae !'BIG 'Le%rel anv -"'e--ailed typo 2 33 klHD- 1 0 8 o-' any project plans that will involve over- -o handle notification, coordina- la-,3 areas, how each IU',P is 4t. tion oi-- a.@-- tha@ move'boyond the overlap area,, A. t- icl ir-.I,,act co:7c,-@iunities served situated in locations served r-@cl,,;S@VC7-y 3jy anol@-h@j: L-@,!.-71 to urge each Coordinator to implement a regularly exchange of information among reporting activities any activities that other Coordinators should be' aware are contemplated or under way. Agreement that each RAG sees that internal communi- cation is strengthened within its staff organization so every niem@ber can be expected go support and foster each RAG's com- k-i-atual cooperation among the three M--IP's. At least twice dur-Lng the year, each Coordinator -"irkgs at each oz fall be urged to at+--end at 'lueast two RAG meet- -:T's. Coordinators, with at least one o ther I s -L-ai@-J'- are ex@ecteL@A to attend all @.ur.L@ meeL@ings, and --,i-rman w'-'l telo-@ho-,a his coun'--er- ach r,:,C rlecting @@:le C.@ L part Lri @ac-,-i o' @ia o@ier P-".Pls at 4-@-le n@@-!el-iiic, shou-,,-' ba thared. W411 Mee@ ic 0-hairrie,-i together at least zLnriun-l@ '--Y, aii-I ri, - Ciair:,-,a@-i call an 4nterim meeting '.le @Lee-is- ad-,,-4-sabi-e to do so. A j 4-- r. g 0- PAG I.,-ill be 234 at jac':so.-i, ilyo,-ning on June 23rd, so that takes care 0- ;IZS. STLS 'ell, it doesn't really, Plrs. Mars. BEE: IV TIl-c @@urf probe.-, is one -,"-hat they-are finally addressing, but it does 1.@ave it does need considerable work. 'LiA:-"S Oh, I didn't mean it takes care of the ,io, not entirely. ZIRS. SILSBEE: We have to keep on top of that all the time. The minutes of 'he last meeting indicated that a nuraber of the activities had to 4o back to their respective Regional l.@ledical.Programs, to make sure there wasn't some problem, so they have not really gotten at the intent, of the w. i o L, 'Lin the Regional thing. .?,S. This is always going to be a problem there. The way the Reg4-on is set up -.t -nust be @a problem, and it al-@qat-s will be. The -Lr4--R@-gional Coordinators hav-@ -et, this ti:,e. o o@@ the P.AG C.',-i=-ir--ien pres-=-n@-. It was a :nost worth- and we are 'L o l@.'Lowing,it u-3 w4-4@-ii a trip to visi4-- %' ou--ita i n@qtates @t,!P in CCen4--d each oj-her's applications i ";,le Ynutually a ---e --ion t!i a t@-i certain specified projects ,7e Fluid coordincito closely witi the other.involved RI-,I,? before nroce@---7inc with 4--'-a eii7,ulcniontation. 2 35 'ID-1101 "The -.ro4ect which has been of any con- cern has been'a bv the University of Utah for i fu' ds 11--o idcnti-Fy pr@ n Ler role of the University as a re,--o-rral training center in what-has been charac- @ica-Liy considered to b3 its trade area." t-.--id sc, c:i a.-I@-- so -4octh. @--'-LSBE7-: And that is signed by Doctor Stud4,--, is it not? -"IRS. -',IAPS: Yes, it is. MRS. SI'USBEE: Well, the one that we got from all of has a slightly different tone. I-IRS. F@UOOD: T-,@,o is serving as Chairman of the Tr4@-Regional Coordinators? L@LRS. SILSBE@@: I'le is. @@IRS. I!kPS,. The other thing that I would-like to say I.-M that the projects were also all submitted to the eight CH'-PB agencies and thev were an roved, the recorimendatbns. arproved b @,z tha-- -Caere not aDDro-,7i--d were also no y the so acrencir--s, of c@e onc-- and a ver,,, c; li ere are eigh@- is a very c-L oiic Hills far as goi-.-.c; to t.,-,e minority problei-,i, 'they .,.,-vc a project .,7jz)inc, @-or ti-i-c wor.-.erl:--,- t@is -Ls being a.-id a cro,-,iD, whic.i of course c o.-, sa ;TL4-n-,rit-Y I,,opulLtion - . @ . --- 7@' @-- , , - . . I - - I I.. I i. :, 236 WHD-111 during the time of the harvesting, and certainly, the needs of it are being addressed, and I would'say that this program will develop into one that will eventually fill the needs. But I do feel that we must give them an opportunity. MRS. SILSBEE: Miss Martinez, you have a question? MISS MARTINEZ: I would ask, of the migrant project,' how community oriented and controlled it is? It is one thing to serve the population without itheir input or direction, and it is another matter altogether to have the community itself set the goals. What kind of a policy is it? MRS. FLOOD: I might respond there. That is one project I have always watched closely in that Region, and they can point with pride to that one, and we don't need to view with alarm, too greatly. It is a community based operation with a fund in Salt Lake City for the services to the migrant. It is not based in the rural outreach area; it- is based in Salt Lake City, but'it is a primary flow area, solit does serve its purposes,, and it does have some continuation funding in this proposal. But from the total amunt of their funding request, it is really a relatively small portion, when you consider the needs of the rural communities of that area and the @eed 2 37 WHD-112 ;,to break away from traditional programs based based only in the urban centers of that Region. MRS. SILSBEE: Doctor Sidel, did you have anyting you wanted to say? He is from the Denver Regional Office. DOCTOR SIDEL: Thank you.' In view of-the discussion and'the relationship between IU.IP and some of the Regional programs in my region i@and my Region, incidentally, consists of the two Dakotas, L @lMontana, Wyoming and Colorado-Utah, so it#s somewhat different Ilin the context that we usually think of a Region in. But a major concern of mine and the Region I repre- !;sent, which is that of resource development in the Denver "Regional Office, has been to improve the level of expertise in the planning area, and I am talking about specifically 'health manpower, and also, planning for all health resources development within the Region. We find that the general level of many'of the -sort of decisions are based not on practical information, but decisions which involve millions of dollars, both in Federal and state money, as a matter of fact, so sometime ago, we ,.initiated a contract action through a source of soft st&ements to establish a Regional Health Planning Resource Center. The concept behind the Center is to provide to improve the level of planning through four different channels: 1. Technical assistance in the skill area, planning methodology and these types of things; WHD-113 238 2. Education, and education based on-sit--,, that is, in a sense, in the work setting, so when people ask for technical assistance it is provided in those areas where it is needed, but then at the same time it also has educational content so that those people are trained to do their own training more effectively. 