I k M- 0 1 I I- B&B lp4Fmiamik-rior4 & im^ae m^p4^oEmE@ moo @eftoz M=st=L"n BOUL"@O UPOOMEN M&%MLMO$tC, MA6ftY"V4D Z077Z a US^ * CZOI) 24@l 10 E001 742 T R A N S C R I P T NATIONAL ADVISORY COUNCIL August 8, 1974 C 0 N T E 14 T S 2 opening bv Dr. Pahl 3 f Remarks by Jr. C. 'Robert Ogden 5 3 Ogden Resolution 10 4 5 Comments of flembers of the Public: 6 Dr. Donald Sparkman 13. 7 Response of Dr. Richard J@neway to Remarks of 8 Dr. Sparkman 20 9 Arthritis Report of Mr. Matthew Spear 36 10 Comments, by Members of the Public: 11 Mr. John Sergeant (Plaryland) 48 12 Dr. Lawrence Scherr (Nassau-Suffolk) 57 13 Review of Applications for Regional Medical Programs: Alabama (!Irs. Gordon) 72 14 Albany (Dr. Watkins) 74 15 1 16 Arkansas (Dr. Komaroff) 79 -State (Dr. Watkins) 83 17 Bi 18 California (Dr. Janeway) 90 19 Central New York (Mrs. Martinez) 102 20 Central I-lyoming- (I-Irs. Martinez) 106 21 Block Action 115 22 Arizona (Dr. Gramlich) 120 23 Connecticut (Tir. Hiroto) 122 24 Inter-i,4ountain (Dr. Komaroff) Louisiana (Dr. ia,-,eway) 132 25 1 Contents (Continued) 2 '4,aryland (,r)r. '@-@7ammock) 3 ilassau-Suffolk (.Tr. I.lIlliken) 142 4 South Carolina (@ir. Haber) 1-52 5 153 Texas (I-irs. r-loraan) 6 Virginia (Ilr. Hiroto) 163 7 Northern Pennsylvania (Mrs. Ilartinez) 9 10 12 13 14 15 16 17 .18' 19 20 21 22 23 24 25 r T k@ 3 IIATICNA!, 7.-DJISORY r-dr.DICAL PPO(-PPIIS 5 6 Conference Room G-13 Parl,:Iai-7n Puildina 5600 Fishers Lane Rockville, Maryland 20852 Thu rsday, Puqust 8, 1974. The meeting convened at 9:00 a.m., Dr. Herbert P@. il@- Pahl, Acting Di-rector, nivision of Regional @ledical Proqrars, ?Dresidincr. 1 PRESI,-'NT: r.T,P-ALD GARDFLL, Acting Deput@7 Director, DPIL@P. i5 SARA.H J. SILSBEE, Acting Chief', Onerations and 1, Development, DRMP, I'@ENNETH-PPUM, Executive Secretary. EDITI! M. KLEIN, Boise,@Idaho. DR. ITOI VOICES: Aye. 12 D@@. P70IL: O!Dposed? (.@To response.) 15 DR. PAIIL: The motion is carr4@e,d. 16 IL,.IPS. I.-!Or.,GAN': As a matter of fact, it @.:ould be -'Llleaal .17 and still is part of the minutes. DR. PAIIL. @-V-,e walk a @-iSht ro-I)e here. I..7e will 'i in just a morient, having a renc>rt fro,-.. ;"@r. I-latt Spear to !--ring 19 2.01 you up to date on tlic- status of the arthritis proaram. 2 1 @;ou Still -"-ccall, at the 1 a,-; t'- council r-.=-eting, "Latt, T Dllst about g--ttinqtdvou at this poin- 22 24 DP,. PI,174L: If that is su--@ici@nt. As you recall at Council meeting, i,ou did listen to a presentation the,'Las- z ii! 25 k I i I i t i I @i I i l@ I I ii ii bo-'--Ia Dr. G@aml cl-i anO,- Ilir. S].)eci'r rc-', ati@,c- to t:,- -iot- 2 prc)grz:m. Prid th@ active 4- i i7 considerations and -,--mal ad hoc Ar4l-hril-is Rev.4.c-w Cor,-j- -.e; 4 recor-Liiienda4L-. is o 5 subsc-ciuc-:nt to have macic- and 7 6 like to call on --Ipz-=ar to d!-=scribe tli@-, current status t',Ae i,-)roaram, an(9 our activities since the last Council' meeting. 9 13 Jr 17 (lo 24 It @@:ill be juf-,t as c7,lvcnien4-, lust rc--aD4@tti-lats so ir-, on 4-h-@ --eccivcd in 1974 -an a.n@L,Iro,7jria4-- -- f-"c r@-n alloca--cn =ar- .@d 4 and a half milli-on dollz,,rs for t, lo ii c-c a 4 arl--Iiriti.E7, c--n'L-c-r. @-"!@cn the requ@st for applications @@:c-nt out @,:c re ce', mi -I i.L,cn 7 a-.o-L)lic,--tions from 43 regions, totalling almost 16 dollars. So it was a highly competitive situation iii Polic,---s were established which too],. out of 'ho@@- Izinds of- activities which did not seem JL-.c,, bc did -iolt-- scem to directly )Dear on pati-@nt sc-- vices and t-= 12 of things for L@atig-=nt@. and the extension c-l-c care t o p a t s . in outco- then, a@- recommended by ad '-c@= ;j arthritis r e v -,q committee and the Counci:l at it's "Last s=-ss-@on i@ 31 c,,f PIIP applications for Dilot arthritis funds i-.ere @7 ap@,)ro@?-cd. The a,, proval exceedee.1, @ic! earmarked ful-,Cis sf-.-.@ sma-L.L amount. I shouldn't say small-ai-ount, that's edi+--or@-al. B@- 0 t of almost a lial4c a million dollar.--,. 1,7ith2 the a:D:Dro- ,n amoun val of Counc4-l or app--oved, tanded to allocation o:" fun-" to all ,)f the rrc,-rcl-7:, t, L i,i@qik--hin the earira--"@ed amounts available to the programs. .7,nl that is 27 of those appr,)vc-d p@grairs, an,4 rc-i-ia-Lning four @..,ho were aoproved, but for which there @.,7er- not earr-,al--!@-@c.1 Eunds,, are -@eincT 2 c'- the a@o,-,n-- 3 program pT.) r o v c cl 4@-hc- Council. 4 to this t-a@- a rr%c-,'oia 5 is Or 4 S I-lot a_ Z?l _)rCVC(3 f 0 -cE,,-rmarked 'z'-n@-3 Or -13 Or is not @-:-).Prov@-d for the utilization of discr@4L--4-o.,ia",@7 fund ,as issu=---- s 7 on Liune 29. Thc. 1,@,tter also requested that eaci.1 of ie 8 receiving approvals for pilot arthritis ac4, --i%ritv resnon,l 4,11- vjritino as to its acceptance of the award, an a,..7ard is 9 lt,3 involved, and or in all cas@is the conditions of the aiiard, ii @,jliich k,,Ls the statement embodied in the aD@-rova'Ls as to the :finds c,@c acti,%ri@ic-,s @hat sh@-uld be und@-r+-aken. 13 And t'@,i LzL 1-@l,ri-iits of the --Funds that could !-)e expende--z 14 activi4i--4-,---s. Tcdall l@e have acceptances 21 of those 15 Il-',!@P's and we are waiting for an additional ten. -o round it 16 up. Eig.1-it of those have been contacted as of yesterday, and .17 they arc, -,-,,orking as rapid!-x;, as thc-v can to cTeL@ their accen- ance s in. As you can iirag4-nc-, gG-ing from a request of sixtee--i million to'somethirg in the order of less than five millions 2i soTr@e drastic cu4--@- i,,,erc made-, and some restructuring o f a C 4L-. i i-"hn t'-i-- aiD,,Drova"Ls h,@F, been nc-cessar,,?, and thos- cl 2 1-ing negotiated. 23 2'z It appears at this moment, that cnlv one or two oz the 31-approved regions may turn down the funds. One apparent',-.- is liavincT sor-,,:2 -ty in dec-'Ld-Ln t t'@@ c -n 0 the re%7i-i.., co@-arittee and Council both recommend 4 two other actiors, both at -Eric sar:te -L-i.-.e , 5 1--herc be some centralized fu-Llo,..,,-up n @,iv-sic. o@ 61 FIegional 11'@-adical Programs. The major,,oart of that I t hi n'%- 7 the T-,osL-1 ir.,.-crl-ant asTDect .4-sadesire t',' I a L-, there be a -ret.-.od 8 and an aonroach to coordinating like kinds of prourams that .@-ieverth.eless are dispersed the 31 Pd-,!Pls. T 7 10 are also in the advice letter of Jt,-ne 29 as'r:e--7 I h P sto give it some thou-ht, and to give US the @@isd= of @Lhei-r c.-:Perience and thoughts. However, they did not h=---e the full information needed b,, then to a--ve a proper reso@s@ in our estimation. 15 An d @,;e are presently preparing a letter to follo,@,- 16 --.'Liat- uD and (Tive them more concrete information such as %,;ho 17 the ball players, who aot and for ,.!hat kincas 18 o-c iyurL:)o--cs and what are the na4L,.Ure of the programs that 19 hLivc bec-%n anproved for fi,-ndirgr- And ust in conclusion, to these remarks, let me --,-ad @ou the draft r@-rL@- of 4L-lie letL--er that r-ur@,or-L".s to e aoD--oved programs. --i@.nhasis of +--he a@)proved Dilo@ 2 procrams is the c>:tens4@on of present knowledge in arthritis 23 i; 24 ii @iaanosis, L@-rcati,@-,nt and care to coordinated services @.jhch 2,, demonstrated improved patient acess to care, and extension O.-- professional servicc-s through n a n cl c- u i 1 a n f c. c, ni i-l@z,@--cn@r-il, @r-l-,r4 tis c---n--s wil.1 be established in r-,20ical centers, co,,Pj-lunity aT-. cormunitN, heal--h f a c 1 c- s Lducat.4-o.-,i,-.1 proc7ra--.,., 7-i an,,., 6 visi@@ing mu'L@-@L-discij?14-narv tear-.s ir.Crc- as'e tl)-- arl.--,.ritis 7 i. hc-indii-i-ic-i capabilities 0'7 and oriva4-@-- !,)hvs4-ci-ans and wi-il eauir) larger nurJDers of medical and hcalth o3rsoiin-c-1. ii -as Support services in hospital clinics and inc--cased L .0 ii )at,-,-it care be i.ncr,3asc-d t'li@-ouah the of pat-@ent traini@-i,7, ac4l--ivities. Seminars and i-:orksho,3s be cc..,-iduc-L"ed at many sites For 4-r.,@rov@-d utilization o@- co nml-,,,iity r,,-sourcc@- L70-- arj-l-r4 - 4 services, inclu,!-'ng care, gu-,7,a-;ce and s L-, urvei@- lc-nca. Ex,,-s4.-4-rg health c2eTDartr.-ont personnel and facilities, I ,C and h@-aL!th groups, such as the @,-isi-ing I',urses Association 17 loc.,-.,! zcunc4-l-s aganc:,, a,-.d operating community .18 proqra,-.s are cooperating and C-ar@nstrations of a@@prov--zd l@ arthr4-is health care Several modest studies 20 to c@.,avalop criteria for qualitiative carc through provided P:2,--"'orr-.ance sjt--E,,ndards are b;@ing convicted, Crew survc@ -Ls niaiine6 in one region. 23 Pnd an enl7)lovee, a-,jloycr educatici-in-'i. ,?ro-r--LI will "@v,@loped in. c -1c@-rt @@,,ith bett--r orga@-ii@,ad occu77,ptional 24 2-5 hea'Ltli services. Z\-notlier region %,,,ill investigate the utili-ZE.%- o f so! ar 7crl-. E: u r,,,@or t I-,aticn t r -Cs tor a4-on0-c- a c tv 7@ nu.--@er- of programs arc 4.7ocuEi-ng on the pro!D-i-e-'s of lo@.@ inco@-,,e arouDs, rural grouses, and others zre -r-ocucz4-,- 5 -LI-ic- C,,,Lv-:alopri-erLt of car-@ 3.n d@ 6 inner-city rosidcnts. Pc-dia,tri-c artlil--il--i-s sc-rvic Li wil@- I-,,a 7 de,,,-elo.0,@-d in a vari-c-@L.@, of,sc-tti-ngs, and one T,))7()CI-a.-'t SC-c 8 stratina i.rLi-,orovc-d services to the geriatric poi?i2lat4@r-lr,. 9 Localities which presently have little or nor tological resources are being supported by c,-- 11. the expansion-of -,,cd-@cal, il,e@.7 medical irist-Ltu-c4.cri cLoabiliti-es. Across the country, chapters of It--he ai-@-hri4-- -L Z:, f ounea-6-io-i are program, coord2 nat 4 @on to a,-id increased nu@LIic-rs of volunteer @,7o irers in c;u-T-)orti,-- r 1-6 services. P-nd ip---reased agcn-',- referrals tc) lo,,:al -erV4r@-3,= 14 and resources. 18 That completes mv report, Dr. Pahl, un s s-,!,.cre ig are questions. 20 DR. PIIIIL-. Thar@k you very much, .@'llatt. Dr, Fir--tbc-r? 21 DR.IIABT"R: I-,hat is, is -It--hcit -@,)roarari w geriatric services? I-IR. SPEAP: In Univ@-rs4-@--v of- -r'4-chigari. you, Matt. Dr. .4 III I i-nd-icatc-Ci to ,,,nu, 1 to i,,ou 4-'or.not h cn able to g@t @,;ith yot:. a li--"--4--1b4 Z .V4ric b@ 4 1 to the road construction %.,,Ii,ch e@elayed Tntr this morning due getting here. 2 I wondered, however', if you have a statement to 3 make generally or i think to add and the information 4 I did pass to you I thought I would like to make an explanatic 5 and statement to council, rather than a formal resolution. 6 But perhaps you would like'to make some comments, as a result'@ 7 8 I would have-a great deal, Dr. Pahl, except to say -that this is a great example of the flexibility of the PILP 9 process, in the administrative organization that is able to 10 accept the task, early on, accomplish it rapidly,- and apparent :1, 11 bring it to reasponably successful solution. 13 Matt's report is superb and I have nothing to add to it. DR. PAIIL: Thank you. Let me just take one or two 15 16 minutes, and indicate to you. IN7e are -.attempting, should 17 there be further funding coming to us this year than anything 18 we have spoken about to date, or@will there be special arthritic funds made available to this pr-o'gram we would attempt to engace 19 in those activities,which'the committe e recommended to you, 20 and you endorse that is to provide centralized audio-visual 21 resources, the development of certain training films, vioeo- 22 tapes and so forth. 