11 a t . MINO Mr - B&B INFORmikriom & lm^ne MAKMASEMENT 300 @oftac @itova SOULXVARD UP,lwcot M,%OtLmommt MA 040 20'772 0 Us^ 0 C301) 24@l 1 0 NATIONAL ADVISORY COUNCIL TRANSCRIPT June 14, 1974 A ORIGINAL TRANSCRIPT OF PROCEEDINGS NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS BOARD MEETING c Rockville, Maryland June 14, 1974 Pages 276 thru 511 HOOVER REPORTING c6mpANY, INC. @l Re@s W"Wngton, D.C. 546-6666 NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS NS BOARD MEETING 9:00 AM Conference Room C-H Parklawn Building Rockville, Maryland Friday June 14, 1974 2 276 C 0 N T E N T S REPORT PAGE Mrs. Wynona R. Gordon, ALABAMA 277 Dr. Benjamin W. Watkins, ALBANY 279 Mr. Mike Posta, BI-STATE 292 Mrs. Esther M. Martinez,. CENTRAL NEW YORK 301 Mrs. Audrey Mars, ARKANSAS 308 Mr. Edwin C. Hiroto, CONNECTICUT 320 Mrs. Audrey Mars,, LAKES AREA 322 Mr. Peterson., MARYLAND 336 Mr. Sewall 0. Milliken, NASSAU-SUFFOLK 341 Dr. George E. Schreiner, NEW YORK METRO 344 NEBRASKA 348 NORTH DAKOTA 351 SUSQUEHANNA VALLEY 352 Dr. Paul A. Haber, MEMPHIS 364 WEST VIRGINIA 367, Mr. Michael Posta, TEXAS 369 Mr. Van Winkle, WISCONSIN 3'(8 Mrs. Maria E. Flood, TRI-STATE 381 ILLINOIS 4og OHIO VALLEY 414 WASHINGTON/ALASKA 418 COLORADO/'WYOMING 421 FLORIDA 426 276-A C 0 N T E N T S (continued) REPORT PAGE GREATER DELAWARE VALLEY 428 HAWAII 43Q INDIANA 433 IOWA 438 KANSAS 443 MAINE 446 METRO WASHINGTON.,,D. C. 452 MICHIGAN 454 MISSOURI 459 MOUNTAIN STATES 463 NEW JERSEY 47P NEW MEXICO 473 NORTHERN NEW ENGLAND 483- NORTHLANI) 487 OKLAHOMA 489 OREGON 491 ROCHESTER 495 TENNESSEEIMIDSOUTH 497 VIRGINIA 501 WESTERN PENNSYLVANIA 503 3 277 P R 0 C E E D I N G S - - - - - - - - - - - MS. SILSBEE: May we please begin? I think we have a quorum, with Mr. Milliken. Okay, we are going to start this morning with klabama. Mrs. Gordon. REPORT OF MRS WYNONA R. GORDON ALABAMA MRS@ GORDON: Since we are trying to expedite things today, I'll not display my ignorance by talking too much. .The Alabama Project, we are asking continuation for 16 projects, 21 new and eight that have been approved before Dut have been unfunded previously, which makes 29 new. I As you see, the reviewers have given it an above- average assessment. They seem to have good rapport with CHP and they have one consumer and one provider from B agencies, the 12 B agencies on the Counci'l. I did have a question. They talked about the 3tate Advisory Committee to the Governor and the State Board of ealth and this committee,, the EMS-Committee of RMP was the iucleus for this and does anybody know what what -- MS. SILSBEE: What is your specific question, qrt. Gordon? MRS. GORDON: Well, actually, pertaining to what qe were talking about last night MS. SILSBEE: Umn hmn. 4 278 MRS. GORDON: -- and so I picked up on the State kdvisory Committee to the Governor and the State Board of Health and was wondering what the MS.' SILSBEE: Mr. Jewell. MR. JEWELL: Are you talking about the E14S Advisory committee, Mrs. Gordon? MRS. GORDON: They said that -- well, that this committee was-made' up primarily of the EMS. MR. JEWELL: Right, that was the nucleus. They are heavy on EMS in Alabama and the tragedy that occurred to the Governor recently. They have established a committee made up of the health interests in the state which is advis4)ry to the Governor on EMS and that will be umbrellaed into 'other areas. MS. SILSBEE: But isn't it an advisory committee Ln the sense that the South Carolina one was yesterday, but I think that is the MR. JEWELL: I missed So@-uth Carolina. I'm sorry, f don't SPEAKER: It is-not. MR. JEWELL: It is not. Okay. MRS. GORDON: As You'll note on your critique, @hey suggested that the PSRO project be increased by $1002000 )ecause it seemed an excessive amount of money for $151,000 0 Start with and they also suggested that the project 82 not 5 279 be funded., mostly because it was for making audio-visual materials. I found nothing to quarrel with the suggestion of the committee on the funding, so I would move that iie accept the funding of $2,028,389. MR. MILLIKEN: Second. [The motion was made and seconded.] MS. SILSBEE: Mr. Milliken, as the secretary- reviewer, did'you have anything further you wanted to @idd to this? -MR.. MILLIKEN: No. I agree,. MS. SILSBEE: Okay. The motion has been e and seconded that the Alabama application be approved at level :)f $2 028,389. Is there further discussion? [No response. All in favor? [There was a chorus of ayes.] Opposed? [The motion was carried'iinanimously.] The motion is carried. The next region is Albany. Dr. Watkins. DR. WATKINS: Yes. The report on Albany seems uPerior and from a review, I feel this. I see high visibility n new legislation such as PSRO,.,' CHP, HMO., EMS and our first concern was that these weren't really true, in-depth working )rograms., but this is what the future is going to be at first 6 28o ight and I think then, combined with the community involvement, they have several community programs and overall they have followed the goals and objectives so that, to make it very 3rief, a superior program can't be criticised, so, to be very Brief, I'd like to say very quickly, let's accept the recommendation of the committee of $1,066,175 less than their request. [Sic.] MS. SILSBEE: Is that a motion., Dr. Watkins? DR. WATKINS: Yes, I make the motion that way. MS. SILSBEE: Is there a second? MS. MORGAN: I second it. [The motion was made and seconded.] MS. SILSBEE: Dr. Haber, did you-have anything to add to this? DR. HABER: Well, I would just like to reinforce ffhat Dr. Watkins has said. "I think, looking at the studies., nost of them were good. I had a few comments to make. The feasibility studies-with CHP and HMO and E14S Look good. The community hypertension feasibility, I think, is vell-thought-out and we have a favorable record of having ?eferred many of these patients to their private physicians. One of the things that intrigues me is that they eally ought to move fast in the HMO area because if I emember correctly, this is one of the regions Qf the country there Dr. Isselston, a pioneer in the whole field of HMO concept 7 281 'aad a group there that -- oh, I guess it goes back 20 years when Permanente was still only a twinkle in MS. SILSBEE: That is the Rip Van Winkle Clinic ifi Hudson. DR. HABER: That's right., and so they., I think, can move favorably in this area and they certainly appear to. be doing so, although I didn't see Dr. Isselston's name entioned in this. One of the real good products is the training for. the delivery of home care. I think they are doing a,very Desirable thing'in moving into this area, but I was concerned about the Project 039., which talks about expanded concept in aome health care. They really are very vague about that expanded concept. Is there any enlightenment possible on thai Issue? Does anybody have'any information about it? MS. SILSBEE: Dr. Haber, the Eastern Operations 3ranch is represented by one person who hasn't been involved qith that particular region, so we can get information for you but right now we do not have it. DR. HABER: Okay. Well, I will desist from further 3avil. I would second Dr. Watkin's motion that this be approved. MS. SILSBEE: Mrs. Flood. MRS. FLOOD: I have a question. Does the contents )f your packet, Dr. Watkinss containing the transcript of the 282 transcript of the review committee process, in any way explain cutting back $175? DR. WATKINS: No. I thought that was just a typographical error. MS. SILSBEE: I wasn't able to figure that out, either, Mrs. Flood. I wasn't at the meeting. @Ir. Peterson? TIRS FLOOD: Maybe its not really relevant to them. MR. HABER: Maybe somebody missed some figures, is all. .MR.,STEVENSON: Maybe I should have brought my figures down. I,don't recall -- it may have slipped MS. SILSBEE: You may have rounded.-- MR. HABER: I've got my notes MS. MORGAN: You think it's just a round-off? SPEAKER: Probably just a round-off. SPEAKER: Maybe we can take up a collection and DR. WAMMOCK: It's too late in the morning. MS. SILSBEE: Just for the record, the Albany, the iew council members,, the Albany Regional Medical Program in ;he past years has had real difficulty because it had gone in i direction that committee and council in trying to get changed 'inally did and brought in a new coordinator and the program ;eems to have moved along. This is one where they had to be :)retty hardnosed with them but it paid off. The motion has been made and seconded that the 28 9 3 klbany program application be funded at si,o66,ooo. Is there further discussion? [No response. All in favor? [There was a chorus of ayes. Opposed? [The motion was carried unanimously.] The motion is carried. The next region in our alphabetical order ..s krizona and, Dick, do you want to give some background first? @IR, RUSSELL: Yes. As noted on the green sheet, there are really three major problems with the Arizona Regional gedical Program. These problems are not new ones. They have been there, I would say, since the Year One. The Arizona Regional Medical Pro-ram is in non- compliance with the DRMP policy on regional advisory groups and grantee relationships. The crux of this problem is really the grantee. As you all know, one of oui- Assistant Secretaries. for Health, Dr. Duval, is now back-in Arizona and he does seem to have undue influence over the Arizona programs. We have talked with the RAG chairman., Dr. Richard Flynn. We have also talked with the By-Laws Committee chairman, Dr. George Bach as late as yesterday afternoon. It appears to .is that the Regional Advisory Group and some of-the key core 3taff are very sympathetic and would like to see the program in 10 284 compliance. Ilowever, the grantee now has other thoughts. Dr. Duval called Dr. Margulies yesterday and said that he questioned the legality of the policy. Dr. Margulies could only suggest to him that if he chose, he could challenge it in the courts. It was pointed out to him, by the time anything was settled, that it would be a moot question, be' cause it would all be in a different ball game. We really have no idea what Dr. Duvalls,response to his conversation with Dr. Margulies is but Dr..Margulies' Etssued Dr. Duval that we would hold to the policy and, I )elieve, indicated that in all probability a funding,recommenda- on which would just allow the Regional Medical Program LU .,3ontinue its ongoing activity would probably'be in order and hey should not really start anything new until we had evidence I;hey are in compliance. Now, the influence of this representative of the ,,rantee has also been witnessed in the Regional Advisory Group leetings where the -- it appeared the initial attempt of the Egional Advisory Group was to peace a high priority on one of 'he Outreach Programs which would go into the rural areas. The epresentative of the grantee convinced the group otherwise ,:nd it was obvious that he did influence their decision more, 1 erhaps, than he should have. There are other evidences that -- I d-on't think it Js really necessary to go into it too deeply here except that 285 he has advised the Regional Medical Group in some cases when a letter would come back to the Program saying, you know, you should do this or this is our advice and this gentleman's response has been he only wrote that because he had to We really don't have to listen to that. The coordinator appears to be an instrument of the grantee or perhaps some other interest in the community rather than a true program coordinator. The deputy has run the show for a number of years. In calling the program and asking for the.coordinator., it appears to us that he has not been involved and can give us the type of information that we feel the other coordinators do. So his role has always been very, very fuzzy. MS. SILSBEE: Mr. Hiroto. MR. HIROTO: I seem to somehow managed to have received some of these-interesting ones. Supporting what @4r. Russell has been saying and in referring to the notes -- thE transcript of the reviewing team, it'seems to,me that their greatest concern of the reviewe;s relative to programmatic matters was that, of those programs which reviewers felt were nost meaningful to the Arizona RMP would probably be the ones bo get the axe and not be put into play, should the request for Funds be reduced. I'd like to suggest to the Council tlTat perhaps we ight earmark certain funds as has been done, I believe in other 12 286 cases and make-our recommendations with'the earmarked funds included. I throw that on the table for comments because .Inuch of this conversation of transcripts seems to lie in the g.rea of concern that these particular things aren't agreed on. They call them C001, 002 and 003, "Shall provide a health education program -- medical manpower.other,served Etreas and expansion of health service sites." which apparently are moving in the direction that the ARMP claims they want to 90. MS. SILSBEE: This was sort of Outreach? MR. HIROTO: The Outreach, yes. MS. SILSBEE.: Outreach activities that they have Deen slow to take up in this region. I would recommend that we approve the reduced t'860,000 and earmark I think it is $300 and some-odd for the )utreach Programs. MS. SILSBEE: Mr. Hiroto? MR. HIROTO: Yes? MS. SILSBEE: The request and Dick -,-y@u"ll have o is for $6553400 for program staff. And the recommendation Is for $860,000 and so, in essence, you are suggesting that )ome of the program staff mon' cated into these ies be reallo ctivities? MR. HIROTO: And they would reprioritize their 13 li@ 1 287 program as well. MS. SILSBEE: Mrs - Morgan. MRS. MORGAN: The proposed staff of 20 professional, isn't that -- it seems like that is awfully high.for a'few ivhat -- even if they took all the programs, they have only got six programs and only three of them, I believe, are Drogram-staffed. MR. RUSSELL: I don't have my copy of the kDplication with me. They are, Mrs. Morgan, trying to move, Into the Phoenix area, out of the Tucson area to start that 3ffice there which wai3-closed after the phase-out. MRS. MORGAN: It just seems like 20 professionals Ls quite high for a relatively small program., MS. SILSBEE: Mrs. Flood. MRS. FLOOD: I might comment that, traditionally, ;he.style of the Arizona RM'P"s has done some good in s@te of ;he coordinator and perhaps the emphasis here of increased staff light be one valid approach to trying, to accomplish something lut I would have to agree with Dlrs.-Morgan that it does seem excessive number of people to work with with.only approxi- iiiately $389.,OOO both for core staff and the program-projects :In that health service site, manpower recruitment and the self ]:rovider education because, in essence, that is the only course 4f operation, as I interpret the print-out. Now, I didn't look at the application. So I feel 14 288 that perhaps Mr. Hiroto's point is well-taken that you do give them this reduced amount, but earmarking the $389-plus for their their programs and hoping the staff will produce more and not increase it [partially inaudible] so that DR. WUIMOCK: I notice this is University f krizona School of Medicine. MS. SILSBEE: Right. DR. WAMMOCK: I was out there in March and you know, 6@lhat is a relatively new school and they have been try.ng to 2!xpand it as a result and they are doing a very good j b of loing it in several areas and I was somewhat impressed with qhat the ongoing projects were at that time, although knew nothing about the RMP program. I was just, you know, impressed very much with what how fast they had travelled in the past few years when, what is it, five years ago they didn't have anything out there it all. MS. SILSBEE: That is as,.far as the medical school @.s concerned? DR. WAMIOCK: Yes, as far as the medical school is -concerned. But I know nothing about its relationship tlthough I do know that this is the Universtiy of Arizona ledical School. MS. SILSBEE: It is the grantee organization that eems to be one of the issues 15 280 DR. WAIIMOCK: They are probably going to be controlling RAG grantee funds here. MR. HIROTO: May I ask Mr. Russell MRS. MORGAN: They are responsible for the'm'and they should use them correctly. MR. HIROTO: -- what your reactions to that might ie? MR. RUSSELL: I think one of the the basic .aroblem here is one of noncompliance with policy and in going along with Dr. Margulies comments to Dr. Duval and having had iscussions with Dr. Paul it would seem appropriate,to rohibit the PJ,,IP from moving into any new activities until ;hey were in compliance. This., I think, Mr. Hiroto, would permit the Continuation of some program staff Outreach activities-which iave, as Mrs. Flood noted, have been very effective. MR. HIROTO: In spite of? MR. RUSSELL: Yes, and I--think, in,-all fairness-to he deputy and some of the othe@core staff and some of the. ]AG members, they have really tried to respond. MR. HIROTO: Then may I change my recommendation? MS. SILSBEE: You haven't made a motion yet. MR. HIROTO: Okay.' May I make a motion -then, that 'Pe accept the reduced funding for the Arizona Regional Medical Irogran of $860,000 and divide it is that it so they meet 16 290 he requirements the regulations of PJ4P relative to grantees. MR. RUSSELL: I think that the provision should be that they could not start any new activities until we were 9.ssured that they were in compliance. MR. HIROTO: Yes. [The motion was made.] DR. WAIOIOCK: That's really.putting them in a bind. MRS. MORGAN: Do we request a site visit,prior to our August meeting, or would this be of any value? You don't want to go MS. SILSBEE: This Regional Medical Program has oeen the subject of a number of site visits. I believe the review committee's recommendation related to'the fact that therE was this long history of this going out and giving them advice and not seeing much change as a result. I don't know that I think a site visit would be ielpful. Now, Mr. Hiroto has moved that the application e approved at the reduced level- of-$860,000 with the provision @bat the Region not undertake any new activities until the RAG grantee policy is resolved to our satisfaction. MRS. MORGAN: Do we want to tag that for their )utreach activities? Part of that? MR. HIROTB: I know we are supposed t-o stay out of )rograms. 17 291 MR. RUSSELL: I think in the feedback, back to the (iR,I.IP, that we could express your concerns adequately over this Darticular area. MS. SILSBEE: And again, if they come in with an application in July, we would be able to -- we can ask for Lnformation about how they do allocate these funds and that night very well relate to this review in July. Dr.lJaneway. DR. JANEWAY: I am not going to vote on this ,)articular issue. I would only say that had I been away two years as assistant secretary and come back to Tucson or Phoenix and saw that -- as has Dr. Duval that -- since they are the grantee., I would want to have some kind of internal reorgan- Lzation of staff, having known that I didn't have much control Dver them while I was gone. MRS. MORGAN: If he was gone that long, I don't knoi, qhy he would want to come back. MS. SILSBEE: Would you,please just second it, 4rs. Morgan? MRS. MORGAN:' I second it. MS. SILSBEE: Okay, the motion has been made and ;econded that the Arizona application be approved at the !,educed level, based on the $86o,ooo with the condition that ;hey undertake no new'activities until the RAG grantee policy s resolved satisfactorily. 292 Any further discussions? [No response.] All in favor? [There was a chorus of ayes.] Opposed? [No opposition.] Let the record show that Dr. Janeway abstained. [The motion was passed.] We'll have to skip Arkansas because Mrs. Mars did iot know we were starting this early this morning, so he is 3till coming in from Virginia. We'll go to Bistate. Mike, do you have any -REPORT OF MR. MIKE POSTA BI-STATE MR. POSTA: Yes, I think I'd better, since this was L pretty tough review in the ad hoc panel, Bi-State.,., Although this region obtained triennial status in he fall of 1972, it has never been Considered an average @lrantee The request of $1,129,608 was scaled down to a recommended $800,000 figure by the reviewers, which is, in fssence, 70 percent of the request, 63 percent of the target Jigure. Poor leadership, particularly on the part of the regional Advisory Group, was noted. It was also-noted that the Regional Advisory Group reduced its leadership to 15 and 19 293 turned over their leadership to what, in essence, was the Executive Committee. The coordinator has been serving on a I 50 percent basis. However, a new coordinator, Dr. Felix, is expected to take over on July 1. Reviewers noted that the proposals do not conform with the needs as identified by the joint RI'IP/CHP conference which met in February of 1974. In @ll due respect to'the region, it wasn't until February 7th of this year that the region realized that the court order had ruled in favor of continuation of -TU4P and further dollars. As a result, the May 1 application only contained two new proposals. One was involved with the @oor. To epitomize still further, or to epitomize, period, there was limited discussion during the ad hoc committee con- cerning the possible termination of this program. However, the reviewers expressed hope that the July 1 request of a'pprox- imately $410.,Ooo will reflect on the identified needs of the region, which has had its problems in the past in dealing with urban St. Louis and rural Southern Illinois.' Mr. Milliken, you might wish to continue this a little bit further. MS. SILSBEE: Mr. Milliken. MR. MILLIKEN: This special information.which staff- MS. SILSBEE: Could you use the mike, please? MR. MILLIKEN: The special information that the staff has provided you' with yesterday indicates that of the 20 294 l,lay lst,, 1974 request for the Bi-State RMP identifies four project sites in Illinois, three project sites in the St. Loui County, Missouri and 10 project sites in the St. Louis City. of Missouri. It seems to me that, recently, this problem of .trying to serve these two disparate areas has improved in that the kind of projects they have are beginning to even oiit, between the two kinds of situations. It would seem to me' that they have moved a little in this direction. MS. SILSBEE: Mr. Zizlavsky. MR. ZIZLAVSKY: I think because the Februar meeting between the CHP and the RMP joint agencies has led to a common assertion of needs in Illinois as well as in Missouri, they have simply stated that they would be.having 31 projects coming in July lst and these would more adequately address the needs and one of these projects would be in line with the Outreach than they have'really had in the past. I don't know if we should prejudge it until we see their July lst effort. MR. MILLIKEN: I-think another problem for this agency is the need for staff expansion. After reading a lot of this material and the results of the committee's evaluation, I kind of have mixed emotions. I feel that they do need some more limited staff but I do not feel they need the amount of staff they are requesting and I think the questi-on is., maybe staff can advise on this, what, where and how to cut this, 21 295 you know, so that we don't shut them off completely -- confine them to their present staff only, but at the same time, I think we have got to be very careful in how much and vrhat' kind of encouragement we give them for additional staff. MS. SILSBEE: Well, with the recommendations like $350,000 less than they requested, that additional expanding may be taken care of. MR. MILLIKEN: Yes. MS. SILSBEE: Mrs. Flood. MRS. FLOOD: May I ask if Bi-.State is still. using the RFP mechanism for getting proposals in from their regions, especially in light of the CHP conference and the priorities for needs that were established there? MR. ZIZLAVSKY: One of the weaknesses that they had when they phased out is that they reduced their staff down to about four or five people on June 30th of '73 with a gal-- under program staff doing about three jobs and getting paid for one was their information officer. One of the jobs that was really left vacant was their newsletter. After this meeting with the CHP in February, '72, what they did was print this'up in their news- letter. They didn't go the RFP mechanism, but they used this through the paper releases plUs their newsletter and sent the newsletter out to.previous project directors and others. ME. SILSBEE: Mrs. Flood. 22 296 MRS. FLOOD: I have one further question. Dr. Stoneman, the coordinator that is apparently leaving, was part-time coordinator and is the new coordinator to be a full- time coordinator or will he also devote part-time and'hold a faculty position and private practice, as Dr. Stoneman did? MR. ZIZLAVSKY: No, he'll be full-time. He'll be 100 percent. DR. HABER: I think it appropriate for me to voice an endorsement of Dr. Felix, whom I know very well. He was, as the brief indicates, former director of the National institute of Mental Health. He has been the Dean of the St. Louis University School of Medicine. He was the chairman of the special medical advisory group for the VA and we were bidding for his services at the VA and we lost out. We wanted him to be the head of our new geriatric research and clinical -center in St. Louis. He elected to go this route instead and I just want to say that he is a very capable man and will, I am sure, distinguish himself in the program. MS. SILSBEE: Dr. Watkins, did you have any comments DR. WATKINS: Well, based on what I.have been hearing, I would second Mr. Milliken. MR. MILLIKEN: I don't know what I said. MS. SILSBEE: Dr. Wammock. DR. WAMMOCK: I don't get through my-thick noggin here the reason for Bi-State Medical Program when you have got 2 3 297 two states, !4issouri and Illinois that have got two states here, 1-lissouri and Illinois, that are making applications and you have got a situation where one is across the river and they are trying to work together and it is sort of lilce a team of horses and I am not sure how you are going to get them hooked up to the wagon and I'm a country boy. MS. SILSBEE: Dr. Wammock, that has been ap issue has been a concern for a long time. DR. WAIIMOCK: I just MS. SILSBEE: The medical trade area is th basis of the DR. WADU40CK: I realize it is a medical tr e area, but I just -- I think, you know, it's trying to fit apples and plums and something else in the same'bag and peddle out something curious a@d I rather suspect that this requires, I.mean, some of the inherent difficulties that are arising in there when you have got another state which is goint-to come up shortly is Illinois. They've got Missouri coming up here. Why can't they just do it, each in their own ballpark? MS. SILSBEE: Well, being an old St. Louisan, they Just don't work that way. DR. WAIvU40CK: Well, anyhow, it makes a headache for the rest of us. MS. SILSBEE: The motion has been made and seconded that this application be -24 298 SPE-AKER: Wait a second. MR. MILLIKEII: I will make the motion. MS. SILSBEE: Somebody said you made a motion. MR. MILLIKEN: They knew I was going.to do'it. MS. SILSBEE: Well, will you say it, please? MR. MILLIKEII: I move that we accept the committee'E recommendation for the funding decision, 63 percent.of the [?] $800,000, 63 percent of the tiger and $329,680 under the request. MS. SILSBEE: Do.I hear a second? [The motion was made and several seconds given.] MS. SILSBEE: The motion has been made anct seconded that the Bi-State application be approved at the reduced level of $800.,Ooo. Any further discussion? DR. JANEWAY: Could I ask an informational question? MS. SILSBEE: Yes, Dr. Janeway. DR. JANEWAY: Knowing Dr-. Felix, I suspect although I have no reason to kmw this -- if this comes in $329,000 down, the July request is going to be.bigger. [Laughter.] Because he is a mover. He is an extraordinarily competent person and I think that some of the cooperation and clerical questions will be solved by that time.- MS. SILSBEE: Mr. Zizlavsky. 299 25 MR.-ZIZLAVSKY: One of the things that we did was ask the program -- all 53 -- for an estimate of their July lst request, so this was made approximately three months ago and one of'the things we have been kind of watching is their making a monthly.total and-then keeping up with this figure and they've carved the projects down from something around 31 to 24 in their own review process and I feel that those 31 projects were about $721,000 and it is down to $410,000, so iwelll keep your comment in mind when we receive the July lst applications so you may receive a surprise. SPEAKER: Good. MS. SILSBEE: The motion has been made and seconded for the reduced level of $800,000. All of those in favor? [There was a chorus of ayes.] Opposed? [There was some opposition.] The motion is carried. Good morning, Mr-s. rtars. MR. MILLIKEN: There was one further thing that staff recommended, that on the RMP request by Med,, Incorporated on the EDIS that the request be approved but that funds not be release., until RIVIPS staff and regional EMS staff attempt to arrange, possibly@through a joint staff visit.-some sort of unified planning capability. 26 300 MS. SILSBEE: Is that a result of their meeting the other day? MR. POSTA: That was a request by the IIEW Region VII office and also during the discussion with the HRA group on Monday and Tuesday we did learn that the arch program, the CHP "B" agency in St. Louis had been approved for a plannin' 9 grant and I think that the rationale here is to be sure that there is IJLU.L-V coordination with the funded EMS activities in that area. MS. SILSBEE: That really does not require Council action. The next region -- we'll give Mrs. Mara a chance to pull herself together and skip Arkansas and go .MRS. MARS: I'm sorry I'm late,, but I thought Iwas" early. Nobody told me. MRS. MORGAN: We decided that after you left. MRS. MARS: Well, I know, but somebody could have CALLED ME. MS. SILSBEE: Central New York. Mrs. Martinez. Mr."Skoloff is the operations offiders for Central New York and Mr. Nash.,'As I said.yesterday, could not be here. If you need'any additional information, direct them up to that end. 28 302 14ISS 14ARTIliEZ: 22C. MS. SILSBEE: It is the EMS. MISS MARTINEZ: EMS Radio. MS. SILSBEE: Miss Maritinez, that is on activities that have been going on before and it is primarily equipment, but it represents a partial payment. The hospitals -are putting up money also. MR. STOLOV: The review committee did discuss this. MISS MARTINEZ: You are talking about 22c? MR. STOLOV: Right, 22C and in its deliberations the review commi@tee noted that the region is'using'matching funds at the rate of 50 percent. local, 50 percent, Niqv. They also noticed that the RAG was astute enough-to give a low priority to putting equipment in ambulances and sticking to their original plan and 'giving it a high priority to putting a central communications systems in the hospitals. So in the event of gettina, an award, there is a least likelihood of C> getting the low prior ity ambulances,.passed through the RAG. I checked the RAG's members and to the best of my knowledge,, I think they made an effort to show that thei-6 was also membership from, say, the medical society and a gentleman- being on the CHP board but orginally when the RAG was formed., these gentlemen were chosen by their primary goals.,. say., representative of.the medical society but Vic Murray wanted to show also that there w@s some representation on his volunteers on other agencies in the community so you were 29 303 right on the 23,but officially the representation is from four of the agencies but -@Ir. '.Iurr-ay-lists the people on his RAG as representatives, primarily from the medical society, but some did have it, as you pointed out, a representation on the other bodies-. MISS I-TARTINEZ: Is that ususal, to have that large a representation? MS.ISILSBEE: I thin'k'that it would represent these are people that are seVving in two capacities and the representation is not because they are @HP but because they are particular individuals who happen to be active in two agencies. MISS MARTIIIEZ: Okay. ',low, there is a number of the number 44. I can't remember exactly what it is nowl Council for Coordinated Health? Is that it? That the function of that grant seems to me to be a county function. MR. STOLOV: 4o44, it's a home care health service project and your question, is that It appears to be a county responsibility? May I ask MISS 14ARTINEZ: That one and the Well Baby Clinic, particularly the Well Baby Clinics because, at least in MY state, that Is a county function. Now, is there any reason iqhy the county isn't doing this in the Central New York? DR. SCHREINER: Maybe I can answer that because I have been up there on a site visit. It is very hard for 31 305 period of time so it sort of leaves me hanging. For instance, number 58 -- number 56, I'm sorry gives you the impression that the people who are now IN ein'g observed by this clinic will be like hanging at the e d of a certain period of time because there is no mention -- in any case,.what I did was, I sort of subtracted the propos ls that I wasn't particularly impressed by and I still came u with a higher.