3. The other is to improve the communication between those groups involved in planning. 4. Through special studies" let's say in the area of health policy determination which may impinge on area designa@ns or a variety of other questions. In response to'the source of soft statements, actually what it came in with at one time was a proposal perhaps to form a consortium of all the We's in our Region, to get .development together and develop a resource center. Now, this of course -- we sent him an RFP; he ,responded to the RFP -- that's a request for proposal, and the :response to the RFP came from HDFC, since we were more'inter-, ested in putting money -- in dealing with the non-profit corporation than actually,putting money into the -- one of the RMP's itself. Now the q uestion then arose, of course, in terms of the legal status of HDFC; it is a recognized non-profit corpora ation, they have had a ruling from the Attorney General on that. We had had no previous experience dealing with this particular corporation, so we have had to ask for an audit, WHD-114 239 both in terms of fiscal accountability and in terms of t he institution and organizational arrangements, and in particu- lar the conflict of interest question. We do not have a receipt of that audit yet, which should be in next week sometime, because we need that prior to any contract action that we can take. The response to the RFP in other respects is very good. The Committee that we have reviewing these in the 'I Regional Office thought that it was innovative, dynamic and a superior proposal in all respects. The other question that has come up most recently I is one that I will have to get some clarification on, which is basically a'staff decision as to whether funds, for example, that are awarded to IRMP can be transferred to HDFC, because actually, in the fiscal proposal we received from them, they list four proposals -- 132, 133, 134 and 135, as direct allocation to their Health Planning Resource Center. So unless you know they can in fact achieve this'. they are not in a position to follow through on whatever con- tracts they make. I have been rather amazed at the ability of IRMP and Mountain States to get together. MRS. SILSBEE: Thank.you, Doctor Sidel. Mr. Russell, do you have anything to add to this. in terms of your recent tour through the four states -- the four mountain states, as far as'the CIIP-RMP or anything? 2 4 MR.- RUSSELL: I am really not quite sure what I can say. If I decided what I could say, I am not quite sure how I should say it. In our recent visit to the Mountain States Regional Medical Program, to verify their,review process, we found some evidence that there was conflict, perhaps hanky-panky involved, between some CHP activities and the Inter-Mountain Region. Mike may want to address this, because I didn't have a chance to follow it through. We also found that the Inter-Regional Executive Council, which was set up to eliminate the problems associ- ated with the overlap Turf, really had not been very effect- ive; a lot of this was due to phaseout, but as Mrs. Silsbee referred to earlier, we have to stay on top of this rather closely. So we did, before this last Review Committee, send out a letter saying that we had to have these assurances. The Inter-Regional Executive Committee, or Council, as it is called, did meet and give us these assurances, and we haven't had time to analyze the multitude of projects involved. I don't know if this helps, but MRS. SILSBEE: Mike, do you have anything, any input? MR. POSTA: No. Essentially I agree with what Dick has just mentioned with reference to the CHP involvement, and WND-L!G 4 -L why perhaps Inter-Mountairr has a little bit more rapport with the CHP(B) and (4)'s in that area. It is primarily because they funded a lot more things to them, and a lot of things they funded have been good. But again, this is only human nature', and maybe I shouldn't even be on the record, but with reference, I do, think, to the representative of Region 8 concerning the Health Development Service Corporation, $415,000 in this particular application that came in from Inter-Mountain was earmarked to go to this corporation. There are considerable -- or, there are some doubts i as far as the IRMP staff is concerned about this organiza tion, about his free-standing position, but you take that primarily because we get the same views from the grantee institution, and I think the grantee's institutional policy will prevail; if the grantee recognizes the Health Developmentl Services Corporation as a free-standing organization, and is convinced that their assets and their talent and staff -- to be recruited -- will be able to carry on the activities of HEW, particularly the RMP-philosophy, they will probably be funded, but I think Staff"s position here a@d in previous conversations under this subject,'wou ld be to recommend at this time that the -- to hold funds in abeyance to that par- ticular corporation until all the concerns of both DRMP and the grantee have been fulfilled. WHD-117 DOCTOR PAHL: May I inject myself into this for just a moment? This question of.the non-profit corporation is one that we really do not wish to have a Council recommendation upon, because we are not able to'provide you with all the information.on which you can make an intelligent recommenda- tion. The reason we can not provide you vith the informa- tion is that we currently are in active negotiation, both with IRMP -- that is, Doctor Studt and staff, as well as the grantee organization, as well as discussions with the Regional; the HEW Regional Office, and I believe at the beginning of last week, the grantee organization had one of its representa- tives come and meet with our Staff. There were a number of issues and concerns raised, and the negotiation status is that we are now awaiting some official word from