23 But this requires a reasonable investment, and we 24 do not have the dollars at the moment. We do intend as llr.' 25 I Spear indicated to try to uull the existir,!7, approved! activities into a cohesive procram throu,7,li the good o.4ficcs 2 3 of !lr. Spear. 4 1.@nd beyond minimal funds needed for some conflict meetings, and so forth, I believe @-7e can accomplish that. 5 6 So .-7e do hope to be 'able to report'baclz to .you at some future'i time that the program is not an assemblaac- of disjointed 7 8 projects but does represent a total national program. 17ow, facing us yesterday and today there are 9 a 10 limited number of arthritis applications in the July 1 RMP 11 applications. I believe five regions saw fit to include jn arthritis requests in the current applications. I-..@ich is to 13 say that most regions clearly understood that the pilot arthritis program was related to the fiscal 74 @r-undina and 14 15 the activities of the specially established ad hoc arthritis review committee which met for one time and was disbanded. 16 17 Thus, we have a situation in tihichI aoministrativel -18 and indicate.to those regions that basically their applications 19 have been submitted inappropriately, although I' think in 20 some cases there have been honest misunderstandings, so that ')j perhaps this news would not be taken lightly. r I feel : ?.t, however, it is important to-reopen 22 23 with you very bri----Ily the fact that we believe the pilot arthritis center program was established and is no longer 24 open. That is, regions should not be permitted to spend 25 43 I currently available funds or %@:hatever -LcunOs core to them 211 in t-ie year, -- the distribution we havc- been discussing 311 this morning to support additional activities. 4 T,.e are timing to build a national cohesive proar,-,rpi 5 -and as a result of that I have 'prepared a statement i7hic'L-! I would like to read to you, and if you feel you need to studl:- 6 7 it we can distribute it. !rhe timing is perfect, Ken, thank 8 you. 9 But I believe it would provide you with the sense of what I believe is necessary in order to be fair to all 10 11 regional medical programs and to try to build a cohesive pro- 1.2 gram from those activities that were reviewed and approved bN7 the Technical Board of Experts. 13 1.4 The statement that I would like therefore, for you 15 to read to you and ask for your endorsement is the following 16 the underlying authority for the 1974 initiative in arthritis 17 was pilot in scope and intent. i@d heterogeneous activities .18 beyond this.level would not be appropriate employment of 19 current grant funds. 20 The full development and delivery of services for arthritis is an enormous undertaking, and requires a continuing 21 well organized attack such as could be initiated under presenr-l- ^2 pending legislation. 23 24 Thus,.while Council is fully aware- of the urgent Z5 needs in the arthritis field, it does not consider expenditures for arthritis, other than for a,@DDrovals and recc:-.@nendat-1c.,,-.E@ made at the June council meeting to be a.@,Dropri,!te in 2 present environment,. 3 4 And the allocation or expenditure b@, individual regional medical programs of funds for arthritis in addition 5 to approvals provided at the June 13-14, 1974 Council meeting;; 6 7 are not approved. The Council will entertain approval of additional thrusts in arthritis in the event of appropriate-_ 8 authority and new grant or other funds become available ro 9 10 the IUIP s . Dr. Gramlich'? DR. GR2VILICH: I heard there-core in the periodizatioxi 12 process at the June meeting there were four applications 13 that were approved by not funded. Those were outside the 14 15 scope of this DR.PAHL: Those four are outside and'they ha-%re been 16 gven specific permission following that Council discussion 17, 18 to.utilize their funds to support-., Because those aDnlicationa went to and through the review process by the arthritis review 19 committee. 20 1 s This Dertains only to those activities that were 21 no-"" reviewed by that special arthritis review group. 22 23 DR. GPAI-I.LICII: Okay. DR. PIVIL: Because regions are permitted to rc-budget,@, 24 and anybody can rebudget into arthritis inthe coming year. 25 I don't know how @@,e can establish a national @-@c.@ra-i L c 2 basically leave it oDen ended. The applications in arthritis that have come be'Lore, 4 you today 1-iav-e not been reviewed by the arthritis @anel, and 5 cannot be because we have no possibi-I.,.-t@7, have no Possibility 6 of calling them together again. 'That we are saying, therefore, is that your Ju.. 7 8 actions, including the forn, which we did not have funds to 9 pay, but were given permission by that closes the arthritis 10 program effort unless special arthritis funds were made avail7 11 able to us, or.unless additional PJIP funds, and then it wouldi II come back to this Council in full measure. 12 13 That is the statement, the intent of --he stater.--nt.' DR. GRAI-IT-ICII: It seems reasonable and perfect---l-,, 14 15 clean to me. I move that it is adopted. Unless Council 16 %@iishes DR. Seco.-id it. 17 18 DR. PAHL: It's been moved and seconded. Is there -19 a discussion? 20 DR. J@IE!@71'.Y: Isn't the intent of that also to exclude 21 those grants which on technical grounds were disanoroved? DP,. PZJIL: Yc-s. 2 DR. I think this will be clear in the sense 23 24 of it. 25 DR. PP-TIL: This then will be incor-pora-L"ed. This i says that cnl,%, a-,)proved activit,,, -- activities in +-hc- June 4 4 se-L. of rc-e--ings can i-,ti-l-Lze "-"P -'Ur,.-lo, disapproved activities 3 cannot utilize them, an-,, activities cannol@- be started with 4 currently available -or expected to available of the 5 actions we have taken to date, 'his -o-nincr. 6 DR. 1"01:AP-,OFF: Do you off hand those five re'gi o- s 7 that we can consider that in making -funding? 8 DR. PAHL: The specific four regions? 'Ir. Spear? 9 TIR. SPEAR:. Florida, @',emrihis, Mississippi, ar@@@ r'-Iri- lo State. DR. FLOOD: Tri-State brought up DR. PPHL: There is a motion on the floor and seconded. All in favor of tJe motion, please say aye. VOICDS: Aye. 15 DR. PP.IIL: All opposed? 16 (No response.) 17 DR. PAIIL: Ilotion carried. L@.at concludes the formal -13 11 business, except for, I think th6 very important public 19 session, and I would like to ask Council whether you would 20 like a brief break and then bring some coffee back to the 4- 21 L-able and have your onen meeting with the representatives, or whether vou would like to continue on, and then have a 23 break@ 24 DR. I-IILLIKEN: Coffee now. 25 DR. P7'"IIL: All right. I think that is fair to our 4 7 1 visitors too. Oon't we try to reconvene in, oh, ten or twelve 3 minutes, as soon as--we can bring some coffee or doughnuts 4 back to the table. And then we will be refreshed for hearing 5 from our guests. 6 (T,-7hereupon, a short recess was taken.) 7 DR. PAIIL: I-lay we -come to order please? Now that we 8 have had achance to get some refreshment, I would think we 9 are in better position to consider the remarks of our guests. 10 I would like to welcome both Mr. Bacon and Mr. Sargeant from 11 the Maryland PIIP. 12 Mrs. I-IcCarthy, Dr. Scherl, Mr. Prasad, from Nassau- 13 Suffolk t@-IP, and of course, Dr. Sparkman has already spoken with us this morning. 14 15 If there are other guests, I dd not have their names 16 here. Ile would certainly invite you to participate in the ope@ 17.!session. I have been asked because of other commitments to 18 if we'could call on Mr. Sargeant,'from the Maryland RRIP first, 19 and I would do so now. 20 And I would ask to have you identify yourself, if you will, for the record. And give us your statement, or sub- 21 .;Init a statement, and then following any discussion will you I 23 lplease -- we'll hear also from Mr. Bacon. If you care to spea 24 and then if that is satisfactory, we will com@ to Dr. Scherl, and others from the Nassau-Suffolk PD@IP. 25 IIP,. SAPGE2\-P','T.- Than'x,l you. T do 1-ia%,c- a 12.00 arpoint-' 2 iment -in Baltimore, and that is what you got wli@n you try to 3 schedule things so tight. 4 I am a member of the Executive Committee of t,Lie i@giona 5 -Advisory Group and the Maryland P@-gional 1-ledical Program. Lilz,-- 6 you I am a volunteer and give my, time for towards hopefully 7 operating an. efficient and.effective regional medical program.1 8 I do have a statement which has been distributed to 9 iyou, but in the interest of your time, I am going to summarize I - 10 :it if I can. lihen v7e.receiv:-nd the news referr,-md to earlier 11 !this morning in--IL4aryland i,7e did discuss it at some; length, 12 ;and felt it important that perhapsepeople coming from all over lithe country are not ascdgnizant of the city of Ba!4-.iirore, and 13 14 i,tne state of Maryland, as they might be, and we felt it would 15 @be important that you understand our case; and our philosophies,,, 16 @and therefore that is part of the reason that I n-,n here today. 17 The gentleman from VA is probably close to ilaryland so understands the geographic situation perhaps better tha 18 n 19 irl.,Co@'t Ot vou and I am sure Dr. Schreiner does, from Ilashington. @Maryland has a fairly large population but our Regional @L-ledicall 20 ;population only serves about three million of ti-lat Po-.ulation1 21 @,@"h,at is made un of 2.7 million, in 11-iryland. 1"2 And 300,000 in Yorlc, Pennsylvania. I-'. think it was 23 24 referred to earlier this morning, that regiorul medical programs- .do cross state boundaries and ours indeed does. As all of 25 I the Regional Progra--is we have been involved in changing Drior- 2 i-,ies, and i change in --he effectiveness of -@undinc,, and so 3 forth. 4 So we have been somewhat pc-r;7!exed at times, and i 5 somewhat harried at times in order to get in our aDolica--Li ons i 6 for money. And I am sure that you have experienced the same 7 situation that we have. 8 Now, of the three million people that i..Te serve in- 9 -Ehe'.'Iaryland Regional 'I'@--dical Program aoproximatel,, two 10 million of that total is included in the metropolitan Baltimore 11 area. That comprises the five standing counties as well as 12 Baltimore 'City itself which is a separate and distinct politt@cz 13 subdivision, not part of a county. And in western I-larvland there are a:,),@_Drcximat-@lv 14 -ater,ent which was 15 300,000. These figures are on the s4@ 16 given to vou, I am rounding it off; on t.n.e Eastern Shore of 17- !.,Iaryland, v7hich I guess is referred to as Chesapea),,e country, 18 there are approximately 250,000, and in the southern part of Ilaryland is 115,000. - 19 20 Then we have an additional 300,0,00 in York,, Pennsyl- 21 !II vania. Interestingly enoucrh,-of the -)o--ulation, and that is @@,io million in the Baltimore area, 7z-).G Fercent of that pop- 2i '- arc- ulation/in the low income area, in fact, 25.6 percent of the 23 1 24 people in metropolitan Baltimore city alone a-re Medicaid 25 recipients. In fact, 54 percent of all the people in the of I-laryland, the entire population of I-laryland @,iho -re me-di-: 3 caid recipients rbside in Baltimore city. lIence, I think 4 ii what I am tryincT to point out to vou is that many of our 5 obligations have been centered on Baltimore city, @.,hich has 6 been o@ the criticisms that we have had. 7 And we have tried to expand our services in areas 1 8 outside Baltimore, but primarily the greater part of 9 and concentration has been toward improving methods of the @i 10 people in Baltimore city to receive medical care. And so, 11 while it may seem out of proportion to the members of the group, and the members of the technical advisory grou indeed, 12 p 13 it ]Isn't when you look uDon the geographic and the economic -ribution that exists in the state of Mar land. dis4@ y 4 15 Now, we have adopted many approaches in our effort 16 to submit grant applications. We have -- amongst thoseincludel i7 support of planning, for IIealth I-'Ilaintenance Organizations 18 we-have been a great deal of patient education in hypertension 19 for the low-income black-famili-es, particularly in Baltimore city. 20 We have pioneered in the areas of home health care 21 @--.Lvj-L;es to neighborhood corporations and we have also assis%@-e,l 2,-) 23 in the training of pediatric nurse practitioners who today in Maryland are serving not only Baltimore c@ity, but they 24 25 are serving in the rural poverty areas as well. 1 I v,,ould 1,3-,e to point out scme of -&-he ver@, important 2 x:i=@c@s ol the @,IP has had cz-1 ac@i-,,i-ti-as in the health field I 3 in the state of I.'