*figure than the review committee and maybe you can explain I can up with $706,879 as opposed to'$600,()16. MS. SILSBEE: Do you want to make a motion to that effect? MISS MARJ'INEZ: Well, does someone want to explain to me how they arrived at 615? MR. STOLOV: Perhaps Mr. Peterson is more familiar with how the review committee came to that. MR. PETERSON: 6h, I think in this region, as in many of them that were considered, while the review committee went-through somewhat the same process that you did, Miss Martinez, examining the projects and the like, far more frequently they made some kind of overall assessment in terms of past track record and the like and from checking the Minutes or transcript on this particular discussion, this was one of the sort of class acti6ns in a sense -- oh -let's reduce this about.20 percent rather than explicitly reflecting a let's subtract this project, halve this one some of that 32@ 306 went into the thinking so in one sense it was an 80 percent kind of region, I guess. MISS MARTINEZ: Okay, well, I'd still like to make a motion at this time to fund it %,*)706,379. I subtracted MS. SILSBEE: I don't think we need to go into this., but would you repeat the figure? MISS MARTINEZ: $706,379. MS. SILSBEE: Is there a seconds [The motion was made and seconded.] MS. SILSBEE: The motion has been made and seconded that the Central New York application be approved au Ljiu -Level of $706,359? MISS MARTINEZ: $706,379. MS. SILSBEE: $706,379. Is there further discussion llrs. Flood. MRS. FLOOD: I only have one question. Mr. Stolov, is there still a report out as of the last phone call that they woulc'rbe-coming in for the July- August review at $1,150,000, which is the proposed figure at the bottom of our green sheet? MS. @ILSBEE: Mrs. Flood, that represents an estimate that was made in early May. We haven't gotten an update. That probably represents, though, some-total of what started through their review process. I would doubt 33 307 that it would be that high. All in favor DR. SCHREINER: I Just might comment that they had made tremendous progress setting priorities and I am particu- with larly happy to see them coming in/the coordinated programs in the North Country. There are two, the new ones. Some of you may not know that there are over 5.,OOO Indians pn the Regis Reservation who never signed a treaty with the United States so they' get no health care from the Federal Government and they are dependent on New York State, which has been zero up to this point on the care that has been provided. At least they had a dental but it had!not even had the cellophane taken off -- the plastic -- and so it looks to me like they are getting down to work and I think Miss Martinez was very generous and I'm happy to I think that they will spend it weil. MS. SILSBEE: Thank you. The motion has been made and seconded that the application be approved at $706,379. All those in favor? [There was a-chorus of ayes.] Opposed? [There was one nay and the motion was carried.] The motion is carried. Mrs. Mars., are you ready to go back to Arkansas? MRS. MARS: Yes. 34 308 EPORT OF MRS. AUDREY I-IARS ARKAIISAS MRS* MARS: I site-visited Arkansas a number of years ago and at the time I was very 'impressed with the program. They had an extremely outstanding coordinator by the name of Dr. Sillverbladt who, unfortunately, has resigned in the last few months. I think rather unexpectedly. He was a very Ambitious individual for his program and a very active person. Fortunately, the new coordinator has been there for the last four years and is a very capable person. He was there, I know, At the time when I site-visited the program. They have a close cooperation with the CHP agencies., both the-A and B. There are eight agencies -- eight,' B's and one A that are funded. The planning and development districts are the grantee organizations for the agency so that if the agencies are disbanded, they -- there still will continue to be a monitoring force for the AFJ4P activities. They have imporved their relationship with these agencies in the last years and some of the ATU4P proposals now have a B agency as a sponsor and their technical assistance in the development of a project has been invaluable to them. The entire application of the Arkansas RMP was submitted for comments to each of the agencies and all eight 35 309 responded. There were very few differences of opinion between the A and the B agencies concerning the projects but the CHP B agencies and the RAG agreed in any unfavorable comments that were made. Four of the six of the projects that received unfavorable comment were withdrawn by RAG and two were sent back to staff for administrative changes to be made before the approval.. They feel that the projects proposed@will be supported by other aspects of the health care delivery system when the ARMP funding is no longer available., @IP has a very well-organized monitoring and evaluation division. It monitors ongoing project activities in relation to their stated goals and objectives, maintains a constructively critical posture. The division of physical affairs keeps accurate, up-to-date records,, working in close liason with the monitoring divisions. The subregional system has been developed exten- sively. For example, they have a contract with the Arkansas League for Nursing and for the-devolopment of a quality assurance program. In nursing homes they have a hypertension screenin- program, quality assurance programs with the hospi- tals and others. There is very good involvement with the'RAG. They have been successful -in securing funds and political support in order to obtain state funding for programs as well as from 36 310 charity sources. The quality assurance is being stressed. This certainly is very necessary in a state such as Arkansas. They have emphasized continuing education as one of their major thrusts. The ARMP coronary care network in Arkansas is the outstanding one now. Kidney disease control program has become completely self-supporting. The expansion of their recovery room services for the,ch:Ddren's hospital project is a very choice example of. multiobjective activity. It will provide an.improved and expanded primary, secondary and tertiary care'and will interact with operations of many health care systems and serlices of v health funding. There is no conflict or duplication of activities being funded with the HSA funds to Arkansas. They have 58 RAG members, the coordinator meeting with them, of course, makes 59. The RAG Is well-distributed between members of the public,, the health professional and private and public health service. Volunteer agencies are represented.I.There are teachers, lawyers, judges, politicians, nurses, higher education, insurance, doctors, health agencies, dentists'. hospitals all represented, so it is a very good composition. And they all seem to take a very active interest. The program has stayed the RAG has stayed the 37 311 same, despite the projected phase-out and Arkansas is planning on applying for another $800.,OOO in July. I am perfectly happy to accept the review Iomrhittee!l I recommendation of $1,500,000. The new coordinator, I think, will-be able to do a firmer staff organization. This is needed. They do 'eed more people on their staff. It really is not as complete s it should be And some of the programs should be reconsidered., such as their sickle cell in light of the year's per od time which some of these programs just cannot be completed or successfully carried on so I move that we accept the eview committee's recommendation of $1,500,000 to the Arkansas program. [The motion was made.] MS. SILSBEE: D@. Janeway. DR. JANEWAY: I will, in order to get on the floor, second the motion for approval of the recommendation of the- committee. [The motion was seconded.] I have a philosophical question. 'I think we are dealing with the only game in town, is one thing I read in this and I have two questions, one'of which is rhetorical and one Of which I'd like the advice of the staff., and that is., I think ffe are beginning to see here a fairly sizeable role of the 38 312 CHP B agencies and the implementation of health services which, from a management standpoint bothers me that planning control and implementation should be functionally in one organization. That is rhetorical because there is nothing we can do about that, I think. The other is, perhaps, just to get educated. I., wonder about providing support for the Arkansas Health Statistics Center when it is clearly stated in the proposal that they wish the funds for one year to demonstrate to the state legislature that this is a valuable project. One wonders if the planning funds for this couldn't be derived from state sources, but I don't know wha@ was cut out and I just wanted some guidance from staff on it, but I second 1-irs. Mars'. recommendation. I,IR. POSTA: Doctor, to respond on the statistics part, the legislature did 'not meet this particular spring. That request to the state legislature for additional dollars for an agency statistics will be pr6sented in the next session. The request to the statistics center here was not approved or was cut down and that was the reason for that. DR. JANEWAY: I'm glad to hear it. MR. PETERSON: I think there is one other small item, Dr. Janeway, in the way of history on this one. Arkansas has a great deal of federal money. They have a@tatewide experimental health services delivery system project and I 39 313 happen to have-been on a site visit to it about six weeks ago and it does appear from looking at it through that end of the tube that the establishment and the initial operational support of this is sort of being traded off between the experimental health services, the R14P and as Michael pointed out, they do have the legislature which still only meets every two years so you'd have that kind of a.problem. That does not necessarily justify it but@it does explain, perhaps, why there is some ES-RI@.IP coordination. It is a new operation established less than two years ago. DR. HABER: Can someone-give us a word of explanation about that expansion of that burn center? 'Yes, sir. This was 'considered a number MR. POSTA: one priority by the regional advisory group that met. Originally, when they got together, the title of this was a little bit different because the first initial request was for total equipment. When we negotiated with them and they approached us with this p@ticular idea., we said there was no way that the review groups would support a program of this type if it -was solely for equipment. As a result, they revised it, went back to the drawing board and came in with mostly soft money. There is a little bit of equipment in it but this is to be funded through children's hospital and it will be an add-on, if you will, to their emergency medical services system. 4 0 314 IIS. SILSB7@E: The motion has been made and seconded that the Arkansas application be approved at the level of .$115002000. Is there further discussion? [No response.] All in favor, say aye. [There was a chorus of ayes.] Opposed? [Th ?re was no opposition and the motion was carried unanimously.] The motion is carried. MR. PAHL: Before we proceed with another appli- cation, Mrs. Silsbee has been giving me a little chore to@do here which I am happy to do, particularl y because you are doing so well this morning, but I think we might have a frame-@ work for todays activities because a few individuals have indicated, you know, what their schedules are and our interest as well as yours is to be fair to all regions, so I think if I outlined for you what we see to be-the framework., you can continue to do as well as you have-'this morning. If we spend about 10 minutes per application, simple arithmetic will show that if you work through the day, including the lunch hour, you will be finished around 4:00 to 4:30. That is no breaks and work through the lunch hour. Now, I know that in some--'Instances yo-u will have to Leave for good and sufficient reasons. What we don't want to 41 315 have happen, and I am sure what you don't want to have happen either is to have, at the end of the day, either a rush so that those regionsreally don't get adequate attention, or insufficient people working into later hours so that,, again, the regions are not represented by primary or secondary reviewers. So, with that understanding, I would like -;o sugge@t that., keeping in mind these facts, we decide Mesa council how we wish to manage our operations now, rather than get rushed at the end of the day, which we know we woixld be. So we have to make a decision, therefore., either to observe IIrs. Silsbee's kind of time framework and tha could be done by having the staff present a few highlights and then the principal reviewer only add that comment or two which would substantively change the recommendation of the review committee. If it is an endorsement, the review committee has done its work. If there is a reason to highlight something which would result in council discussion or perhaps a different recommendation, that is, of course-, what we should do. If that is the operation, then I think one can see completing the work in fairness to all regions through the day. If not, we should make our decision to either work into the evening hours or stay over till tomorrow . but I do think it is unfair not to give this framework early in the day and then have people drift off later. 42 3 Perhaps the council should just decide how it wishes to manage its affairs so that Mrs. Silsbee can be guided by your decisions. MRS. SILSBEE: Mrs. Morgan. MRS. MORGAN: Judy, I am sure there are certain regions which, having not gone through everything, had every.- thing to go through, that have been flagged as problem areas. It seems to me you could -- staff could mark these off and maybe we ought to hit these earlier while we have a'fresh thinking MR. PAHL: There are a few that we,have identified MRS. MORGAN: Right. MR. PAHL: -- some of which you have been discussing and that is what I say, you have been doing very well this morning. MRS. MORGAN: But I think if those were flagged and you started to do those, then maybe within the next hour we'll have a much better idea of what -- after we have gotten rid of some of these more difficult ones-, what our timeframe is going to be. MR. PAHL: We have, indeed, already identified a few. You handled., perhaps, five of them and there are perhaps six regions that we would take up -- Dr. Haber. DR. HABER: I was just going to modify that suggestion. Is it possible for you to present to us a list 4 3 317 of those things that are likely to be noncontroversial to be voted on en bloc, giving us some time, therefore, to spend on the controversial ones., rather than spending an equal amount of time on each? MR. PAHL: Yes., we have identified those. Just taking up for.a moment, let me say that you must recognize that this council is handling more at this meeting in the way of total applications than any council has in the last four years because yesterday you had an arthritis discussion both in the morning and the afternoon with 43 applications and this council, in terms of RMP application, at this'meeting is handling 53 applications, not the normal 17 or 1B. So both you and we are under the same kind of impossible time pressures and my comments here are not meant to state that any of us, as staff, are in any way dissatisfied or frustrated, but we are indicating to y-6u that knowing schedules and in fairness to regions, we have to work within that framework. I would suggest, Judy, @hat what we do -- for example, Dr. Schreiner has to Vpqar on the Hill here for testimony -- either this is the real world and we want your advice for the regions and we will try to get through as many of these before you have to leave and I think what we ought to also do is take up tho se regions where we know we need the council discussions as we have with some of the others that we have been handling this morning and then we can pace 4 4 318 ourselves during the day. DR. HABER: Especially those problems first and then we can see how they work out. MR. PAHL: That is correct. The other thing is, at an appropriate time after some other coffee is brou,7ht in or so forth, staff will be glad to bring in coffee or if you want sandwiches brought in .or depending on how you wish to run your day, but MRS. MARS: I just want to @et a sandwich, that's all. MRS. MORGAN: Yes, we are not going to work all day without at least a sandwich. MR. PAHL: Yes, and I think a little later in the morning, but I wanted to say we do appreciate that you'have an unusual workload. You are doing very well but we also have to recognize fairness" to the regions at the tail end of the day when everyone is tired. MRS. SILSBEE: Well, in the memo that I sent out to the council, I identified about- 11 regions that I thought needed some special attention. You have already dealt with four of those, so the remaining ones are the ones that staff identified, that need kind of deliberations of this council and in terms of the corimittee's recommendations, Connecticut Lakes Area, Maryland, liassau-Suffolk., New York Metropolitan, Texas and Wisconsin. 45 319 !4ow, that would be my agenda. Then we also have, Dr. Haber has to leave at noon. Dr. Schreiner leaves at 11:30 and Dr. Janeway is going to have to leave this afternoon at about 3:30 so we have got (juite a bit to do in two hours, really. I wonder if it would be helpful in terms of Dr. Haber and Dr. Schreiner, who leave this morning i-' I could ask them the regions that they reviewed. Dr. Haber, you had Memphis and'Washington-,@laska, as I recall, as primary- DR. HABER: West Virginia. MRS. SILSBEE: West Virginia. Are either f those going to require any changes in the committee recommendations? DR. HABER: Memphis might. MRS. SILSBEE: How about among yours, Dr. Schreiner. "Yes, well, I can handle them pretty DR. SCHREINER: fast. MRS. SILSBEE: Okay. Slnce the next one on the list is Colorado-Wyoming, our record should show that Dr. Gramlich is not here today. MRS. MORGAN: Do we want to do that, or do we Want to do the difficult ones? I'd say, let's go to the difficult ones and then get Dr. Schreiner's and Dr. Haber's and then come back to these. MRS. SILSBEE: Okay., very good.' Connecticut is 46 320 a difficult one. Dr. Watkins. DR. WATKINS: No -- TIRS. MORGAN: No, that is Ed's. DR. SILSBEE: Oh, Ed, excuse me. MR. HIROTO: It may not be that difficult. REPORT OF MR. EDWIN C. HIROTO CONNECTICUT MR. HIROTO: Inasmuch as their application is for continuation of only one month of programs and one year for the staff and there is a considerable amount of conversation that occurred between the -- amongst the reviewers and since the July application will probably bear the brunt of the review, I would recommend that we accept the surveyors' recommendation and recommend $510,000 with, really, the bulk of the review to occur at next cycle. MRS. SILSBEE: Is there a second to that? [The motion was made and seconded.] Okay, any discussion? DR. WAMMOCK: We-1l,otheire is a sentence down here that says "The RAG chairman's response to CHP, comments, as well as CHP comments themselves, indicated that the IU4P-CHP relationships remain a problem." MR. HIROTO: Yes. MRS. SILSBEE: Yes, that's true. MR. HIROTO: They are. 4 7 321 DR..WAI'E@IOCK: llell, there's nothing new about it, huh? I,/IRS. SILSBEE: There is something the council can do about it. DR. l@IAMIlOCK: Yes, well, I mean, I just I,-IRS. SILSBEE: It was a problem and it-is not just something that has emerged. The motion has been made and seconded that the Connecticut application be approved at the reduced level of $510,000. Is there any further discussion? [No discussion.] All in favor. [There was a chorus of ayes.] Opposed? [There was no opposition and the motion was carried.] The motion is carried. The next one is Lakes Area -- a problem and .-Irs. Mars is the rimary reviewer. p MRS. IIARS: I seem tG, get all the tough ones. MRS. MORGAN: Tha t's because you do such a good job )n them. MRS. SILSBEE: Mr. Peterson, I wonder if you would ind stepping up here, because you chaired that particular anel and Ilr. Nash is not here. I-.IRS. MARS: These microphones seem to be makin- a 322 funny noise. REPORT OF IIRS. AUDREY I.IARS LAKES AREA MRS. MARS: Again, I think that the funding reduction here is too drastic. I site-visited this program a number of years ago when it was in very bad shape. At that time, the grantee was taking a tremendous percentage of its money. Dr. Ingall, who is one of the most capable of the coordinators, I believe was chairman at one time of the steering committee of the coordinators, i.s the present acting coordinator and has been for some time and at that time he was about ready to resign. I think that the site visit helped considerably and all suggestions that were made at the time were followed. The program, was Completely turned around and I would not be surprised, but if we reduced the funding to the'degree that has been recommended here by the review committee, that Dr. In-all would not resign, which'would be a pity that he would not be able to see the p;og-ram through to its termination. lie separated the program from the grantee and formed a nonprofit agency to act as the grantee and'has a five-member board. The program covers seven counties irrnew York State and two in Pennsylvania with a population of over three 49@ 323 million people.. They have two CHP B agencies and these agencies have representation in the RAG. The criticism that I would make of the RAG is that it is heavily weighted by the medical profession., perhaps too much so. The two programs which the review committee, letl.s say, brought to attention and which apparently deserved it greatly and were of particular concern to them was the request for the funding of the telephone lecture network. This is. a very unique project. This is an area where in the wintertime snows pile up to 12, 14 feet and I guess at times, 20-feet drifts which means that there is practically no communication in this. area. This telephone lecture network is far more than that. It is their only means of communication. It is a continuing education program and it i§ just a unique and valuable dispensable program to the area. It is an expensive program but I felt that every penny that is put into it is wVthwhile. The other program that they were concerned ab out was the continuation of the cancer registry. This is the fifth year for that and as all of you know, cancer registries are not as much use or cannot be proven of use, really, until five years has been completed. So that I felt that despite the fact that we have been trying to vet them out of this tumor registry., inasmuch as they are 50 4 32 still in, it seems to me that the continuation of the registry at this point would certainly be worthwhile and., undoubtedly, it will be taken over by the participating Hospitals at the end of this five-year period. The complaint seems to be that we should give a stron- message to the practice of continuing support projects beyond three years. Of course, this has been our policy, but, nevertheless, there have been other programs t hrouc,-@out the RMP funded over a period of five years' time and there is no absolute set rule, I do not believe. Is that true? To that degree, that if a program is worthwhile, that it cannot be continued for a lot iger period. DIRS. SILSBEE: Council policy is-to encourage three-year funding. MRS. MARS: @ight. MRS. SILSBEE: And to have, at the initiation of the activity, some plan for take-over by other resources. MRS. 14ARS: Exactly. SQ-that with the tumor registry, the plan is such that the participating hospitals will take it over and I think eventually that as RTIP withdraws its support for the telephone network, I am sure that this likewise will be taken over. So that I really felt that this was more or less something that did not justify destroying a program to say that we are going to give a strong message to for the sake of this money which.is already being put in. You 2 3 are simDly scuttling a program that it just doesn't justify doing that. The staff, my criticism is, does seem excessive in number. They certainly need to eliminate some of their staff and replace them with people who are more competent. The CIIP relationships seem good. They and the Rl,!P did not agree on all of the projects that were presented, but the staff and the RAG took heed of this. The total,dollar request for the 11 approved projects is @780,453 and five new projects were presented in their application that require $260 000. The funding that the review committee has suggested is $400,000.below their current annualized funding and as I say., at this late date to deliberately try to scuttle a program for the sake, of teaching them a lesson just does not .seem to make sense to me." This program has done a great deal of good to improve the health pattern in the area and I feel that it certainly is an average prograia, although the review committee rated it below average and I think that it could hold its head up against any average program, so to sppak. So I would like to suggest that instead of -- and I will move -- I not only suggest but I will move that instead of the $1 million committee recommendation against the $230723000 they requested, at least to give them the $400 .000 which is now the funding 52 326 is less than their current annualized figure. So I move that we recommend $1,400,000 funding. [The motion was made.] MRS. SILSBEE: Mrs. Gordon. MRS. GORDOII: Well, I can appreciate the value of the telephone network. We don't have drifts 12 feet high, but we do have somewhat the same problems with communication and that sort of thing. However, I agree that it is a shame to scuttle it at the last yesar. But it would seem that they could have put more emphasis in -- toward getting other funding. It was a valuable program to them and there should be those who are willing to support it. MRS. SILSBEE: Mrs. Gordon, I believe that a part of that support is that there are a number of hospitals in the area and they do it is a matter- of gradually getting all of the hospitals to take up their portion of the cost. There has been -- costs for @his project have gone down over the years and it is used-as a method for having committee meetings in-the winter and a network in, oh, emergency medical service relay from one hospital to another. So it has been more. The term telephone lecture network, that doesn't really tell the whole story on that. MRS. MARS: It should not be termed that, really, because that is too ambiguous, I think. It do-es, as I said, so many other things besides that-. 5 3 327 14RS. SILSBEE: Mrs. Mars has made a motion to -- for $1.4 million. Is that seconded? Dr. Haber: DR. HABER: I second it. [The motion was seconded.] I,IRS. SILSBEE: @s. Flood. MRS. FLOOD: On the yellow print-out,-does the symbol "C" at the extreme right signify funding beyon the three-year support or funding beyond 175? MRS. SILSBEE: Beyond '75. MRS. FLOOD: They are requesting funds her then, for fiscal '76? MRS. SILSBEE: Right. There were two proj cts, I believe, because they were asking for tiqo-years' support. MRS. FLOOD: Then may I ask who the 'sponsors are of, for example, the telephone network? 'That is the grantee organization MRS. SILSBEE: which is a nonprofit organization. MRS. FLOOD: Well, it was my understanding that. there would be no funds allotted past June the 30th of 1975 for any core staff. Now, how can it be a grantee project and they request funding beyond that fiscal year' if it is going to take four staff to operate it? MRS. SILSBEE: Mrs. Flood, in this particular organization, is as a nonprofit organizatio n, @hey have other sources of funds. I believe they have gotten funding from 5.4 328 other Dlaces. I,lr. Pahl. PIR - PPJIL: I'd lilce to,speak in general terms. This, is as good a case as any., but there is a general problem which runs through a number of applications, so my comments are really not to the application under consideration, and that is, how does the RMP manage its affairs when it makes its' awards for activities which will extend beyond the termination! date of the PJIP in question? Since RMP's are to terminate on June 30th, 1975, the question is a proper one. We have been interested in addressing this question now for two years because of some interest in proposed phase-outs-last year and possible termination of the program this year. In practical'terms, there is no resolution at this time to that question. Sotne grantees will be able to manage affairs beyond the life -of the TU4P because they happen to be institutions that have a life of their own and are willing to absorb the cost necessary to monitor those ongoing activities. On the other hand, it would be fair to say that the large majority of grantees are not for-profit institutions or are medical societies or schools that do not literally have the funds to pay the staff to monitor such activities. Now, staff has recognized this situation for the second year running and, actually., I have discussed this 55 320 matter in recent weeks with Dr. Margulies and have proposed to him that the agency sent out to all RMP grantees a statement of federal policy which basically would say that it i@ the established practice of the government -- and I can gLve you any number of examples out of personal experience -- -,hat it is the established practice of the Federal Government to provide for the monitoring and surveillance of activi ies which extend-beyond the life of a program. when that program ihas been terminated by the government. For example, the chronic disease control program was absorbed into the Regional lledical Program and th-@re was no more chronic disease control program but we in our organ- ization have spent the last three years manao-ing federal commitments and contracts in the kidney program area and part of my staff has been doing work that was obligated to three years ago. We had a series of HEW regional offices. There is a decentralization thrust to put appropriate functions in these regional offices and there will continue to be head- quarters staff either under the title of RD4P, Health Resources Planning., IIRA or some organization. I have in my briefcase a statement which has been drafted by RMPS and will be Forwarded to Dr. Endicott for official consideration as an agency state ment for RI,.,IP grantees which merely provides assurance that although we have not 56 identified the manner in which the government will assu- monitoring responsibilities, that this problem is both recognized and the grantee, in good conscience, can let contracts for periods beyond June 30, '75 whether the present grantee is in operation or not. I hope that addresses both this and a number of other issues. MRS@ FLOOD: Well, but you are clarifying the C> concern we have for management of T)hase-out projects by contract mechanism, but here we have a grantee who intends to continue projects themself beyond IIR. PAHL: Well, there is a clearcut statement' by the administration that no costs may be incurred by an RMP beyond.June 30, '75, regardless of what the applicant wishes. You can't stop the applicant from stating whatever he wishes to do but there Is a clearcut statement in all'of our instructions that costs cannot be incurred by RMP's beyond June 30, so this situation falls into the very one I am mentioning. He cannot go-beyond June 30th. That is the administration policy. Therefore, he falls into the class that I am talking about, if the project is to be continued., then either the individual rdgional offices or some head-' quarters program,.whether we are the same name gr not,, will have to assume that responsibility or we have to make 57 331 arrangements for some other organizations to tal,e on that responsibility and, as I say, we are tryin- to develop a policy. It is very strange that I cannot send to any grantee xerox copy of anything out of HEW as to how to manaTe such an activity. Yet the Federal Government does terminate proo-rams all the time and there is no grants-manageme,it policy in this area. So we are attempting to develop one and ho e, Agency will respond. 'MRS. FLOOD: Then I must inquire regarding the tumor se'rvice registry here, if this, then, is fifth Ind sixth year support? MR. PAHL: Yes. MRS. FLOOD: And in that case it was the same status for the telephone'network. MR. PAHL: No., that is a different thing than either one of them. MRS. SILSBEE: No. MRS. FLOOD: Fifth and sixth year. No, tumor registry MRS. SILSBEE: Is fourth and fifth. MRS. FLOOD: Fourth and fifth. Can you tell me if the budget reflects decreasing funding in the sixth year of the tumor registry or if there is full support again in the sixth year? 58 332 I,IRS.,SILSBEE: I can't. In terms of the way in which they put this money in, in one lump, we don't know what the costs for the fifth year would be, but they put it to- gether as a total.. I-IRS. 14ORGA'I'I: Except for Texas, I didn't know we supported tumor registries for six years. DR. WAM'i,,IOCK: This is $200,000 here for a rather br,oad area andlIld like to address myself to the importance of a tumor registry, because--this has been a project that has been promoted by the American College of Surgeons since almost the day of its inception. It is called the clinic activities record and it is the only way that you can have any control over survival, not only survival, but quality of survival,, because, actually, what we are talking about is eradication, paliation, et cetera and so on and if you do not have any kind of mechanism where you can look back and see what you have taken inventory [of], then you do not know whether you are making any progress, so everything-goes for naught and the average individual doing any kind-of clinical work says, I have got a case of carcinoma of the colon, it is cured. But, hell, if he looks at 100 cases he finds out that 95 of them are dead and they died all on the surgical table or something like that. So this does have -- this is a nitty=gri:tty proposition and some people do say that the tumor registry is not worth the salt that 59 333 I,IS. SILSBEE: This is an issue, Dr. Wammock, that the council has dealt with. DR. WPJIDIOCK: Well., I realize that. MS. SILSBEE: And in general., they feel that it has been the experience that once you pick up the support of cancer registry, you have got it they go around seeking one grant program after another., so council has been discouraging DR. WAIT-IOCK: I recognize that-and I just wanted to name that particular area there. I would not question the councils position. MS. SILSBEE: Dr. Janeway. DR. JANEWAY: Isn't in general this -- I could ask our administrator reimbursable per dium cost,-the- patient care thing would be a medical record, includible in -the administrative costs crf running a hospital. DR. WAMMOCK: That has been debated. DR. JANEIIAY: Well, it has been accepted in North Carolina. DR. WAIT,40CK: I'd say some people here are considering ilk-.. I mean, I'll rephrase my statement. MS. SILSBEE: If I could make a statement about the way in which the committee arrived at the recommendations which, in looking it over, they did'arrive at this differently than they did most of the actions. 