the grantee'as to how they respond to (nr- tain questions that we have. So, we are not in a position, really, and'I don't tlink Council is in a position, to act upon a matter on which we don't have the full picture, the full information, and I don't really think that is important to this application, very --honestly. What we are looking at is the review and the merit on the funding level of the Region. The funds which are tied WHD-118 up possibly in this new organization are hard to identify if the funding level is below -- that is, if the recommendation by Council is below in the request. We are not sure; it is up to the RAG then as to what it wishes to do. So I would like to divorce, for your consideration, the status, legality, appropriateness and so forth, of the HDFC aspect and return, if you,will, to the merits of the overall program, and we will be reporting to you at the August Council meeting the conclusion of whatever these negotiations happen to show. We are just not able-to make a determination our- selves at this point. MRS. SILSBEE: At this point in time I need some. help from a parliamentarian, because Mrs. Mars,made a motion to the effect that the recommendation-be $2,849,425, whereupon Mrs. Flood made a -- seconded the motion, but she suggested that it be $2,300,000. Now, what do I do to get this resolved? DOCTOR SCHRIENER: Mrs. Mars has the option of accepting or not accepting the amendment. MRS. FLOOD: If-I may, I believe t said $2,349,425, and I will just run it to $2,350,000, which -- you know -- solves all these small figures, if Mrs. Mars accepts. MRS. MARS: No, I do not accept. MRS. SILSBEE: All right; Mrs'. Mars had made a A WHD-119 motion to the effect that the Region be approved at $2,349,425 and it has no second. Is there a second? MRS. MARS: Then we have another ma-tion. MRS. SILSBEE: All right, the motion dies for want of a seoond. I am ready to entertain a new motion. MRS. FLOOD: Mrs. Silsbee, I would recommend that we approve a funding level for Inter-Mountain Regional MediEal Program of $2,350,000. MRS. SILSBEE: Is there a second? MISS MARTINEZ: Second. MRS. SILSBEE: The motion has been made and seconded that the Inter-Mountain Regional Medical Prmoam be funded at a level of $2,350,000. Discussion? MR. MILLIKEN: What would the instructions be with this to accommodate the difference between what they have asked for and what they are being provided? I have some anxieties that some things may be cut out that we think should not be, if they are allowed to do this. I see no assurances. MR. CHAMBLISS: The activities of the corporation will certainly undergo some discussion here in Staff, and that might very well be MRS. SILSBEE: Now, Mr. Milliken, if you take your ;e 4.@1 WHD-120 viewpoint to its fullest extent, the only thing you could do is to approve the level they have requested. So in terms of advice, if you would like to specify something, we would be glad to follow up on that. DOCTOR WAMMOCK: I only want to say one thing. I looked at this and there are six states involved, and that is a lot of territory to cover, and I can see some inherent problems -- transportation difficulty and all these other things, and I don't know what the answer to it is,, whether $2,350.000 because you have a large territory to cover: there, and I do not know what the total population is of these six states, whether it would be 6,000,000 people or whether it would be 3,000,000 people. MRS. SILSBEE: Well, Doctor Wanunock, that same large territory is also covered by two other Regional Medical Programs. We have a motion on the floor. MR. MILLIKEN: Do Staff have some insights into this, or recommendations for instructions to this applicant? MRS. SILSBEE: think the instruction that we would try to interpret from your discussion is that you have felt that on the one hand the IRMP needed to get into the outreach,' looking at the needs and the -- try to assist in the health care of population groups that have been under- served, and on the other hand you feel that the Region is WHD-121 2 4 r- onrerfunded and that they should concentrate on these areas, at a reduced funding level. MR. CRAMBLISS: We will express to the Region the,- concern coming from Council about the minority issues in terms of project activities; you have cited the fact that the Region has hired one minority individual, and I seemed to hear'you saying that this is a continuing concern. I further hear you saying that the project activity touching on the minorities, and there are several minorities in Utah -- the Indians, the blacks, the Chicanos, that there is concern from Council that their health needs be addressed in a more pos@ve way. MRS. SILSBEE: The motion has -been made and secon- ded that the Inter-Mountain Regional Medical Program be funded at a level of $2,350,000. All in favor? (Chorus of "Aye") Opposed? MRS. MARS: No. VOICE: No. MRS. SILSBEE: Let the record show there were two opposed, but the motion is carried, and let the record also show that Mrs. Klein has been absent during this discussion, and Doctor Gramlich. All right; do you want to call it quits for te day? WHD-122 24 7 NATIONAL ADVISORY COUNCIL ON REGlov,,.,AL MEDICAL PROGRAMB SOUTH CAROLINA REVR.F-W MRS. SILSBEE: Now we will ta-ke up South Carolina. Lee, do you want to put it in perspective? MR. VAN WINKLE: It was considered to be an average or above-average Region; they had requested $3,600,000, and' the Committee recommended $2,200,000. The basic reason for this reduction was that here again, this Region had requested escrowed fundsil if you will blank checks, as I heard referred to earlier. With another Region, they were asking for authority to spend funds in the area of regionalization of services -- health manpower develop,r- ment and improvement, strengthening quality assurance, and other activities. The Committee did not buy this, or did not accept it; they did not think that these activities had gone far enough through the review process in South Carolina for it to be acceptable, and that is how they arrivi3d'at their reduc- tion. There are many other things that could be said, but Isuppose they will be covered by the reviewers. MRS. SILSBEE: The primary reviewer for South Carolina is Doctor