.'.Iar-,.rland. In Baltimore -- I can sure that 4 those of you associated with medical schools in the city. -re is al@.,,ays great rivalry bet,lqeen the medical schools I T@ 5 is going to be the first i@:i4L-..i w hat 6 7 In Baltimore when we developed our mechanism for 8 let me get the correct title here. l,idneN, Transplantation'- 9 Program. l@7e were funding part of this several years ago. 'qe were able to bring together the state's two medical sch@Ols., io 11 the z;tate Ilealth Deparlt--,T,.ent, 'a kidney foundation, and two or three of the community hospitals 1.7hich had their own pro- 12 13 grams, to bring them together. 14 So now we have one unit working in a cooperative 15 manner to accomplish the objectives that four or five units 16 were working towards before. '.-%'e think that this is a very positive accomplishment that has been made in the city of 17 18 Baltimore, particularly ,%,hen as Z-said earlier, there have al- ways been rivalrv. 19 20 llnd I see some.smiles on some DoQtors faces here. 1,7-- also back in 1969 asked for and received a grant of sll5,oob 21 ill'ro,,,--i(aed off 'or a three vear closed chest cardiopulmonary 22 resuccitation training program. And this has been taken over 23 since that time by the Ileart Association of L@ieryland who has 24 25 trained some 13,000 individuals in the life savincT technique. materials into Dutch. L'@nd is using them in connection %..-itl-l 2 its patient education programs in Europe. 3 So, agai@, w3 ti-,inl-. that this is a very important 4 for us. 14ovi, these three t-hinas that I have just mentioned 5 to you. We feel thev demonstrate the vital role that the 61 411aryland Pegional ".iedical Program has pla@7ed in the development 7 of new and effective methods of providing critically needed 8 services where few if any previously existed. 9 You have before you today, or you will have beforel 10 you today two projects which applied for in our July application 11 two of them applied directly to the Western part of Maryland. i 12 Where tliree hundred thousand of our population reside. hey 13 ".LI= PcLrt Of the second application TDrogram. 14 They involve health education in one case, health -15 education for teachers and professionals.in school system, 16 a joint effort to educate the teachers so that we can corrunicat 17 this information to the students, and the school system i-n 18 Western @laryland, which is part of the Appalachia Poverty 19 Region. area. 20 Over on the Eastern shore we have, which is 250,uvv 21 population, we are funding a clinical cancer program -- a 22 -hospital discharge planningirogram and continuing educational program in aeneral, in Tivert County. fall three.of these are 23 24 now being continued under private enterprise and private funding York, Pennsylvania which we serve, with a population: 25 i4 1 with a population of 300,000, approximately we liavc-, g@L@,,en 2 continuous attention to this area. 3 @Nle have a@ acute intermediate and long term scope 4 care program begun in 1969 with a grant of $561,000. This 5 established a special hospital unit for the total care and rehab of stroke Datients. And since the termination of',@-he 6 7 funding for that program, in 1972, the entire program has beelt, 8 continued, and today is serving an areas with a population 9 of 300,000. I 10 We are very proud of these accomplishments. Which 11 we think are positive things which perhaps in the rush of all the other applications and information coming to you may be 12 13 overlooked. I would just like to make one last comment, to 15 point out that each of the eight projects that we have pro- 16 posed for funding which will be before you today, at least, 17., we anticipate is aimed at achieving a specific objective spel: ee 18 out in the latest, I said latest-interpretation because as I 19 have indicated earlier, there have been continuous changes of Federal guidelines, and that is developed cooperative 20 21 relationships in the improvement of care in underserved areas. Developing innovative approaches to medical care. 22 1 All of these projects received full review by the Technical 23 P-@view Committee of our Regional IIedical program b-,r the compl@,-t.- 24 .11 regional advisory group and by the '.'Laryland Comprehensive 25 SI 5 11-3alth-,Plan agencv. 2 1 '--'-an!: you vnry much for --,,our time. I have been 3 as brief a5 I couicT,. 'I'Te do have complete details on material that has already been distributed. I am glad to answe r 4 5 your questions. 6 DR. PAP-L: Thank I,ou very much, !@!r. Sargeant. Dt 7 Gramlich? 8 DR. GRAI@LICIT: Ilr. Sargeant, I am sure we all very 9 m.uch appreciate vour lucid comprehensive remarks. Play I asY. 10 !i your occupatioi-l? 11 IIR. 5ARGE.AITT: I happen to be the Executivc- Director of the State IL-ledical Society. 12 11 I DR. G@-ILICII: ror the state of l,@laryland? 13 MR. SARGEA14T: Yes. 15 DR. PAIIL: Dr. Wammock? 16 DR. X,7AI-LNIOCK V,hat did you say about the medical 17 schools competing together. I,.Ihat? 18 ilIR. SARGE.-WT: Ivle did geE them into a kidney transplant 19 program. It has been very effective and %.ie have very active 20 recruitment for kidney transplantation that,are -- 21 DR. W,@@%U,4@OCI": But that is the only program they get !-together on. 23 IIR. SARG-@i@IT: They have gotten together in many others. The university medical service program is working 24 25 verv closely with them, as is the i-ILedical Society, lv7e have a close relationship that we try to bring them together. Try I I to get them to see each other's view points. t]-iin)z COM-! petition is good. illo@-,levc-r, @@ie don't thin)-. that is en4--irel@, 3 bad. 4 DP,. Pi'fflL: Is there any other discussion or comments. 5 Thank you very much, Mr. Sargeant. We hope you make your 6 appointment in Baltimore without breaking the speed limits.. 1 7 Mr. Bacon, do you have anything to add? 8 MR. BACOII: klo, in view of the time pressures, Dr.- 9 -Pahl, it has been a pleasure to be invited. Pnd if there 10 are questions I would stay around. But I also want to get 11 .'-Ir. Sargeant back to his me eting. So I won't interfere with 12 that. DR. PAIIL: Yes, Dr. Jane@%,ay. 14 DR. J2UIE@@IAY: Could I ask one question of Mr. Sargeant: 15 When you say you got them together, does that mean in the 16 -kidney transplantation and d.ialysis, are being done in only 17 one of the universities? 18 MR. SARGE2U4T: We have-in Maryland, perhaps, a unique 19 situation. Two years ago the state legislature passed a 20 statute which set up a I-laryland Kidney Commission. That 21 1--iaryland l@idnev Commission has jurisdiction working with the CIIBA to designate onl certain areas for kidney transplants y and dialysis. 23 24 In answer directly to your question, no. That does 25 not mean that there is only one university in Baltimore doing 7 I that. Obviously there would have to be some interchange 2 back and forth. 3 There ar6 many dialysis centers. But I thin}-, I bel4@,z 4 to my understanding there are onlv L@-%-,o units, two tranrT)lanta'- 5 tion units in the City. 6 DR. PAIIL:' Thani@ you ver@ much. 1-7e certainly,under-; 7 stand as you dash off to another appointment, perhaps.@.,7e may 8 now turn our attention to I believe Dr. Larry Scherr, 9 -.from l,'.Iassau-Suffolk has astatement, and Dr. Scherr, if you 10 will'identify yourself for the record we will be pleased to 11 hear from you.. 12 DR. SCIIERP,: Dr. Pahl,,members of the Council, I!m 13 i)r. ia@-irence Scherr, Charman of the 1,Tassau-Suf--@olk regional advisory group. ]\-nd I am a member of the areals medical -15 community. I appreciate the fact that I can appear before 16 you. 17 The purTDose of my visit here is to express the .18 strong support of the regional advisory group for our progra T 19 and to answer any questions th-atlou may have. I-le recognize 20 very well the c'ri-@iquec of this Council and the organization' 21 cf. our RAG group. 2'") And actually to that and I visited the division 23 of the regional medical program with another member of RAG 24 to speak with the staff, to work out means to put into effect': 25 what was necessarily to present this grant before you. Yesterday I unfortLuiately could not be here, but ranv of 2 you did hear our coordinator, @-ir. Prasad co over the contents 3 of our nrogram. 4 You also have a prepared state,-,ent from me and I 5 @@:Lll not c, o over that again. The content of the program and 6 any questions referable to that I will ex-nlain -- they are 7 explained in that statement. 8 I just would like to clarify one or two points, 9 that are not in that statement itself. To begin with, our 10 r3gion, Long Island, the two counties as in @lar_vland has a 11 corperable population of 2.6 million peonle. The distribution 12 of the population is in a rather hetero aeneous fashion. 13 Ilalf being in an established suburban community, 14 the other in . a rural community f ast l@ecc.-iing a suburban 15 community. Secondly, there is a rather unique geographic 16 Dosition of our region. It is penninsular in origin, and i '17.1 finds itself admirably to regionalizal@-ion. 18 Zmd it is that end that we have developed our pro- -19 gram. It is a cc-xiunity based-'regional r@-,edic,-tl program whLr'@ 20 has been in actual operation for the past four years and 21 has been recognized by the community as an appropriate agency 22 for the implementation of certain health ;Drocra:7,s. 1,To@,7, earlier this year, the r-.egional-Advisorv -@rou@ 23 24 through iL-.'s committee had established the goals and priorities 25 o' ambulatory care. The actual development of delivery ser' 5 vices and diagnostic services of preventive care and t@-is 2 -Fortunately confcrrqc-d to our arc-as, the goals and priori'---L=-s 3 of @iassau-Suffolk Com,,Drehens iVe T Health Planning Council and 4 was actuall,, the start of-good effective coo-@Dc-ration bet%.:een 5 the two agencies. 