60 334 Instead of looking at the request and deducting those items that they really were concerned about, they looked at the current levels and deducted so, in a sense, I think the recommendation did need to be looked at again. We have a motion MRS. MARS: I-lay I, before we -- I just wanted to tell them a little bit about this network, I'll only take a second, as to @hat its activities were, just to give you an idea that it is far more than just a lecture network. There were, however, 187 one-hour lectures on 14 scheduled series. The total att-endanc e was 16 743 people and an -- there were two new lecture series were developed in medical librarianship and food service. There were 600 previous network presentations that were reviewed. There were special lectures offered in anatomy and physiology, emergency medical technicians certification, interpersonal relations, secretaries, alcohol problems, third-party payments. They provided audiovisual support at 33 teaching days and conferences throughout the region. MRS. SILSBEE: Mrs. Mars, I MRS. MARS: So these were things that it did do, which you can see, it is far more than just a lecture series. MRS. SILSBEE: Thd motion has been made and seconded that this application be approved at the level of $1,4oo,ooo. 61 3 I,IR. IIIROTO: May I ask a question before the question? I.,IRS. SILSBEE: Yes. DM. HIROTO: What is to ensure that this $400.,OOO in addition would be used for the purposes you feel a,e so important? '@4RS. IIARS: Well, it isn't for that. It i- simply this is their annualized money. They used this money, I can't say as to whther they are goin- to put it v7h@@re'they are going to put it. MR. HIROm-0: That was the prior yearls? I,IRS. lfARS: Yes. yes. MRS. MORGAN: Question. [The question was called for.] I-IRS. SILSBEE: All in favor of the motion, say aye. [There was a chorus of ayes.] Opposed? [Two voices were raised.in opposition-and the motior was carried.] Two. The motion is carried. Now, do you want to take a quick break at this point? [General assent is signified.] Okay', the next problem area is Mary@d and I wonder if you, as chairman 62 1 336 DR.; WAYUIOCK: Oh, my aching back. TIRS. SILSBEE: This won't take long. Mr. Peterson chaired that particular session. Mr. Mank is not here. I wonder if you would just make a brief statement, Mr. 'P6terson9i REPORT OF'MR. PETERSON MARYLAND, MR. PETERSON: Well, I think anybody who read the transcript, as I am assuming Dr. lqammock did, it was summarized lvery neatly by the review committee after considerable discussion because, as you see from your green sheets, they, ir effect recommended phasing out the Maryland RFIP. They said -- I think I am almost quoting verbatim in the way of summary, this is a region which has been almost since its inception plagued by an ineffective coordinator, an inactive RAG, a self-serving grantee and we could overlook all those things if they had done anything. [Laughter.] Finally., and I think that whoever has got the verbatim, I am not saying it wfy stronger than the review committee summarized it finally, we don't think this is worth preserving as a building block for whatever comes down the road in the way of health'resource planning. I think those were the conclusions they arrived at. Whether those lead to the recommendation is so@thing else again. This was one of two regions which they did recommend 6 3 337 phasinc- out on the third morninE when my groun reconvened briefly. I, in effect, opened.up ',Iaryland and Ilassau, since I .they had had a night to sleep on it, as well as looking at all the other actions taken and they decided not to reconsider or at least revise their recommendation of the earlier day on Maryland. DR. WAI,'U40CK: I'm going to fool you today, very decidedly. This program was not'approved by the review committee. Therefore, I concur. It'is difficult to under- stand what they are trying to accomplish. It is not very well organized. Period and that is it. [Laughter.] SPEAKER: Motion. @SPEAKER: Make the motion. DR. WAIDIOCK: I move that we sustain the reviewers' comments that it not be approved as a solvent program. SPEAKER: Second. [The motion was made and seconded.] MRS. SILSBEE: Dr. Watkins, you were the secondary reviewer. DR. WATKINS: I concur. MRS. SILSBEE: Now, this is a major step for this council. SPEAKER: Sure is. MRS. SILSBEE: Dr. Janeway. 64 338 DR. JAIIEWAY: Just one question. We are not dealing with a very great number of people at the moment. Is there any provision when something is phased out with re-ard to the people on board so that they are not cast adrirt? MRS. SILSBEE: That will be negotiated by -,he staff. The intent DR. JAIIEVIAY: You know because there is s)me kind of personal element in this and we have to think abou'; it. 14R. PETERSON: It was made explicit altho,igh no figure was arrived at that while they recommended ])ahse-out and there was a zero figure, it was with the understa ding that staff would need to negotiate if the council co n urred to see how much money would be required for a timely but orderly phase-out. This involves considerations of how much funds do they have on hand that would remain unexpended as of June 30 and other considerations so while it shows as zero, the intent was not to preclude some negotiated award to permit the phase- out,. again, if council should concur. DR. WC-IMOCK: They only-@described one project in here that I could find of any sort, I mean, that was in the MRS. SILSBEE: Well, Dr. Wammock, essentially this' is more or less/of a continuation application. There were other things. They are comin@ in with the July thing which has had -- been under development. I have to -=-I was not present at the committee review. @I have read the transcript 65 339 and I must say, from the standpoint of being responsible for the -- all the regions, that this region has not had the kind of staff work -- it was not gone to see whether the r@gional advisory -- there is a new chairman now. We don't really know, so in a sense, this region is being looked at in terms of the situation as it was a couple of years ago-and we donI.t know whether it has been changed.or not. l@. PAHL: I'll make my comments off the-r(@cord. 14RS. SILSBEE: Okay. MRS. MARS: Well, is there any program the e that could be taken over that would be worthwhile to be taken over by., say, Delaware, in order to supervise the phaseout of it, or MRS. SILSBEE: I don't think in this'particular situation that would be a very valid way because Greater Delaware Valley doesn't re4ally extend. They have trouble enough with their area as covered. SPEAKER: Question. [The question was called for.] MRS. SILSBEE: The motion has been made and seconded that the Maryland Regional Medical'Program be phased out. While no dollar amount is recommended, it is understood in this motion that staff will negotiate to,make sure that this is done in an orderly, judicious manner. DR. WA,"114OCK: That would be included in my motion.. MRS. MARS:- How long will it take to phase it out? 6,6 340 MR.- PAHL: Off the record, please. [Brief off the record.] MRS. SILSBEE: All in favor of the motion. [There was a chorus of ayes.] Opposed. [There is no opposition and the motion is carried unanimously.] The motion is carried., MR. PAHL: Off the record, please. [Brief off the record.] DR. WAMMOCK: -- it would take., really, too long to describe and everything here, I can see nothing @hat sustains the continuation of that kind of proiject and I would compliment the staff on doing a very difficult situation [sic] because I recognize that when you phase out something, that is a blow, either above the belt or below the belt or around in general. I don't care what you want to call it. MRS. MARS: Thank you, Dr. Wammock. MRS. SILSBEE: NasscTu-Suffolk is the next program that was a problem. SPEAKER: I wonder if we could have the staff with us on this? MRS..'SILSBEE: The Nassau-Suffolk Regional Medical Program originally was part of New York Metro qnd then it broke off and became the Nassa@-Suffolk Program. It had the 67 341 unique organizational pattern of havinc- the executive director serve as both the coordinator of the Regional '.:edical Program .and the director of the CHP B agency. The staff was under this one man and the advisory councils and so forth were sort of inter-ieshed. That has been a problem for us. Last year, they divorced. The B agency and the RIIP went their@separate ways and'since the phaseouts' the original coordinator., who was the -- kind of the man who developed the B RMP relationship has departed. His deputy was coordinator for, oh, about six months. He left and we now have the third coordinator in' the course of this year. .The region has not had its review process verified. There is still a problem with the b.y-laiis for the Regional Advisory Group. The reviei--;er for liassau-Suffolk is 'Ir. I-lilliken. REPORT OF 71,!R. SEWALL O.-I.IILLIKEN ITASSAU-SUFFOLK I'd. MILLI@A'E-'!: Well, I concur completely with the committee recommendations. I do have a pro-@lem. In looking throur-h the material,that was taped, I was trying to find some indication of what appropriate phase-out cost.might be. The closest I could come to a fic-ure on that was $240.,OOO but I do not find any documentation as to details on 68 342 that, so I am not sure how reliable that is. 1,IR. PETERSOI@L: I don't think it is necessarily reliable, Sewall. It reflects, I think, some sort ofia guesstimate but here again, I think'the clear intent of the review committee was to leave to st aff the termination from negotiation with Nassau-Suffollc if the council-shoula concur, what would be required in the way of additional funds@ Pgain, it is not only determining how much money is needed for a timely, orderly phase-out., but how mu,,h money would they have still on hand as of June 30 and I thiiik3 again, whether a quarter of a million dollars or $150 000 that is something that would need to be worked out. The figure.was spun off, I believe, in the trans- cript, but I don't think anyone would hold to it because we have not really looked into it until the council takes action and that reflects final action rather than a review committee recommendation. l@IR. MILLIKEN: @lell, based on the same concept of'. the one we just deleted, it is my motion that we accept the committee recommendation and terminate this program. [The motion was made.] MRS. SILSBEE: Is there a second? SPEAKER:' Second. [The motion was seconded.] MRS. SILSBEE: The m6tion has been made and 69 343 seconded that ilassau-Suffolk Regional '.Iedical Program be terminated. I%Ihile no dollars are recommended, it is under- stood that staff will negotiate a figure that will al@ow'for an orderly phase-out. Is there any further discussion? DR. HABER: Yes, I'd like MRS. SILSBEE: Dr. Haber. DR. HABER: Will someone give me a reply t) the question, if the RMP has not complied with the RAG grin ee policy, in what respect has it not complied? MRS. SILSBEE: Dr. Haber, the board of the grantee organization has -- it is on the'regional advisory gr@up in toto and we have been.concerned about the dominance of that board. Now., they have been sending in various changes in this and it is my understanding at the present time that the numbers of the board that are now on the RAG are somewhat fewer. There is a jurisdictional dispute between the grants management branch and the eastern operations branch as to whether they have completely complied. - Since that was just one issue in this whole appli@ cation, I didn't think that it was a major thing at this point. We have had the motion made and secon-ded to terminate the pr ogram with the full knowledge that money will 344 70 come forth for orderly phase-out. All in favor? EThere was a chorus of ayes.] Opposed. EThere was no opposition and the motion was carried unanimously.] The motion is carried. We do New York Metro next, Dr. Schreineri REPORT OF DR. GEORGE E. SCHREINER NEW YORK METRO DR. SCHREINER: Yes, this is a large MRS. SILSBEE: Oh, let the record show t@at Dr. Watkins will be out of the room. DR. SCHREINER: I won.It say anything until he leaves. There were two reviewers, one who was in on the site visit and one working from the application. I reviewed the transcript and also the grant request here. This was rated b-y t@t- review committee as average. The projects were given a grade in the 40 percent range. I think this is a situation that is perhaps brings to mind something Mr. Rovell said yesterday and that is, we have to be careful not to be prejudiced too much by past performance. New York, as you heard in the speec@yesterday, is a very complex place with 10 million people, the medical 345 schools, 200 hospitals and there have been a number of conflicting wheels within wheels in terms of internal politics. I think it is a remarkable achievement, actually, that in the past two years or so there has been a semblance of coordination and there has been some rallying around the new grantee and the new director and the RAG has been much more representative, as far as I can see. Taking one program alone, which I happen-to know very intimately and that is the transplant situations there were 12 transplant units working in the city. I think there were, at one point, nine typing labs, three of whom were using totally different semantic systems. It was a real Tower of Babel and there still is a considerable competition in this area, even the Better Business Bureau got in the act to try to settle things with regard to transplants, I was '@f the directors. 'told some time ago by one Now, the one that looks like it is going to survive, to me, is the one that is being sponsored by the Regional r J.-ledical Program associated-witIT the Blood Bank. Very recently it has come to my attention that there iz still another competitor in the field trying to turn the Medicare Social Security reimbursement into a commercial enterprise so I think it is vbry important that we-not let this little game go down the drain because there are a lot of hawks waiting on the fence, waiting to rush in if this is 72 346 not supported. So I think that the committee request is -- I would'@ normally consider I mean the review cor,.nittee's request for $2.5 million I would normally consider quite a fair and adequate allocation in relationship to the outlining of the projects but the two things that have happened recently.,' one is, Dr. Koontz arriving from California, who is one of the country's outstanding transplant surgeons, which really mobilized a good core of people around him and a very expanded program. The other is that I suspect that they will probably be asked to pick up about $96,000 in onmoing stuff from Nassau-Suffolk in the organ donor procurement programs that ties in, that they will be asked to pick up some of this so I would, unless the staff has some strong objections, I would like to move that we up this to approximately $2.9 million or even $3 million. I would make a motion for $3 million, for this area and believe that it will @e well-spent and some.of it will be allocated, it sho-uld be-emphasized, to try to, strengthen this transplant program, which looks like it is about re-ady to fly. They did 250 transplants last year in the metro- politan area there so they would do 500 to 1,000 if,it were adequately banked. [The motion was made.] 7 3 347 DIRS.:SILSBEE: Dlr. '@lilliken. MR. PIILLIKEIII: I agree, concur. [The motion was seconded.] DR. JANEIQAY: Is Koontz Einaudible.] DR. SCHREINER: Yes. They had done just as an example, they had done no transplants -- well, they had done two , transplants in four years before he came and he did 30 the first six months. MR. MILLIKEII: I gecond the motion for $3 million. MR. PETERSOII: I think there are acouple of things that ought to be, perhaps, laid on the table for the benefit of the others. Many of the projects in this request were for two years. Thus the request @-,,as a $6 million-plus one but it reflected in large part sort of a two years of activity and I think the review corL,@iittee's recommendation has to be seen in that light. The second thing was, as Dr. Schreiner I am sure is aware, and if you have glanced at the transcript the review committee, in making_its particular recommendation, in effect said -- and I don't remember the exact,words, but that given what had happened in the way or turnaround or the kind of health care jungle that New York City is, that certainly, looking at the July application or the council if additional funds proved to be available, that this was,a re7gion that they might well view more generously. I think that those are 75 349 I am, sure Dr. Bauer of Mississippi was one of them, but don't recall the other two. MR. ZIZLAVSKY: [Inaudible.] MRS. SILSBEE: We can't hear you up at this end. DIR. ZIZLAVSKY: All three of the kidney coIasultants ad hoc technical reviewswere completed from out of st e. provided the @'Tebraska R';iP with negative comments. Th allowed $10,000 or $15,000 flexibility. MR. POSTA: Dr. Schreiner, consultation fr)m staff here to the coordinator, we had recommended that he c ntact Dr. Flanigan in Arkansas to get three certified revie ers that had been approved by DRIIP in the past. Dr. Bauer was one but I don't recall the other two. DR. SCHREI14ER: Yes. The reason I am' not really totally prepared to acce'pt their evaluation because one of these individuals was very"vocal and so evangelistic about home dialysis that he never approves anything that involves satellite dialysis anywhere in the country and in this kind of a situation where you have long distances involved between Places and no real back-up., I am not really sure that every- body can be put on home dialysi s and this was probably the basis for his comments. part of those areas have depended on The '4innesota for back-up in their satellite di alys:Ls and I sort of iew this project as a beginning attempt to try to go it on 76 3 -@ 0 their own and get units in various are;-zs that are quite rural and with quite alow population dens,'L@Uy. Therefore, I am going to move that it be approved in the $950,000 level, putting back some of the -- the only project they criticized was that particular project and I'm putting back some of them. [The motion was made.] MRS. SILSBEE: The secondary reviewer on Nebrasl,:a was Mrs. Kleini. MRS. KLEIN: [Inaudible.] MRS. SILSBEE: Could you speak into the microphone, please? MRS. KLEIN: I couldn't find anything that I disagreed with in the cor@mittee's repor' and so I would concur. .MRS. SILSBEE: Would you second Dr. Schreiner's motion? MRS. KLEIN: Yes. [The motion was seconded.] MRS. SILSBEE: Okay, then, the motion has been made and seconded that Nebr-askals-R:,@IP application' be funded at $950,000. Is there any further discussion? [No discussion.] All in favor. [There was a chorus of ayes.] Opposed. 77 351 [The motion was carried unanimously.] The motion is carried. REPORT BY DR. GEORGE E. SCHREINER NORTH DAKOTA DR. SCREINER: The next one is North Dakota, which was rated average and below average and given a rate of 75 percent. The projects are,interesting. I think that from a_ critics point of view., one could question some of t@e priorities which they have established but, nevertheless3, they have established them and they are their priorities and they are going to do them, I am sure, well, and I think the people'out there have impressed everybody with their general honesty and integrity so I think the committee's recommendation on this which was somewhat of a reduction in the requested amount of"$774 -- the committee reduced it to $582 and I redid from the project and came up a couple of thousand dollars away on the basis of this report'and I think that the committee's recomm-end@,ion is just about on target here so I would approve the recommendation of the committee. [The motion was made.] MRS. SILSBEE: Mrs. Gordon. MRS. GORDON: Second. [The motion was seconded.] MRS. SILSBEE: The motion has been made and 7 352 seconded that the "4orth Dakota application be approved at the level of @.1,782,517. Is there further discussion? [14o discussion.] All in favor? [There i-ias a chorus of ayes.] Opposed. [Th@ motion was carri'ed unanimously.] The motion is carried. Susquehanna Valley? REPORT BY DR. GEORGE E. SCHREINER SUSQUEHAN!4'A VALLEY DR. SCHREINER: Susquehanna Valley is a real problem, although it wasn't on your problem list. [Laughter.1 All of the programs the request or the recommendation for $400,000 or suggestions [inaudible owing to side conversation in mikes] -- that I gather as I add up the program, the most you could get out of the @rograms would be $96,000, so we the taxpayers are,being asked to spend $600,000 in order to administer $96,000 program I personally think this is immoral. 14RS. SILSBEE: Dr. Schreiner, did yo@ see the memorandum that DR. SCHREINER: Yes. 79 353 !-IRS. SILSBEE: -- the July application. DR. SCHREIDVIER: It didn't impress me. I,IRS. SILSBEE: I-lell, I didn't expect it to impress you, but I do think, in terms of the way in I think.the background of this region is, it is a cautious region and the ifact that they could very well have just taken oPf a lot of" their projects that they were all ready to -o with a year ago and sent them in in'this application so that you would see more activity per staff -- but they chose to go'back through the whole process again and reevaluate them and for that reason we don't see the pro,,r@@ part of this region. DR. SCliREI1,41ER: Well, everybody knows the RI@IP has a short prospective 1-1-fe and it seems to me that they are so unrealistic that they don't realize that one of the reasons RMP has been in trouble is the amount of money spent @fo r staff in relations)-iip'to pro,7rams and to start all over .again to build a great bi- staff without any programs at all, it seems to me that the normal direction would have been to go out and scratch for some lo,-,--bi-idget programs. If you can twist my arm a little bit,, I might be lwillin-- to give them $200 000 but there is a lot of sentiment on the council. I personally think we ought to seriously consider discontinuing it. MRS. SILSBEE: Mrs. Flood. MRS. FLOOD: I would like to inquire if historically 80 354 this particular proEram had utilized staff effort heavily or i-thether they founded independent outside agencies, institu- tions, et cetera? I-IRS. SILSBEE: Jerry. MR. SHOLOV: Yes. I believe -- you were asking whether they were using the money,for force studies? There is only one force study in the application in front o@ us for a unified health plan in this application. SPEAKER: He didn't understand. MRS. FLOOD: Well, yes, there are many proTrams, Ri,TP's, that use heavy staff to actually carry on prog@ams or projects throughout the state., rather than -- and car y them as core staff functions to provide full projects in the core staff base and I just needed to know if this is their traditional format? Otherwise, I would have to agree with the doctor that this is a heav"Y investment in staff just to monitor some projects that they hope to., you know, send to us in the July review. I,IR. SHOLOV: May I just comment that the only investment that they have in the current staffing project is funding,a B agency directly and, again, they only asked for 50,000 for one unified planning staff and this application is what you see in front of you. MRS. SILSBEE: But., Mrs. Flood, traditionally, it is.a mixture of staff and project activities. The 14 people 355 now on board have just come on board. They had three up until recently. DR. SCHREINER: Yes, the total project, outside of program staff on the yellow sheet only add up to about' $6 000. The July projects that we know about are such thin-s as the Fulton County Public Health l@ursing Service, the Huntington County Home Service, the Center County Home Service the llorth Penn Home Health Agency. It sounds to me'pretty much like county health-type projects. There is one for consumer health education program and there is a dental program which is $81 000 with the $16,00 in direct costs. It just sounds like an enormous build-up of staff for a very, very thin program and I am not very enthusiastic about it. MRS. SILSBEE: Do you have a motion that you wanted to make? DR. SCHREINER: Well., I'd like to -- Iwould either move for $200 -out and I was .,OOO or move f-or %ero and a phase trying to see if there was.any strong sentiment on the council or staff for phasing out. MRS. SILSBEE: Dr.'Wammock. DR. WAMMOCK: I read this several times'and I can't solve the problem and I concur in the fac-t that the ..budget here for staff was extremely large and that sort of 'turned me off, I am sorry to say, right then, although I did 82 356 leaf through it. If you want to take into consideration the location of the Susquehanna Valley and what their medical needs are,, they are not available to them like they are in some of the other areas. Now, I think that, certainly, some consideration must be given to whether -- what will stimulate them to activity and I would say this would be a token, whatever we do with $200..,OOO.or $300,000 will stimulate them to@w at they could do for that particular area and perhaps that is what we might do here but, in essence, it is really a poor program and I have one of two choices to give them somethi@g or just wipe it out. I-would be more inclined to show allittle bit more compassion by givina- them some stimulus under the circumstances. DR. SCHREINER In that case, I'll move for $200.,Ooo. [The motion was made.] MRS. SILSBEE: Is there a second? DR. WAMMOCK: I'll second it. [The motion was seconded.] MRS. SILSBEE: Mr. Stolov. MR. STOLOV: Mrs. Silsbee referred to a memo given to Dr. Schreiner on the reading of the Susquehanna.grantee RAG chairman and coordinator we had with us. My only point, did everyone at council hear this? It was brought up in this 83 357 .meeting that the commitee's concern was exactly that,of councils and that is why they did meet with us. We did discuss this with them and that is in the memo. My oilly' addition to the factual on this is that they do have '.4 people on board now and they came on-board as a recruitment by the newly-appointed coordinator and some of these eople.- are already experienced in IU,IP and the $200,000 recommendation made was for a reduction of staff at this point and'ttat is my only point right now. I-IRS. SILSBE.8: The motion has been made an seconded'that this region be its application be fu ded at 200 000. Is there further discussion? DM. CHAMBLISS: I would simply, in an effort to make sure that the council is aware that this region has been advised about the level of-ttaffing. I would simply want to reendorse what Dlr.- Strolov has said. We have had a very @ecent conference with the leadership of that program and I are with him the view that if the-.level of funding as is now ,h )efore us -- is now on the floor -- that level is accepted, 'hat it would probably cut into the existing'staff that that- -egion has. I do feel that part of this was taken into account y the review committee when it reviewed the application. I,IRS. 14ARS: Are you saying, Ilr. Chambliss, that 84 358 if this is cut to $200,000 that, really, there won't be enough staff left to stimulate any type of program? 14R. CHAMBLISS: I do., because we did admonish that region early on that they were too low of staff. We have a specific letter in the files saying, build up the staff. That was right after phase-out. And they built it up and I must admit3 with you, that they have gone beyond that, but I think what I,see the council is considering now may get them back actually to where they were when we advised them early on that they should increase the staff. Now, I do this only -- only so that coun dil may have before it as many facts as,we have here on staff. DR. SCHREINER: Now, I appreciate what you are saying. Ithink this would be a real concern, for example, if we were looking ahead tb three years of project development) but I think you have to ask the question, build up staff for what? I mean, there has got to be.-a.program that -goes along with that build-up and in this.case I can't find the program. MRS. SILSBEE: liell, that is because the program is going to be primarily contained in the July application. Dr. Janeway. DR. SCHREINER: It is not that impressive in the July I've seen the July projects and they don't require 14 people, you know, for a county nursing service, a home .85 359 health nursing service to sponsor does not require all thaL-. staff monitor strength. MRS. SILSBEE: Dr. Janeway. MR. CHAMBLISS:I am very sorry, and'I apologize for interrupting. If I may just further illuminate this council, in a letter we sent to that region, we even suggested that they go out and get former RMP staff members and bring them on to augment the staff and we further suggested that it might be worthwhile to bring on three to four part-time physicians. Now, that was a region that was operated without M.D. staff -- M.D. on staff. So I can re port to you that they did go out and employ three part-time physicians as we had recommended and they are now on staff and I believe that what you are now considering may wipe out the staff that they already have on duty. MRS. SILSBEE: Mrs. Flood. MRS. FLOOD: feel strongly that this particular region has been victim to what we frequently on a site visit call the "yo-yo effect," and quite markedly. Apparently they took quite seriously their 'phase-out instructions and then were reticent to tool back up because of what you have described as a conservatism of the region and now'are following what they interpret as a directive from DRMP. But if we can have some insight as to what their core personnel budget is today, with the existing staff that they have on board now. 86 36o Can 'l,'Ir. Stolov shed any light on this? MRS. SILSBEE: I just did a calculation the other day, in terms of even the committee recommendations. It is in salaries alone, about $189,000 on an annual basis. That doesn't allow anything for projects, rent.,.telephone, travel for the council -- the regional advisory group or any of the. committees. MRS. FLOOD: Then I would have to add my,v) ce to the expressions of concern of Mr. Chambliss and Mr. S;olov. now before us., that with a $200,000 funding level, we would, indeed then, be better off telling them to close up shop because, in essence, we are doing that. We are criti izing them for lack of programs that is broad in scope and has sufficient projects in it and then on the other'hand, we will turn around and cause to .discharge recently-acquired personnel and the first to go will bt the high-priced part-time docs and,they will not gain any, you know, impact on developing programs. MRS. SILSBEE: Dr. I-lanmock. DR. 14AIU-IOCK: Th ey have a total of 26 staff and 11 vacancies here that need to be filled. MRS. SILSBEE: The $189 was of the staff that is now on duty. DR. WAMMOCK: Yes. Now, the other thing is this'. I read this thing through very carefully and I said that the 87 361 original bud-etiof t7OO,OOD when the staff is 'y4322,00,3 was too far and the statement was made, a description of the project that it is perhaps the most outstanding achievement of the SVRP over the last few years has been its -6rassroots involvement and that is where it is, it is -,,-assroots level. Apparently they have made some progress in primary care units. They have provided a neighborhood health center for some 1,200iblacks -- 12$000 blacks, accordin- to this report in here. Apparently, they have not made an adequate survey of their needs in their particular area and also as related to the total program of th6 State of Pennsylvania. Their endeavor to develop manpower for the primary health care in and rural areas,/provi'sion of information on existing services in rural areas, consumer education and use of services and et cetera. Their endeavor to increase manpower availability for the primary health care in und6'rserved urban a.reas, accessibility and so on. They put some em hasis on heart disease and nothing .P that I can see is related to stroke, renal disease or cancer. This program, it seems, is not well-de-signed. That is the substance of it here. But if you pull it down to $200,000, that will completely wipe it out, I believe. That is nothing for a group of people in that area there. I don't know 362 somewhere I have the population of that area. Ilere it is here MR. STOLOV: 2.3 million, 27,000. DR. WAMMOCK: Ilow many? SPEAKER: 5.23 million. DR. SCHREIIIER: I think you have made some c-ocd points. I would be inclined to change my motion to @300,000, which I think will give them a warning that their job is not to build staff. I'm afraid they have been told to build staff and not to build programs and -- or at least they have not heard the admonition to build programme I think if we do this, they can come back in in July with projects and vTe can look at them fresh and at least it will be enouC-h to keer) the thin@ alive, so I'll @-,iend my motion and chan:-e it to @300,000. FThe motion was arr.--nd,ed. ,wil'IS. SILSBEE: 71"ill the seconder, Dr. @-!a=ock DR. 1,11@"-i@,IOCK: I'll second that ,.iotion. [The motion was seconded.] MRS. SILSBEE: @-he motion has been made and seconded that the Susquehanna Valley R".IP be funded at $300,000, that the aDnl4-cation be approved at that level. Is there -Lurther discussion? MRS. IIARS: '@'ould we put an amendment on that that not all the @Y300,000 be used just for staff, but that progra.,-,ii-iin,- be included? 89 363 SPEAKER: That ;ron't be. necessary. @@IRS. SILSBEE: I think that will be taken care of in terms of the advice. Is there further discussion? SPEAKER: I call for the question. MRS. SILSBEE: -All in favor? EThere was a chorus of ayes.] Opposed. MRS. FLOOD: Ilay. [The motion was carr-i'-ed.l. !IRS. SILSBEE: One opposed. The motion is carried. !-low, I have an announcement for the staff. There are going to be sandwiches brouc-ht in for the council members and if any of the staff wants to get their order in., -landle is ric-ht over there and it has to be done ri--ht Do you want to take a SEVERAL VOICES: Yes. [Laughter.] MRS. SILSBEE: All right, ten minutes. [Brief recess.] i-IRS. SILSBEE: Dr. Haber has two I would like to have discussed before he has to leave. Memohis. 