Haber. DOCTOR HABER: In reading the May-June review on the yellow sheet, and the confidential comments in the 2 4 8 WRD 12 3 6:OOPM proposal, I sometimes wonder if I am looking at the same pro- ject. With four different perspectives, it became diffi- -cult to reconcile these all. Very briefly, because the hour is late, their pro- posal goes through a narrative history which is a very good focus. It shows the development of a typical Regional Advisory Group. There are a couple of comments'in this that I think are worthy of reiteration. one of them is that the Regional Advisory Group has maintained its integrity, quantitatively and one must assume qualitatively -- in the face of what they call a limited future outlook,'but they proudly aver that not one member has resigned. The organizational structure has been modified since, the inception of this program; they have gone through a number of changes since their inception in 1966, and they now have a triple-headed Regional Advisory Group -- I'm sorry; a triple-focused Regional Advisory Group structure which seems very adequate to the task at hand. The review process and their relationships with the CHP(A) agencies look good in spite of the somewhat tortuous relationships in South Carolina, and the comment is made that there are at least five different types of planning groups, CHP agencies (a) and (b), the Appalachia Group, the WHD-124 249 Regional Advisory Group, hnd a new group composed by the Governor, and the comment is made that this group is the line to his office, through a dotted line which seems to imply a tenuous future. The caliber of the people involved, although I have not had the.benefit of a site review, seems to be exemplary. I don't think we can fault them on that. The individual projects themselves, I think are worthy of comment on reviewing. I would disagree with Doctor Gramlich's previous expression of dissatisf@ion with concen- tration in one area. They haviv a number of projects related to hypertension, and I think this is good. They have a number of projects which are related to the detection of hypertension through kidney disease and neuropathy, in black female children, in the adult male popula,- tion, in general screening, and I think they are moving into an area very solidly, conceivably-with some overlaps, but a massive approach on this important debilitating and life- threatening disease is evident. Some of their projects look a little naive to me. There is onein improving ambulatory care, which would apply certain statistical models to ambulatory care. There are such models in existence, and it seems to me they xe trying to invent the wheel. I am concerned, although I don't have enough infor- wHD-125 250 mation about this World Mobile Health project; it seems to I me it is inadequately funded for all the wonderful things they intend to do. I was concerned about the nurse-midwife project, which has been approved but not funded, and then withdrawn, apparently because of the difficulty of getting people. It was very modest funding; it seems.J-ike an eminently worth- while project, and I would hope tELe Council could somehow help them in going ahead with this. I think that this shows a good balance of projects between rural versus urban populations,,minorities, between various kinds of diseases, and I would say that in total it seems to me the r organization is sound. The Regional Advisory Group has fared better than the RMP, which has lost, I think half its personnel. The ,quality of people is good; the proposals seem in the main well-balanced. I think it has been judaed average to above-average and I would concur in that, and I would also agree with the target that has been set for them; they asked :for $3,000,000 -and $2,200,000 seems eminently reasonably. MRS. SILSBEE: Mrs. Mars? MRS. MARS: I agree w:Lth.Doctor Haber and wit@ the Review Committee's recommendiation.. Ifelt that it is a particularly well-structured RAG,I 25 WHED-126 has a good review process, but there are SO many of these projected activities that have not had time -- I have not had time to go through this entire process by any means, so that they are really requesting funds for some projects which are still very problematic, so I'agree entirely, and I second the motion. MRS. SILSBEE: Mr. Rubel? MR. RUBEL: I would like to address one specific project that the RMP has proposed; I don't know how the numbering system works here, but it is something like 32-F; is that it? Which is that -- an attempt at setting up an organ- ization that would plan for the implementation of legislation that I spoke about this morning. I would like to present you with two facts and see where it goes from there. The Governor has expressed his very deep opposition to our funding this project without approval by the Health Council that he set up. Governor West has devoted a major portion of his last-two years to working on health problems in .this state, and very frankly, he feels that setting up of this organization is an attempt at by-passing the state entirely and trying to position the RMP in such a way that it would become -- or play a dominant role in whatever kind of organization comes about as axesult of discussions on WHD-127 252 Capitol Hill, Governor West has on several occasions discussed what he is doing in health-with the Secretary, and Doctor Endicott, and many other people. The Department, for one reason or another, is doing all kinds of things in South Carolina -- I don't even know about them. There is a lot of interest; that's point Number 1. Number 2, the HEW Regional Office in Atlanta has expressed a lot of concern about this project for a number of the same reasons. It is feared that the RMP is dominated by the medical profession and that, as I said before, there is per- i erneld haps an attempt at posturing here, that they are very conc ,:about. While it is alleged in the application that the CHP agencies are in favor generally, the Regional office has been told by many of the (b) agencies that they are very much opposed to it. I don't understand all t this state .he politics of of South Carolina, and certainly not the medical politics, but we have a very difficult situation on our hands here, I certainly think we would