6 1-loi%7 , the grant before you is really a revitalized. 7 approach for our i@lassau-Suffolk regional medical program. 8 Ti-,Te are proud of the stated objective and the methods of acl-iiev- 9 ing these objectives. 10 mLo go into details it does have fourteen directing I 11 ambulatorycare-projects. It has two emergency services projects 12 which are in essence ambulatory care projects. And it has 13 t@qo renal programs which have ambulatory care components to 14 them. 15 Thereby meeting our goals and priorities. Now, somei 16 of the programs, despite the current limitation on PI.'Ps future 17 course do require two years for realistic completion. Our 18 grant contains provision for this-as well as the means -r,--)r 19 continuing staff support. 20 That is, not only for the monitoring those particular 21 pro.-rams that are carried forward, but for monitoring what 22 has gone on before, what is going on this year in the programs. 23 that have been started in previous years. And-we believe 24 that is a rather vital and important role. 25 Just three other very brief items. one is the 1 P-IP staff. The advisory group believes thn-t our rc-wl%-, r-=cc7ani-z: C) staff under the direction of I-,Ir. Prasad has the str-@nc-.th and 3 the wisdom and the@leadership to help us carry this program. 4 Through to it's successful completion. 5 The grant before you will, I think, not on!-, reflec@-s 6 their dedication, but I think it reflects, their expertise in- 7 their field, and I point out again, that their technical 8 competence and their cooperation with regard to our area-wide@, 9 comprehensive health planning council. 10 Secondly the PIKG itself has corrected some of its 11 imost of its prior organizational difficulties. That is, the separation of t@.functions of the grantee organizations 12 13 from the regional advisory group itself. The by-laws have 14 been revised and completely conform now, to IUIP directives. 15 And I think they have sustained a continuing interest-., 16 1 I;y the way, in it's,objectives by this representative co.L=,unit-,, 17 group. 2'md we believe that it is a major and a viable- organi-.=-- 18 tion to serve the health needs, on Long Island. 19 Secondly, a word abou-E:-Ehe grantee organizations. 20 OUr grantee organiztion -is independently Incorporated specific 21 ly to deal with r@1--i@p functions. I would just likd to no'Lnt 22 @-out that in a recent fiscal audit, covering three to five 23 months on a rather intensive basis, really on a'dailv basis, C)4 the grantee organization was commended for its' expert handlinc 25 of the fiscal matters. r 1 This, I understand, is' 'LLnusual to have a coin-mendat4-ct) 211 on an e@it conference. Filially, in ci3sinci, I @@7ould ju,-,t 3 like to reaffirm my.-support of our program in the support of 4 the regional advisory group. 5 lie believe that the program is well designed and 6 it is well coordinated to meet the'needs of the people 'of, 7 Long Island. Ile have asked for an amount which exceeds slig'n4-1 8 two million dollars for this next period. We do ask and do 91 request and do request that you favorably consider this, and 10 thank -you very much. 11 DR.PAIIL: Thank you very much, Doctor. I am sure vou 12 would be very responsive to any questions that may come up. Is there a discussion question? ILIR. il"lilliken? 13 14 MP,. MILLIKE'LL: @@7ith regard to past budgets, in rega 15 to the projects that you are Droposing, or recommending, i-;ithi@ 16 this, what has been built in to see that these projects are 17 inter-related with other sources of funding. And what is '18 the potential for their continuation in case the RD'IP money is 19 not available after this grant period. 20 DR. SCIIFRR: That of course has ali..ays been a major 21 consideration of the regional advisory Group. Despite the -ng, and that is to seek a %-;a,,7 to 22 i-supposed last year of fund4 stimulate the project to begin with. find encourage the pro3ec:t 23 24 office or other provider organizations to picj:. up the program 25 provided it is demonstrated its worthiness. Now, I think that therein is the strength of our 1 program. Those programs that have s4--arted have been picked un 2 in some asn--c@- by other organizations emergency services b,7 county health departments, renal programs, bv some institution-=, 4 ;I and by community medicine, and by !.'Iopc-full,,, the institution bv T,,.!hich '@-haL- is developed, and so on. 5 6 It is our intention from the very beginning to use the reaional program as a stimulus to start developing- 7 8 each programs, ultimately to be picked u,2 on a more permanent 9 basis by other means. 10 DR. PAHL: Thank you. Is there further discussion 11 il of questions of Dr. Scherr? 12 it' (.,To response.) DR.PAHL:Mr. Prasad, would you have anything to 13 add? 14 ii !!R. PPASAD: No. I spoke yesterday. 16 DR. PAHL: Would you use the microphone, please, if 17 !I you car-- to make a comment? 18 @1,R. PRASAD: 140. I spoke yesterday before the Reviexr 19 Co-,mittee, and most of the Coun6il members who were present, 20 and I have no comments to make. Unless you have some questions 21 to ask. DR.PAIIL: Thank you. Iliss M.cCarthv? 22 @',IISS liCCARTHY: No. Thank you. 23 DR. PAHL: Well, then, if there is no further dis- 24 cussion on Ilassau-Suffolk, I want to thank you for return2.n@ 2Z here today, and submitting your statement throiioh Mr. Prasad yesterday. Are there anv rp-mbers of the p@ol, c who wish to ...a! 19 MISS MARTINEZ:- 82. 20 MRS. SILSBEE: -382,000. Is ther6 a second? 21 (No response.) 22 MRS. SILSBEE: Is there another motion? 23 DR. KOMAROFF: I move the Connittee's recomrienda- 24 tion of S450,000. 25 DR. JANEWAY: Seconded. n42 1 MRS. SILSBEE: The motion has been made and seconded 2 that the Central New York, application be approved at the 3 level of $450,000.-. 4 Is there further discussion? 5 (No response.) 6 MRS. SILSBEE: All in favor? 7 VOICES: Aye. 8 MRS. SILSBEE: Opposed? 9 (No response.) lo MRS. SILSBEE: The motion is carried. 12 13 14 15 16 17 18 19 20 21 22 23 24 25 106 n43 1 COLORADO/T-7YOMING 2 MRS. SILSBEE: The next region to be reviewed is 3 Colorado/T-7yoming. And let the record show that Dr. Gramlich 4 is out of the room. 5 Miss Plartinez? 6 MISS PIARTILTEZ: I am waiting. 7 All right. I believe the Committee's recommendation 8 was for $200,000. Again I am a little low in that I recom- 9 inend 146,959. 1 have a comment to make on one of the projects 10 in particular -- well, two, all right. 11 one, number 59, seems to me to be primarily an a 12 education project. And I was wondering whether/Staff oerson 13 could tell me if this was developed in cooperation with the 14 educational commission of Colorado? 15 MRS. SILSBEE: Miss Murphy, did you hear the ques- -16 i tion? 17 MRS. MURPHY: Yes. I have to check.it. 18 MRS. SILSBEE: Could you get over to.the microphone 19 please? 20 MRS. MURPHY:. -I really know no mbre about the 21 project than what is on page 15. 22 MISS @IARTINEZ: Well, if it is the information that! 23 I read last night, then Ijust make the observation that the 24 educational commission or agencies in the Sti7te were not consulted and that the project description was extremely 25 107 n44 1 hazy in my mind. So I have severe questions about that 2 one. 3 But the bne that I really object to is number 64, 4 which is entitled, health promotion service, primarily a 5 project to reach senior, Spanish-speaking senior citizens,. 6 sort of an education project. And at one point the comment 7 is made that the money is 'going to be given-to the public 8 health department to,hire nurses who will go out and try to' 9 overcome social barriers. 10 That doesn't explain how it is going to be do.Li=,, 11 it doesn't explain who, you know, what criteria is going to ii be used inthe selection of staff"to do this. To me, this 12 13 is an example of a lot of poor planning that goes into pro- 14 jects which are supposed to reach minority people and don't. 15 In other words, it is an emmpl@ of the use of a 16 minority population for funding. And I would suggest that 17 either that project proposal be developed so that it is under:, 18 community control and hires community persons to do the out- 19 reach or that they be requested to not fund it. 20 MRS. SILSBEE: Dr. Haber? 21 DR. HABER: I have a serious question about project 22 I'.number 61. Could Staff enlighten us about what is intended with the $17,000? You can't buy band-aids for S17,000. 23 MRS. MURPHY: That proposal has bed-n called into 24 EMS 'for consideration. We will not fund it until it gets 25 n45 1 approval. 2 DR. HABER: Very well. 3 MRS. SILSBEE: It has not been referred to EMS. 4 That was one we wanted to get the Committee's views on, 5 because it doesn't conflict with the legislation. 6 DR. HABER: I would like to point out that a burn 7 center is an extremely expensive operation,.reauiring heavy 8 staffing by very skilled people. And I think that we sadlv- 9 -or badly need the development of such burn centers. But 10 unless this is some kind of exploratory project -- I can't 11- tell here -- I would say that the scope appears to be hope- 12 lessly inadequate. 13 The demands of these burn centers are such that 14 i you should deploy these with the createst precision and in .15 areas where they are likelv to be well utilized, and concen- 16 trate the rest on developing transportation svstems to aet 17 people to where the burn centers are. 18 I don't know what this- but S17,000 seems to be 19 so inadequate that it is ludicrous, Iwould think. 20 MRS. SILSBEE: Mrs.'Morgan? t 21 MRS. MORGAN: I don't believe Colorado has a burn 22 -center or such at the present time. They have applied to 23 the legislature and were turned down last spring for money 24 to build-a burn center. 25 This $17,000, I believe, mainly is to take a nurse 10 9 n46 I who has been working in, quote, unquote, what they call 2 their burn center where they treat their burn patients, 3 which is a $12,OOCL., add to it travel about the State, and 4 1 think really to urge passage of a legislature bill where 5 it will be taken care of by the State at,the Colorado 6 General. 7 DR. HABER: Well, if it is preparatory or educa- 8 tional 9 MRS. MORGAN: I think it is really a study to get 10 information to develop one. 11 DR..HABER: T,7ell, O.K. Under those circumstances 12 1 will be mollified. 13 MRS. SILSBEE: I haven't had a motion on Colorado/ 14 Wyoming. -15 MISS MARTINEZ: Yes. I would-to make a motion thatl 16 we fund at the level of 146,959. 17 MRS. SILSBEE: Is there a second? 18 DR. KOMAROFF: Second.- 19 MRS. SILSBEE: A motion has been made and seconded 20 that the Colorado/Wyoming application be approved at the 21 level of $146,959. 22 DR. KOMAROFF: Including that caveat that she 23 mentioned about thespanish-speaking 24 MRS. SILSBEE: That is project 54 25 MISS MARTINEZ: Yes, either it be developed with I n48 I number 64, unless that project can be developed to include 2 a community control policv board and outreach workers who 3 are from and sensitive to the needs of the particular popu- 4 lation being served and that if s.uch conditions are met 5 that the funding level be increased 6 MRS. SILSBEE: No, you have to go the other way to get a motion like that. 8 MISS MARTINEZ: $4iooo. 9;I DR. KOM-AROFF: 187, 188, but restrict the $41,000' 10 unless they do it right. 