90 364 .REPORT OF DR. PAUL A. IIABlw7R i,riEP-I,PIIIS DR. HABER: 'The reason for wanting discussion of 14emphis was that I'd like some elaboration of this problem, 01 the escrow funds. In general, I heartily concur with the ad hoc committee's recommendations. I think that the project is well-conceived. The staff is vigorous. The comment was made that this -roup did not consider the future bleak and I guess one of the consultants said they seemed to be sufferina- fro--i unfounded euphoria. '.'.,Iaybe'that is another word for failure. [Laughter.] But I think thatthe individual projects looked very 'Lmp@-essive to me ard -L was pleased with the relationship with the CAP and vii-t@lh the establishment of their reE:,-'-cnal advisory group, well-stafi@e- '-ent people, highly U3 Conl-ne@ interested. I wil'L have a counle of i.-iords to -say about sri@-,e of the individual projects but one of the disturbinc-- things that,ca.me out in the ad hoc cor,-,Pit+.-ee's review was the disclosure that so.-le '@@@OO,OL'JD isbeing held in escro,.,z in two projects, I believe one of '@00 000, 'one of @Y500,000 for an umbrella trusteeship which is euphemism for sor,-,etli,-n-. [Laughter.[ I don't know what. Would somebody enlighten me on tl-lat? DR. WAI.,Il,'i)CI@',: lj'hat's that', v'.,ord you used? 365 DR. HABER: lluh@, DPL . I-IAIll.!OCI'@: IIhat's that word you used, euphemism? DR. HABER: Yes, it's a euphemism something. I don't know. i,laybe it's that hole in the mattress they talk about. I-IR. VAN III"TKLE: No, I don't think so. This is another example of what you discussed yesterday on a couple of projects. It really isn't any different. They have set forth these thrusts that they wanted to carry out. They don't have them -- the individual activities before you at this time. They will have at a later date. They will be co--.iinc, in i..ith those. If these funds are allowed and the review committee had decided that at that point in tiie they could look at them. '.hey didn't have sufficient information L'o cons-i'-de.- t.-.eri and that -.,ias the basis for their reducu-4@on. DR. HABER: I think that is fair. Let me com,.rqent on some of these. There is one project, C008 for analysis hypertension which I think is good. A couple of activities smack of oublic health concerns. One of them on the trends for registering of vital statistics. That seems to me to be kind of not entirely new and innovative and clearly a function of the public health officer-or commission. 1-i-R. VA@4 WII'JKLE: Is that 13? DR. T,!,.BER: Yes. And I .-.,ould say the same thi-n@ is 92 366 on 33, improving the qualit7y of the death statistics without, I think, going through-the business of this, apparently they said it would be a single individuals project. On the other hand, some of these. activities are., I think, very exciting, health services education activities, the 021, the high-risk for infants with the special intensive. care unit for the infants. I think that is really great. Some of that stuff gets funded at NICHD but as a planning activity, I think that is great. And the post graduate intensive care and the hypertension control I would certainly agree One thin- that bothers me is that 052 , rnultit)hasic screenin- evaluation -- it seems to me that has been done and r@-done and reredone and there oucht to be some general rules that are knoiin by this time ivhere i@,,e don't have to keeD plo-v,rinc.- that ground over and over aF.-in. CL The project 056 @or t'@-.e nei--liborhood health counselors, expandin- the nursing role 'I think was good ancL 0:@)7, the Yalobusha Grenada Leflor@ chronic disease detection center sounds very good to.me. So I would move concurrence with the committee's recommendation for funding at that level described by them. [The motion was made.] I-IRS. SIL,')B'-rE: ihe motion has been @de and seconded that .",Mphis aonlication L,@- approved L,-- 9 3 367 $2 600 3 ,000. Is there any L-urther discussion? [71o discussion.] All in favor say aye. [There was a chorus of ayes." Opposed? [There was no opposition and the motion was carried unanimously.] The motion is carried. All right, West Viro-inia. REPORT BY DR. PAUL A. HABER WEST VIRGI:IIA Di@l. HABEIII: I-TesL' Virginia 'vias a delight to review because everybody was universally approvin- of it. One can only envy 'them their relative paucity of resources, I suppose because in total darkness, a candle looks ai-.Tful bright, but apparently this -roup has been very highly motivated, has u @-lorked very ..iell, has b-ou,-,ht additional interest and Money into the state. There seems to be'- as the reviewer great $ 3 concurrence of the effort on all -levels of the state, the medical school, the governors office, the local boards, RAG. Out VA di-rector of the VA Hospital -Doard is a member of the regional advisory group and everybody is very complimentary of them and I do not dissent from that. I would move that they be approved @u the present o,:-' @66-jl,'L32. 9 4 368 !,IRS. SILSB'-71@: Dr. Jarieway. DR. JAi'17-,WAY: I will recommend approval but I would just mention in passing -- thought !Ill second the motion -- that the distribution on the pro,,-ram basis between staff cost to program cost is quite similar to the situation that existed in the Susquehanna Valley. But I find nothing wron- with this. I second the motion. [mLhe motion was seconded.] f,T4RS. SILSBEE: The motion has been made and seconded that the West Virginia application be approved at the reauesL-led level of $60'3,132. Is there further discussion? DR. T@,TA@@;!!,IOCK: You are talking about the salary here. The request was for '?3,085,000. !.as it been recommended SEVERAL VOICES: .'-Io, you're in the wrong state. MRS. SILSBEE: @-le are iri' West Virginia now. Is there further discussion? [1@o further discussion.] All in favor, say aye. [There was a chorus of ayes.] Opposed? [There-was no opposition and the no@ion carried unanimously. 95 369 The motion is carried. We'll go bacl. -- pardon? MRS. IIORGA14: We never did get to Texas. MRS. SILSBEE: Okay, we'll go back to our problem areas. Or at least, we'll relook at the committee recommendations and let the record show that Mrs. Flood is out of the room,for the Texas application. Mrs. I,,Iior,-,an. REPORT OF MR. 1"ICHAEL POSTA TEXAS MRS. MORGAII: Mike is going to give it. r/,RS. SILSBIT.7 El@ike, do you v!ant to give an introduction to Texas? @-IR. POSTA: Well, Ihave a real long one here but I'll try to keep it short. iiet ,ie jus'u proceed as quic'r-Ily as possible. Texas did submit a unique request of $2,333,551 but the real problem, as the reviewer saw it, was that approximately 'Pi.4 million-of tile-request calls for a series of open-ended contracts which would concentrate in.the implementation of five -orograriuiiatic areas, RFP'S, and that is, request for proposals for future contracts were submitted to the various consumer provider or animations throughou- the 9 state. On the da,r of 'lie ad hoc oanel review, those 96 370 reviewers were notified by telegram that 62 applications responded to -- responding to those RFP's had been received by the Texas Regional Medical Program. The total amount of the responses totaled $6.2 million. In the same telegram to the regional advisory group, they requested the review committee to approve the Texas program in the sum of approximately $1.4 for the implementation of the contracts to be rev iewed'by the June 28th regional advisory group. Considerable debate took Dlace during the ad ho- group and they decided that they, in all due conscience could not approve open-ended application of this sort without seeing the specific 15's and 16's on each. ',,low, we have been notified just this morning in two of the programmatic areas that the RAG has been meeting this week and, for instance in ',-,he area of the manoower thrust, 18 contracts had been received. The consultant RAG members and staLf have selected ei'@ht of those, of which five to six will be funded and they ra-'nge in the neighborhood of close to $1100'.1000. The access committee, which was another proEramimac-,c, thrust, received 14 contracts and it had selected seven and together those seven people about $520,000. I think that the question before th@ council as recommended by the revieo,, co,--,,-,,-;--Utee is to allow the -revi-e,@! 97 371 'ttee that meets on July 17'1-, and !8th to take a look' c om -n. L u soecif@Lcally at the contracts and the forms sent in with budgets so that they, in turn, could approve them in order for the contracts to start as quickly as possible. If .you did not approve that, this council, meeting in August, would have to approve them and it would probably be September at least before these contracts could be initiated. Their "Urack record in the past, through evaluation, is that the longer the contract has been funded3 the better the staff -is in carrying out the particular program.1 i-IR@-. SILSBEE: '!irs. i.-lorgan. iPLS O,'-LG.C'I. I site-vis2'ed Texas on, oh, 18 month ago, something like '.-hat At that time, Dr. 1-IcCall was the coordinator. 7v'ery ambitious, excitin@- person to'knoi-i, really. Dave @--erEusoii, -.,,.,ho no-,," the present coord@Lii@u@i.L' was his deputy and had been his deputy for some time. Texas has many problems. In the first place, it is a huge area. In the phase-out, it closed down many of its subregional areas. '@s a matter of 'act, '.Iaria Flood was '-he subregional director of the El -Paso area. In doing this, I think they centralized their la.-- into Austin, i4hich makes it just about impossible to cover the entire sta@ue from Austin, right now. They have had many Iro.blei,,is since RI.'IP started in Texas. It started in-the Houston area, where it was 98 372 Iconcentrated with about seven, eight medical schools right in that area and I believe now Texas has something like 10 medical schools to work with. There has been a problem with the RAG. In fact, they did not have minorities on it, et cetera. They have- attempted to correct this all along. It has been questionable as to how much @ent into their attempt to correct it, but they have tried. I believe at the present time the RAG is very active. Dr. 7-astram is still the RAG chairman. He is enthusiastic about ,-,he R,,AP and does do a fine job. I beli-.-, in fact, that they have not the minorities we'd 1'ke on it and whatnot, is immaterial at the Dresent time with only ayear, to work on it. They could out all the minorities on it in the world and 4L-@ is not Going to change the fact that they have only got a year to work on it The biggest problem I s'e'e is in their request for i proposals and all their work in T-exas is really done by contracts. We do have a record here. The current status well, they received 111 contract proposals, I believe, according to this, which means they have got plenty of peo-ole who are willing to do it under contr act proposal.' The w@ole thing is, we do not have their@oroposal. I recommend that committees recommendation o. @Y1,100,000 be approved at t-@his time with the idea that these 99 373 contracts can be approved at the review cycle and let at that time, prior to the August counci.l. MRS. SILSBEE: Would you Like, to; reword that in terms of the maximum that you would approve and then the balance of the pending review committee approval? MRS. MORGAIT: And then $1.3 for the sake of argument could be approved if all af these- contracts are approved at the present time. It is $'T,,296-'.,599 were what they were asking for contracts and there iio@,uld not be -- there was not if we had approved the $2,3-,33,551, there would not have been an a-oz)licat4-.on in July for any, more fundin- at all. MRS. SILSBEE: So, is your @.'ati-on aDDroved at the $2,33,551 level with delegating to the review committee the approval oL' $1,298,599 for contracts once. the specifics are available i;IRS. @'-.IORGAN: Right. They are 15's and 16's. [The motion vias made.] MRS. SILSBEE: Dr. Schreiner was the secondary reviewer here. Does anyone on the this -aioo@lion has been made. Is there a second? SPEAKER: Second. MRS.. SILSBEE: Any discussion? Mrs. Martinez. @,A I-IRS. T' RTI@ EZ: Yes. I'd like to suggest that no matter how short tire vear is and no ri-@@-er ...,haE-'-!)e ic,.:-0 U-- fund-nr- is, liat .,ie -,rake a successful effort to Einaudi-o-le] 374 especially in Texis, I don't think there is anv because, excuse for that. SPEAKER: Say that again? DR. JANEWAY: I don't want to be obstreperous, but I think that that motion subverts the intent of the review committee. Their major complaint was that it was open-ended. Now, it seems to me that one either gives the authority to the RMP to grant these without further review or if grants at the- level that is recommended by the review committee and forces them to bring a flushed-out plan in contract proposals to the '@l for revi'ew committee consideration and then cancels counc, consideration in 'M'u,,,ust and does it in two steps, ou or that y jus,.- say, okay, regardless of what the review committee said i-ie know you are a good ouL-,.L@i-+,-, even though it rated average CD @o ahead and fell revie-,.,@ the- to beloi average and .,ie said, u !I after the fact, after you have already obligated the furds.. @'%,Tow, maybe there is a technical way to do it or an I -Tve way to do it, and if so, I'd like to be admnistrat- enlightened. -ly only retort. I don't thin'.,, I'll ,,'R. PO@@TA: zero in specifically on your comment, is that the review committee considered this region to be a o,-ood one, triennial status, developmental component in the past, good.,- capable staff. The @rant-ee was changed in December, 19-72 to a nrivate, nonprofit and the re,-,onal advisory groll,,) a4.- -ha@ 1.01 375 time advised the regional staff to pursul- the contract route and that is what they have done for the lost year and a half and the iihole purpose, I think, here is ta get these conty.@,,,,,,i going as soon as possible. I.don't think the review committee had any intentions to usurp the council that mee-ts again and I am not,i again sayinv that I am specifically ansi@.ering.your concern. I would say this and I might @ out of order the chair can rule me out. I do think that several other applications that you have reviewed today did have, in exxence openended contracts but they were not in -- not nearly the size of this Texas application and that is why the reviewers put their foot down and said no on this particular issue. 1.1@@'S. SILk@dBE-7: Dr. Janeway, it seems to me that J.,Irs. I'lorgan's motion doesn't take away the review committee's responsibilities, in essence. It would be approval at the- requested level with that '?1,298,gOO conditional -- not to oe released until the review committee looked at the 15's and 16's that made up that balance, specific :Lnformation. DR. JAIIEWAY: Well, if that is the intent of the motion, I am less unhappy with it. l@. POSTA: Well, let me say my understanding DR. JAIIEWAY: I wasn't worried about anybod@., usurpin" the council.- I'm worried about t.Tie council going in 102 37tD there and sayin- to a review committee, we are goin- to fund them 100 percent anyway and you have got to look at it MRS. MORGAN: No, no if P,'LR. PAHL: I think that/tlie moticm, perhaps, was made in such a way that the coun-cil recommended _$2,333,551 with the delegation of authority to the revievi committee to exercise its discretion within that ceilin,-,,funding level following the.receipt of information, I think this would accomplish what you want and save the Texas program a few weeks time, if you feel you wish to delegate that authority to them within that fundinc- level. @TRS. SILSBEE: Mr. Peterson. '@l-R. PETERSON: Am I reading something wrong, or is it perhaps misdhrased'. I thought, from looking at the green sheet several L'-4L-,@-s the fip:ure 1298 has been evoked. Tiat is additional money they would be coming in for, is it not? 11 ilo, sir, -it is not. MRS. MORGA': I-IRS. SILSBEE: Texas had opted to come in i-iith one application in this time and that $1 million represents the difference between the 1.1 and the requested amount. 7IR. PETERSOII: I see. IIRS. SILSBEE: Oltcay, let me restate the motion now so we know what we are talking about. The council moves to approve the Texas aDnl-'Lcation up to the an@ount of $2,333,551 deletatin- to the committee the 103 377 approval of the balance fo@ the contracts with 15's to 16's to come in in July. Is that clear? Is there further discussion? MRS. 1,@IORGA!4: Just a note. There is a letter from Dave Ferguson that they will have all their 15's and 16's available July 10th. MRS. SILSBEE: Further discussion? [No furl.-her discussion.] All in favor. [The:&e was a chorus of ayes.] Opposed. [There are three nayp.] i.iR@-. SILSBEE: T,".aybe we had better raise hands. All in favor. ":-here is a siloi@,r- of hands. L Opposed. [There is a small show -bf hands. The motion is car.-4-ed.] Three opposed. The ayes have it. The motion is carried. Now, Wisconsin is next. l'Ir. Van Winkle, did you want to give a brief overview here? MR. VA!@l WII@KLE: Very brief. 10 4 378 REPORT OF i'-LR. VAN WINKLE WISCOTI.iTsil@ I,IR. VAN WIlql",LE: The reviewers felt that this region had had a very illustrious past history but '.-hey certainly felt that they are in a crisis of leadership at the present time. Their current coordinator was the-- was previously the evaluator on this program. The reviewers found little evidence that the RAG had accomplished much during the past year, although their past performance has been quite o-ood. Their CHP relationships, as in the past, are still good. Their overall objectives and priorities are extremely vague. Both staff and committee felt that this proposal was a series of poorly conceived, Lragmented project activi-',-,ie some very researchy in nature, others, such as the major push in rn,enL@Ial health, not in kiieDing witLa the usual DR,:.,IP goals. Or, I would say, with Wisconsin's goals and we weren"u too sure that this was appropriate for funding and except for the I evidence of past Performance, there is little evaluation of what is currently going on in the region. In looking at the lar-e variety of new activities CD that they came in with, if you have the application, you will note that they are basically centered around the University off Wisconsin and I.I@rquette University. They don"t seem 41-lo <@-c4v- outside of i,iadison an d i"-,L-,-'@iiauzee and they just seem to be 105 3 7111 pulled together, put in a book and sent forward. MRS. SILSBEE: Mr. Hiroto. MR. HIROTO: It is apparent $that this RMLDS is having difficulty realigning themselves with their new leadership and the RAG is somewhat weak in creating the leadership necessary to create the proper point-of viei,@.,and attitude for it. It seems to me that the committee's recommendation is really a stab at a number hopefully coming up with something that is reasonable for what has been going on and to provide them with that support and, hopefully, that they be able to come up with a clearer program in the next cycle. I just -ot that out of a conversation. l@IRS. SILSB@-,T@7: Reading transcripts? T I,IR. HIROTO: Yes. MRS. SILSBEE: -I.,Ir. Millil@-en, did you have any comments about @@lisconsin? MR. !,IILLIII)El@T: Only that I agree with the coL-nit@v--,-, recommendation. 'dRS. SILSBEE: TS L there a i-@iotion? MR. HIRO'LO: Imove that the recommendation of $2 million be accepted by the council. D-IR. IT TIK-N: Second. [The motion was made and seconded.1 MRS. SILSBEE: The motion has been made and 106' 380 seconded that the Wisconsi@ R14P. application be funded at the $2 million level. Is there further discussion? [No discussion.] All in favor? EThere was a chorus of ayes.] Opposed? ,[There was no opposition and the motion was carried unanimously.] DR. JAI-IE!iAY: Madame ChairDerson, could I ask a question-off the record? MRS. 'SILSBEE: Yes. record.] [Brief off the MRS. SILSBEE: All right, we have got Dr. Janeway all cleared up now. There is one -e-ion that was site-visited and I wondered if i-,@aria Ele.-ia, if 'you didn't feel you ;,ian-ued 'u-0 -o hear your recori@-qenda L hold as manir of the committee here 4u t4on@ MRS. FLOOD: If it woul'd be feasible. l,'I'RS. SILSBEE: 5o I di-dn't have it listed in this memorandum, but because th-cre was a site visit, it was obvious they did have concerns and the site visit was on I-Ionday and Tuesday and Dr. William Thurman, Dr. James Musser and Tirs. illaria Elena Flood were the site visitors, along with Stolov and @dr. I,.Tash. -@,ie have copies o' 'he hastily-prepa.-ed site L u 107 381 visit report and Mes. Leventhal will distribute them to the council. REPORT OF MRS. 'IIIARIA ELENA FLOOD TRI-STATE MRS. FLOOD: Yes, I think it would be of help to the n@eribers-of the council to have copies of the site visit report. I might comment that the committee has some proble@,s@ with this application, as you can see by the recommended fundin- level that they sug-ested to us and their concerns rD were deep-seated'enou.-h that not only were they concerned abou@l, the fundinc- level, but they were concerned that there was C:., perhaps inability to truly interpret what Tri-State was attem,ptinc.- to address in their applications and, therefore, there i;as areservation -ado for a site visit if it could be launched Dri-or to council meeting. 1-lith that relative short notice to both pul@-tinc@, together a site visit team and the'burden it placed on staff and also, I suppose, the burden that it probably placed on Tri-State, this visit was undertaken on Monday and Tuesday of this week. As Mrs. Sislbee pointed out, the visit team was chaired by Dr. @-filliam Thurman and Dr. Mark J. Musser and myself comprised "Uhe other tTio 'rier,-,bers. l@!e we@e als'o accompanied by !:Iir. @4'ash and I-"r. Stolov and a representative 382 from the regional office in Boston, Daniel De!4ates. There was outstanding attentance at the session oL' the site visit and listed on the site visit report you will see the Deople that appeared. In the report, I would like to cover the Tri-State region in a-two-part approach and I might make a note that there is no ilew Hampshire component, either in our review nor in the present application before us for consideration. The '4ew Hampshire component, along with other applications for project proposals, will be submitted for the next.review cycle. The Rhode Island segment of the site visit was primarily to evaluate two very'expensive projects and both of these caused concern at committee level and not all questions were answered by ',,-he documents before them so we addressed ourselves Primarily to these two high-cost uro,4,ects. One is called the RIIIST--'C and that is a term gi ven to the Rhode Island Health Science'-Education Center and this is [inaudible] type of a oroject.- The request in the programs propo,sal is -for fundin,- to include monies for Fiscal '76 and this raised some flak. There had been intention also that there was a larr,e amount of unexpended funds available to this particular project at the close of Fiscal '74 but upon retmest, ,@ie obta@-ned @Lr,+@'orr.-iation re-artft-in- t'iaeir present unexpetak-1).ed L.> u n',,13 109 383 for RIIISEC project and where information hnd reached the RITIIP that there might be in'the neighborhood of $300,000 available to RIHSEC unexpended at the completion of the second year 'of their funding -- they were originally funde-@T,, I mimht point out, for-close to $600.,Ooo, $598,000 -- we Lr@-ave received reports, documented that they only have arrunexpended balance of $14,953. Now, we try to ascertain why th@e seems to be this large a discrepancy and we feel stron2fEy that it was a lack of reporting mechanism from RIHSEC to Tri-State and the information received at DRMP was from the Tri-State Regional [?.] Office and there had been some recent encounters, as our site visit renort says, from questionably effective or I think I could use the word, mediocre -- studies in the last 90 days and they were -"@39,000 IL-lo the Rhode Island Health Services Research, incorporated and $9,000 to the Rhode Island I-.,@,edica Association for a component -oart of the corL.-tumer education program. DR. l@IAI--'I'L"IOCK: I'@u h ? MRS. FLOOD: Yes,, sir. The area,health education activity in Rhode Island had entered into a contract with the Rhode Island T@,ledical Society in the amount of $9,000. DR. WAMMOCK: For what? MRS. FLOOD: For a conti-nuinf- education se-r -,lf-. DR. [Inaudible.] 110 384: MRS. FLOOD: I might say tL%P-t one of the problems with the RIHSEC development had in the leadership of R,RHSEC, there was, at its head, a particular p@erson who because also of what we term the ?'yo-yo effect" of' stability of fundirl:l had been ineffective in gaining the stability for RIIiSEC's development that had been expected of him. Frankly, little was done in the first two years of this operation and the responsibility rested with the board of directors of 'iIHS;-Zc and they still had not fully addressedithis. 'father that discharge a weak director when they became aware that they were way behind., sponsors of this particular project, they relegated Iiii-,L to a secondary role and he is still on b-oar@..-. The on-site visit report and, hopefully the advice letter to them will recommend that some remedial action be tal-%-en very quickly. The decision to replace the director of RI4aL w a s made in ',.@'Tovember of '73 and only in ililay of' '74 did they find a replacement for h-im but they did,-as I say, keep him on in a secondary role. The new director of RIHSEC is a very capable individual with knoi,@,ledgeability of both regional medical program activities and the concepts of an area health education center. He seems to ha-ve ra-,gp.,ort @@iith theleadership T n the State of Rhode Island. I.e is reco nized and reE@iDecL, n all of the different associated with the hospital 385 association. We had representation of the medical association. All of them hang all their hopes on the indivi- dual, Robert Laughton, who-is not an Unknown name to the RFPA or RM'@DA and had been at one time the deputy coordinator of Tri-State RMP. In the very short time that he hard been there, it is evident that he does not intend to reflect the same natterni of inactivity of the RIHSEC project as had been the history for the past 21 months before his arr Now, the site visitors had to take this Tri-Sta'ue visit in two segments and to address myself to the RIIISEC segment of their proposal, the visitor,& felt that they should be approved for the continuation fund:in,- of RIHSEC for Fiscal '75 at their previously agreed--@upon budget level, but approved at a level of only -- let's see -- $100,000. ',r, that correct, i@,ir. Stolov? S'L'OLOV: Yes, $100,000. MRS. FLOOD: For the fo'u-r@L.,Il year 0,1'- fundin- for RIHSEC Fiscal '76. This would force tl.,-e R=SEC Board of Trustees to face the realisms that they -"ust,become a,sel'- supportin- entity and that the participating institu-4ons and agencies would also support the sarae positions. I!i'.e did also state that we would require' that the pro,,ress renort of the RIu'@C activities be submitted at '-,he end of the six months period -- Dece.@ber 30th o,' 1"11. There seems to be a great deal of hope in i@hode 112 386 Island that with the new leadership, that this Droject will indeed reach the goal that it had been charged to reach. Therefore, we were in support of its continuation fundin- but with the limitation for the fourth year. Now, the next project for Rhode Island's segment of Tri-State was a rather interesting one and I think I used the word yesterday -- and there is no way to express it except to call it blatantly political-. This project was based and the project pro- poser 'PAHL: !,!aria Elena, perhaps before you go on, we have been handed a table, a budget table on IIIIISEC and so forth and it has a question and.if you would just make that a part of your presentation? IV,S. FLOOD: All ri-ht. Is the form.,. that I have the same one that you received? IIR. PAIIL: Oh, I cuess we i,,,ere just c-iven our copy of what has been handed to yd-U. j'4RS. FLOOD: We-11, they gave us a printout of this @@Lhode Island and then we found a inath ei-aatical error. [Laughter.] MRS. FLOOD: In addition. So., apparently, then, he mailed the corrected copies in to the RI"IIP. MR. PAHL: Okay, thank ,Cil. ---OOD: -qay go on to the ne,@,L-, c,,,. i e 113 87 3 the title of this particular project is called, "PlanninC for Health Services in a Time of Economic Transition" and IV-he applicant is the Governor of Rhode Island, the Honorable Phillip Noel. Now, this was a relatively interesting approach and we pressed very hard for the rationale behind 1-iavin- this project based in the Governor's office and there are some particularly interesting aspects to Rhode Island at this time with the closing of the naval facilities at Quonset @oint and '-'Iewport -- I thin'Ac. There has been a tremendous economic impact on the co.,=.,unity. The application is actually a little behind times in its request because it proposes to do an analys-Ls of ,-.hat impact these shut-do,,,.tns will have on the health delivery sys'Llei-I in one segment, and that is aL@'L-,e@- the fact because those particular ILacilities have closed down and the impact is: alread,, there. But the second segment of the proposal was to address the impact that the Governor's drive and his Bureau of Economic Development, or whatever you want to call it, has undert@,,en to bring new industry into the Quonset area and develop the entire.area into an industrial complex and anticipatin- already having 7otten some obligations fro-.i d also Favor ins urance companies to i-no,ze its some industry an major offices there.,.they will have an impact, they estimate, 114 388 of about 50,000 employment or rather, families comino- in from the employment, 50,000 persons as the result of the Lamilies employed in these-two new attracted industries to this area. This does, indeed, present some problems for the health care delivery system of Rhode Island. We question severely that the planning for this project Proposal in Rhode Island had been done by the Governor far the people of Rhode Island and not with the people of Faa(te Island and there shows obvious lack of understanding by L-ep@-sentatives from the Governor's office as to the realisms of t-he health delivery system, the capability of the health professional associations and societies to participate @-rr meaningful plannin@ endeavor of this type and analysis of the needs. The Tri-S@uate RI.IP has been urged to carefully monitor this particular project to assure th:at these component parts are included in the Governor,"s office. It gave a feeling that the Gove@ was really just trying to develop a staff capability in. his office for future economic Dlanning and analysis and @ing heal't@ care as one of the keys for it. Nonetheless, we again approved the concept of funding this at the discretionary level the-t,,the Tri-St@e RI@IP placed on the aT)-olication and I might paint- out th2.'-- ev.-n thou,-,-h it is at a $250,000 orice tag at this time, the 115 389 the original application td Tri-State was $472,000 and the Phode Island RIAG they have sub-RAGs for each state -- cut I the project funding to that level. There is a desperate need in Rhode Island for this type of activity. The question arose as to why hasn't a comprehensive health planning agency perhaps addressed this long ago were easily answered by a totally ineffective comprehensive health planning agency. There is only the A agency for this state. There are no B agencies either seated in the state health department and the Governor's proposal showed a stark -lack of knowledge as to a-vni lable data and statistical information. The state health department, indeed, has ini'@m@u±on anu"could be utilized if their original -oroDosal -..,,as roincr to generate all of thi-s inf-'or-,Iation. They wanted to do impacts on heart disease because of the stress and strain -and ulcers of havinlc- no jobs or bein insecure 9 about one's job which, of course,,there was some information already and by staff of DRI,IP here -- kir. Stolov and Mr. Hashis able assistance in garnerinr,- documentations'and I believe Mr. Stolov contacted in the short time from committee to site visit somethin@ like 17 different departments and ac-encies t,, gather data and information that could have been utilized@ for the Preliminary sta,es of such an analysis. !Ie @ot stuff -from the 4',Iavy Deuart,-i--nt, Depar@u:,-ic!iit of 7abcr, o@ @,y 16 3 9 many segments of HR4'L and this bibliography was provided to I;lr. Kevin 'L.1c'llenna, a very angry young man who is an admin- istrative assistant to the Governor in charge of this particular proposal. Still, there was a rallying of support for the need of this by the community leadership of Rhode Island and the Rhode Island Regional Advisory Group had given this ,project its approval at the reduced funding level and we !will [be] in concurrence to continue the funds and potential for this uroject. 14ow, if there are no questions about the Rhode Island segTient, I will transfer to the DR. WAPl@@iOCK: flow, this is the Governor's idea, is that right, because of the phasing out of a project there, of closing un and brincr-'Lng in ne,-, industry and he th4Lnl-:s they are ,-oinE to have some 50,000 people and he doesn" know what; they are going to do as far as their pulse and respiration are concerned? [Laughter.] 14RS. FLOOD: That is correct, Dr., Wammock., Let me explain that .