very much appreciate getting your recommendation on how to proceed here. I would like to just set out four possibilities, and while it is true that the Council usually does not deal with specific-proposals!, it has on many occasions said Y-ea or Nay to specific ones WHD-128 253 when the occasion warrant&. Be fore I get to the possibilities, in going through all the applications in front of us, there are other states there are other Regions that are proposing something like this, but I think it is fair to say that South Carolina's is the most blatant, or perhaps the most forward, depending on how you might view it. We certainly know, and as I discussed this morning, that RMP's as organizations, and the people that work in them, are thinking about the future, and are trying to do all kinds of contingency planning, and in fact different places work in different ways. You just heard something about what goes on in Inter-Mountain, and that is going on around the country, and we can't ignore that. On the other hand, to what extent do we want to allow money being -- coming through this channel to serve as abase for one organization or another here? Essentially, the four possibilities are: 1. Tell them, you know, you decide what you want to do,.based on whatever level of funding the Council recom- mends, which essentially says that if that gets to be import- ant they can go ahead and do it. Second alternative is to say: "You can't do it." Period. The third alternative would be say: "Go back and WHD-129 254 you had better start negotiating with the Governor, and as part of the application due on July 1, if you can get their approval, or it you can't, at least if you want to propose it again, please do, but we won't fund it during this cycle." The fourth possibility is a conditional approval, saying that there is a requirement for coordination here and for working together which has not been demonstrated, that you may proceed and do this but only after you have consulted- and gotten approval of the other factions-that are involved, that are going to be involved, in whatever the legislation covers. If you-can get their approval, then you can proceed. Those are the four possibilities, as I see them. Perhaps there are others. MR. VAN WINKLE: The Review Committee -- this was one of the thrusts, Mi.'Rubel, that the Comm ittee addressed, and this was what they based their reduction of funding on. This was one of those that they said they could not consider at this time. MR. RUBEL: It is one thing to provide the reduced funding; it is another to preclude money being used for this purpose. MRS. SILSBEE: Does the Council have any suggestions as to how we proceed? This refers specifically to that one project. DOCTOR WAMMOCK: Is that 32-P, did you say? WHD-130 I 255 MR. RUBEL: That7is 32-F. They are proposing, essentially, to spend 4165,000 to set up a new organization. - With the RMP funds? DOCTOR WAMKOCK: MR. RUBEL: Yes, sir. MRS. FLOOD: But all of the 32's A,B,C,D,E except for F., aren't'. they rather nebulous? Or at least, is it D that is sort of a blanket fund that will be spent on non-RFP's? MR. VAN WINKLE: All of those are in that nebulous category; yes. MRS. FLOOD: They add up to a million-four. MR. VAN WINKLE: Yes. MRS. SILSBEE: That, as I understand it, was why the funding recommendation was cut back. Now @Mr. Rubel is suggest-bg that not only the fund- ing recommendation be cut back but that there be some kind of outline or alternatives which -- and theyuere all valid altern- atives, and we need to have some motion in terms of the fund- ing level and what you do about.that particular thing. DOCTOR JANEWAY:- Can I ask a question, Mrs. Silsbee, before we get a motion? That is, can the Review Committee make any specific comments relative to the areas that were discussed? Because it could be circumvented and not be a Council policy if there were specific recommendation from the Review Committee as to WHD-1@>'L deletion. MR. VAN WINKLE: Not in terms of addressing this particular issue, no. MR. CHAMBLISS: As a matter of fact, there was a correspondence that came in since the Review Committee. DOCTOR JANEWAY: They were not privy to this infor- mation; is that correct? MR. VAN WINKLE: That is right. DOCTOR JANEWIIY: Because it seemed to me the sense of the Council, considering the second resolution of the Ad Hoc Review Committee was such that we were not in principle going to consider that proposal, that RMP organizations pre- pare temselves for some possible future role. MR. VAN WINKLE: They did not address that. All they said was they don't think these activities are suffi- ciently developed at this time for them to consider. But if they come back in in July, then.they will consider them, is essentially what they say. MRS. SILSBEE: Doctor Janeway is saying that the Councills previous action7with regard to that proposal -- the resolution, that the Committee in a sense answers this. DOCTOR JANEWAY: It doesn't have to be dealt with inany substantive sense on the basis of this particular Council. MR. RUBEL: I should point out tat this is referred WliD-132 257 to as a Phase 2, that the RMP has been involved in these activities. They did sponsor a conference back in January which Doctor Endicott did attend. Then here they have a very specific proposal here; this is not nebulous. This is it says: "We're going to do something. We're going to set up an organization,, and until we set it up we are going to use RMP's staff to do it and what it is sup- posed to do." So we can't fall back on: "We %ion't know what t---- is all about." DOCTOR HABER: Well, can we approve all save that particular project? And then adopt one of the four alterna tives that he outlined for us? Can we do that? MRS. SILSBEE: You can do -- yes. DOCTOR HABER: Well, I so move. I move that we adopt all that we fund this at the level recommended, with the exception of -that particular portion to which Mr. Rubel has reference. MRS. FLOOD: 32@F. MRS. SILSBEE: Now, in terms of that particular portion, are you.saying Option 2, no-go? They could not fund it? DOCTOR@HABER: I am trying to separate that out from the rest of the program. If we can get a motion approved tha, 258 NUD-133 all but that would be approved,.then