11 miss MARTINEZ: O.K. Does it come out exactly 187? 13 MR. HIROTO: 188. MISS MARTINEZ: All right. Let's try this once 15 again. Imove that Colorado/Wvoming be funded at 188,182 16 with the condition that project 64 is to be developed to 17 include acommunity policy board and community outreach 18 i@ workers sensitive to the population in question, and that 19 if such conditions are not-met that the funding level be 20 reduced to 146,959.... 21 MRS. SILSBEE: You have heard the motion. is there a second? DR. WAMSOCK: Second. MRS. SILSBEE:: An]( further discussion? 24 (No response.) 25 112 n49 1 MRS. SILSBEE: All in favor? 2 VOICES: Aye. 3 MRS. SILSBEE: Opposed? 4 DR. JANETQAY: No. 5 MRS. MORGAN: No. 6 MRS. SILSBEE: Let's see. Let's have the ayes 7 raise their hands. 8 O.K. Let's have the nays raise their hands. 9 The ayes have it. The motion is carried. 10 Dr. Janeway? 11 DR. tANET,7AY: It seems to me that there must be a 12 reasonable balance between fulfilling all the responsibilities is and carrying out the policies and statutes of the Rt.!P versus 14 the selective identification of particular projects. The 15 technical review has been done. 16 And there are only two Council members who have 17 7uae opportunity even to read the forms 15. 1 would just 18 hope that we don't-get'-like the fellow who went down into 19 the swamp and he saw an alligator down there, and he beat 20 that alligator over the head and he killed,them. 21 And he just kept running into more alligators and' 22 killing alligators and forgot after he was down there with 23 all those alligators around that somebody sent him down to 24 clean out the swamp. 25 DR. WAD,@IOCK: Common, Sam Ervin. 11 3 n5O 1 MR. PIILLIKEN: You mean he is up to his elbows in 2 alligators? 3 MRS. MORGAII: He's not quite that far. 4 DR. JANEWAY: I have to abridge the story a little 5 bit. 6 MRS. PLOOD: As a matter of comment--- and again, 7 as Dr. Janeway occasionally says, gratuitously -- I do think 8 though that we have some responsibility. If the technical 9 reviewers or the Regional Advisory Group itself does not 10 take into consideration the problems of dealing with minority; 11 groups and using terminology such as overcome cultural 12 barriers rather than to address cultural barriers in a 13 manner that can be adapted to the health delivery system. 14 And we do face the responsibility of questioning 15 the development of individual projects when they are serving! 16 a population that many times is not articulate in expressing 17 its own needs. 18 DR. JANEWAY: I don't-disagree with that one bit, 19 MRS. SILSBEE: Thank-you. 20 The transcript for Arizona has arrived, and have t 21 you had a chance to look at it, Mr. Hiroto, or would you 22 rather go ahead? We can come back later? 23 MR. HIROTO: All right. I will take-Connecticut. 24 MRS.-SILSBEE.: You'll take Connecticut. Do you 25 have that one? 114 n5l MR. HIROTO.: No. 2 MRS. SILSBEE: We have to hold -for just a few 3 minutes while there is a switch the changing of the guard 4 here. 5 (Whereupon, at 12:30, a luncheon recess was taken 6 until 1:00 p.m.) 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 115 1 AFTFRNOON SESSION 2 t4S. SILSBEE: The meeting will.come to order. 3 In the break that-we have had, I've had about three or four 4 requests of individuals in regions who have to leave early 5 and I'm prepared to accomodate them as much as vossible, buti i 6 weire going to have to move along. Mr. Hiroto. 7 MR. HIROTO: Ms6 Chairman, would you entertain a 8 motion that should the primary reviewer and the secondary 9 -reviewer have no problems or difficulties with the result 10 of the Review Committee, that we vote in block on those and 11 go along the table and list those states that we feel secure 12 with and only review those or discuss those that some people 13 may have questions about. 14 MS. SILSBEE: I will entertain the motion. 15 MR. MILLIKEN: Second. 16 DR. HABER: One mechanism for accomplishing that 17 might be if you were to read down the entire list of remain- 18 ing proposals and ask if objection is raised on the part of 19 primary or secondary reviewer with the committee's recommen- 20 dation. A negative answer would seem to indicate that it 21 would then be part of a block to vote on. 22 MS. SILSBEE: Right. 23 DR. 1,7ANlMOCK: You said-you would read down the 24 list? 25 DR. HABER: Yes. There are several ways to 11 6 1 accomplish this, but the most expeditious wonid be for 2 Mrs. Silsbee to read down the list and if anyone feels 3 that he doesn't q@ along with the committee's reuort, he 4 so states and it is then removed for- individual considera- tion from the Block Vote. MS. SILSBEE: I think the record should show @hat 1 6 7 the entire council has before them the composite recommenda-i 8 tions of the review committee showing the requested level 9 and the committee approved recommendation. I also think 10 that the record should show that this is in view of the .11 fact that you participated as observers in discussions of 12 the committee's deliberations yesterday. 13 I-IS. GORDOIT: Was there any problem with the con- 14 flict of interest? 15 MS. SILSBEE: Not on block action. All right, 16 the motion has been made and seconded that we go through 17 this. I'll go down the list and if anyone has anv objec- 18 tion to the committee recommendation, we will take that -19 particular application out for-@discussion, otherwise there 20 will be a motion about the block action. All in favor. MS. SILSBEE: opposed. 21 22 Motion carried. I will not only read the list, but I-will read into 23 24 the record what the recommendation was as far as the funding 25 level. f: MS. SILSBEE: Arizona $150,000. MR. ITIP@OTO: Object. 2 3 MS. SILSBEE: Connecticut $750,000. 4 DR. GRAMLICII: Object. MS. SILSBEE: $600,000 Florida. 5 Greater Delaware Val-ley $684,512. 6 Hawaii - $486,7.50. 7 Illinois - $750,000. 8 Indiana - $240,000. 9 10 Intermountain 11 DRi KOMAROFF: Object. 12 MS. SILSBEE: Iowa - $173,929 Kansas - $363,545 13 14 Lakes Area - $150,000 Louisiana 15 16 DR. JANEWAY: Object. 17 MS. SILSBEE: Maryland - $650,000. 18 DR. WAMMOCK: I think-we had better go over that. 19 MS. SILSBEE: Memphi,s - $950,000 20 Metro-D.C. - $256,000 21 Michigan - $500,000 Mississippi - $2,000,000 22 23 Missouri,- $540,000 Mountain States - $300,000 24 25 Nassau/Suffolk 1 DR. KOI,IAROFF: I think we had better discuss that.1 2 MS. SILSBEE: Nebraska - $95,000 3 New Jersev - $1,100,000 4 New Yo rk Metro - $950,000 5 North Carolina - $120,000 6 Northern I.,Iew England - $600,000 7 Northlands - $300,000 8 Oklahoma.- $25OiOOO 9 Oregon - $148,693 10 Puerto Rico - $131,335 11 Rochester - $1,000,000 12 South Cdrolina 13 MRS. GORDON: 'Objection. 14 MS. SILSBEE: South Dakota - $88,850 15 Susquehanna Valley - $500,000 16 Tennessee/Mid-South - $570,000 17 Tri-State - $610,000 18 MS. SILSBEE: We'll co-me back to Texas. Tri-State 19 $610,000. Virginia - $960,860-. 20 MS. MARTINEZ: Object. f I-IRS. FLOOD: They have an arthritis program. It's! 21 not essential, it's automatically taken care of. 22 23 MS. SILSBEE: From the previous recommendation. 24 Washington/Alaska - $530,000 West Virginia $1,000,000 25 MS. SILSBEE: Wester-n Pennsylvania $450,000 DR. HABER: Objection. 2 MS. SILSBEE: Wisconsin - $200,000. 3 We'll review Arizona, Connectucut, Intermountain, Louisiana,i 4 5 Maryland, Nassau-Suffolk, South Carolina, Virginia, Western I 6 Pennsylvania with Texas. 7 MRS. MORGAN: I move that we accept the Re view 8 Committee's recommendations for funding of the regions 9 not specified to be taken care of separately. 10 DR. KOMAROFF: Second. 11 MS., SILSBEE: Is there further discussion? (No response) 12 13 MS. SILSBEE: All in favor. Opposed. 14 15 MS. SILSBEE: Motion is carried. 16 We'll now go to Arizona. 17 MRS. KLEIN: This is just a minor thing, but we 18 had taken some this morning and-the way the motion was 19 worded, all those other than the ones that were recently 20 enumerated, so I think the motion should show,, except for those already discussed and approved. 21 MS. SILSBEE: I think that was the consensus 22 of the discussion beforehand. 23 24 25 % 120 1 ARIZONA 2 MS. SILSBEE: Arizona Dr. Gramlich. 3 DR. GPN4LICH: As a matter of principle, Arizona 4 has had difficulty with the organization, the leadership andi 5 had had some other difficulties that were technical with the, .6 DRMP and counsel said to clear-it up, so Arizona cleared 7 them up and the Technical-Review Committee rewarded this 8 function by cutting their allocation --- their recommenda- 9 ..tion. The question is one of principal. Do you reward 10 virtue in a negative fashion or a positive fashion? 11 There's not much question about the technical capabilities 12 of the region to accomplish the project it had ordered. 13 That was a minor element, but the concern on the part of 14 the technical review committee was, if you haven't been goodi 15 up to now, that you've changed everything we said you shouldi 16 do, so we're goina to reward you by cutting your grant. 17 MR. HIROTO: I,echo that. I was going to request 18 the council to consider changing-the amount of the award 19 to $240,000 --- $240,718 because-at least it meets the three 20 component projects in the upper three projects that have the 21 highest oriority. DR. GRMILICH: If that's a motion, I second it. 22 MS. SILSBEE: The motion has been made and 23 24 seconded that the Arizona application be approved atthe 25 level of $240,718. Is there further discussion? 12i (No resnonse) 2 MS. SILSBEE: All in favor. 3 opposed. 4 MS. SILSBEE: The motion is carried. 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 12Z 1 CONITECTICUT 2 MS. SILSBEE: I-le will now go to Sonnecti-cut. 3 Mr. Hiroto. 4 MR. HIROTO: I can appreciate the problem that 5 probably we all face with Connecticut and that Connecticut's; 6 program has continued as it was designed until just the last 7 10 months. The technical reviewers, one recorimended'a 8 a level of $250,000; the other recommended a level of 9 $1,400,000, which reflects, I think, the difficulties we 10 all have in reviewing Connecticut. Dr. Gramlich, if you 11 have any comment that you would like to make. 12 . DR. GRAMLICH: Yes. Again, these are general comments and more philosophical then technical. Here, 13 14 apparently and I don't know the region well at all. I 15 may be in error, but it appears this is an RMP set uo with .16 a different kind of program from the pattern throughout the 17 rest of the States, throughout the rest of the nation and 18 therefore, our last Technical @eview Committee said, well,, 19 since it doesn't conform, we shouldn't give them anv money. 20 Now, maybe this is an entirely wrong interpretation. I 21 would appreciate staff input on the assessment of the justification for dropping the funding because of the fact 22 23 of the different kind of program, one from the'other. 