@Lhode Island has a specifically interesting problem in that its entire economy, practilly, was based on the services ancillary to and the employment potential of the 9 naval bases and the%T are mone. y D;'@ JA,@ll- It sounds like it is based on 117 391 now. SPEAKER: J'hat's right. I,.,TRS. FLOOD: They are now gone and besides being gone and their effect on small business on'the island of liewport, they have had a close-down of 93 small businesses in the past six months. Also, these people that were employed, Civil Service employment, have not found positions and we have a large segment of retired naval personnel in that part of.the country that utilized the naval health resources and now do not have easy accessibility to the health care and are relying now on their chanpus coverage into the private sector.1 I would raise the question, and I @7iR. CHA,.IBLISS: think it is rather fundamental. I have looked over this project and I really would like to ask you, would this not, in fact, an economic development type of activity as opposed I to a health activity. I throw that out simply to get more discussion from council so that vie can be ful'ly aviare of your views regarding this problem. I.,IR. HIROTO: Imight refer the Governor to the Chamber of Commerce. DR. WAI-11,!OCK: I think it is unfortunate to drag the Governor into the situation because vie had this situation ,yesterday afternoon with another project T-,,hich@,ias con'.i,,iucd upon anproval of this by the Governor for ethical funds and 392 we debated this for an hour' yesterday afternoon and here i come along with another, state with the governor involved in this and this looks like it is an economic problem and not originating in the re-ional medical program. The Tri-State situation here, you've got -- what is it, three states involved in here? MRS. FLOOD: Yes, sir. DR. WA@-IMOCK: We had headaches yesterday with problems. We have got some more this afternoon coming up and it is difficult for me -- and guess I got a single trolley car line or whatever it is, to absorb all of these things that are Dut into this and it disturbs me very greatly that Ilhen you co-.@ie to a r-7ri-,Ojtate or a multi-state pro-ra,-l involved and so on, and yet you have the Governor comint- in here MR. @IRO'LO: T,ror, one of the three. DR. MR. I'IIROTO: From one of the three states. DR. IIA'I"17, @:-OCK: From one 6L' the three states and it makes it difficult to sort it but. if we were dealing with it state by state, it would be simpler to do, @."Ladame Chairman. MRS. SILSBEE: '@j'ell, it is a Tri-State E,!P and in ter.-.ns of the charL-es that the committee made to site visitors You went and rr,ot the information and ,,ou are c@,,.in@:: on@- ard it is up to the council to 119 393 accept or reject or modify the recommendations. I-IRS. FLOOD:- Do you Ti;an@u-to go on to the next slu-ate- DR. HABER: I would just like to attest to the economic deprivation and its effect on health care in that part of the country. We operate a small outpatient clinic there and have often wondered whether it should be continued or not and felt., after visiting it, that there was -- that to remove this small clinic.,,vould have been symbolic of a disinterest on the part of the Federal Government and in the health care activities. It is certainly theoretically possible to divorce that froii7, any other consideration, yet one must remember that this area has been a depressed area and it has been becoming .more so. Prior to the loss of the naval operations there had been continued loss in L,,anui@ac4v-uring industries in ',-,h!---u r.)art T 4 @aode Island particularly, and of the coun@ury in ew LnEland, I thin!-: that the people there are very, very sensitive to the L removal of any operations. So I would endorse iihat I-Irs. Flood is sayin,-. I.'IRS. FLOOD: Before I go on to I.'Lassachusetts,'I might add one uoint that your comment that this is really an economic development proposal might be valid in one comment but the true point of the medical assistance program to try to assist in accessibility and availability of-healt@i does pi,--y aii uart did pla@, an important in 120 394 our considerations and definitely-this analysis is needed there. Under whose aegis, council may reach a decision on later, but they have no valid information put together in a coherent manner at this time to address an availability and accessibility problem that they will be facing the major impact of in the very next few months. l@ow, if I may go on to Massachusetts, we have also two component parts of the Massachusetts segment.that presented some problems. One was a proposal offered by the Institute for Governmental Services of the University of Massachusetts. A-ain, at preliminary review by review committee, it also appeared to be a politically-oriente d type of a proposal but as we saw one of the most refreshing sights that I have observed in site visits or in deliberations of projects proposed, seated around a table, a ,.-.,arm fellowship -- that is the best I can describe it -- of CIIP's out of the Governorls office, human development resources is where the CHP is seated there -- the University of-Massachusetts Brown University -@ no, not Brown SPEAKER: !Harvard. MRS. FLOOD: Harvard School of Medicine and the other one it begins with B P -7 P.., 1, T3oston University. -ILOOD: Oh, Boston University. I l@nei-., it was 12 1 395 a B -- Boston University work,ihrr in close liason in res,----- to a desperate need for the utilization of tremendous resources available in academia in that state to make legislation addressing health care institutes relevant to the realistic needs of that state. It was a fascinating process to watch. I personally, and other members of the site visit I think would concur we'll have to give the entire credit to this blending of the different phases of that state, the political, private education, public education and physician community to the coordinators, Bob Murphy is responsible for stimulating this first agreement to agree to the political entities utilizing the Drivate education system, harvard School of I'.',edicine's research center for information, tied with Boston Universi4u-yls ",--ticular Institute .@i@uh the University of Massachusetts' blendin@ of skill.s to rrovide the necessary information for a jud-ment reachin@ on lon-- ranme planning by comprehensive he alth planning and the legislators' needs to understand the health care needs in order to develop responsive legislation. @-le were very inoressed by this project and we urEe that it be considered no,-, to be withheld in their total L fundin-. T D@ . would 14, 1-,st ILI--'@e to add content L-lo that because if 1-Irs. Flood's observations are true they are t22 396 all the more remarkable because,several of those institutions have just completed a Very blood internecine battle, the net result of which, two of those medical schools were uncere- moniously kicked out of the Boston City Hospital grou-o and they had a cannibalistic orgy and if they can be said to have cooperated in this endeavor, I would think anything iie can do in the way of pouring on some healing balm we ought to do. MRS. FLOOD: I'd like to comment, one added aspect that I think means that the pressure here -- as review co,,,iri@Lttee looked at this application and saw it coming fro.,.i a state university, an institute for governmental services, they thou.@ht, here we go, another rip-off and -- but when 'vie got thc@re and saw that, in essence, this application i-ias solicited by the re@ional @-,edical proCraii, Tri-@OL'ate, of this a,-ency to be the seat of this unifying endeavor, it chanr,rlcd the entire co-,Dlexity oL' the situation. i,IRS. SILSBEE: Dr. Jandway. I D@'L - JAIIE,,IAY: -k, is my recollect-ton., ilrs. Flood, that at the time of the planning l-or the new medical school in I,.Iorcester thaL-1 the 'Uovernor had an office of health poli cy Is that a -- do I misrecolledt about the l,lass government? He had considerable help from the IIT-Sloane School of illana-ement and the MIT Harvard iDro-r@-i it that-tiric far as their legislative liason and date ofL' production. 12 3 397 PerhaDs I am incorrect on that but I MRS. FLOOD: That was not brought to light during the site visit. MR. STOLOV: It might just have been formed at -hat particular formation the request of the Governor for 4u of the medical school. The best we can determine from the health resources agency which was there was the agency was given this responsibility but he did have strong legislative both the Senator in charge of the health'committee and the Ilousels representative person [inaudible.] So I felt that there was a need and we could check this out but to my knowledge., it didnot surface at the meeting. DR. JA',','E'@.-IAY: I present that as a recollection, as best as I can recall at this point in time. i@'IRS. FLOOD: The recommendation for this Droject was unqualified approval, althou-h, in executive session, the site visit team did call attentiop.to what we felt might be -o the coordinator of Tri-State R',,P and an excessive budget 4L, this budget was in the process of negotiation and could be markedly altered. l@loii, there was concern in review committee that the programmatic concerns of Tri-State might not have been addressed and that their review process might be lacking. This, we did not find. l-e found careful- description of '.-he-!.--" 124 398 goals and objectives and an adequate review process and, certainly, broad participation in the review and, in fact, we found strong review by the Rhode Island components as they chopped back at the governor's project, for example, and then it got strong-review processing at Tri-State. MR. IIIPOTO: I noticed a discrepancy between your committee's or your site visit of $1,676-some-odd-thousand as opposed to the committee recommendation of $800,000. Was ,that recommended primarily by the governor's program and the rehash, or whatever it is called? MRS. FLOOD: Primarily, it falls into those categories, that's correct. l,ilell, actually, it is three and I am goin-@ to cover a one-fourth se--ment.here. tD CD 'IIIRS. SILSBEE: I wonder if we could hold for a minute? She has to chanc-e a tape. [Brief off the record.] T i.,RS. FLOOD: I might respond, on record,, if you wish, to Mr. Hiroto's question. The regional request for 6yl,886,000 in essence, resulted by our reviewing -only a cut back of $100,000 for the phase out of monitoring and @100 000 on the bureau funding for the .@,IHSr.C. T ow , the last componcn'u that has raised some oricern at rev-Le,.-i co::iriit-uec i-,,ao @,ri item that .,;e have iscussed at council and that is the idea ol-- havinc- a contract et for continuation monitoring of ongoin- projects beyond 125 399 Fiscal '75 anid since the policies have been clarified that this is indeed appropriate, the ri-State R'P had proposed a request of $275,000 to have a contract given to the Ilarvard r 1.@edical School to monitor the operating projects of .@iscal '7-. Our recoririendation was that it should be approved if legal, which-is now unnecessary, but for a bud@et of approximately w@100,000. tD @.-IRS. SILSBEE: Could you clarify? Did the RIIIISEC approve it for the two years? r-IRS. -PLOOD: Yes, but with a lesser fundin- level than they reques'te,-' for the continuation beyond the .-e-ional su-)n@o.-t, a @7,ari:ed reduction. -iRS. SI"@SBL@IE: ilr. Ifiro4-o. '@R. HIRO@'O: Yes, I have one other question int'-@,--@a'Uion for the Jul,7/-"@.uz-L,,--t review listed it as ;@@?-OO,on and ,,Tou 7-ndi-cated an increase to -@-1,800,000. u -Ion. I",,F,S. FL'JOOD: Yes, I mi hof"er some explana'u !,!hen we reached Tri-State, it was -o'ur understanding that the application for the next review c@cle would be in the vicinit-, of 6,800,000. '.Iir. 71"iurohy, @he coordinator, informed us on our last day of visit, that there are projects floodin':- in iiave merit and are in the review nrocess and that at this point in time, it looked as if they may come in for Y'1.8 in the next cycle. '7TO7- O'\T: ,@cto,, there was also 1 1 -.on L 126 400 worth of grants processed MRS. FLOOD: That's right. MR. STOLOV: by Tri-State for this next cycle that is coming up. I-IRS. FLOOD: They have over,,@!3 million in requests. MRS. SILSBEE: Dr. Janeway,-. DR. JANEI,,IAY: May I ask yoii. one qi;,,L-stion? Was Dr. Weiss at Harvard enthusiastic and mWpo@.ive and is he going to be actively involved in this @alth policy? IIRS. FLOOD: He was effusive., DR. JANEI.,TAY: He is solidlT,, t@ehind it. L7,@IRS. FLOOD: file was in attetmfance, solidi@,r behind it, effusive and told us in no uncertain terms that even if this fails in Dutting to@ether surj'ic-tent information to be of value, it @,.,as stron- in its ,iierit of being the L'@---s@. segment in which these multiple aspec(1-s of 1-lassachusetlu-S community were going to work together and p.@na-os his testimony, above others swayed us to r-azt full support for DR. JA!iE!-,,-AY: It would si-day r,-,.e, t,oo. MRS. SILSBEE: Mrs. Flood, would you like to' su-imarize the recommendations of the sTte visit.tea-".? !,IR@. FLOOD: The site visit. tear,-, vias., in the Tri- State Regiona 1 T Program, feels that the Tri-State has a strong staf-@P. broad knoiiiedc,-e and es-ecial-ty Cor7,@ends Mr. "-lurphy for his efforts in tying together many problem 127 4ol areas in that region. It has a good regional advisory group, a strUI16 board and advisory subcommittees. The commitment of Tri-State to the entire concept of blending the private community with the public sector was obvious. We would recommend strongly to the Tri-State Regional Medical Program that they function more strongly in monitoring roles, especially in Congress in the State of Rhode Island, but recommend to this council that funding be approved at a level of-$1,686,907 M-RS . "IOIILGA,@T: 86 or 7? MRS. FLOOD: I'm sorry. Jerry, I'll have to I,IR. STOLOV: I have 1676. 17!RS. FLOOD: Okay, @1,676,907. I-IRS. MORGAII: Is that a motion? L'4RS. FLOOD: Yes that is a motion. 14RS. MORGAN: I second it. [The motion was-made and seconded.] MRS. SILSBEE: The motion has been made and seconded that the council accept the site visitors' recommendations and aDDrove the Tri-State application at the level of $1,676,907. Is there further discussion? Dr. Janeway. DR. JAITEI@IAY: I feel compelled to make what may be 12 8 402 a gratuitous comment. If the Massachusetts State Governr,,ent is go'Ln,.- to have a study of health Dolicies, I would hoDe tha@Ll they would involve more than the medical schools and that the Mass. ?@ledical Society has some in-out and I don't see anybody from the I",Iedical Society on DR. WAI.,IrlOCK: Hope, I didn't either. DR. JANEWAY: And I think that is a serious error, if they are not going to have effective representation on that. MRS. FLOOD: That point was mentioned.%.Dr. Janeway, and I can'@u recall -- it has been severa days now -- what the response -,,ias. D@'L . JA@@JIEI@,AY: Tell, it is really none of our business. As I say, it is a c,-ratuitous conr@ient. is,good advice, Dr Jare,.,,,ay and i.i.LS. SIL"3E": -L U we certainly will convey that to the reSion. ilia. HIRO-TO: 1 a.-,q still unco,,7,L'or'u-able with this project 52. TIhat happened to the @verall 'Lri-State !I,.iP what .-Irculd happen, if your-recorimendation .@;ere to be reduced by the amount reelected he-re? I"IRS. SILSBEE: Is 52 the Governor's Rhode island study? 1,@ IT I@ .010: Yes. FLOOD: rinaudible. L "ILSB7Z: Dr 129 403 DR. l@@'Al.llIOCK: I didn't get your comment. He asked about what would happen if this 52 was struck out. Is that v;hat you were talking-about? MRS. SILSBEE: I didn't comment. I was going to let Mrs. Flood or Mr. Stolov comment on that. MRS. FLOOD: Ilell, besides a probable very violent temper tantrum. on the part of one angry young man in the Governor's office, I am not sure that there would be others who would address this, with the expediencies that the potential is available here. Now, I might broaden the statement. We questioned that they were tryin- to build staff and .e offered some counsel and statements about possibly utilizing consultants groups to answer -this in a more massive impact way rather than garner staff and sL-Irenrthen the Gove.-nor's office. This was well-received and I don't know if there would be anyone else that would take this up and address it and it is a necessary component of some future planning for Rhode Island. DR. IqAT@l@-IOCK: I.Id like to call your attention to the fact that I read this as, proc-ram staff is $654 3000.,Ooo and the budget you have got up here is $1 million. MR. PAHL: We appreciate the budget increase Dr. Wamiiock. That is $654,000. T',I;j C I,' DT'-' .',"A-, That is a lou of money. 130 4c)4 MR. PAHL: It is, indeed. DR. IIAI.U@IOCK: And the other thing is, that item 52, here, health service time of economic transition. That may not be the only state that is going through economic transition. -1--laybe the other states are going through economic transition and I think we have to take this into consideration from the standpoint of what role will the RI@IP play in this when we are trying to provide health care services. MR. PAHL: Well, I am glad you made your remark before mine, because I'want to merely say from the point of view of the pro@ram staff that I believe pa-e 2 of the site visit resort points out the weaknesses and the stren-ths and from what I listened to the discussion of the site visit, if we can divorce ourselves from the Governor's office for a moment, I think that a good bit of discussion has centered around an appropriate role for PilP, perhaps in this area and I think you could make your decision, not on the basis of whether this happens to be-the Governor's office or not, but there has never been a-consideration in councils prior to this one. This has been an unusual council in that t,,-iice now we happen to have situations which involve the Governor's office and this outs a different complexion on the R@.I.P pro@r-am than have ever had in '.-he historx, oT the -o-o-rar,. T 4-hjiiz the site visit team has done In this case u J- 131 405 Ian exemplary job in tryi.ng to weigh very accurately real ,-hs and real weaknesses and I think this council should streng4u decide whether it is in the interest of the RTIP program to approve or not approve this project. You have heard all of the discussion and I think now comes the decision on-the basis of.iihat you believe to.' be the merits of the funds in this area. I would feel that we could support your recoizi-ien- dation Whichever way it happens to be. I frankly have a personal feeling about this but I think it is the counci s job to tal,-e -iin@uever -a-ction appears appropriate. I do not see where a -1-ri-L'itate 7@' 1.P o rRhode island RAG has to do one thin- or another and I don't think you have to do one thing or another, either. I think you should decide on the basis of the merit of '--,he situation. "-,--s. Flood. 1,M 1-7 . L'@ i'JOOD: I'd to COA-"ren-@ on the staff costs. 'L"hey are all very -@,:el-IL-paid people, bu+.- of ouL'Istandl-nc- capability and- their - numbers are not extrac" CD dinar--'Lly high for the area they serve, but they are still -the most capable peoiD"-e with well-,i)ai-d positions and that does account for high staff budget. ,,IRS. SILSBE'@: Looking at the p@-nt-out on just --i the nroo-ran staff line, Dr. i,lammocl@, in and of-itself does not tell irou ,-iucli I,,,--cause, particularly their contr-@c@L. ccstc 406 and so forth that have tuilt into staff activities, so we have to look at the DR. IIPIIL@IOCK: I recognize that part of the situation, but I mean, it doesn't trim the astronomical part of the total. Plus the fact that this is a Tri-State situation and I come back-to the question as to what Dr. Pahl said, that this is the second time that we have been confronted with this a governor participating in a pro-ram. I%IRS. SILSBAVIE: Is there further discussion on this point? I-IR. STOLOV:- l,lay I ask just one question? I am unclear about what Dr. Pahl says and that is in terms of, does the council feel that the@ are holding an economic project? Because Dean Thurman, I think, and the site visit tear, were able to get the ful-IL-blo,.-.rn orojec@u and revie,..T it and the ,-@aiori@uy felt the orojecl@, .7as dealinr- ,.rith the health aspects only of a thrust out of the Governor's office, usin@ every acency at the Gove@-nor's disbosal to deal with it because of the eimht percent [inaudible] Dr. Haber mentioned, these peoole no lonver have health benefits and we checked -that area about what is !.Iedicaid doin- in the state and they said, everybody who is now employed -ets divorced and the LD families are separated and we can then take care of them on Medicaid but in essence, "Uhe proposals, the ma-jority of the ProDosals in Tri-State are for people who are not d4-rectly 13@ 407 dealing with the health care delivery sys@uein but usinc- the method the Hill-Burton Program the laeaT;'@h Department the state health department currently sitt:Lng- @ the Governor's office., the definition of how they plan tego about it through subcontracts and one of the sut-contracts was with the local group in Newport, $50,000. Again, all of this has to be negotiated, but to pull together the !,,Iedical Society, the hc,,--pital community and give them $50,000 to plan their hea3-th needs in the community, well, I hope by the title in the computer print- out you are not misled'by the economics af it because Dean Thurman, I must say, focused in on that quite well. MRS. SILSBEE: Mrs. Flood, @ci you have something further? I,IRS. FLOOD: Well, no, -iy response to the co=ents of Dr. l@.ammock was the true Personnel c@(Dst;-T at this time are really closer to $300,000 than the rest ofthe, you l@now 3 contracts for staff costs. MRS. SILSBEE: Well, the motior,., vias been made and seconded that the Tri-Stat-e application be ipproved at @e level of lyl,676,907. Is there further discussion? [Therewas no discussion. All in favor say aye. [There was a chorus of ayes.] Opposed. 13LI r,,OCK: No. DR. WAI,'I,,L [The motion was carried.1 IYIRS. SILSBEE: The motion has be@-n carried. Now, the sandwiches are here. P-re you hungry? Would you like to take a break? [General consensus.] [Whereupon, at 12:00 O'clocl-, n(-@ca, a recess was taken for luncheon.] LI@ RI'4P 4o9 rc AFTERNOON SEQ@SION /17 (12:25 P.M.) MS. SILSBEE: We would like to get started again. There are a couple of announcements I wanted to ,,mke. For the record, Dr. Merrill was not present during the Tri-State review; he'is not here today. -And with regard tothe Arizona application, after we got all through with discussing it, we noticed that the Arizona Pd4P did. have an arthritis application, so we are in- eview that that does not ap terpreting the sense of your ply to that earmarked activity, in the program applications, Now we will do Illinois. Lee,did you want to o,,ive any real brief remark? Dr. Janeway, you did a review. T @Ul,. VAN WII@,@KIC- I would just as soon he Lead off and If he wants me to respond to any question, I would be glad to. DR. JA NOWA Y: If I can find it in my book. DR. WA M40C K: I-t com,---s rioht after "Hawaii." C> DR.JANDIAY: In order to get the'topic on th@floor, I move approval of the recommended level by the committee of $2,8i6,935, which is LOO percent of the request presented to the Ad Hoc'Review Committee. O-R GIN: I -econd it. Mol. SILSBEE: I)r. Wammock, secondary reviewer, do 4-LU you want to -say anything? DR. WAI,114OCK: Icame across this business of public' awareness of venereal disease that sort of worried me a little bit. -And really, there is not much about it; I thought it was a well prepared situation and there is no point in nit picking, anything of-that sort, so I would second it. DR. JANEW.AY: In brief comment on the topic, I think that in the general guidelines for following it, it is a superior program. I think that one bit of potential difficulty that ought to be made available to the Council is the fact that Dr. Creditor and Mrs. Creditor are both Leavino, the prooram. And since that represents the coordina- CD C3 tor and -the -rants manager, the Illinois RMP, I think it is a difficult task to replace the@,n. r Dr. Creditor has a reputation for strong leadership: and advanced planning and.has a very interesting monograph on the subject. From the standpoint of --proposals, I would make onL,r one comment, in my review2 which-I noticed was covered in the transcripts also, is that the hypertension control pro- gram that they visualize themselves to me rather ambiguous considerino- the amount of time that is available in order to CD carry out the project, but it is worth while and, well designed I am not sure they canattract the s-taff and get the: computer base and all of 'the mechanics necessary to- coriple@uc,. 4ii ess recommend the project as they see ft. But I nonethei 3 approval as the committee recommended. MILS WRTINEZ: (Ina uci ib le) DR. J.ANEW.AY: He is going full time at the University of Illinois,. @ledical Branch. The Dean there is a reliable 'person. If he said it is going to be a generous 25 percent, it will be, and I have known him for sometime; he is quite interest--a in the RMP program. I am sure that wilk happen. DR.. I would like to asic one question here If I could find the page. It is an amount of *i@b,000 for PO@IR medical care evaluation. This is a demonstration of the usefulness of 'the model system in other settings at KL@EL Reese Hospital, and assessments for adaptability to do amb-ulatory care settin.-I. 1,2 S. 'Lfi.ORG-Ali: What number is tta-.t? I)R. WmZC,-40UK: Page 90, pac-e g@G. It is 33 is what it "@s; pro'ect I)evelopment 'Ves-t and feedback, method for the system, evaluation or first year..of the project anLi promotion e for@ system at the institution. It is goin- uo oe Cone in one hospital, @@8,OuO. Thau is a good 6ize "chickenl'eed. L)R. JjiN,@-fmY: They have bit @into the.,plaie- on the' system on the computers capital P, c@,p,-tat H.- JJR. Ye@. 412 -UR. JjilTEW,,iY: mnd I thinic they nuve been usina, @he PO,MR throughout Ilil'noiz3 for inpatient and medical audit purposes, The extension into ambulatory care is a necessary one in my opinion, but considerably more difficult in its im- plementation than inpatient. DR. WAMOCK: Yes@ that is what worries meg imple- mentation on the outpatient basis. DR. JANEWAY: That is where it is goin.- to be at, though, to use an old Western Pennsylvania phrase. DR. W.A NRAOC K: "Where it's at." MRS. FLOOD: This particular project will be seated in one facility as a test? DR. W.Al,,L@OCK: Yes. MRS. FLOOD: 11-lay Iask an additional question. L-- t me clarify, Dr. Mort Creditor will now be, 25 percent of his time will be coordinator of IRI"@IP period? Or-- DR. JANEWAY: My understanding of the proposal Is that thio will extend through December of 1974 and it is not a 25 percent spread; it Ls 25 percent generously, but -U will! .presLL,ne to terminate at a year or so. It is more time actually, Is that your understanding? MR. VAN WINKLCT: Yes, yes, it is. MRS. FLOOD: I have some reaT 413 rc 141. VAN WINKLE: They do have a ---earch team at the present time. MRS. FLOOD: They do have a search group formed? MR. VAN WINKEE: Yas. MRS. FLOOD: Definitely thtz has. been the power behind the successes of IRMP, and if tthey don't address the sufficient transition time, you kncw, to r@-place the coordina,'@ t toro they would face a lag I think i-r@r, pu u-ing all these piec&sl together and perhaps a crucial time-.w7ben they must enter wiridii QPO MS. SILSBEE: Dr. Wammock. DR. WANlt4OCK: Another praj@eat on page L07, -that pro,- i 41, PSRO evaluation of technique in, Cbicago. Quality of disease information of Cook County phwsial-ans. It bugs me a little bit, it Is a form I am sure of continued education in some on-- form or another, but it costs $L35,000. MRS. MORGAN: There are a. L."zt of physicians hereo though. DR. WAI,51OCK: I recognize that, but if you a@lyzed;l how many attended out of the total-- DR. JANEWAY: I think the number is goino,- to go up. DR. WAMOCK: You think it will go up? You mean Ju-.t for PoLitic,,iL reasons? DR. JANEWAY: No, no. Reality. 4i4 MR. H IR OT 0: If they want to stay licensed. DR. WA,,NL'40CK: That is all I have. MRS. MORGAN: Question. MS. SILSBEE: Motion has been made and seconded that the Illinois application be approved at the requested amount of $2o8l6@935. Is there any further discussion? All in favor say "aye." (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response.) MS. SILIBEE: Motion is carried. Next one is Ohio VaLley. DR. Jfi@NEi-AY: @ledari Chairperson, the Delegation f rcm Ohio VaLley (Lau-hter) WOI-,Tl@LI-1,CK: Want to cet the Council on this? DR* DR. JANEWPY: In order -to place @the topic on the floor, I move approval of the committee recommendation of $2,205,636, plus @@LOO,000 for project 27-D. MS. SILSBEE: Hold it just a minute until Mr. Milliken gets out of the room. (At this point @fr. Milliken withdrew from the room.11@ MS. SILSBEE: ALL right. Excuse He is out. 415 DR. JANEWAY: Thank, you. I move approval of the committee recommendation for the Ohio ValleyRMP in the amount of $2,205,636 plus $100,000 for project 27-D, to fund ToLedo, Lima, Dayton Region. MS. SILSBEE: Is there a second@ 'MRS. MRS: Second. DR. JA @iA Y: I am a little bit, Less enthusiastic about this proposal than I iias about t@ Illinois proposal. I think that leadership in my. opinion remains to be! demonstrated, both in the coordinator of the program and In the RAG. I think that with the phasing out of other programs in Ohio, that they 'Lace severe political difficulties in bring- ing other regions, other parts of the state into the funding mechanism because it appears to me that the great maor,'Lty o--' their pro.-rams are divided a third, a t@rd., and a third; then the participatin- medical schools, There is no fault in the direction of the great, majority of their proposals but I do thTnk they underestimate the difficulties that they may face as they get more vocal from the regions that have not been in. I am not quite sure how this is going to be resolved i.,,ithin the framework of the proposal they presented. Although the overall program J-z presented In a 416 well printed forms It is difficult to follow exactly what thel accomplishments of the region have been to date. And Ithink there Is going to have tobl- a lot of salting out in this re- gion before they accomplish what they say they are going to do, Inherently I think in a program that crosses state boundaries is this type of problem and they have ju.,ztv in miti gation of what I said earlier., done quite well in hand L'ing the fact that it does involve three states. MS. SILSBEE: I should explain to the Council that Toledo-Lima-Dayton part of the application, bec use last year when we were phasing out, two of the programs at formerly covered Ohiop Ohio State program and the Northeast Ohio, were phased out. At the time that these applications were being pre- pared, Ohio forces began to wake up to the fact that there was money to do some things that they wanted to do and under the terms of the court order, the money has to go through the 53 existing regional medical programs$ so we suggested to various people in Ohio to-go either to Ohio-VaLLeyp which covered the';part around Cincinnati,, and Kentucky and part of Indiana,, or to'go to Western Pennsylvania or to Michigan,, and so in this particular round of applications, Ohio VaLley, RAG agreed to take this on. And Western-Pennsilya-nia applica- tion you will be looking at Later was to try to do portions of 417 activities in Ohio without taking on the whole state. Lee, did you have anything to add? MR. VAN WINKLE: I would explain in the rccom'menda- tion that the 100,000 was explicit for this expansion into Ohio, and I understand since the committee met that these people have applied and this will be forthcoming, wt-ichwould eventually probably raise this-level to $2.3. ])R. JANEWAY: My only problem with that 'if $100,,OOO is just for starters. I don't think we are going tc have any difficulty with that. It is when that area getE organizer, what are they going to do? MS. SILSBEE: I think these are for speci ic pri- orities in the Ohio Valley programs MR. VAN WINKLE: That is correct. MS. SILSBEE: Health education services, that type of activity. And they h'a've made it quite clear to Ohio they are not interested in a lot of different kinds of activities. So these are related to the goals'of this particular regional medical program* MR. VAN WINKLE:- They have no intention of helping to form a new medical school. MS..SILSBEE: Okay, the motion has been made and seconded that the Ohio Valley application be approved atthe level of $20205,,636., plus another $100,000 foF the Toledo- Lima-Dayton,, Oftiot area, 418 IQ- Is there further discussion? All in favor? (Chorus of "Ayes.@) MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: The motion Is carried. Okay, Washington-Alaska. DR. JANEWAY: Is there anybody here from Washi ngton- A Laska? MS. SILSBEE: No, but we should get Mr. Milliken back, Okay, DR. JANEWAY: I thought you wanted to wait for Mr. Id II Ike n. MR. VAN WINKLE: He may be difficult to find. (Laughter) MS. SILSBEE: Let's just keep going. DR. JANEWAY: Okay. (At this point Mr, @ilLiken returned to the room.) DR. JANEWAY: I move approval of the colmni t tee recommendation on the Washington-Alaska RMP in the amount of $2,,077,,311. MRS. MCRGAN: Second. DR. JANEWAY: The program always has been superior In my oPinion with very forward thinking leadership and a 419 great deal of cooperation with the University of Washington. And Dr. Van Sitters, who is the dean there, has since he has been dean been quite supportive of the RMP program, There has perhaps been some criticism at the very close relationship of the'university -- the medical school with the RMP program. But I think on balance, It has been to the betterment of the program and that there is no conflict of interest inherent in it,, The constitution of the RegionaL Advisory Group does have some preponderance of providers of medical care and particularly people who are related to the medical school environment. Once again, I think that both Dr. Sparkman, whom we have seeno and the people who are on the RAG are able to associate themselves and wear different hats at approp- riate times. I am a little bit concerned that although the com- prehensive health planning relationship with RMP has been very goods there is considerable difference in some of the proposals .that were presented this -time,, which strikes me as a Little bit unusual since t@ RMP and CHP in Washington look a great deal Like an interlocking directorate to me. They have advanced planned to the point of prediction almost, it would seem* It Is nothing explicit.but it is implicit In the 420 request, I am also not sure of the integration of Alaska into the program, but I think thau is not surprising. They made-good strides in their minority outreach programs and are getting representation on the RAG in minority areas and I think most of the things I would have to say about it are good. MS. @ILSBEE: Mrs. Russel; did you have anything to add? MR. RUSSELL: No, I have not one thing to add. MRS. MARS: Why did the CHP agency complain about this position extender placement program? I -would think in Alaska that would be one of the greatest boons that there could be. MR. RUSSELL: Mrs.')4ars, I am sorry, I cannot answer that specifically. I don't have copies of those letters with me. But since the comments have come in to the Washington- Alaska MedicaL Programo the-Executive Committee sat down and addressed each comment specifically and have,reE:pondecl, so those Issues have been cleared up locally. I am sorry that I cannot answer. MRS. MARS: You don't know what the basis for-- MR. RUS SELL: No, I do not. (I)Lscussion.off the record.) 