we can handle this for those four options. That is holding up the whole thing. MRS. SILSBEE: IS there a second? VOICE: Second. MRS. SILSBEE: All right. The motion has been made and seconded that the South Carolina application be approved at the level of $2,200,000, with the exception of 32-F. Any further discussion? DOCTOR WAMMOCK: If you look up there at 32-D and 32-C, and 32-B -- I mean, I see no description here at all; it is only just-by title here. It seems to me it all falls pretty much in the same category. MRS. SILSBEE: In terms of the issue that the 32-F is directed at, which is that the Governor's Council -- that is a slightly different issue. DOCTOR WAMMOCK: It's got a different twist to it. MRS. SILSBEE: That is right. Further discussion? All-in favor of the motion? (Chorus of "Aye") Opposed? (No response The motion is carried. Now,. do you want to deal with 32-F? DOCTOR HABER: Can we have those four options again, Mr. Rubel? W'.P.D - s 1 3 4 MR. RUBEL: First, you can leave it where it is, let the RAG, based on the decision you just made, determine its priorities. Second is a flat: "You may not perform; this projecti is unacceptable." Just as we said earlier that any of those unapproved arthritis applications can not be done by the RMP'. Third is: "Come back in your July 1 application, but satisfy us that you have worked together with all these other bodies and that they agree to it." DOCTOR HABER: That is the option I want, and I am making a motion on that. MR. RUBEL: The fourth says: "You may use the two million whatever it is, or part of it, for this project only after you have worked with the other groups and only after approval by the Director of the Division of Regional Medical Programs." And that would only occur after he is assured that those groups have been consulted. Three kind of puts it into the next cycle; Four says it is okay under this cycle, provided certain conditions are met. MRS. O.ILSBEE: Doctor Haber, in terms of your.con- sideratim of this, of Number Three, it is now June 13th, and they have to come in on July 1. Now, whether they can satisfy[ QHD-135 260 all the things you are talking about by July 1, I DOCTOR HABER: We know they are not going to satisfy! all MR. RUBEL: Perhapsit would be useful for me to read to you a paragraph of a letter from Chairman of the South Carolina Health Policy and Planning @uncil: "I told you in Washington r would not consider writing this letter without the full ledge and con- -and without my @ng personally sent of the Governor, assured that he completely understood the issues involved'6 I This I have done, and I am now writing with his full knowledge and consent, and in fact under his direction, at the request that any application or communil cation seeking recognition or funding for any purpose in this field in South Carolina, which might be filed with the Department of Health, Educat:bn and Welfare, not be considered without having been referred to the South Carolina Health Policy and Planning Council, which is the official State body created by the Governor's Executive Order in January 1973 with the specific respons- ibility for planning, reviewing and coordinating all health efforts here in South Carolina." DOCTOR SCHRIENER: There are two ways of saying: don't do it. WHD-136 MRS. SILSBEE: I wouldn't want to enter into this, but in terms of the Council, you are in a position to do what you think is best. DOCTOR SHCRIEIIER: Oh, I think that is best. DOCTOR HABER: I would'still make a motion for the third alternative, and I do so. And I put that motion.Derore the Board. DOCTOR WAMMOCK: Would you so state what we are going to vote on now? MRS. SILSBEE: The alternative Three is that the that Region may not do that with these funds. If they choose to go back and negotiate with the agencies and the Governor's Council, the Council would entertain a request in the July 1 application. MRS. KLEIN: I hesitate to talk about this because I.I know so little about it, but it seems to me that the Ad Hoc Committee did approve this,, did it not? The funding that we are discussing, this aspect of it, and they had not had this opposition expressed to them at time? Well, it seems to me then that if they did, as far as the merits of it are concerned, that we are agreed that it is proper, then also, if they negotiate with the Governor, knowing how they sometimes operate, there is a possibility that they could clear this portion up, and for that reason I would certainly feel that we ought to go along with the WHD-137 262 fourth proposal, and that is to"-a'pprove it and then permit them to make their peace, if they can. So I suppose the-way to handle this would be to vote on the preceding motion, or I might offer a substitute motion, if that is in order with the procedure that you use here. MRS. SILSBEE: I am the poorest parliamentarian going, but -- Doctor Haber? DOCTOR WAMMOCK: She is making an amendment now. MRS. SILSBEE: She is offering a substitute motion. MRS. KLEIN: This would preclude the other one, I suppose it would be a substitute. DOCTOR HABER: I would accept that. MRS. KLEIN: Well, I would suppose that was proper. I would second the motion, then, as amended. DOCTOR WAMOCK: Well MRS. KLEIN: He accepted it and made a new motion, which in effect I am seconding, just so we can get a vote on this. MRS. SILSBEE: Mrs. Flood? MRS. FLOOD: I have a question, or perhaps it is a concern, that by making the statement that we would fund this type of a project, should North Carolina -- should South Carolina RMP make amends and get friendly with the Governor, we have set the precedent then for a request for funding for WliD-138 263 just such organizational structure out of RMP dollars across the country. Now, we just said earT+er that we did not want to encourage, or at least we wouldn't-accept as a policy state- ment, a statement that said we raged the staff to start investigating the administrative.structure that they might endeavor to approach in light of potential new legislation. But here we are talking @ ut setting the precedent for buying the complete service or development. MR. RUBEL: As I tried to indicate before, this kind of activity is going on in every Region in the country. MRS. FLOOD: Yes, but