24 MR. HIROTO: Dr. Gramlich, I don @ think that is a primary consideration. The problem seems to be that all 25 3 I of the P14P funding or most of it has gone into the institutional area, rather than into other areas and 2 despite staff eff@rts to spread the program a little nore 3 fully throughout the state and throughout other institutions., 4 this was not accomplished At the last council meeting, i 5 council agreed to reduce funding dramatically because this 6 7 was the only way that Connecticut would get the message, so to speak. They have gotten the message to a degree and 9 .so the $750,000 level seemed reasonable to rhe review 10 committee. DR4 GRAMLICH: Rebuttal.time. 12 MS. SISLBEE: Dr. Gr@.lich. 13 DR. GRAMLICH: To begin with the May request for 14 funding was not large. It was something in the order of 15 $,636,000 dollars. The major request is what we have in front of us now. Therefore, since the timing again with 16 17 Connecticut, was differnt, we are penalizing them even 18 further by not killing their program by refusing to accept I '19 their major funding request. MS. SILSBEE: Dr.Janeway. 20 DR. JANEWAY: It is my recollection, Dr. Gramlich 21 that one of the things that was taken into consideration wasi 22 23 considerable amount of their funding was going'through into I 24 1976. 25 DR. GRAMICII: Correct. 124 1 DR. JANEIIAY: And the way I recall the technical 2 discussions, there was a general sense of that group that 3 felt they should not fund projects through 176. 4 MS. SILSBEE: There were several considerations, 5 Dr. Janeway in terms of the level. One of them was the 6 two year funding request. The- other was a contract that 7 would have enabled the monitoring capacity to go bey ond 8 June 30th, but in addition, there were the two university 9 -.resources that were funded at a fairly sizable amount. 10 Other portions of the program that would have been of con- 11 cern was the--third faculty. There were no funds requested 12 for that. The Connecticut application in May, Dr. Gramlich 13 was requesting support for staff plus two months of continua.- 14 tion projects. This amplification asks for 10 to 22 months 15 for some activities and 10 months for others so it is 16 complicated by that factor. 17 DR. GRAMLICH: Right, but neverthelsss, if you 18 take all the two year projects And this iscrude arithmatic- 19 but nevertheless if you-take t'he two year projects and cut 20 each of them in half and award them one h,alf of the two year 21 total, you're in effect awarding them for one year. They still wind up with a figure $1,430,000. The way I visualized 22 23 this, it was incorrect, that since Connecticut'came in for 24 a small grant request last May, if we cut them way down this 25 time, we're in effect, killing their total program. 126 we have--- MRS. GORDON: --- it's not a matter of a new activi 2 3 so much. 4 MS. SILSBEE: I think we may need some help here 5 from Mr. Nash. The two year projects, are they all new 6 or are they continuations? 7 MR. NASH: I think some of them are new. The i i 8 onces, I think, that concern the review committee, the - 9 -four projects going to Yale and Yukon are fo:e over $800,000 10 for the two year period. 11 MS.@ SILSBEE: Mrs. Gordon, because you were not here yesterday, there was considerable discussion with the I 12 13 committee and Dr. Pahl about the two year request. The 14 re gion recieved its money and has the option of putting 15 some money away for some activities, if they feel they 16 shoudl go longer than two years, if they can work out some 17 kind of a contractural arrangement, so this is just a way of! 18 arriving at a level and I don't-think that should,be a major 19 worry for you. The Regional Advisory Group will make that 20 decision. Mr. Milliken. 21 MR. MILLIKEN: My understanding is that you have--:1 my understanding is that Yale was just awarded one of the 22 few large cancer centers --- ca ncer development tesearch. 23 Are they going to be able to spend all of tITis with the 24 25 limited staff they have there? 127 1 DR. GRN.ILICH: The money that goes into the 2 Regional Medical Program aspect of this.loroqram would 3 not --- this is their community outreach part of the 4 university budget. They won't --- I don't think they will 5 have much of a problem spending money. MS. SILSBEE: They have had experience in this. 6 7 The motion has been made-and seconded that the Connecticut application be approved at $1,430,500. All in favor. Couldi 8 9 ..I see a show of hands? Five. Opposed - the opposed have 10 it. The motion is not carried. I will entertain another 11 motion. 12 MR. HIROTO: I move the review committee's 13 recommendation of $750,000 be.approved. 14 MS. SILSBEE: Is there a second? 15 MR. OGDEN: Second. 16 MS. SILSBEE: The motion has been made and 17 seconded that the Connecticut application be approved 18 at'the level of $750,000. Is there further discussion? 19 (No response) 20 MS. SILSBEE': -All in favor? 21 Opposed. The ayes have it. 22 23 24 25 12 8 INTERMOUNTAIN 2 MS. SILSBEE: The next application to be reviewed 3 is Intermountain and the record shows that Mrs. Klein and 4 Dr. Gramlich are out of the room. Dr. Komaroff was the reviewer. 5 6 DR. KOI-IAROFF: Intermountain was rated by the 7 June Council as an above-average region. -They were awarded 8 2.23 million dollars, as a result of last councils session. 9 They now request a supplement of $481,000 for 19 new project 10 activities. The last council expressed several concerns 11 which appear@--most of which appear to have been resolved 12 and let me summarize them briefly. There has always been 13 a turf problem with the Intermountain regions, the mountain 14 states and Colorado and Wyoming regions. This appears to 15 have been resolved by some interlocking membership of the 16 advisory groups and frequent regular meetinas of the members 17 of the advisory group --- of the members of each of the three 18 advisory groups as well as by s6me joint funding of pr@'ects 3 19 which have a geographical overlap with these three PI.IP's. 20 A second concern has been the relationship of this 21 RMP its CHPH agency and apparently, according to the-staff- review and the CHP letters in the aDolication, there is now 22 23 a serious review by CHP under consideration by the RAG of 24 CHP. 25 The third concern that the council expressed last 2 9 time involved the role of the RAG in developing and rion4tor-- 2 ing projects. The region has developed what they call a 3 drag advocate pro-@ram whereby individual members of the RAG are responsbile for shepherding a project Droposal 4 through it's passage and subsequently monitoring that 5 project after it has been funded. It seems like a worth- 6 while idea. There was a .question of conflict of interest 7 8 in the establishment of a health development services 9 corporation. Dr. Pahl mentioned yesterday that,throucrh 10 action by the State Attorney General and through meetings I 11 with the RMP:staff members, this conflict of interest ques- 12 tion has been resolved. There was concern that council 13 epxressed regardingthe university domination of past I projects. In this cycle, 18 of the 19 projects were 14 15 sponsored by outside agencies which may have created a 16 problem, but has solved at least the concern of council 17 from the last time. The directorship of the program and 18 th@ capabilities of the four staff are deemed to.be good by those people who know the region best. I have not -19 20 visited there. The project proposal, however, seemed to 21 me to be exceedingly non specific and hard to evaluate. They have some very uninspiring continuing education Dro- 22 jects and they propose to develope their own audio visual 23 materials. Many of them give the impression of duplicating 24 kinds of activities which have gone on in other regions with7 25 130 out giving evidence that they nlan to build on the experience of others and I have the uneasy feeling that they may bs 2 repeating the failures and not the successes of other such 3 attempts at @IP, but it's hard to tell from-these abstracts. 4 One nrooosal is to establish a workshop on drug ,5 and alcohol abuse, and I just wonder why they haven't .6 applied through the institute for drug and alcohol abuse 7 8 or such an activity. It seems to me on the fringe of 9 P14P's funding mandate. Several strong projects are 10 listed. One of the most interesting involves a computerized 11 agency referal for extended services in which they would 12 try to do a better job of referring patients to apparently 13 social service agencies. I would --- I'm not concerned that 14 the projects are over inflated as has been described by the '15 past council and the review committee yesterday. In fact, 16- if anything, they appear to underestimate the cost and time 17 needed to accomplish local-objectives, but I have a feeling 18 there is a lack of cohesion about the whole Dackage and I 19 take issue with the committee's decision to fund them at 20 virtually 100 percent of their recruest and would reduce 21 the request from---reduce the award from $450,000 to 22 $350,00.0, out of a total request of $480. I would also 23 convey to them again, as council did at its last meeting 24 that the project --- the corp staff, not the project staff 25 shQuld include more minority representation, particularly 1 3 2 1 LOUISIANA 2 MS. SILSBEE: The next region to be reviewed is 3 Louisiana. Dr. Janeway. 4 DR. JANET-IAY: I'm the secondary reviewer---I'm the 5 primary reviewer. The reason why I wanted to take it out -dvice ft 6 ofthe block was partly to get some technical a OM' 7 the staffon this. I am concerned about the application 8 for $75,000. 9 MS. SILSBEE: Bring Dr. Gramlich and Mrs. Klein 10 back in. 11 DR.@JANEWAY: I'll hold my comment until Mrs. 12 Klein gets back. She's a lawye@ and she may be able to 13 help. 14 (Dr. Gramlich and Mrs. Klein re-entered the 15 hearing room.) 16 MS. SILSBEE: Is staff ready to listen to the 17 question Dr. Janeway has. Can theycome up tothe table, 18 please. 19 DR. JANETIAY: My questions are technical and 20 relates to Project C-10 in the Louisiana application which 21 is entitled "Study of N. 0. Tax Supported Clinics Serving Title 19 Recipients." It's the major request in the 22 23 Louisiana Application and I would like to know-whether it is appropriate that RMP funds be used to evaluate the 24 25 activities of the clinics supported by other tax funds. 3 3 1 One wonders if that shouldn't be the function of either 2 the state, per se or the agency that provides medical 3 funding. It's just a question that I, myself am unable 4 to answer it. I don't have the knowledge. 5 MS. SILSBEE: Mr. Sibloski, do you have any 6 comments? 7 MR. SIBLOWSI: Not really. It's a hard one to 8 swallow. 9 DR. JAIIEWAY: I brought it up BECAUSE Nobody in 10 Technical Review even mentioned it. 11 MRS. GORDON: As secondary reviewer, we only ficured 12 what they were trying to do wasget an impartial judgement 13 on it and the other federal agencies weren't impartial. 14 DR. JANETIAY: It might pay to have Blue Cross co.-..e; 15 in and do it for them. 16 DR. GRKMLICH: My impression of the medic-aid 17 level is extremely low. 18 MR. SIBLOWSKI: 'I can.