421 3 MS. SILSBEE: The motion has been made and seconded that the Washington-Alaska application be approved at the re- quested leveL.. $2oO77,,311. Is there further discussion? All in favor of the motion say "aye." (Chorus of "ayes.-") MS. SI@BEE: Opposed? (No Responses MS. SILSBEE: Motion is carriecl.. Okay, now we are-goino., back to our original plan, we are going back to our alphabetical. Coloraclo/Uyoming would be the application under consideration. The record should show that Dr. Gramlich is not here, MISS MARTINEZ: I thought this was an extremely well put together programs very well written. Very well coor- dinated with other agencies,, and they had a very good EEO statement, which was unusual on the EEO proposals that I reviewed. About that subject, I am sure it is much too late, btt I did forget to make one comment last time when I was reviewi nk; Central New York; that iso their minority representation is extremely poor. They have one black person on the RAG and that Is it. And I would sort of recommend that they Co some- thing about that. 422 And also just one more aside,, in looking at the forml itself, that is used for the statement,, I would suggest that it be modifiedto eliminate possible double counting f minorit7 females. I Con't know if that is a problem here, buti I know it was in our states, so we had to change the system. Now, I am going tb go just very quickly, I am pretty much In agreement with the review committee's funding level,, I just want.to make'very quick note of a couple of prop:)sals I object to. One is C002,, which is primarily for a confe encel*p C 009, the need for that really wasn't developed In th proposaL. it wasn't backed up; C010 is a small allocation,, but primarily for a series of s'lides.. audiovisual; C013 is interesting becau;e I knew this was going to come up againp it is $104,000 pri- marily as an insurance policy for extension of trouble the way I read it. I may be wrong about that. And there are a,few others., such as 041 which the reviewers mentioned also, bone pathology center cancer diagnosis. I don't know if that is appropriate. I should think the American Cancer Society or some other group would do that. It is setting up a continuing laboratory for analysis, And' '048 is continuation of a program the funding of which was dropped by NIH. I don't know if that, :is particularly appropriate either. 423 In any case, when I finished s.ubtracting,,I came up with $L,573,592, which isn't too far off. And I wouldn't mind stick to the committee's recommendation If the extra few thou- sand dollars wasn't used on those small programs that are going to just produce audiovisual materials and a conference. MS. SILSBEE: Dr.-Wammock. DR. W-AMMOCK: 041,, bone pathologist center., for the benefit of Dr. Janeway in Boston' Dr. MS. SILSBEE. Would you speak Into the@mike, please? DR. W-AMMOCK: Many years ago a bone pathology register, used to collect slides and send them all around over the country. There is a great need for emphasis on t is situa- tion. The fact these are common to us, yet they are rare,, but they are difficult for diagnosis, I imagine It would be quite a problem. I would like to address myself to support this number 41. MISS MARTINEZ: Could I -ask,, is this a pilot project;? There was no mention of its being taken up by-- ,DR* W.AMMOCK: It would make no difference to me whe- ther it Is pilot or not. I thinit- it is a place where patholo- gists,not only pathologists but orthopedics@@itnd,orher individuals, even pediatricians, ought Do be cognizant oL' the fact of the problem ol' bone tumor we are faced with. 424 15 I am sure If they have started this, they are going to continue on this. This is my impression in Colorado. I am not sure who is on this programs whether George Moffitt-has anything to do with it or not. MISS WRTINEZ: Woub they be seeking funds from other sources 'and that wasn't brought out? MS. SILSBEE: Miss Martinez.-in terms of the change--. you are willing to go along with the committee recommendation..- we can-give advice' to the region in general terms, particularly the audiovisual and the conferences and so forth, MISS YARTINEZ: It is only something like, $6oooo. MS'* SILSBEE: But I don't think we should be In the position of saying yes on this ones no on this ones unless it is a policy Issue. MISS MARTINEZ: No, NR. CHAMBLISS: I think I should respond to Miss Martinez's question. I saw it as being appropriate, as far as RMP funded,, the answer to that is yes, -it Is quite appropriate for RMP sup-. port, that being one of the basic categorial'cares the program started out with. MISS MRTINEZ: It wasn't so much the proJect as lact: of other support. MS. SILSBEE: WouLci you make a motion? MISS MARTINEZ: Yes. I move it be funded at 425 $I,,587,,644. MS. SILSBEE: Is there a second? DR. WAMMOCK: I will second it. MS. SILSBEE: Mrs. Flood. ERS. FLOOD: May I raise a question as to whether or not Intermountain, Mountain States, Colorady/Wyoming's total applications have indeed gone before their tri-regional coordinators conference and ironed out their problems of over-= lap? I can't seem-to locate it. There is such a counsel- ing genetic component in Colorado/Wyoming, as I recall it was either Intermountain or Mountain States addressing the sainie particular concept of need for that region of the country. .MS. SILSBEE: I think they are all related to the one in Denver. It is outreach part of it, MRS. FLOOD: But they haves all three-- now we hashed the Intermountain status of going through-- MS. SILSBEE: All three applications went before the Interregional Council. We have a letter-indicating that certain of the ones that were identified for overlap areas are now going through the processor being cleared by respective agents. MRS. FLOOD: Thank you. MS. SILSBEE: Motion has been made aiTd seconded that the CoLorado/Wyoming application be approved at the level of 426 $1,587,,6'44. Is there further discussion? t MRS. MCRGAN: Question. MS. SILSBEE: All in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response.) MS. @ILSBEE: Motion is carried. Next region is Florida; Mrs. Gordon is the reviewer* @NRS. GORDON: -Florida has ranked a superior regiont and one of their great strengths seenEto be their record of attracting outside funds for their projects and for the con- tinuation of their projects. Their funding agency Is an ince- pendent corporation. They deal in large numbers, both in people and in money. They will ask for one and one-tenth million in July, at least that was the forecast, one and a-half million this says, They do have some new programs which are quite expen.- s.ive,, but the reviewers seem to feel that in'Light of their pa@,,t records forgetting continuation funds from other sources, that they would continue this good record and therefore they would be willing to go along with the chance of putting this much money in'.to start,, although they did not recommend full fundin@,, but very cLose to Lt,.about $300,000 off. 427 So in light of their past track record, I would move that we accept the committee's recommendation of $2 07,00,000. MRS. MARS: I second it. MS. SILSBEE: Mrs. Marr4 as secondary reviewer do voi want to comment? MRS. MRS: I think you might point out they have an exceptional kidney transplant program. This was begun before- there were any special federal funds given, allocated to it, for this purpose. And -they developed a statewide plan which described a network per organ, harvesting covering major cen- ters for dialysis facilities, and required supporting services So that Florida is I suppose one 'of the best covered states actually as far as kidney transplant system, as far as I know. MR. VAN WINKLE: They are very much looking at quality of care right now in that area. MRS. MARS: Yes. So I think they do have some reall@r outstanding programs. There was a Southeastern Interregional Symposium on quality care evaluation. So other than that,, except to say they do have some exceptionally fine programs, I have nothing ;o add. MS. SILSBEE: Motion has been made aE-c seconded the Florida application be approved at $2,,700,,000. 428 19 Is there further discussion? .MR. MILLIKEN: Wuestion., MS. SILSBEE: All in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. Next region is Greater Delaware ValLey. DR. WATKINS: According to the reviewer above average program, I recall this program was organized around region-- I remember It myseLf., around five Philadelphia.medica schools. Also there was as@ccession,, if I recall, of first state.. Delaware,, but there seems to be a metamorphosis of this region. We find today that it Is controlled or run by a new coordinator who Is really oneof the old members, and that they have involved communities-p ,especially the Inner city,, In severaL programs. Their biggest drawback was an inordinate astuteness In financial recommendations,, being they apparently were sub- si.dizing professiorr-ts of the medical schools., and tt still seems to remain a slim question which I believe we will lnves-- tigate because I don't think over three years the same thing should exist.. so I am sure you are going to investigate that further. But In general., the program has Improved, the program 429 is following the guidelines it has stromg leadership shows direction. Proposa Is were reviewed by CHP and the history in general looks good for this program, so I would propose that the $2.3 million recommended by the committee be given'to this program, MS. SILSBE.M Is'there a second? DR. JANEWAY: Second, MS. SILSBEE: lir. Janeway.. did you have anything further t o add? DR. J.ANEWAY: No comment. MS. SILSBEE: I have one thing to add to the record,, because at the Review Committee, there came a-letter from one of the CHP agencies with a negative comment* This was one that had not yet been to the Regional Advisory Group. They sent It directly In here, So we called to ask what the pro- cedure was as far as the region in terms of looking at this, ard they said they would-.- because of the particular project, they would work with'the CHP agency before they intended to move into that area. And if indeed the Cb) agency decided they did not want them,, they would not go. So It seems to me the region was responding to the comments. Motion has been made and seconded that the Greater Delaware Valley program be funded at $2,300,000. Is there further discussion? 430 MR. MILLIKEN: Question. MS. SILSBEE: ALL in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response. MS. SILSBEE: Motion is carried. Next region is Hawaii.. Mr. Hiroto. MR. HIROTO: Madam Chairman, I recommend that the Review Committee's recommendation that Hawaii RMII be funded for reduced amount of $I,,LOO,000 with $305,,107!of that amount earmarked for the Pacific Basin, be approved Comments I would make is I was a member of a review site visit team in January and In April of this'year. A new coordinator was named and in the two short months that he has taken overo he is apparently moving towards meeting the many problems that Hawaii RM.P had. is far as the reviewers 6re concerned., he Is obvious Ly moving Hawaii RMP In a proper area, There is only one I think still remaining concernt which had to do with the kidney tissue typing, and we would,,-I guess,, suggest that they solve their problems. MR. RUSSELL: I was at the RAG meeting when that was discussed and the Regional Advisory Group chose-to put the progress right back where this belong;* on the two Institutions 431 involved, making them guarantee that either two separate programs were needed or coming up with a joint plan. MRS. MRS: Has the RAG been changed? Is it being-- MR. HIROTO: There is a new chairman of.the RAG, I should have mentioned. about composition of it? MRS. MARS: What MR. HIROTO: As a result of thato they are moving forward,, are they not? MR. RUSSELL: Yes,, the by-lawstave been re@ised. The Regional-Advisory Group has been revamfed,,bringing on board consumers, more different types of indiv Is; the medical school, school of public health, Hawaiian ical Society are delighted withthe change In directors and the new direction the program Is taking. It Is a-completely different program. MRS. YIARS: I should hope so, because it was just about ready to be closed down. MR. RUSSELL: No doubt about It. We were very en- couragecl by the last few months, MS. SILSBEE: Mrs. Klein,, did'you want to comment? MRS, KLEIN: I don't have any comment. MRS. FLOOD: I would second Mr. Hiroto's motion. MS. SILSBEE: The motion has been made and seconded that the Hawaii program be funded at the Level of $11,100,,Ooo, with $305,LO7 of those dollars earmarked for the Facific 432 Basin programs Is there further discussion? Dr. Janevay. DR. JANEWAY: CouLcl I ask a question? MS. SILSBEE: Sure. DR. JANEW-AY: Did Ibeat the call? MR. MILLIKEN: Right. DR. JANEWAY: Just for education,, how did'Hawall get around to -- let me ask it this way, is It because of 'the Pacific Basin that Hawaii has no CHP (b) agencies? M. RUSSELL: No. MR. HIROTO: Hawaii Is such asmall-area. DR. JANWAY: So is Rhode Island. This is just for my own education has nothing to do with the proposa L. MR. HIR(YTO: You can answer better than I. DR. JANEWAY: If they didn't have the Pacific Basin In their proposal,, could they have a single RMP and (a.) agencyo no (b) agency? MR. RUSSELL: Ye 8 What you have iff this program is you have a Pacific Basinp separate program from that program conducted in Hawaii. As Mr. Hiroto said, the very size of Hawaii and with the population center being In Honolulu, where the (a) agency Is operating,, and it Itself is not very strong In terms of being able @o move things forward, It has a very 433 )4 small staff. At one time there was an attempt to set up some not necessarily areawide agencies,, but sort of subcommittees out on the outer islands. And that thrust-- I really don't know how far it has gone. MS. SILSBEE: To answer your question,, yes,, I think in the DistrLct of Columbia that situation;was truep there was an ,(a)@iagency, because that was it,, and 'no (b) agency. We have a motion and it has been seconded.' All in favor? (Chorus of "ayes.") MS. SILMEE: Opposed?. (No response.) MS. SILSBEE: Motion is carried, Just for the records that is the shortest discussion we have had on Hawaii in f'o'ur years* NRS. MARS: That's trues very true, (Laughter) MS. SILSBEE: Incliane6 Mrs. Klein. MRS. KLEIN: Indiana was rated by the committee as average or below average. You,can see by your green slips. The comments In the comments the committee talked a good deal about the broad general nature of tlle report its&-If and the fact@there were not very many specifies in Lt. And I 434 had to concur with this when I read it. As a matter of fact, being a novice, I decided that I would read the comments of the committee first and see,if I agreed with them, and attempt to find points of disagreement, as a matter of training myself sort of. The report showed a good working relationship with CHP, but it didn't specify in what manner these working rela- tiohships were carried out, Many of the program E; and they did have mgny pro- grams were a little difficult to assess because th y weren' specific in terms of what they were actually doing They were conducting some sort of study to d termine health deficits they called it., and they were developing pro- grams in quite a wide variety of areas,, including continuing education., legislation for statewide emergency services., neigh- borhood health centers, s@ate stroke therapy, and hypertension and coronary care units, and quite a number of others too, Most of their-requestecl appropriation was for alloca.- tion of funds, I guess I should say, was devoted to staff. Am[ Although I think the Ad Hoe Committee was sort of in the mood to cut them,,a good deal because,of the inadequacies of the reports they decided that since most of it was for staff and they had so many programs, as I Interpreted it anyway,, that th4,-y were doing something,, and that they should I'@ b-e permitted to continue the principal part of the program. 435 They dido however,, cut the recommended funds by $100,000, and I have a little difficulty determining on what basis they did. But there were-Beveral items they parti cularly questioned. One of Lhem was sort of a teleanswer series in medical education,, sort of dial-a-disease program that the com-. mittee apparently wasn't very enthusiastic about. Also they were studying-- wanted to study he pre- vention of organ rejection, and the committee felt thaU that; was a basic science study which could just as well be funded by some other method. -And they also questioned the continuation @f the emergency medical service program, In any events the committee decided to cut them only $ioo,,OOO and considering the wide variety of progra@ that the7 were conducting,, I felt thl, probablyin my uninformed manner,, that thib was sufficient.out,, and that lc@ the reason tha@ I have moved thai; we adopt the committee's recommendation of $ L@ I,, L59. NR. MILLIKEN: Second. MS. SILSBEE: Do you have anything, Mi ss Martinez-t' !)r, Janeway, DR. JANE-WAY: Perhaps it is in the trans cripts. It doesn't show in the yellow sheets.- Steve Beering is now the Dean at Indiana, Have they 436 7 changedp got a new director coordinator? MR. VAN WINKLE: For sometime Steve has been the coordinator on a part-time basis. Even prior to the time he took over the deanship. But they do have a full-time program director. I guess you get into semantics -- director versus coordinator. But Steve still is maintaining a very a,-tivelrole in the direction of this program. DR. JANEWAY: Good. MS. SILSBEE: Mrs. Flood., NRS. FLOOD: The Review Committee apparentl raised"some questions about the R4S activities, It w also an area for staff concern, But I see no assurances that this was an inappropriate EMS activity in Light of the MS action. Was this particular-- MR. VAN WINKLE:"WE flag all EMS, not necessarily because of concern but for reviewers' consideration. We saw no problem with th'e EM activity they are en- gaged In. They have been instrumental already in obtaining legislation establishing a State Commission on EMS, and have- very small appropriation to fund that Commission. But what you see the funding here was strictly staff work for RMP themselves. MS. SILSBEE: I think the committee was concerned 437 are 26 about that, maybe trying to get an idea* MRS. FLOOD: Yes. The green sheet ref lects the com- mittee believes the support of EMS activity was below private or at least open to question. But they classify that with-- based on the information presented. I haven't looked at the whole application, but I Would guess it was low priority at this point in the EMS, development in that area, NR. VAN WINKLE: As I recall the discussion they were raising whether this EM activity was appropriate for funding in view of the EMS legislation. They were raising the same question. MR.JEWELL: That is true. MRS. FLOOD: But they really didn't cut funds. MR. JEWELL: Yes. ma'am,, I think that is the reflee- @ion;as I read it, Mrs. Flood,, that is the reflection. Because the EMS proposal is $1000000. There is nothing new in this application. ALL con-, tinuation. M. VAN WINKLE: -ALL continuation, NR. JEWELL: That is reflected In the committees recommendation,, I believe. MS. SILSBEE: The motion has been made and seconded Indiana program application be funded at the level of $1,121,1!9. MRS. YARS: Question. 438 29 MS. SILSBEE: All in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No respo@ e.) MS. SILSBEE: Motion is carried. The next region to be reviewed is Iowa. A nd Dr. Wammck Is the reviewer. DR. IWAMMOCK: Well,, some people speak from experience and some people from experience won't speak. MS. SILSBEE: WILL you 'speak Into the microphone, please. (Laughter) DR. WAMMOCK: Just once only, I can't do it again, -WeLL,, I caught a slippage hereafter I reviewed this, I find an epistle right back of the green sheet. But the .epistLe-- this is in all due respect to the reviewers, under- stand., has no reflection on any characters, living or dead,, past or future; in the first place, this projects the program was very well put together-, very well documented. And as far as review,was rather easy-to do. And a request was made for $1,06L,349, was so approved by the committee. And I will make reference to the review by members of the staff at a Later moment here as I go thro@ this, This program was well organized. A few comments I 439 wish to make, very comprehensive,put together very wellin veryl orderly fashion. Most of the activities originate under the ,aegis of the University of Iowa. I point this out, it seems to be controlled in that direction. Of course, I take into consideration what goes on in. the State of Ohio. I think that would be perfectly legitimate a,thing under the circumstances Family nurse practitioners for use in rural area,, I don't know whether you classify this as assistant,,physician's assistant. But you may need to. Primary family care planning program, this Is tio design two statistical models,, one to explain and predict; the other to identify-- (inaudible) The other institute, talking about primary care planning, $24pOOO, number "two is to collect and use available demographic health geographic data in testing the model in app:@ ing it to past and present circumstances, or pertinent to Ioewz, subregions, Maybe somebody would want to explain all of that to me. I don't quite understand what it is all about. But I will pass it up if somebody wishes to refer to it all right. The other plan is a homemaker, home health, a train- ing project. This program has been used in other areas and one 44o area I am particularly familiar with, we fou@ this to be very beneficial to people who cannot be contained in a hospital over a Long period of time, but do need the systems et home. We found this a very good program. We put it in operation many years ago. Politicians in our Local area failed to take it up and carry it on, because they t ought it would cost too much money to do aprogram. They wou d rather keep them in a hospital than worry about that. The other point is the remarks about the uriform .record system for quaLity care Improvement. I think I have no particular quaLms about that, Hospital cost study, this I wonder about whether this Is a part of the Regional Medical Program. This Is one of their projects. I say that is about aLL I have to say abou4v- this.. except for the fact to come over to page 234, maybe the re- viewer would want to comment on this,, paragraph here,, we-re- ceived on the twentieth of May coordinators-- this Is about the CH (b) agencies, Maybe staff would like to comment 'on that, MS. SILSBEE: What page was that? DR. WAMMOCK: Page 234. That has to do with the breakdown of machinery. MR. POSTA: I would Like to have Mr.. Zizlausky talk to this point. He has gotten additional Information 441 32 from CHP. I would Like to say this if I might,, sir, I woul d say Iowa is considered a superior region. DR. W.AMNIOCK: I apologize It was above tc) superior. I enjoyed reading it, real pleasure to read it, because -- some of them, you know MS. SILSBEE: It pulled together well. DR. W-AM@IOCK: Pulled together? Trash cars I am talking about the way that the project that was being applied for it was presented to the RMP here. MR. POSTA: Mr. Ziziausky. MR. ZIZUUSKY: That is project 60 you are saying, primary medical services?. MS. SI@BEE: Page 234. DR. W.AmMOL;K: Page 234 on'your transcript. Got the transcript? Or shall Iread it for you? bM. ZIZLAUSKY: I don't have it with me. What is the area of concern about? DR. WAMOCK: It- is about the CHP, the relationship with the RMP. MR. ZIZLAUSKY: Fine. What had happened is when they submitted their May Lst application,, they were caught in a lot of the'project de- velopment last time In this. We approved a.three-day ex- tension here for an application coming In May 3rd, They haa 442 not had all the CHP review and comments in, all the proposals were out to CHP (b) agencies. Subsequently we received, and we-are still getting in comments from the CH (b) agencies on these project activi- ties, and so far none have been negative. DR. WAMMOCK: I have three here which are a part of the project request here. Dated I-lay23rd. And none of these have been negative. MS. SILSBEE: The.aclditional ones that have come in? MR. ZIZLAUSKY: Now, we have additional health pLannino, councils who have submitted additional letters for revie@w and comment, and the program staff is negotiating the differences* There aren't any major differences We explained what this one project, project number 6 I thought you were taLking about project number 6. family services in Iowa, was recommended for disapproval. This was one of the Northeast Iowa Health Planning Council recommendations. They have ironed-their problem out and this is on the yellow sheet. It is the only negative comment, but that negative comment has been resolved. DR, WAMMOCK: That has been resolved? MR. ZIZIAUSKY: Yes, sir. DR. WAMMOCK: Fine. MS. SILSBEE: Mrs. Morgan. 443 MRS. MORGAN: I think it has been more discussed than I can. MS. SILSBEE: Okay. Do you want to make a motion? DR. WAMMOCK: I make a motion it be approved fo@ the sum of MS. SILSBEE: $i,o6t.349? DR. WAMMOCK: -- $i,,o6l,,349. Again.. I apologize for not recognizing the Prepa'ra- tion and review of this by the staff and calling attention to this abov e average to superior. I appreciate those-- that gives me, youknow, a springboard, MS. SILSBEE: Is there a second to that? MRS. GORDON: I second It. MS. SILSBEE: Motion has been made and seconded that the Iowa application be approved at the Level of $1,061,349. All in favor? (Chorus of "ayes. MS. SILSBEE: Oppose!? (No responsi2.) MS. SILSBEE: Motion is carried. Next region is Kansas" and Mrs. Gordon, the record should show will be out of the room. (At,this point Mrs. Gordon withdrew from the room.) MS* BILSBEE.: Mrs. Morg an. 444 @5 MORGAN: The Kansas RMP was reviewed as being above average to average. Dr. Browp has been coordinator since 1966 and has done very well in coordinating with the Kansas factors. The Review Committee really only showed two concernE one was what they felt was an overambitious project, regional- ization of perinatal careo project.number 91. The committee also showed concern over lack of docu- mentation that the continuation of these activities after 197-@, we have since -- this was reviewed by committee receives from Kansas various letters showing that these are-being con- tinued. The Berkely project being continued by a lung cancei Mary? And Dr. Brown is very enthusiastic the perinatal project will be continued by the state. They did,, during phase out, lose an outstanding black professional from their staff. They do have female pro- fessionals on their staff. Minorities aren't as well repre- sentecl as we would like to-seoo, but this occurred during phase out when I think minorities were the first to Leave the staff when they were afraid of It being phased out. The'Review Committee did decrease their request by $100,000, this being to alert them to take a more careful look at the project 91 perinatal care* I move that we accept the committee's recommendation 445 of $i@633,380 to the Kansas RMP. MR. HIROTO: I second that. I have this one question, I would Like to know what this community health education program number 51 entails? MS. SILSBEE: Miss Murphy, project 51. MISS MURPHY: That is one of the H/SEA's in Wichita.@ They are expanding considerably. It is an H/SEA project' in Wichita; they are expandifi7 it considerably. ER. HT-ROTO: Okay, thank you. MS. SILSBEE: Mrs. Flood. MRS. FLOOD: Mrs. Silsbee, may I inquire, you said you had received communications from Kansa4 possibly from Dr. Brown,, about continuation funding of the perinatal program from the state. Can we know what segment of the state? MISS MURPHY: I have the whole proposal, the cover letter. Ihaven't gone into it in that detail, Specifically, I think she meant the other, the new projects. Dr. Brown felt this perinatal care projects differe@t components of it would be carried on by different phases within the state. MRS, MORGAN: Not the state legislature., just the State of Kansas, 440 DR. JANalAY: That is a fairly common thing for states to support, premature nursing programs, MRS. FLOOD: My concern is., we'--have gotten some fairly strong assurances of continuation funding for those projects that had some concern to the committee. Why are we cutting them $Ioo,boo for an ab ve average area? What was the criteria for the $100,000 cut re ommended', MRS. MORGAN*. I don't thin the committee lelt they- could utiLize that amount in a year's time. 'MRS. FLOOD: Th ank you. MS. SILSBEE: The motion has been made and seconded that the Kansas application be approved at the level of $1@633,380. Is there further discussion? MRS. YIARS: Question. MS. SILSBEE: All in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion Is carried. And would someone bring Mrs. Gordon back in. (A tthis point Mrs. Gordon returned to the room. MS. SILSBEE: Next application to be reviewed Is Maine. Mr. Hiroto, 447 ,8 MR. H IR OT 0: I move that the review co=ittee's recommendation of fundin,, level of $L,,76Q,,OOO be approved, The only comments I have are that the Main RMP is considered superior in all respects and they meet all the criteria and they meet the review requirements, and they have obviously been doing a very superior job. MS. SILSBEE: Mrs. Morgan. MRSI MORGAN: -It ma' y be noted that Maine was one of - the few, probably the only IW that when durino, phase out had appropriation from their state legislation to continue that program, I think this speaks well of how high the Maine program is regardedv7ithin the state and I second the motion. MS. SILSBEE: Motion has been made and seconded that the Maine application be approved at the level of $1,760,000. IL there further discussion? ALL in favor say "aye,, (Chorus of "aye. MS. SILSBEE: Dr-. Janeway? DR. JANEWAY: Perhaps I didn't hear it. I may have been sleeping. But did the staff have any explanation,, why did they cut it $300POOO if it is all that great? MS. SILSBEE: Mr. Peterson. MR. PETERSON: One of the running th7reads in panel B, which considered Maine, was looking at not only the amount 44 .9 requested, but also such factors as what are they funded at presently and to population, and it was pointed out that Maine was a state of about half a million people,, thatthis level of funding would give them one of the highest per capita. Whether that is a valid point or not is for this Council to consider. But it was on that basi.% and indeed Maine was one of three regions which In the sort of wrap-up session went back and looked at all 25. They decided,, well, iie will up this 10 percent. We dealt perhaps a little too harshly with it. But that certainly, as I understood it, was the rationale for cutting Maine somewhat. DR. JANEWAY: Does the staff have an opinion as to whether that will limit their capability for fulfilling these superior programs? MR. PETERSON: I can't speak to that because I was acting In a chairman function. I rea-Ily in the sensd'of not that conversant- with Maine's overall program,,-I think it is-- MS. SILSBEE: I can't really speak for Mr. Nash,, who is not here, but at the present time @his region is ade- quately funded. I don't think it is going to be-- it cut back son's of their activities,, but I don't think it wilt-hurt them. DR. JA@TAY: They don't fall peril to the fact the 449 0 state government was too forthcoming? (Laughter) MR. PETERSON: It wasnt that forthcoming, MS. SILSBEE: Ms. Resnick. MS. RESNICK: Correction on the population; it is ove a million. MR. PETERSON: I am sorry, it is over a milVion. MS. SILSBEE: WeII, th e motion has been made a'nd seconded that the Maine program be-funcled at $1,760,OCO. MRS. FLOOD: I feel like Janeway, probably this is one we are really pointing with pride to ancl,laucling and applauding, and then we cut them. And although we may feel it doesn't hurt them, per- haps our primary reviewer could tell us a Little bit about the program strength as it relates to,, you know, goals and objec- tives. If it is all there, aLL put together, then why do we buy at this point a particular philosophy that apparently permeated one review committee, and we know has In the past been sometimes brought lnto.play; is the capitation dollar spent in a state, which Isn't valid in my f@'eLing as a way to, measure the amount to be spent in a region. MR. HIROTO: I think there are probably three regions that have a superior -- and I may be wrong -- ranting, and Maine and Florida, and there was one others and they all tend 450 to be reduced.somevhat if I am not mistaken. MRS. YIARS: Feeling of compulsion. MR. HIROTO: I just went along with the reviewers' concepts. IC. SILSBEE: WeLl, do you want to reach all of this by a voting on this motion? The motion is to approve it.at the recommended level the committee gave, $L,76o ooo. All in favor say "aye." (Chorus of "eyes.") MS. SILSBEE: Could we have your ha ticl son that? I think it.is weak. DR. WAMMOCK: I am sorry, I was out of the room. MR. HIROTO: May I suggest we gp backto these par- ticular ones and review them. DR. JANEWAY: I didn't mean to open up a hornet's nest. I thought the staff had morec.dpmmentstith&n they get on whatever color the sheet iir ltis blue or something like that -- only when It is si-tting on top of ye,Llow. I thought it was green. You know, that there would be a comment that there -was some padding on the part of the budget, or somethings MR. HIROTO: Doesn't say that. MS. SILSBEE: The staff member familiar with this 451 42 region is not here todW,, That is why I find It difficult. DR. JANEWAY: It is altogether probable they had full and sufficient reasons for doimg it. I just dorlt see anything-- MS. SILSBEF. You are right. 