not at $165,000. MR. RUBEL: Well, you know; you can do it in various and sundry ways. You know that it is happening; as I have been going through the book here Ihave maraged to detect very similar kinds of projects, and some people have a better way of hiding them than others, in I would guess, at least a half-dozen other Regions. So it is not a question of: this is the only one. They are the only ones that are doing it quite as blatantly, but remember this went through a review process and nobody really picked it up. Nobody said; there is nothing I read, and I mean, the first I heard about it was when I got this nice cozy little letter here. MR. VAN WINKLE: They refused to consider it for a WHD-"L39 264 different reason, too. MRS. SILSBEE: Mr. Rubel, I think there is, in terms of interpreting the messages that have gone out-to the Regional Medical Programs, and in terms of the whole thing, it would seem to me that the Region is trying to respond in a way to a national initiative, and I guess I am a little concerned about the idea that it is trying to get there "firstest with the mostest." Now they are there, you have asked them to get ready, and they have used various ways of doing that. I just don't think -- and they have the, money@, so the fact that they have the money doesn't mean necessarily that they are not being involved with the others. Miss Martinez? MISS MARTINEZ: In some of these other states that you mentioned, that are doing this thing, is there the same opposition from the Governor? MR. RUBEL: There might be if he knew about it. You know, I know of many, many situations where there is a fair amount of-conflict there. It is very diffi- cult to say, because these applications haven't been reviewed by Governors, so we don't know whether they are opposed or not. MISS MARTINEZ: I think whether or not ittis happening on a smaller scale, I think with several of the WHD-140 265 srialler projects, and,whether or not it is a response to a possible national direction, I don't quite agree with the policy of spending program moneys on the possibility of a change when they are -- there must be better ways to spend program moneys. I don't quite agree with that kind of-philosophy. DOCTOR WMIMOCK: Mr. Rubel, what does South Carolina have? What is her plan called under the Governor, if you would please state that again? MR. RUBEL: South Carolina Health Policy and Planning Council. DOCTOR WAMMOCK: Well, there you .'.are, see? He is in direct control of that. MR. RUBEL: And that is right over the Department of Health. DOCTOR WAMMOCK: I venture to say they are the very first state that have a program that is controlled by the Governor. DOCTOR SCHRIENER: I just wanted.to say that I am not terribly swayed by the argument,that some of these may be buried in other proposals. The point is that we are dis- cussing this proposal; I think this I personally don't think it is a good way to spend RMP moneys, and I will vote against any other proposal that has it, just like I am going to vote against this one. VIHD 14 I ') C7 -14' 1 it until they have shown us -that they have already done it. MISS MARTINEZ: I still think it sets a bad prece- dent. DOCTOR WAMMOCK: Me, too. MRS. SILSBEE: Do you want to vote on that motion? MRS.-GORDON: I would like an exact wording of the motion. You are saying the same thing different ways, but it isn't the same thing. DOCTOR JANEWAY:' I was wondering, if we are talk- I ing about "safesmanship," if one really wants a motion? And a vote, on something whereby you are going to establish policy! by exception. And it seems to me that Staff could sense the feel- ing of the Council with reference to this particular portion 1 of the grant request and indicate to RMP the strong feeling of the Council in this regard. Because Wu are getting into two situations, it seems to me. One is, you are overruling a Technical Committee of the Ad Hoc Review Committee, which we have the right to do, but it is not the general order of things. It is a specific project. And if it is a motion, it is not only intent, it is policy. Now, I think Doctor Watkins made an extremely valid WHD143 26d point very early in the meeting about whether we were indeed required to vote on proposals that we elected not to have come before us. And the sense of the Council would carry the weight of a vote without having any. MR. RUBEL: We in HEW are going to have to deal with this one way or another; you know, if you decide to let it go to the ext ent that you disapprove it, that is the end of it. There is nothing we can do. But if you decide to let it go, we still have to deal with it,.,one way or the other. You can choose to tell us which way you would like us to deal with or, or you can let us deal with it ourselves. The problem is not going to go away; the Governor is going to be there tomorrow, and he is going to pick up the phone and call the Secretary and we are going to be right in -.the middle of it. MRS. SILSBEE: Mrs. Klein? MRS. KLEIN: We would be setting another precedent if we refused to approve-this, or approved it in such a manner that it implied that the Governor's approval approval would have to be had for every funding that we undertook from now on. That would be my concern; I would be more concerned in that direction than I would be in the directicnof asking NUD144 269 them to cooperate in getting approval by the Governor and these other agencies before they actually went ahead with the program. MRS. SILSBEE: Miss Martinez? MISS MARTINEZ: Isn't the issue one of .the RMP duplicating part of the function of the Governor's Council, and isn't that why, rather than all that RMP I don't think this would set a.precedent for approval of all RMP projects. It is simply a matter of RMP duplicating its committees. DOCTOR SCHRIENER: Mrs. Klein has a point as far as I am concerned. I don't think it is a very good expendi- ture of RMP program money. MRS. SILSBEE: Well, Mrs. Klein? MRS. KLEIN: I am sorry to be so persistent about this, but this, to me, would be sort of a flimsy reason for disapproving the program. If the Ad Hoc Committee approved it without knowing of this problem, as far as I amconcerned, it must have had some serious merit, and I am not in a position to say