-'t really respond. I really 19 had some concernwhen I was tal-king to Dr. Savlier as to why 20 they decided to participate. He was basi cally saying that 21 the F.MP is in the only neutral position in the state to. attack it. Everybody else seems to be involved and it's 22 23 a non biased review assessment and if you look.on Paae 16, the people all involved in this --- are involved with the 24 25 consulting firm of Shindell and Associates. The Louisiana 1 3 4 1 Division of Administration and Planning; the Division o-@ 2 Family Services; the Division of Health Maintenance; the 3 Charity hospital @ystems division and it seems reading in between the lines that many Board members in many 4 organizations, it is a non biased type of thing where the 5 6 RMP is entered in and is trying to fulfill a certain role. DR. JANEIIAY: Let me ask you --- try to explain to 7 8 me the comments coming out of the HPC in Lafayette, Louisiana 9 to which is attached, at least in my copy a memorandum, the 10 last paragraph which says, "This study is intended to in- 11 fluence the manner in which HEW funds out patient medical 12 services in the state and may result in increased availabilit,- 13 of these funds." I'm only asking this question because I i 14 don't want the people in this 14ational Advisory Council to 15 be put in the position of approving something which is 16 against statutes. I'm not trying to hurt the Louisiana 17 RMP. 18 MR. POSTA: If I could make a brief comment. 19 This is not related directly -to your question, which I think is quite valid. 20 The last council, if you will 21 remember, one of the reviewers specifically requested to get-them more involved with the REgional Medical 22 Program, more involved with bringing the private institu- 23 tions-in and,the private sectors into the indigent clinic 24 25 or the hospital system. I'm not saying this was developed at least recipients and they are going to contract this out, it says in the memo here they will contract it out to 2 Shindell Associatds. 3 MS. SILSBEE: He is questioning the leaality. 4 5 DR. JANEIIAY: Far be it from me to question the legality. I'm questioning whe ther it is lecal. I want -7 some technical input. 8 MS. SILSBEE: That's a better way to put'it. The legality of counsel taking action. 9 DR. PAHL: As usual, I am not preoared, certainly 10 on the spur of the moment. I think what we would like to 11 have is your recommendation within.what the legalities are 12 13 and we can determine then post counsel and act accordingly. In other words, on a technical matter like this, I'm not 14 really prepared to give you an answer that has any force 15, behlnd it. lihat I would prefer to do is find out whether 16 17 it is the consensus of this committee that, if leaal, do 18 you recommend that we make theaward which would include 19 that or if not leaal, do you recommend a fundina level which 20 encompasses those dollars, but they could use those dollars 21 for other purposes, so we need your assent and we will 22 determine the legality. 23 DR. HABER: I too was concerned about this project, but in-a direction somewhat different from Dr. janeway. I 24 25 thought this was a particularly apt use of funds, Regional 1 37 1 Medical Program and at a stage when winding down is in 2 process and when one would hope that funds appropriated for the project would be susceptible to a final verdict, 3 4 1 think that one of the purposes of the RecTional Medical Program is the development of innovated projects and 5 6 certainly the evaluation of ongoing government mechanisms. 7 I agree with Dr. Schreiner assessment that Louisiana is 8 hard put in terms of development of medic-aid programs 9 .and I think it would be very useful to get independent 10 surveys. I think it is appropriate. I'm not qualified 11 to judgethe legality-In terms of appropriateness, I think 12 we ought to approve it though. 13 MS. SILSBEE: Is there a motion? DR. JANEI,7AY: In light of the discussion, I move 14 15 therefore that we accept the recommendation from the 16 Technical Committee that louisiana be funded in the amount 1 17 of $168,680 dollars, pending review by the staff on the 18 le4ality and appropriateness of-C-10. '19 MR. HIROTO: Second.-. MS. SILSBEE: Dr. Janeway, does that motion en- 20 compass, as a rule, if they could not spend money on that, 21 that the region should have the money or have it taken awav.; 22 23 DR. JANEWAY: NO. 24 MS.-SILSBEE: is there any discussion? 25 (No response) 13 8 MS. SILSBEE:' The motion has been made and 2 seconded that the Louisiana 'application be approved 3 at the level of $i68,680 i-7ith the condition that the 4 funding for the amount of money for Project C-10 be contin- 5 gent on our staff review of the legalitv and appropriateness. 6 All in favor. 7 Opposed. 8 The motion is carried. 9 10 .11 12 13 14 '15 16 17 18 19 20 21 22 23 24 25 1 IIARYLAND 2 MS. SILSBEE: The next application to review is 3 Maryland. Dr. W@ock, would you get the microphonebefore i 4 you start? 5 DR. ll@-IOCK: I think so. I was the primary judge! .6 in this case and at the May-June Council meeting, there 7 was a request of $762,000-dollars and this was denied and 8 then they put in a new request for $724,000 dollars and 9 .786 cents and at the meeting yesterday it was approved for 10 $756,000 dollars. I need a little bit of information here. i 11 The total program staff - C-0000 - is that $336,604 correct? 12 MS. SILSBEE: Let me look at the sheet? 13 MRS. FLYNN: That was May-June. 14 MS. SILSBEE: Mr. Nash, could you come un to the. 15 table please? 16 MS. SILSBEE: Did you hear Dr. Wammock's question? 17 MR. NASH: I did not. 18 MS. SILSBEE: Dr. Wammock wants to know-what abo-.,- 19 was it 338 --- ? 20 DR. WAMMOCK: $336,467 was the original mroaram 21 staff --- total program staff. The original grant in May and I June, the request was then $762 and the new one is for Program 22 Staff of $233,000 and $724,000 for July. The Program Staff 23 24 of $233,000 with the approval yesterday of $-350,000 --- no, $650,000 --- that's one-third for staff. 25 14 0 1 MS. SILSBEE: Dr. Wammock, ifyou will look at the 2 printout labeled 7-74, you will see that the total request 3 was $724,000, of which the staff is$302,961. 4 DR. 1-72U.LMOCK: That's right, the indirect column is right,. 5 6 @MS. SILSBEE: There was no money provided for 7 staff because there was no money provided from the May 8 application, so this is it. The.$650,000 as I understood 9 the committee recommendation yesterday would allow for the 10 staff, about half for staff and about half for the activities 11 that were proposed. Is that right, Mr. Nash? MR. LNASH: I thin, one of the recommendationswas 12 13 that $250,000 for staff and $400,000 for projects. 14 DR. tVAtU4OCK: 400 for projects and 250 for staff? 15 MR. NASH: Yes,sir. 16 MR. OGDEN: I think we ought to be aware that a 17 great deal of the activities that may go into this project 18 is staff activities, so that you can't judge the total 19 request for a particular project as being the total cost 20 because some of that activity is being carried out by staff 21 people themselves. 22 DR. 147@L%IOCK: I recognize that. 23 MR. OGDEN: So,'I don't believe the action yester- day of say $250,000 for staff and $400,000 for programs 'IS 24 25 any-sense out of line. 4 1 I DR. 1,7k".I-'40CK: You don't think that's out of line? 2 MR. OGDEN: No, I don't. I recommend that it be I 3 accepted the way 'it was yesterday. 4 DR. 1'77L?@r4OCK: I just reopened it for the questioni 5 of clarification in my own mind as to which way this was 6 going because I wasn't quite sure. I went through this-thincr 7 7 and looked at the various projects which I descri bed and I 1 8 don't know whether they're goingto be implemented or not. 9 Perhaps it may do some good and perhaps it may not do any 10 good. I'll let the motion stand as it is as of yesterday, 11 but I wanted,to bring this up for clarififation in my own 12 mind. I make a motion. 13 MR. OGDEN: I'll second it. 14 MS. SILSBEE: The motion has been made and 15 seconded that the committee recommendation of $650,000 16 stand. Dr. Watkins, did you have anything to add to that 17 as secondary reviewer? 18 DR. WATKINS: No comment. 19 MS. SILSBEE: The motion has been made and s econde 20 that the Maryland aD of -placation be approved atthe level 21 $650,000 dollars. Is there any further discussion? 22 (No response) 23 MS. SILSBEE' All in favor? 24 Opposed. 25 The motion is carried. 14 2 1 NASSAU?SUFFOLK 2 MS. SILSBEE: The next region to review is 3 Nassau/Suffolk and.the prira@, reviewer is Mr. Milliken. 4 MR. MILLIKEN: Was this discussed vesterdav? 5 MS. SILSBEE: Yes, sir. Do you have a transcript on that? 6 7 MR. MILLIKEN: Yes, I do. With the information 8 we had this morning, it would appear that we do have to 9 .,change our previous decision of no funding. I have no 10 evidence to find fault with or change the reviei-T committee 11 recommendation of $900,000, although I personally question 12 if that much is necessary due to the situation therein. 13 Maybe the second reviewer has something to add. I'll make a motion later on. 14 15 DR. GRAMLICH: I find this interesting. It 16 ' appears we're reversing our position of June and iulv. 17 They have made a strong appeal and I guess if council has no major objection to reinstating them, I would have to 18 '19 support that decision. -so movb. 20 MS. SILSBEE: Second. 21 MS. MORGIU4: Second. 22 MR. OGDEN: Could I ask the members of council--- 23 MS. SILSBEE: Mr. Ogden, could you use the 24 microphone. 25 MR. OGDEN: Look at the page concerning Nassau/ 1 4 3 1 Suffolk. The program staffing here of $343,000 for what 2 they have proposed to be slightly over a $2 million dollar 3 program, now if we'@e limiting this to $900,000 dollars, 4 obviously we cannot let the entire $343,000 for the DrocTram stay, so I think there needs to be something said if we 5 accept the $900,000. 1 didn't hear the review-committee,, 6 7 yesterday. 8 MS. SILSBEE: They made the point, Mr. Ogden, it 9 Kas not in the motion, but it was in the advice to the 10 region. 11 MR. OGDEN: That may be in the minutes. Idon't have 12 that in my notes. MS. SILSBEE : The pink slip says: "Based on the 13 14 funding recommendations for the attending period, it was 15 further recommended that the Nassau/Suffolk R-NIP be adjusted, 16 -Staffing request to be proportionate to the forthcoming award. 17 18 DR. GPA14LICH: In relationship to the presentation this morning, I was a little at a loss and wondered if the '19 20 applicant was fully aware of the fact that this council felt they should be in a nhase out period 21 22 MS. SILSBEE: Mrs. Flood. 23 MRS. FLOOD: May I ask if staff.'hzis verified that 24 Projects 021 and 022 of the EMS projects are @Dropriate to 25 the allowable concepts of our funding. 