'They originally had approved it at a higher level and went back and it wEs-- MR. PETERSON: No, they had approved it at a some- what smaller level' and added ah,-tldditional 10 percent on, MRS. FLOOD: Felt guilty and came back'. MRS. MORGAN: Dr. Thurman was on that. MRS* FLOOD: No, not really, it doesn't.@ I haVe-a thing about capitation -calr-ulatio so @,'d6n't think that the dollar spent In sparsely Populated diverse climates and terrains can be mea-sured against a dollar spent In a high impact, highly profe bsionaL setting, with a lot of availability of services. It bothers me a little, the thought there might have been this thought taken into consideration when the funding level was recommended. MS. SILSBEE: We-have a motion that was haLf-way voted and for $L,,760,000., and the "ayes were about to put their hands up so we could count them. (Show of hands) MS. SILSBEE: Four. All right., the nays? 452 !4 3 (show of hands) MS. SILSBEE: ALL right,, we need another motion. MRS. MARS: I would like to make a motion that we fund the program to its full request of $2,o2o,875. MISS bMRTINEZ: Second. MS. SILSBEE: Motion has been znade and seconded that the Maine application be approved at $2,920,875. ALL those in favor say "aye." (Chorus of "ayes.1t) MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: The motion is carried. The ne@t region to be considered will be Metropolitan Washington, and the record should show Dr. Schreiner is not here. 'Mr. Hiroto, you are it again. MR. HIRC)TO: I am? Oh. my gosh. I have to remember what I read. The committee reco@nd4 and I move their recommenda- tion be approved, that there be reduced funding of $1,100,000 for the @tro Washington, D.C., RMP.- They are rated averageto above average. And their estimated request for May of 1974 is assumed('to be $450,,000. There are continuation projects requ@sted and four news 453 4 Several of these relate to kidney disease. Dr. Schreiner isn't here, unfortunately, MRS. MORGAN He wouldn't have been here anyway. MS. SILSBEE. He wouldn't be slowed to speak to that. MR. HIROTO: No, he wouldn't. But conversation by the reviewers in regard tothe kidney disease programs tends to make it seem extremely Locked at with good favor. I don't know why the reductions the $172,385 reduc- tion. MS. SILSBEE: Mr. StoLov, is he here? Mr. Peterson? MR. PETERSON: I can't reaLLY I haven't refreshed my memory on this one by Looking over the transcript again. Some of the discussion certainly about this region was related to the fact that it had been a poor performer, an under performer up until very recently. It seems to have some heartening change in thatr regard, and it may be part of a general e,4uation that It wasn't all that good. Butp you know,, I don't recall on Washington Metro D.C. there was a particular rationale. Here was a group of activities that they had questions about, not the kind of consideration that went7-into the Maine decision. I do6lt recaLl anything from the panel discussion. 454 MR. HIROTO: There was a question raised about the $132,,,OOO that was going to be expended for the comprehensive health planning, but apparently that was okay. That Is all that comes to me out of th@t review. MS. SILSBEE: ALL right. Mrs, Klein, did you have anything to add? MRS. KLEIN: No, I don It real Ly. I will second the motion. MS. SILSBEE: Do yQu move? MR. HIROTO: Yes. MRS. KLEIN: I think the motion was made. I will second it. MS. SILSBEE: All right. Motion has been made and seconded that the Metropolitan Washin.-ton application be approved at $L.,100.,000. Is there'further discussion? ALL in favor? (Chorus of "ayes. MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. The nextregion is Michigan, and Mr. Milliken is the reviewer. MR. MILLIKEN: I would like to have.-a-rundown by staff on this. 455 46 MRS. MARS: Can' t hear you. MR. MILLIKEN: I would, like to have staff give some backdrop on this before we get Into it. The program has evidently slipped considerably lately and my question is, alternative of..,funding them in a reduced amount or, on the other hand, questioning their future? MS. SILSBEE: Questioning their what? MR. MILLIKEN: Their future completely. MS. SILSBEE: Mr. Van Winkle. MR. VAN WINKLE: Well, it was considered by the reviewers to be an average or below average region, a.nd if you look at it retrospectively, this region start off with Dr. Hustis as a coordinator who is quite an able one, and after he retired,, the program slipped badly. Then Dr. Tupper came aboard and brought it back up to an A region. At the time of the threatened phaseout, Dr. Tupper accepted another position at Grand'Rapicis,, Michigan, donating a portion of his time on a-contin'uing basis to this program* Judging from the- application,, we would kind of feel that it has slipped under the new leadership also, Sewall. We have some concerns about what we see In the packax,e the same as the reviewers did. The RAG is still intact. Again, we had some concerns about the process, 456 17 looking at some of the program activities that are included in this particular proposal. I did raise the concern yesterday about the auto- mated territory peritoneal dialysis, with Dr. Schreiner, a nephrologist., He'-d-idnl.t see,,atiY, serious problem with this, He says it is probably not of high priorltyin the nephrology field. He sees nothing wrong with it., but he didn't seem to think it held very high priority. The main concern.I think that the reviewers had' was the EMS activity that durirgthe previous four-month period or six-month perico, I am not sure, had been funded at a level about $37,,OOO and, as you can see in thisapplication, it jumper to $750,000. And they doubted seriously,, after Looking at it quite carefully, that they could dven begin to carry out what they had laid out for them to do,, even in this one proposal,, in a one-year timeframe. IC. MILLIKEN: I gather from the committee's recom- mendation, it was felt that there V-as a potential of at least effectively using that much uni5er-the present circumstances? MR. VAN WINKLE: Yes. MR. MILLIKEN: I would then move the committee recommendation be funded at $2@5OOoOOO. MS. SILSBEE: Is there a second? MRS. MORGAN: Second. MS. SILSBEE: Dr. Wammock, did you want to comment? 457 48 DR. WA M/iOC K: I came to about the same conc Lus ion her that has beenalreacly pointed out by 1-ir. MiLliken and Mr. Van Winkle,, about the project being average or below average. Twenty-four-hour statewide emergency drug analysis feasibility study, I don't know about that. Neighborhood pharmacies aftC hypertension controls I don't know about that, And IEMS, as was pointed out already, $36,000 a year previously jumped to $750,000. These were things I picked out actually before I got this review here, trying to figure out which way we were going. The vocational educational center to plan to develop systems for continuation regional health calls. Renal .disease, radio and television spot announcements. And then educational program for automated renal dialysis ' renal failure, raised some doubts in my mind, and there are 4L projects here@ And it looks Like It will take a Lot of sweep- ingto cover all those projects. MS. SILSBEE.-' Do you think that the reduced funding level will alleviate some of the concerns that you mentioned? DR. WAMMOCK: I think It would have to reduce it to some Level or other,, I would think it would. I am sure that the reviewers have gone over this In great depth much more so than we have had the opportunity to doy 458 to analyze this thing and review it. But with Milliken Is observation hereo I think that we are all thinking about in tte same direction that there has been overheating of the stove here, you know, and that something has to be done to cut it back, I think the recommendation here-- MR. VAN WINKLE: They cut roughly $1.3 million. DR.IWAMMOCK: -- $L.3 million has got to cut something out. They can't carry no 141 projects. No way they can do it. Did you get a second to t? MS. SILSBEE: Yes, we did get a second* Mrs. Morgan was very helpful to second it, .DR. WAMMOCK: Thank you. MRS. FLOOD: My only concern would be the advice .letter notifying them of possibly reduced funding, If we vote this particular way., would be that theybe advised that the EMS component would more appropriately"be under the,new legisla- tive actions rather than from this source., I would hesitate to encourage them, to even use a portion of their now reduced funding to continue this kind of a massive EMS expansion under their responsibility. DR. JANEVAY: Except there are certain things In RMP, specifically say you ought to get into EMS-areap directed activity. 459 :-)o MS. SILSBEE: But not $73,000 level from $750,,000. Now., the motion has been made and seconded that the .Michigan application be approved at $2.5 million. Is there further discussion? DR. WAINIMOCK: Yes. MS. SITSBEE: A-11 in favor? (Chorus of "ayes.11) MS. ILSBEE: Opposed?' (No response.) MS. SILSBEE: Motion is carried. The next application to be considered is Missouri. A ncl Mrs. Morgan is the reviewer. I MRS. MORGAN: In the comments heret reviewing committee, Dr. McPhed.rin, who used' to be on this Council, was primary reviewer. You can read it and practically feel he is in the room again. (Laughter) He goes on to say he had received additional materia. since receiving the Missouri application, but he hasn't changed his mind a whole lot. It amounts to really coming down that Missouri has had a tendency to go along with what the needs were with the current legislation. It hasclone very well at th-is. o When it was computer bloengineering type output, the,,r 46o were very very heavy on this. And it was extremely difficul over the years to get them to turn off of it. They would far have preferred to stay that way. Finally.. It has, in this proposals be turn d off. There is one question, and this is among t eirrumer- ous I believe it is 11 proposals of EMS, tota:Ling bo@t. $600,000, and they appear to be rather fragmented pr osals, none of them are into a statewide unit. Ithink that the recommended funding was lower than what they had requested of about $600,000, approximat Ly the amount of their EMS proposal. They were rated average by the reviewers, L ter when they compared it to other RMP,S they rated it superior as far as this goes. MS. SILSBEE: That means there were two reviewers$ one rated average and the"Other rated it superior. MR. POSTA: And the superior was based on grantsman- ship. (Laughter) MRS. MORGAN: And they have done very well over the years, I agree with the Review Committee in that these many EMS proposals are quite a bit of money for a Lot of little proposals that are not very well coordinated in-to a state EMS statewide organization, And if they used their money made 461 52 available to them, they should be -- or we should be assured that.they are working towards a statewide comprehensive pro- gram, go along with committee recommendation of $2@364,333. MS. SILSBEE: That is a motion? MRS. MORGAN: Yes. MRS @ MARS: Second. DR. JANEliAY: Right on target. MS. SILSBEE: Does staff have any comwnts? -MR. P 6sTA: I would like to bring Lip just one and,, Leah, feel free-to add anything to the Regional Office as far as comments. .Again, back to the EMS review group, it met on Monday' and Tuesday of this week. There w@ two planning grants b.obrovedo about $45,000 eacht one to the (b) agency in C'Olumbi right in the center of the state, and one at Kansas City. Now, EMS has been cons@red a number one priority of the Missouri R14P. They have put in an awful'lot of money. It was a concern of the pELnel review group ip n Monday and also from the HEW regional office who submitted their comments to us, that before any further E14S activity lsfunded by the RN:P, that the Governort council shouldbe consulted to be absolutely assured of what types of activities would be f-wnded throughout the state in this area. 462 )-3 Leah, Would you like to make any other comments? MS. RESNICK: Except to emphasize that EMS project proposals are,really stemmingfrom their state law -- they did not feel that the new legislation would give them enouEh time to develop a total plan. And so they wanted to go ahead and try to help the oQ@nities meet their requirements as best they could within the coming year. Sta e law is an emergency medical services standardi- zation law requiring certain equipment and training of atten- dants on vehicles. MRS. MORGAN: Is It funded by the state? MRS. iRESNICK: State law is just a regular authority for them to go ahead. So far they do not have money; they are hoping to get it through legislation, M6* bILSBEEo. 'Motion has been made and seconded. Dr. Jpnewayo DR. J.,",NEWnY: We may be into it again I wonder if the primary reviewer or staff had comments? I hate to ask about proposals C042..' pilot model,, new health legislation? MRS. FLOCD: Yes* (Laughter) MRS. MORGAN: Go ahead. I don It have that. MS. RESNICK: The reviewers observed that and made a strong pitch against supporting not only C042, which is a 463 ,4 central program operation, but the liaison district offices which are part of this total plan, and plan pending new legis- lation. DR. JANEWAY: That will be In the reco,@ndation? MS. RESNICK: Definttdly. MS. SILSBEE: -All right, motion has been e and- seconded the Missouri application be approved at the level $2@364,333.. -ALL in favor? (Chorus of ayes. MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion carried. I also should say-that ib one of the shortest re- views of Missouri on the case. Next is Mountain States. Let the record show Mrs. Klein Is out of the room and Dr. GramLich was not.present durino- the review of this C> application. (.At this point,,M-rs. Klein withdrew from the room.) MS. SILSBEE: Now,, Dr. Wammock, DR. W-4MMOCK: Fotar states: Idaho, Montana@ Nevadao and Wyoming. I appreciate thits compliment. The overall request was $2,,4O9o356. -Committee recommended $2,.50,000. This was above average, 464 5 I am sure the reviewers would like to discuss this'program and then I will make some comments along here if I have'them-- if I have t lost them. Yess there they are, right here. A. MS. SILSBEE: Do you want the staff to say something DR.WjiMOCK: I -think it.would be appropriate here, because there is a sit@tion, not an epistle here to this sitauuion, so @e are going to take a-- MS. SILSBEE: Okay, Mr. Rutsell, do you want to do it? Or Miss Flythe? MR. RIFSSELL: Miss Flythe and I just spent an entire week in Intermountain program reviewing, review processed We were extremely impressed with not only the review procdss, but the management.of the program where one has the regional office, which serves four states, each of thoue statc&c having their own office ads staff. One just cou.Url t'help'but wonder what type of management problems might be encountered. We were very., very impressed with the communications among the staff involvement of the program directors, involve.- ment of the Regionalmdvisory Group; as we told the RMP, we felt there must be something wrong and we kept looking hard and harder -- just couldn't, find it. It was a very rewarding visit. We also got a much deeper appreciation of traveling, .in-7 bhat type of geography, in a rural area. MR S. G ORD ON': In 'mpril. 465 6 MR. RUSSELL: It is quite an experience. They do have a travel and communication problem which I think they have overcome very well. I would like to ask Mr. Mereker;..who was t re at the same timej looking at their management review, t, ir manage- ment process,'so broad, just fill us in very brief-,,-,, .,,e capability of the Mountain States as management. MR. MERCKER: The very first of jiprit we conducted the routine administrative review;of.--the.,management of the Mountain States Regional Medical Program. We found their managementto be complex., but very,, very effective and very well carried out. It starts with the Regional @'dvisory Group, which Is extremely active, all members participating on site visits, all members serving on committees. The work of the Regionalhdvisory Group is tied together-- that is the city work by the Regional m'dvisory Group itself. In the same manner and Paralleling it., the program staff related very., very well to the Regional advisory Group; there were four states as you know, each one having a state office, program staff. And the work of the four state offices Is similarly pulled together by a regional office -in Boise,, Idaho, the centra-I program staff, The'-,greantee has good sound management practices 466 which were well implemented by the appropriate staff, some years agoo They had direct control of the program, both the administration, finance.. and also the program itself,. Thiz has changed and they have assigned functions tc the program staff, which noi-7 carry out the administration of the program. -again., it is complex: the structure would seem to be one that would be difficult to operate, but it operates extremely well and they have a high Level of interest in manage- mbnt and they communicate things very effectively. MS. SILSBEE: Thank you, Dr. Wammock,, do you have anything further? DR.W.'hMMOCK: I think it's a little difficult to be- labor some oi' these programs hereo There are over 32 here, anJ the recommendation from-$2,409,356 down to.$2,L50..OOO would probably take care of some of these Little things that I have Jotted down here, Probably correct themselves without any difficulty. mnd T don't believe it would be worthwhile to tak@ up anybody's time to discuss, It has been reviewed; as I say.it Is a four state mechanism and it has been reviewed, given "above average." There are a few other things here and there. MS. SILSBEE: Loucler@ please. DR. WHMMOCK: Such as activities of the physical assessments skills for nurses, and so on. Then the other 467 -D8 thing was a serious question is raised as to the validity of Regional Medical Programs financing supporting the basic curricolum-of nursing schools. Mnother one was shared service projects,, shared cost of materials at the Nevada Hospital association. Here is one, mechanism of development of activities, community child health abuse, I understand that is a pretty serious problem. -nnother one related td PSRO. I would move that this program be approved for $2.,L5OoOoo. MRS. FLOOD: I will second the motion. MRS. GORDON: Two hundred or one hundred? MRS. FLOOD: -$2,150,000. @'Ithough this region always seems to come up with pluses and.not to lessen the glow that all of you had on your recent assessment visits, and indeed their process gives impeccable, if possible -- I think it also leads to an additional prob-lem that Is sometimes not viewed by a survey visit, such-as-you have just accomplished. @nd that is, from the applicant level or the consumer level,, if I will, and they find that this very, very precise process that began with WICHE@-.aC'th'e' time that it was really control- Lino, the program., and Hank is ifi@-ttill,";today, it Is a very difficult process to wade through to get a project funded, and they find the system Less than responsive. 'Mnd most of the 468 59 proposers of projects in that region find by the time it gets throu-h that process,, they wouIC. have preferred to have soLgh help from one of the overlappln- RMP's and oftentimes do. Which in some cases aggravates the turf problem. I would urge, I am in accord they have got a good record and the funding level is probably most appropriate,, but I would urge that staff work with thib fantastic adminis- trative and review process to h'u.ssle the process through,, which I think in the long run will help overcome some of the turf. problems. MR. RUSSELL: I think this point is well taken,, but ,I would haaeto-- having watched the process and the type'of programs that are developing, and I will use as an example what hat; happened in the area EMS. Recognizing that is a popular program, very much needed one in all three of the state@; we witnessed in Nevada., Idaho,, anC, in Montana how the approach o.-L-' the Mountain States Regional Medical Program, throumh its core staff working with the communities, bring?- ing them in; starting out in Nevada$17,,OOO CHP, in a very short period of time t@hi@-- covered the state and involved a number of the consumers. The Mountain States approach ib one of a programmatic regional approach which I thInK they have Cone a very nice job among those LA.nes, Now, you are absolutely right, the process involved-- 469 .and thib is where the turf problem has created an-awful lotcf problems, here is where we saw CHP's playing ctie RMP against the other. MRS. FLOM: Yes, sir. MR. RUSSELL: Thi@ i--- where we recognized the Interregional Council. It Is referred to as the 'Inter-triba,t Council. (Laughter) But it has not been effective. 'nnll we f@Lt it was that councils job to get their own RMP in shape to elim- inate thi---, type of turf problem. MS. SILSBEE; But,. Dick, what I hear Mrs. Flood saying, and I think thlsmessage shoulL, get'back to the Re-ion I Medical Pro-ram, that their. very fine structure should be looked at in terms of its responsiveness, in that it is so Long for an I-V to get through the process. I think they shouted be made aware this concern was expressed, MR. RUSSELL: We did feed'this bzck at the end of our review process. MS. SILSBEE: I think we need to do that again MR. RUSSELL: Fine. ICS. FLOOD: I will add one further comment. It all falls up there in this turf situation and the Tri- Tegional Coordinatorl-@ Council. I see thpt reviewers questioned a portion of the 470 Wyoming EMS project and again that is right back in the Tri- region -- you kno@ Coordinator's meeting. nnd It will never be fully resolved. But Is there any serious concern that this,c.ompo- nent section is a complete overlap of services? MR. RUSSELL: I don't think there is really,, because @e found the relationships between the Mountain States proo-ram and the Colorado program to be very, very good. MRS. FLOOD: Thank you; Those were my -questions-. MS. SILSBEE: Okay, motion has been made and secondeJ that the Mountain States application be approved at the level .of $2,150.,000. MR. MILLIKEN: Questions' MS. SILSBEE: -nil-in'favor? (Chorus of "ayes.11) MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. Will someone c-@ll MM. Klein in. @t this poin4 Mrs. Klein returned,to the room.) MS. SILSBEE: Next application is New Jersey. Dr. Watkins. DR. W@TKINS: Finds itself superior in all respects, according to reviewers. Original request was $3.,970,024,, and the recommendation 471 )2 is $3,190,000, and sometimes you start to be concerned when I say superior in all respects. The committee concurred this was superiors a superior program, well utilizes funds made available to it. 'Mlmost $800.,Ooo was reduced. It shows therE is involvement in quality of care.0 in excess, shows ther is inner city where attention setting quality for standards, a nd so forth, shows an involvement with the CHP groups2 except one CH (b) sent a letter which was later refuted,, so that that is- the main question here, why it was reduced, Maybe one of the reviewers can tell me, MS. SILSBEE: Mr. Peterson? MR. PETERSON: One of the chairmen; I think the principal rationale here had two components to its going up tc the nearly $4 million.leveL,requested. There was some ques- tion whether they could hope to mount that level that quickly and they also saw them coming in at least with an anticipated $600--l think it is $600,,000,, roughly., They certainly did not, &Ai they did in some other things, say here are a number 'of activities which we think are questionable. It was more along that rationale, Whether it was valid or not is something else again,, but there was so@ real concern about jumping up to almost a $4 million leveL; althoug.,l 'the staff has hung together fairly well, it has-been reduced and that was the principal thin& as I recall it, from 472 refreshing my memory with the transcript. DR..VZ.TKINS: With that explanation, I would there- fore move $3,,190,000 be given to this program* MS. SILSBEE: Is there a second? MR. MILLIKEN: Second. MS.-SILSBEE: Miss Martinez. MISS YviRTINEY,: I only have one comment. thought the proposal was very good. My only comment is in New Jersey, which hFd such a-heavy Spanish speaking population, bsolutely none, no Spanish speaking persons on the @G'in New Jerseye MS. SILSBEE: The record should show there is a PSRC proposal in there to the tune of about $225,000, and I have been trying to reach a man., he calls me when I am out of the office and I call him when hc Is out of the offices with the PSRO staff, anu@ that will have to be resolved before New Jersey can put any money into that portion. But we will handle that from a staff end. Dr. Janeway. DR. J,;NEW@Y: How can an RMP organi@b 4 pSRO? MS. SILSBEE: That Is the question; we can't. DR. J@NEW.'MY: It is agin the Law, isn:t it? Ms. SILSBEE: Right. It Is just a matter of clarification of what that-- and it Looks, from talking with 'the coordinator., that is exactly what they are@bout to do. .Mncl we will just no'-u allow itp because it is against policy. 473 64 MR.- HIROTO: We have hvcl several related PSRO'S. MS. SILSBEE: Thai, will be generally looked at. MR. HIROTO: Okay. MS. SILSBEE: Motion has been made and seconded tha the New Jersey application be approved at the Level of $3,,Igo.,Ooo. Is there further discussion? iill in favor? (Choicus of "ayes.") MSO SILSBEE: Oppo s ecl ? (No response) MS. SILSBEE: Motion carried. The next application to be considered Is New @xico,, anCA lot the record -show,that Mrs. Moroan is out of the room, (Jit this point,, Mrs, Morgan withdrew from the room.) MS. SILSBEE: Mrs. Gordon. bMS. GORDON: New Mexico"was supposed to have a new director as of May Ist. I-as@me7that transpired? MR. POSTii: Yes.- MRS. GORDON: 'mnd sometime ago they expanded their RiiG to 120 members. I understand thi-- was in response to criticism. MRS. MNRS: How many?- MRS. GORDON: 120., Which I found to be just--fantaEti6. 474 DR. JmNEWjY: hrkansas has 100. Everybody in the whcile state. MRS. GORDON: I don't see ho-..- they can have a mean- in6fuL group of tha6 size functioning. Somebody wants to fill me in on that a little bit? I would be happy to have theii, MS. SILSBEE: Do you want that discussed right no Mr. Zizlausky. MR.IZIZ@USKY: Dr. 'Gay came aboard 1971. His criticism was a small gro@p @ad been making decisions. (Laughter) So he decided to increase it and mak,- it more repre- sentative of all interests. m'ncl h@ has brought it up to 120. .We were kind of watching to see where he was going,, and he brought it clown to 73 people now, in the application. One part of the application it states L20; in the othcr places there arn 73. MRS. GORDON: I sort of gathered attrition made :L t730 MR. @IzLiUSKY: They actually sent,out pink slips to unattencing @G niembers. MRS. GORDON: So they are weeding out the nonpartici- pants.- MS. FLOOD: If I may-add a point.of-tnformation.. New Mexico is our immediate neighbor an@- I am a little familia? 4 7 66 with wha- they di.' on that @G and it was phenomenal. Bua, - they did regional concepts in a sen-e. The state is ver, diverse in both clima@ue., terrain, attitudes, and service @cappabilities,, and so Dr. Guy's concept was a develogmenu of a sort of subregional @G concept. ' They were all @C members, all invited to the total @.G meetings but there were also some@ specific assignments of responsibility to be spokesman for thel southeastern section or northeastern section, ."ncl icl did., I believe., become a, little unwieldy., be- cause occasionally believe it or not, they darn neax pushed a hundred something at some meetings. MRS. GORDON: Then do they have .--LiGS in ddition to all of these @G members? MS. SILSBEE: No, I think she I,,-, saying they serve in the local advisor@ capacity,, have functions. MRS. GORDON: Sdme people then? MS. SILMEE: Same people. NRS. GORDON: That mgkes,.it a L.",LttLe better. The reviewers seem to feel that most of'the projects were actually -- or as I interpreted,it,, program staff projects. But as I understand It,, as Dr. Wammock said', the epistle the DRMP staffdJ4 not agree with this assessment. Is that correct? MR. YIZU.USKY: Several oL' their project wtivities were people with the university. This was a problem two years 476 67 ago. We ask-d them tu identify these people as project direc" I torso provide a project number and @k@ oure It ha6 I;hree-year, funding, notoome under the arms of the university on(,-e. the pio-'. ject ceases. There are'a few project activities here which are program staff people, but they are not all project sloaff people directed to this project. NRS. GORDON: Says something about being PILYSically- in@the same building, but not-- MR. ZIZ@USKY: Program director's program staff are physicially located on the University of New Mex co cam- pus, and some are in thesame building. MRS. GORDON: The Executive Committee of @G met twelve times last years so'I assume from@that that the execu- tive committee had major responsibilities. find., of course,, I think with a @G of 120 or 73,. or whatever is in between,, that you would almost have t@ have that, They were rated averageo with recommended funding of $i.,644,754. I gather primarily because they were rather ambitious. Some of their programs, such as the neonatal infant trans- portation, In New Mexico -- I would question that activity in just about any place except New Mexico, or some other terrain such as that. Then they talk about project 25., "should have technical 477 68 reviews site visito by out-of-state consultatns who are - familiar with the RMF project." Could you comment on that? MR. ZIZLUSKY: Yes. MS. SILSBEE: Would you speak up a little. MR. ZIZ@USKY: This project was originally, oh, about two years ago, originally requested about $400,000. The site visit team recommended approximately a, $100..OOO level. The phase-in and phase-out, now increased their request again., reviewers thought they would perhaps were quite ambitious for theirrequest for their activity, and they suggested since everybody -- well., discussion from the Review Committee was since everybody is involved with this type of activity maybe they need soxm out-of-state reviewers to come in and take a o-ood.. hard "Look at It, MRS. GORDON: This is health education and as I read the project, it seemed to be they were going to produce or had. hoped to produce audiovisuals-and this sort of thing on their own, MR. ZIZ@USKY: Yess that is correct, they submitted seven or eight audiovisual films., HEW clearance. MRS. GORDON: Beciuse of the particular nature of their population, MR. C@MBLISS: I think the Council should know that 478 59 we had a demonstration of health education to the public fromi New Iliexico@ right in thi.D room, jind we were Less than impressed with the entire approach. We felt that a good bit had been made of it, but Little was coming from it, I simply throw that out, just for your information. NRS. GORDON: ns you can see, the committee recom- mendation Is quite cut,, and I assume that. this particular project 25 would be-- MS. SILSBEE: EMS project proposal is for $91L.000 alone. NRS. FLOOD: If we took their funding from January throuoh December 3Lst,, annualized it., what'would be their current funding? MS. SILSBEE: It Is apprcKimately $1,L million, MS. FLOOD: Thank you. MRS. GORDON: So in view of these considerations.. I would recommend-$ I move the adoption of the committee recom-- raencation of $1,644.,754. MRS. KLEIN: I think I am going to second that., but; I would LIke to ask a question first, if I may. I notice that these reductions-- MS. SILSBEE: We can't hear you. MRS. KLEIN: I am sorry. jis was pointed out., the reduction is substantial in 479 70 comparison with the amount of money requested, and it says that the project objectives could not be accomplished within one year* mnd then on the estimated request of May L974, they haven't requested anythinm, CD I was wondering particularly in these emergency medical services in a state 121-ke New @xico with a variet.y'of topography and problems of transportation., similar to what we have in Idaho I think, if they were not able to attain project objectives within a year,, consequently the funds were not--' the total requested were not c-ranted for that particular pro- ject number L8? Would they have an opportunity to come in and ask for additional money if they haven't made th" is request as of May 1974? In other words, the funds for that particular proje'a@ would be cut off at the end of the year, to which this grant applies? MS. SILSBEE: That Is true. MRS. KLEIN: @nd they won't have anything to go beyond that? MS. SILSBEE: That's right. MS. KLEIN: Even tough they haven't accomplished all their project objectives. I wonder If that is a good idea? MS. SILSBEE: Well that is sort of-the basis on whLch most of these programs have requested their funds. 480 ms a matter of fact, New Mexico has not requested anything beyond June 30th, have they? MR. POSTM: No. MRS. FLOOD:-. ht least the printout doesn't show MRS. KLEIN: Maybe they failed to request t on the basis of having requested this more than adequate fu din-, in this one. MS. SILSBEE: I think some background Oll t@Le EMS proposal is in order, Frank., could yougive an Idea how long that has been s uppor tecl ? NR. ZIZLI.USKY: This pro'ject activity started July L, 1972., so we are going into the third year. Essentially the project director put a third and fourth year request into a one-year request. That Is why the money has ballooned, youknowo quite substantially. That is basically it. MS. SILSBEE: Wo-UIC4 you speakLp., please., Frank? We Just can't hear you down here. MR. ZIZ@USKY: This is in its third year of fundi@., and they started July L,, 1972. 