there wasn't -- you know, that it should be disapproved, possibly -because I don't have the information, but my problem here is coupled with the Governor's need for approval and that sort of'thing, and I don't thtk we ought to -- I think it would be a bad policy to require that approval before, you know, we do any funding. Otherwise it certainly would get us back to 270 :WHD-1 45 the point where we would -- what are we here for? MR. MILLIKEN: Point of information. Does the Ad Hoc Committee indeed approve or dis- approve, or do they recommend to this Council? MRS. SILSBEE: They recommend to this Council a funding level. Yes. DOCTOR WAMMOCK: I am sorry, but when you look at the titles again across here -- whatever in the name of God i that means, I don't know; the specific categorical entries Prime Health care, and Advanced Health Resource Planning? MRS. SILSBEE: 'Are you looking at the print-out, Doctor Wammock, or the individual 15's? DOCTOR W@IMOCK: It is the print-out here, you see, for this whole thing. it is all described here, and it se-...- to me -- Health Sources Development Initiated Phase 2, Advance! Planning, Corporate Mechanisms in South Carolina, and anotner one, "Program Needs on March lst announce Health Manpower Development Improvements;- one of the six really broad program areas whichiere eligible for consideration in the future con- tracts for project funds."- I believe it is-semantics; it is ill semantics. They are all going in the same direction. MRS. GORDON: Did I not understand you to say that one of the reasons for the cut in funding, or for the cut, wa because the Review Committee did not see the value in these 271 146 particular programs? MR. VAN WINKLE: Not that they did not see the value. These are thrusts that this program is making; it has been approved by the RAG. This is the way they intend to get into it. But in this application the program had not developed far enough for them to consider it. They said: "If it comes back in July we'll look at it," but they don't have who they are going to contract with, they don't know wno the project directors are; we don't know the amounts of the budgets. until@they provide us with that, they are just not going to look at it, is what they said. So therefore, we are going to cut the proposal by ,$800,000. DOCTOR JANEWAY: Then the Ad Hoc Committee has already said this. MR. VAN WINKLE: That is in their'recommendation. DOCTOR JANEWAY: That is@all we have to say anyway. MR. VAN WINKLE: They did not consider the proposals, at all. They just said: "At this time we don't know enough about it.' MR. MILLIKEN: Ques@n, on the motion. MRS. SILSBEE: There has been a motion made, and I don't know that I have the exact wording, but maybe, Mrs. Klei you could reword your motion, since it has turned out to be WHD-147 272 yours? MRS. KLEIN: I don't know that I have the exact wording either. I would prefer that someone else word it. My motion all right; I'll make an effort. As to these programs that we are discussing And I don't even have the information about them DOCTOR HABER: IT is the Health Services Development Initiative, Phase 2, Project 32-F. MRS. KLEIN: Flunding was approved by the Ad Hoc Committee, was it not? (Discussion off the record) MRS. KLEIN: They did not approve it? MRS. SILSBEE: They did not specifically disapprove anything. They reduced the funding level, with advice to the Region that they should come back with specific informa- tbn in July if they wanted anything. MRS. KLEIN: Well now, I have made all of my motions. I am really gumming this up. I have made all of my motions with the premise that the Ad Hoc Committee had appIroved the funding., MRS. SILSBEE: They reduced funding for the Region. MRS. KLEIN: They actually reduced the funding without knowing of the Governorts opposition, and the motion now would be to go contrary to the'recommendation of'the Ad WHD-148 273 Hoc Committee by approving the funding? MR. RUBEL: The issue, very succinctly -- given the funding level that they have gotten, $2.2 million, may the RMP embark on this project? And as I understood the motion that you made, it was that they may embark on this project within the limit of the $2.2 million, only with the specific approval of the Director of the Division of Regional Medical Programs, and that approval is contingent conditional on-acceptance by this Council and the (b) agencies in the state of South Carolina. MRS. KLEIN: In effect, then, this motion would go contrary to the recommendation of the Ad Hoc Committee. VOICES: No,. No. MRS. SILSBEE: No, because it just further specifies the recommendation. MRS. KLEIN: I see. In other words, their approval was just on the reduced funding, and this motion would increase the funding? MRS. FLOOD: No, it would leave the funding the same. MRS. KLEIN: All right; that is the motion then, as to these specific projects, that the funding be approved subject to their obtaining the approval and cooperation of the Governor and the other agencies. MR. VAN WINKLE: One project. WHD-149 274 MRS. SILSBEE: One project. The motion has been made and seconded that the South Carolina RMP be funded at the level -- at the previousl yi recommended level Council has already acted on of $2,200,000, but that any funding by the RMP'of project Number 32-F is conditoned upon the Region indicating to DRMP that they have the backing of the (b) agencies, the (a) agencies and the Governor's Council. Is there any-further discussion? All in favor? (Chorus of "Aye") Opposed? '(Chorus of "No") MRS. SILSBEE: Could we have hands on the "aye's?" (Show of hands) Six 'Aye's." Four "Nay's.' The "Aye's" have it. All right; now do you want to call it quits? MR. CHAMBLISS: -May I just say this? I think the Committee should know that there is one-sixth of its workload completed. I don't say that to deter the discussion;-simply to let you know where you stand in terms of the overall work- load that you have accomplished. WHD-15ri 275 MRS. SILSBEE: What time do you want to meet tomorrow? The Staff will be present, because a lot of them have already gone. At 8:30? Would you rather start earlier? All right; 8:00 ollock it will be. (Whereupon, at 6;25 P.M. the Council recessed until 8:00 o'clock A.M. June 14, 1974.)