'nncl they essentially put a thircT and a fourth year request together aW this is what causes the huge expansion of the project in the request. MRS. FLOOD: Could I as@ Dave,, Frank is familiar 48, 72 with what the.status is of the Governor's Division of Highway and Traffic Safetys and their purchase of radio communica- tion6 equipment. one bime the Governor was going to allow',some funds availabilty for radio communications linkages from vehicles to land bases, hospitals,, and perhaps even make available equipment to link into the mass helicopter poten- tial that Is based In Fort Bliss, at El Paso,, Texas-,, which rektl- ly serves a greater region in El Paso than it does-Texaso 'jincl if the Governor's office. does indeed fulfill this equipment part of it, what do they want almost a million dollars for;tha; -sounds like equipment money? For one year. MR ZIZLIUSKY: I am not'familiar with what they are doing in southeast New Mexico part-of the EMS proposal. They have had a very close linkage with the L)epart- ment of Communications, as well as their own L)epartment of Transportation. -All these people'around the Governor's Blue Ribbon Committee,, when the state receives their Defrrtment of Transportation fundso the project director for New Mexico RMP sits clown side by side and they select the sites. The same thing goes for the communication equipment; they have 3ust received-- Robert Woods Johnson grant for EMS, for communication equipment. I haven't seen a copy of that grant and I don't know where that equipment is intended to be, the 482 '3 -site selection. MS. SILSBEE: Frank, am I not correct that they were trying to put in this application those things @h@'they might need if the Robert WoodsJohnson money Cidn't come thro h and if some of the EMS money did not come thro-gh? ER. ZIZL.-.USKY: Right. We have learned th4Lt the Navejo health authority has also received money,, but a third of it spills over into the corner of New Mexico. kol)er't Woods Johnson has come through for them. Possibly we have to check it out, but possibly Presbyterian Medical Services also in New Mexico has received .a Robert Woods Johnson Foundation &rant. If they received the grant, you know, I am pretty sure it is-safe'to say there won't be any duplication, They may have a Little excess, IARS. KLEIN: Madam Chairman., I will second the motion. MS. SILSBEE: t'A'LL right.,-'motion has been made and .seconded New Mexico application be approved at the level of $I.,644,,754. Is there any further discussion? MR. MILLIKEN: Questions MS. SILSBEE: 'nLI In favor? (Chorus of "ayes.11) MS. SILSBEE: Opposed? 483 74 (No. response. MS, SILSBEE: The motion is carried. The next application to be reviewed -- would someone have Mrs. Morgan come in -- which is Northern New Eng'land@ which is really@the one. (At this point, Mrs. Morgan returred to the room.) MS. SILSBEE: Northern New England, Mrs. Morgan. (Discussion off the record.) MS. SILSBEE: Northern New England, Mrs.-@organ.- MRS. MORDAN: I never did quite get this through here,, what all is included in Northern New England. MS. SILSBEE: It is really Vermont. bES. MORGAN: It is really Vermont? Okay. The Review Committeea-i Northern New England did recommend quite a cut in what they had requesteCp even though the region Is rated above average to superior. Their feeling is that the program as requested as proposed was all a continuation of projects with quite an increase in funding. Program staff was $430,800,, almost 47 percent of the total amount requested. Because these were on-going projects, the Review Committee felt that this was a little high, particularly in program staff portion, 484 Th-. committee recommended that the application be reduced to the level of '@4700,000 with a stipulation that hlgh-priority be given to thi,- rea-ion for Increased level wit the July application seeing what the new programs were going o bet were going to consist of when they come in with the July application. In going through this, it does appear to be a very good program, The coordinator has been there approximately a year, They do have a good review system. I feel they just did not have the time to put in for n--w programs, which will probably be coming in in July. Therefore,, I will go along with the committee recommendation of the reduced level of funding of $700,000, which will certainly keep them in operation, ready to do .many of their programs, anC with the fact that this region be considered for high priority depending upon the committee's review for the July application, MS; SILSBEE: Do- you move? MRS. FLOCD: I -will second Mrs. Morgan's motion and for my information, the present grantee is a nonprofit corpora- tion? MS. SILSBEE: The present-- M-r. GardeLlp I will neec your help. The present grantee as of thi-- moment is still the 485 university,, Ls,it not? NR. GNRDELL: (Inaudible) MS. FLOOD: @s of July I it becomes-- MS. SILSBEE: That has been an action under way for sometime and has to do with the concern of the Reoional -ndvisory Group at the himh indirect cost rate the university poses,, so thi. doesn't have anythina, to do with the new'.Look or anything,l This is outcome of that concern. MS. FLOCD: My question was pointed towards that because I recall the high indir@-ct rate from Northern New England program and wondered how long this endeavor had been undergone in the process of development, because some of the vacant position-@ that they'reflect in their personnel; core personnel, accountant, comptroller., and I wondered why these positions weren't filled if the transition had been ac- domplished sometime ago. @'nd these were the services that had always been questioned as bein- high priced from the uni- versity. But again, it is one of tho@e gold stars type of areas that did a lot for the region anCA I can do nothing but confirm the recommendations in light of the high staff costs to await the quality of review for the secondary application,, iihd offer advice for strong consideration at that time. MS. SILSBEE: The motion has beef made and seconded I tha'u- th-- Northern New England application be approved at the 486 77 level of $700.,000. DR. W-MMOCK: Qu@stion. MS. SILSBEE: All'-In':favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. Yes, Sir. DR. JANEI-TAY: Now, sometimes I feel compelled to .Come to the defense of what is termeci.more or less PE!rjora- tively indrect cost, And I wished that someone woul come up with a name that Is better than "indirect cost" or verheacl," or whatever you want to call it. Because if you are an honest grantees grant recipient, the calculation of indirect.cost, tc use that term, is additional costs caused-by reception of the grant. And pursuant to it. And is demonstrable as a very well accounted item. I understand how everybody feels about -it. I just' .felt compelled to make that comment. (Laughter) Because it bothers department chairmen too. MS. SILSBEE: Well, in this particular instance,, you would be interested to know that your fellow dean., Dr. Lukenfield, is one of the leading proponents of getting this omt of the university and into a nonprofit organization, 487 DR. JAl4Zv,'AY: He and I share many common ideas,--.- Ms* SILSBEE: You are right,, you can't just make a blanket state@nt. But in this particular instance@ they felt they weren't getting the services sometimes. MRS. FLOOD: That was my only wish to add also -- n) one is unhappy to accept the high perhaps percentage of indi- rect cost ratling by an Institution when It Is a grantee If indeed the program gets the support@it needs. But we do @ind regions who have full accounting staffs, full personnel departments,, full evaluation -- even planned separate compute:, systems while their grantee gets this high percentage of in- direct costs for supposed services offered. .DR. JANEUAY: That is not right. MS. SILSBEE:' All right, having resolved the indire(, cost issue (Laughter) we will go to Northlands Regional Medical Progray, And the reviewer there is Dr. Watkins. DR. WATKIINS: We come to Northlan(Js and find that the reviewers regarded overall as below average or average. And, of course, it would seem that that was based on the fact that it is low staffing, lack of activity, and primary care, and possibly fundina, of PSRO. However, this program has a history of excellence 488 79 in its'performance so we are going to say that denotation is not'the best, I guess, for this program. However, it does show that there are Li EMS and 4 QNP 11 emergency medical services programs and 4 PSRO, or what have you. -And run the gamut through the nonspecific programs from clinical pastoral ministry tothe Mayo Clinical based health education. Even with all this and with the,fact it seems to la-dk some kmgination, I would ask that the $1$700,000 as opposed to requested $1,889,395, $lo7OOoOOO be given to this program. MS. SILSBEE: Is there a second? NRS. MORGAN: I will second it. MS. SILSBEE: I)o you have a comment, Mr. Van WinkLe' MR. VAN WINKLE: -Yes,, if I could, please. The committee was concerned about one activity than-. they considered to be a PSRO activity. Mr. Wilkins was on the phone only yesterday morning with usp and the foundation for health care evaluation, which was to be the recipiento---'-these funds,, has indeed been declared to be tt P6RO in Minnesota, and, Mr. Wilkins said that thp.-t particuk.,r contract will now be givew @o the State Hospital -Association to carry out the Intent of the contract, which would eliminate, as I understand it, the concern of the committee. MS. SILSBEE: The motion has been made and seconded 489 80 that the Northlands application be approved at $1,700,000. Is there further discussions MR. MILLIKEN: Question. MS. SILSBEE: ALL in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: The motion Is carried. .The next application be b,-- reviewed is from Oklahoma. Mrs. Mars is the primary reviewer. MRS. MARS: This program was rated average nd below average, which means there were two reviewers. The latter was based on the review of the applica- tion before they had a chance or he had a-chance to study the comprehensive statement, regarding their concept and objectiv es. Actually I like their present concept as it seemed t) reach out to the grass roots and w6'rkecl upwards. Their program thrust and emphasis seems to be on the under-served rural areas of Oklahoma, and certainly this should be that way since Oklahoma is a very rural state. The major thrust of the program have been successful ALL their original continuing education centers are functional They have a teleconference network wh-ich will soon be expanded to include most of the state areas for programs 490 8i of health manpower development skills improvement and education. The RAG composition includes Indians and blacks. They have not neglected their minorities. They have a weIL-balanced RAG with 54 members. This has retained really a remarkable continuity of membership, which has provided a very high level of understanding of both health needs and capacity and function of the.RMP to meet those needs. They have budgeted for staff increase of seven more additionq,which doesn't really seem to be justified. There Is apparently no assistant director and cer- i tainly the director does in this case need an assistant. -Also there are some secretarial positions which are vacant at the moment.. and which would be necessary even to help terminate the program if nothing else. The four (b) agencies have been approved, the. Individual proposals and the (a) agency generally concurred. On the whole, I think it"is a fairly good prograbu And I would concur with the reviewers' recommendation for $1,C)62,237, against their -request of $L,382,243. MS. SILSBEE: And you so move? MRS. YIARS: I so move. MS. SILSBEE: Is there a second? MRS. MORGAN: I second it. MS. SILSBEE: Our seconder will second it. 491 C 82 (Laughter) Is there any discussion? Okays it has been moved and seconded the Oklahoma application be approved at $L.,o62.,237. ALL in favor? (Chorus of "ayes.'I) MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. The next application to be reviewed is Orq!gon, and let the record show that Miss Martinez is out of the room. And the reviewer is Dr. Wammock. Just wait until she gets out. (At this point, Miss Martinez withdrew from the room.) DR. WAZEAOCK: This application is for $1,201,357., and it is approved and it was assessed as being superior. There is another epistle with this, and I would .address this to the reviewer for his comments on thisp because I think he has this much better than I do: W. Russell, do you have Oregon? MR. RUSSELL: Yes, sir. DR. WAMMOCIC: If you wouLcl,, pleasep then I will com- ment on it or come back to it. MR. RUSSELL: I have nothing tDadd other than what is 492 3 in the green sheet. Historically this RMP has had an outstanding record. DR. WAMMOCK: So the green sheet has really covered, in essence,-twhat you have covered in your review? MR. RUSSELL: With the Review Committee., yes., sir, the transcript. DR. WAMMOCK: All right. Oregon has continued to be an exemplary well- managed program with strong leadership. 'The regio@ has a, viable Regional Advisory Board with a good review process. The relationships with CHP's are good. These agencies are apparently involved in program planning. New staff has and is being recruited to fill existing vacancies. The on- going and proposed activities are well developed and in Line with program objectives. I was rather interested in the statement here about how many of the new activities are going to be processed through or managed by the University of Oregon, because a great many of these are around the Lhiiversity of Oregon. And just the n@ers.-I out,!;of LO or 10 out of 10, or number of these projects will be managed through the University. NR. RUSSELL: I am not quite sure what-you are Look- ing at or what the reviewer-was looking at when those comments were made; but., of courses the University of Oregon is the grantee. 493 B4 Now,, there are a number of program staff activities which the program staff monitor provides surveillance, so therefore as a subsidiary of the grantee, it shows up University of Washington -- University of Oregon is the sponsor. DR. WAMMOCK: That is what, in essence, it boils down to. MS. SILSBEE: That's right. It just so happens there are ten.of them, staff,' I just counted them. DR. WAMMOCK: One.-individual pointed out here Oregor is trying to keep the people from coming into Oregon and also led the story in gas rationing. This struck me very interesting in description of one of the projedts,, about family and self-help education pro- grams, and I think it worth-while taking a moment to read this, "Citizens frequently make poor decisions regarding .common day-to-day health problems. "Injudicious action often Leads to Inappropriate utilization of scarce health resources. This problem can-be particularly acute in isolated rural communities or in other health scarcity areas,' "Major cause seems to be lack of 'practical guidelines for making health related decisions. As a results people are prone to seek professional care when it is unnecessary, avoid expert care when It is necessary,, impose-improper folk remedies and fail to employ simple useful and proven home care 494 areas. This not only applies to the rural areas, but applies to the urban areas." I don't see anything I felt it was a well p repar d document here, the Oregon pro-ram. It is easy to reed, to go through,, and table of contents, et cetera. I come to this peer review quality assurance proo-ran,, again, that crops up, and also shared service progral for hospitals and related agencies in the south coast of Oregon, the only two areas I Looked at. But wouldn't make tco much of a quibble about that. So I would therefore move that the recommended sum of $I,,201,357 be approved for the Oregon program. MS.. SILSBEE: Is there a'second? MRS. MORGAN: I MRS. FLOOD: I second. MS. SILSBEE: All right. Mrs. Morgan, you were the secondary reviewer on that. Would you like to second? MRS. MORGAN: No,, just knowing Dr. Reinschmidt and being familiar with the program, you can rest assured it will be well spent. NR. HIROTO: On this 028 group purchasing,, is that Institution-"L hosp:Lt.-L group? They really didn't have to do that. -It is covered under Meclicare-Medicaid laws. 495 86 That is all. MS. SILSBEE: O@ay, we will make a note of that. The motion has been made and seconded that the Oregon application be approved at $1,201,357. Any further discussion? All in favor? (chorus of "ayes.@') MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. Dr. Janeway,, thank you very much. (Discussion off the record,) MS. SILSBEE: Could someone call Miss Martinez back again. (At this point Miss Z4artinez returned.) MS. SILSBEE: The next application for review, you wLLL be pleased to know we only have four more to go. let's have a slight break. (whereupon, a short recess was taken.) MS. SILSBEE: Would the Council come to.order. The next application to be considered is the Rochester application, and the primary reviewer is Mrs. Klein. MRS. KLEIN: As you can see by your I guess aqua col- ored sheet MRS. GORDON-. Now she has got it. 496 87 MRSI KLEIN: -- the reviewers rated this program as superior, and recommended that all of the money they reques- ted be allotted-.to them. And I certainly would go along with this, I think the two reports that I reviewed show the difference between a bad report and a good report. This one, even a person as uninformed as I am could be very well"-very readily understood. They set forth their programs with clarity. They even outlined their objectives and in great detail, and put a dollar value on each one of them. And gave a graphic history of the staff. And had a number of other informative graphs ln'this report that I thought were excellent. It was a short report and very readily-- it seemed easy for me to understand anyway. I enjoyed it. bMS.' GORDON: Is this Rochester? Is th%,Rochester,, New York? Minnesota? MS. SILSBEE: YeB, @ i-s Rochester, New York. We should be clear. That is the headquarters and it covers that tier of counties below Rochester. MRS. KLEIN: As I say, it set forth its goals and its objectives very clearly and the funding and asked only for really a continuation of very small program and a small staff of I guess about ten people. And just gave them a 497 88 small increment in salary. And they had several well defined projects which /were, as I say, outlined ingreat detail in the report. And I certainly would feel that they ought to be allowed this amount. I noticed, too, that they are asking for about over a million dollars in new funds on the next application, probably to institute some new proposals with a good nucleus of a staff. So I would move that the amount that the committee recommended, $361,,437, be alLowed., MS. SILSBEE: Second? MR. MILLIKEN: Yes. MS. SILSBEE: Mr. MILLikensas secondary reviewer do you have some comments? MR. MILLIKEN: No, I have been on a site visit,there. .It is very good. MS. SILSBEE: The motion has been made and seconded, Rochester application be approved 6t $36Ls437. All in favor? (Chorus of "ayes.11) MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. The next region to be reviewed is application from Tennessee Midsouth, that covers Nashville and the eastern 498 89 Tennessee an(I-the area around Nashv'iLle. The reviewer is Mrs. Mars, MRS. MARS: The assessment of this program is that of being average. However, I think it is a fantastic'program since September of 1973, they completely dissolved their RAG in fact., the RAG dissolved itself, and reorganized itself as an entirely new Regional Advisory Group, This apparently was very necessary if the program wals going to-succes@fully continue, The significant improvements Included were in the bylaw revisions and grantee responsiblities were limited. A definite Limitation was placed on the size of the RAG, bringing it down to 36 members. The @erm of office for RAG members was limited,, and there were adequate conflicts of Interest provisions Included. So@this has changed the whole more or less course of the program. And now they are beginning 'to move into an outreach program where the needs were so great, Tennessee, of course, being again a very_rurtLI state, The new chairman is medical director of the Universi;y of Tennessee, and they aiso have a new coordinator. He.was with the program from L968, but he has now been acting and is coordinator as of Septembero I believe, of 1973,, somewhere In that area. He hasn't been in that position@oo long. The former coordinator got fired and I think by the 499 go grantee, and both the men, the one that was fired and the present one is a University of Tennessee man, so they all seem to get along all right. The money that they have requested to the sum of $2,133,972, seem-- to be in order. Howevero I would suggest that when they request another $850,000 in July and August review, that it be looked into very carefully and examined before it is granted. They have a-gooa past performance. They did carry cut their priorities in the past. They funded 68 separate activi- ties'in the past two yeax4 and the budget as now in the applica- tion 49 percent is budgeted for continuation activities and 37 percent is budgeted for new projects, 14 percent is budget- ed for staff. There are eioht new projects. Six of these relate ,to rural application health districts one concerns a disad- vantaged areas and although some of these new activities are'classified as continuation, Many of them have come about since November of 1973,, since the-reorganization of the RAG. So.that in a,way, I suppose you can term them both new and continuing projects. I therefore move that we do accept the recommendation of $2,133,972. NRS. MORGAN: I Will second., to get tt on the table,, then I have a question. 500 MS. SILSBEE: ALL right. MRS. MORGAN: I wonCer., on their current staff, how one can be considered full-time professional and still be located as a fuLL-t@ professional outside of the RM.P office? MS. SILSBEE: Lee? MR.,VAN WINKLE: Which one are you speaking of? MRSI MORGAN: Under six full-time professionals, one of whom Is located as fuLl-t@ professional outside. Is he fuIL-time professional still in the RMP but outside? MRS. YARS: His work,,,yes. Carries regional t'hrouch the state. MRS. MORGAN: All right, that is all I wanted to say*' MS. SILSBEE: Mrs. F lood. MRS. FLOOD: I notice reviewers questioned the logic of a cancer program for the timeframe of potential funding. But yet the topic listed in the pr@intout is that of lung cance detection and in this part-icular-region of the country, this Is a particular problem. Could someone expound as to was the project perhaps' that of screening detection and planning for Long-range care,, or something of this natures that It was not feasible within the timeframe? MRS. 14ARS: Which program are you referring to? 50, 2 MRS-, FLOOD: It is numbered 93, Mrs. Mars, and in the'printout it is called lung plan, lung cancer detection. MR. VAN WINKLE: Life adjustment, Life adjustment. to can-cer. MRS. FLOOD: That is, 92 is being questioned; 92 is beino, questioned M. VAN WINKLE: Yes, ma'am., MRS. FLOOD: Thank you. MS. SILSBEE: The motion has been made and seconded Tennessee MidsoLith application be approved at the level of $2,,133o972. Is there further discussion? DR. WAMMOCK: Question, MS. SILSBEE: ALL in favor? (chorus of "ayes.") MS;@ SILSBEE: Opposed? (No response.) MS. SILSBEE: The motion"is carried. IncidentaLly., Mrs. @rs-p the rejuvenation of the RAG and so forthi was not done.without a good deal of prodding from staff here. MRS. MARS: Staff here. It certainly needed It obviously. MS. SILSBEE: That has been a problem for some years The next application to be reviewed is from Virginia 502 93 and let the record show Mrs. M,-rs is out of the room. (At this point, Mrs. Mars withdrew from the room.) DR. WATF,.INS: Virginia was reviewed and regarded as average. They are asking for only $L,000,000. It seems that Dean Perez is still doing the job that he has done before, that is allowing some of his staff to remain-- positions toremain vacant. It shows a preponderance of similar projects reflect no- some lack of imagination, However., he has followed'the guide- lines of RIP objectives and authorities. He also, I saw,this over there, he also has accom- mocated a number of disciplines,, Including RN's,, and it shows dental hypertension projects pharamacisto and he does have these on his RAG'S. I saw this when I was there. In factx he does have even a dietician program. So I would like to recom- m,--nd that he-gets' the $L million in fact,, that is my propos),L, he gets the $1 million. MS. SILSBEE: Miss Martinez. MISS MARTINEZ: Secorld.-@ MS. SILSBEE: She seconded It. The motion has been made and seconded that the Vir-inia application be approved at the level of $L million. Any discussion? All in favor? (chorus of "ayes.") 503 MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: The motion is carried. But I would like to clarify the record, Dr@.Watkins, their request was at $1,290,000. DR. WATKINS: Thank you. MS. SILSBEE: Okay, could someone bring Mrs. M,-rs back in and we will do the Last application,, which,is from Western Pennsylvania. (At this point, Mrs. Mars returned to the room.) MS. SILSBEE: Yes. MISS MARTINEZ: Western Pennsylvania, rated as an average. I agree with the,rating of the committee. I would like someone from the staff to clarify the 'concern that it had with the kidney project, or the Review Committee had with the review project. MS. SILSBEE: The concern was primarily in the wordi 9 of the page 15, which made one-of the reviewers think thatthey were developing transplant centers in more than one place. This was not the case; they have got one center, and satellite hospitals that relate-- in other kinds of services. So we feel that concern has been alleviated. MISS WRTTLNEZ: Okay. I do have two other shortcomings-- I hate to sound 504 95 Like a broken record,, but they have no Spanish speaking persons on their RAG, and secondly, I noticedsomething when I was Looking at the staff, In administration, they have someone@, a woman,, called "administrative assistant, 11 who receives a lower salary than it executive secretary." N014P I think if she is a secretary or.clerk, she. should be so named. Because I have seen this happen so often, when people want to count a woman in professional administra- tio@ to give her a title which has nothing to Co with her salary or duties or anythin& else. That is a question- I am addressing,to whether that is the case or why the title if she is not an administrative assistant. MS. SILSBEE: I really don' t know the answer to that but I will be most happy to ask the region that question. As a matter of fact,, Miss Kettle, who used to be wit.,i this staffo made a big point of that in site visit one time. MISS YIARTINEZ: Okay. In that case I would Like tD move that the committee recommend_@@L,370,,285 for'the program.. PLus $170,285 for the heart function be approved. MS. SILSBEE: Is that plus or-- MISS IMRTINEZ: Isn't it plus? Oh, it LncLudes? Sorry. Amend that to Include, including the Mahoning--,Shenango project. NRS. MORGAN: Is this to make sure the Ohio project 505 -)6 is good.? MS. SILSBEE: Yes. MRS. MORGAN: I seconclo then I will get it on the table. MS. SILSBEE: Let me explain a little bit about the Ohio-project. This is one of the activities that was supported in that special ear-mark a couple years ago, health services educationactivities, At the time the Northeast Ohio RegionaL Medical Program was phased out that program had been funded for a couple of years, money was provided there. It was m ving along well. -And so for a year we Were able to fund it as a 910 activity. Because of the court order and the worCing of it, we could not continue in that capacity,, so we asked Western Pennsylvania-if they would agree to fold this into its program and monitor the activity and they did agree. So $170,,285 for that project represents the request .of the project. Mrs. Flood. NRS. FLOOD: I am not familiar with this region, and am not sure who the grantee institution Is. MS. SILSBEE: University of Pittsburgh. MRS. FLOOD: University of Pittsburg@ So there would be no problem in continuation monitoring of projects 25 506 1 i@ 97 and 26 into fiscal 76, which their request does reflect fundin@ for,fiscal '76? MS. SILSBEE: The action of the committee in duttin-I back on the funding was to -- they felt that those a(Icliti'onall dollars should not be allowed at this time. MRS. FLOCD:' Fiscal'76 portion of the fund" MS. SILSBEE: However, in terms 'of your initial question, the capability of the'university to contin,ie' I don't think there would be any problem along that litieo MRS. FLOM: This was the rationale. MS. SILSBEE: They didn't put any kind of restric- tion on that,, but at the d6LI@-r level they were maki g that suggestion. FLOOD: Thank you. MS. SILSBEE: Mr. Hiroto. NR. HIROTO: Ye@'s. I am repeating myself, but there is something, $31,000 in there, about quality assurance. Agair, is-that going to make certain-- MS. SILABEE: Yes, we w-ill make certain on that. .Let's see., you were the secondary reviewer. Did you have any further comments to make? MR. HIROTO: No. MS. SILSBEE: The'motion has been made and seconded that the application from the Western Pennsylvania Regional MedicaL Program be approved at the Level of $1,370,285, which 507 3 includes $L70,@85 for the Ohio health education Project. Is there further discussion? All in favor? (Chorus of "ayes. MS. SILSBEE: Opposed? (No response.) MS.,SILSBEE: Motion is carried and that ends the review of thel53 applications.' (Applause) DR. WAMMOCK. have one other comment if I may. DR. PAHL: Go ahead. DR. WAIC40CK: Article about RMP,"As I knew himo the rise and fall of an idea," and it ends with a quote, mourners are -urged not to send flowers but money." (Laughter) MS. SILSBEE: That is from the New England Journal of @dicine. Before closing, I thought the Council might be Inter-- ested in the overall recommendations that have been made. You have add-eC funds to the committee's recommenda- tions to the tune of about $3.7 million. You added money to Central New York., Int;ermountain, Takes Area, Maine, Nebraska, New York Metro, Texasp and Tri',State. You took money away from Susquehanna-Valley, The total difference in the amount of all of these 5o8 99 actions was @3'.648,458, This means that the committee recommended the level of @@85,047,597. MRS. MARS: What? MS. SILSBEE: $85,047,,597. The Council recommendatiotis'-total6d $88,696,055. DR. PAHL: Thank you very much, Judy. Dr. Watkins, DR.IWATKINS: Tell me'brevity Is the soul of wit,, so I wiLL'be very- brief, This Council shows a,mix of jocularity, mental agility, and mental alacrity and I want to say I am happy to be back, (Laughter) bR. PAHL: Thank- you. MRS. WRS: Very happy to have you. DR. PAHL: Before we adjourn, I have just one or two coimnents, particularly for the new members of Council. It has been a baptism by--fire and I am sure it seems like almost ages when I--welcomed ;you yesterday morning to sit on the Council. MRS. GORDON: "Sit" is the word. (Laughter) DR. PAHL: I am glad to see we have solved the long-standing problem of "indirect cost.".. I wi-LI pass that word on to the appropriate authorities in HEW and elsewhere, i 509 DO It isiparticularly Interesting also to see and listen to the humor, and I think I will remember about Czechoslovakia and sheriffs for sometime. (T,aughter) Very seriously, again, I remind y6u that you have probably worked harder with greater workload than any Council I have been associated with In this pro@ram. MRSJ @IARS: Except for' the last one. DR. PAHL: We were somewhat reduced in numbers. MRS. MRS: Yes. DR. PAHL: But you have also set a precedent today,, and I have just been doing some calculating and I think @he August Council meeting should run no Longer than about two hours and eight minutes if you stick with the same kind of good activity. But very seriously, you should know thk the recom'- mendations that you have made wiLL,, of course, be Looked at and I am sure there will be great Interest by the individuals who sat here yesterday morning, and indicated to you their interest in the direction of the program and charge you with various kinds of responsibilities at that time. I feel very, very comfortable. I would Like you to know, to represent both the Review Committee and -the Council In Its recommendations on each and every prog3Lam, I feel that you faced up to some very difficult decisions. 510 There have been so,-,e Sood discussions on complex Issues. The record Is w ell doc,-z,,entecl. And I would want you to kncwthat I am probably more comfortable at this time than any @ime In recent months in defending to o-ur own -Administration the quality of the review throughout this entire process, It will be a pleasure to be able to sit with them and indicate ust what recommendations have been and why we have reached those. SO Without holding you further, I hope that we can see you and others back August 8 and 9, and we will be most happy to-respond to questions and inquiries in the interval should you have any. Sew a:l L? I,IR. MILTIKEN:' Your remark about productions, I don't think we could have done It without the unusual staff work that has been done, very well done, NRS. MARS: We owe you a. vote of thanks. DR. WAMMOCK: It has been a great help and I am sure the constraint of.tim'e here has really been something. DR. PAHL: Mrs. Silsbee may indulge In a predinner highball this evenings for a job well done to her and the staff. A lot has been done behind t-he scenes# as you all.know. Thank you very much. 511 ,2 I declare the meetino, adjourned. (Whereupon, at 3:27 o'clock, p.m.p the meetin@ was concluded.)