1 A 4 1 MS. SILSBEE: We have -had a return from Mr. Reardon 2 who is EMS Systems Chief and he doesn't see any problem with 3 regard to their portion of the legislation and we got a 4 telephone call this morning from the part of HRA that is 5 administering the training part'of EMS and they also do not see any problem or conflict. That is not to say they are .6 looking at it from any other standpoint but that. 7 8 MS. FLYNN: Those two line items approximate $400,000 dollars and even though we're recommending from 9 10 committee that their staff be brought into line by readjust- 11 ment according.to the award, if they're just given an award i 12 without further recommendation, other than staff limitations, 13 it would appear that their only endeavor would be emergency 14 medical services and emergency medical training. MR. STOLOV: We have received the priority level on 15 16 the projects and the equipment is below the $900,000 dollars, 17 however, the EMS training is above it,but again, I feel it 18 is expensive, but it was their determination where to put 19 the money once they get this $90.0,000. They may not put it 2o all into that EMS training. The Nassau County which is the! 21 more populated and richer county is way down at the bottom of; 22 their priority list. 23 MR. OGDEN: Would you explain to me what this 24 $355,000 is, how-much of this would be funded out of the 25 $900,000? MR. STOLOV: I believe Dr. Pahl mentioned vesterdal- 2 that we still have not developed policy regarding iiha+-.haDoen-@ in terns of independent @'4P beyond June of '75, so we don't 3 1 4 kno,@%, IIE';L wide if this is allowable under arants and administr=- j; 5 tion Practicesy but I believe it would have been a contract 6 lin their o-v7n' Nassau/Suffolk M.IP Inc to carrv this out in this 7 iscone and amount. then the-conmittee looked at this, it did 8 not consider this in their funding level. They left it out.- 9 MS. SILSBEE: The Chairman suggested the $2,000,000 1 10 Irequest be cut down to $900,000 and that maybe a moot issue 11 in terms of continuing the program or putting money aside. 12 DR. SCHREINER: I was -primary reviewer on the 13 1last go round. MS. SILSBEE: Accordina to the old assignment list, 15 Mr. Milliken, you had it last year also. 16 DR. SCHREINER: I was hoping it would be somebody 17 !here. I'm very impressed as Dr. Scherer hanpens to be an 18 jold friend of mine and I was wondering if this was in line 19 With his $900,000 speed. 20 DR. PAHL: Mr. Milliken, right, Ilm afraid you're it. 21 MS. MORGAN: Mr. Milliken, you were it last time. 22 MR. MILLIKEN: I don't recall all the details. 23 MS. SILSBEE: In terms of making the assignments, I try to keep them as consistent as possible. 24 25 MR. MILLIKEN: On the yellow sheet, the second yellow 14 6 1 sheet, the second item CO-5,COG-5, Grantee Central Service. 2 Could somebody explain %..,hat .-hat is? 3 !,IS. SILSDEE: That is what we were just discussing. 4 MR. STOLOV: It's an independent P2.IP, therefore 5 according to instructions, they should close bv June of '75 6 and they have to issue contracts to extend beyond that r)driod 7 and they felt it would be good use of Government monev if thev 8 continued to fund the grantee should over ride contracts be 9 issued. 10 DR. PAHL: I was about to make a statement on that 11 when we got to Dr. Schreiner's question. We have a nolicv 12 which comes-out of the DHEW decision not to permit staff or 13 Ian R.?@IP to perpetuate itself beyond June '30 of '75. To 14 merely state that al 1 grantees, regardless of what they wish to 15 do in terms of contract activities may not engaae in that kind -16 of situation which would perpetuate the RMP or the staff beyond, 17 June 30 of 175. They may contract with groups to carry out 18 activities past June 30 of '75, bu not in such a wav to '19 perpetuate themselves, so-if Nassau/Suffolk, and I don't know 20 the details of this, if Nassau/Suffolk or some other R.IP has 21 ifunds in..it which, in effect, would continue to sur)Dort staff Peyond that iDoint in time, then I believe we would take 22 23 hpproDriate administrative action with our office of manage- 24 ent because we're applying a uniform rule in -accord with 25 departmental policy. I hope I have made that distinguishing 14 7 1 line rather clear. 2 MR. @IILLIKE"q: I still go with the action of June 3 and the reDort of the committee unless there is new informatic,-, 4 or evidence that shows reconsideration should be made. l@IS. SILSBEE: Would you state that motion again 5 6 and into the microphone so we can all hear it. 7 MR. MILLIKEN: I'move the committee recommendation f 8 of a phase-out award of $9 00,000 be awarded to this state. 9 MS. SILSBEE : A "phase out" award, do you want 10 that stated in the motion? 11 MR. MILLIKEN: Yes, I do. 12 MS. SILSBEE: Is there a second to that? 13 MR. KOMAROFF: Point of clarification. Would you 14 resolve your ambivalence? 15 MR. MILLIKEN: I will remove from the motion the 16 "Phase out" words, but I would like staff to be instructed 17 to have them understand that this $900,000 dollars is for the 18 ipurpose of helping conclude their efforts and not continue 19 the program as they propo7sed. 20 DR. PAHL: I'm-not sure I'm going to clarify this 21 situation at all. I think we do understand that in all of Z@2 ll:these recommendations, particularly where there has been some 23 drastic cuts from requested levels and I'm sure more so in 24 the case of this region, that it will have a very serious 25 impact on their program development. I think it would be 4 1 really in error for us to characterize this more than some 2 others that we have been concerned with here as phase out 3 or terminated. I think we really should onlv accept the 4 motion for a funding level recognizing that probably what 5 you say will cause serious dislocation from what they had 6 anticipated. 7 ,@IS. SILSBEE: Would you restate your motion. 8 MR. @IILLIKEN: I move that council accept the 9 -committee recommendation to fund this agency at $900,000 10 dollars. ii MS. SILSBEE: Is there a second? 12 MRS. MORGAN: Second. 13 MS. SILSBEE: The motion has been made and seconded 14 that the Nassau/Suffolk application be approved at the level 15 of $900,000. Is there further discussion? 16 DR. ;I@MMOCK: I would like to ask a question about 17 32 family nurse practical and critical care' nursing patient 18 family nurse, that comes to $150,000. Will somebody explain 19 that to me? 20 MR. STOLOV: Your addition is correct on that. 21 MS. SILSBEE: What do you-want explained,' Dr. 22 !"ammtock? 23 DR. 1'7P2,U.IOCK: Are they going to train practical 24 nurses or what.@ 25 MS. SILBEE: We don't know if they're going to do 14 9 anythina because they have had a request of $2 million. 2 Jerry, do you know the purpose? 3 M. STOLOV: They are separate projects. One is 4 the university base and the other is a community base. 5 one is nurse trained - nurse practioner and the other 6 is more of a socio emotional thing to train nurses in 7 giving support to families who have critical illnesses. 8 They are different projects. 9 MS. SILSBEE: The question is, where do they fall 10 on the priority list? 11 MR. STOLOV: I'll check that out on my paDer 12 work. 13 DR. GRIOILICH: May I ask a question? It does not 14 relate to the subject at hand, but it does relate to the Nass4u 15 question. In one of the other regions, we find that the 16 regional advisory group apparently worked very well and in 17 Nassau/Suffolk, they apparently did not. 18 MS. SILSBEE: That has a long history. I think they actuallv didn't have-a c 19 ombined board. There was a 20 combined grantee and we made them have a different regional 21 advisory group and a different council. Thre was some overlap 22 butthe combined grantee situation did not work out andthat was 23 was about a year ago September or so. We had joint staffing 24 too, Dr. Gramlidh. 25 MR. STOLOV: I have on both projects my paperwork. I 0 -5 1 On both projects - familv nurse practioner which was S142,000 2 project, it ranks n umber 11, which the critical care nursina 3 project, Number 16.-, The dollars fall out,if they stick to 4 the original dollars submitted, $860,000 off of nrojects 5 1 through 10 and it stops at venereal disease. These 6 are well below the level again.' 7 MS. SILSBEE: So,they would fall out. 8 MS. FLYNN: If I may just ask, does Project Z',I-umber- 9 @'9, fall out. 10 M.R. STOLOV: Project 29 does not fall out. 11 MS. SILSBEE: That project--- 12 MS. FLYNN: They left their priority and snending 13 dollars the same? 14 MS. SILSBEE :Yes. There is a motion on the floor. 15 MR. STOLOV: Mr. Ogden raised the question, what was 16 the title of the project. 17 MS. FLYNN: It's a computer analysis of whether 18 health educational materials have been written bv authors in '19 a leval that is readable-by the health care consumer. $36,0001 20 dollars to have a computer analyze all health education 21 materials so it will be at the 4th grade reading level. 22 MS. SILSBEE: There's amotion on the floor to the 23 effect that the Nassau/Suffolk applications be approved at thet 24 level of $900,000 dollars. Is there further Discussion.> 25 (No response) 151 1 I-IS. SILSBEE: All in favor say "aye". 2 Opposed. 3 The motion is carried. 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 '19 20 21 22 23 24 25 1 52. McLane 1 MRS. SILSBT7E: Mrs. Flood, we will convey your rml 2 concern for this complete documentation at v7hat level health 3 education materialg'need to be prepared for consumabilit,,r 4 canabilitv. 5 As this discussion went on before vou finallv 6 acted, there was reluctance, but in terms of the final a:ction 7 Nassau/Suffolk now has $900,000. I-le will be glad to work 8 with therq further on this. 9 lo 12 13 14 15 16 17 18 '19 20 21 2'Q) 23 24 25 1 5 4 rm3 1 very veliementlv because thev felt that the representatives 2 of the 17@overnor's commission had been a Dart of the -- both 3 the technical review and the regional advisory groun in 4 iihich the decision had been made, and there were none o.L 5 these difficulties raised, and thev felt that the project 6 had had oroper review, but we have been explained bv phone, 7 the council's condition took the consideration, but still 8 felt there had to be a resolution locally. That has not 9 yet occurred. 10 DR. IIADER: T.,.Iell, that is unfortunate, of course. 11 Nonetheless I feel, and riv contention is that the funding 12 review that some of the reviewers, have recommended for this 13 is undulv harsh. I feel that this has been a good Droara- 14 In the face of adversity thev have tried to keeo it together. .,15 They have replaced their losses with admirable fortitude. 16 I think that manv of the Drojects are well constructed and 17 conceived. It seems to me we are criticizing them, or at 18 least some of the reviewers are criticizing them, for a.w,-de 19 variety, apparently, of disorganized Drojects, and yet in the@ 20 earlier criticism was that it'tended to be too global and t 21 not specific enough, so we are getting them both ways, and 'I think this unfortunate. 22 Again, I feel that manv of the projects are Z3 24 well constructed. I feel that there is no point in.our 25 perpetuating our own indecision or worse, contrary views, 155 rm4 towards them. I thinl- they have had the endorsement on 2 pages 104 and following the CliP PJ,IP annual review conference. 3 1 thinlz that they have; it seems to be indicated the ultimate 4 phase-out of this bv modest extensions of some of these 5 activities, and I would suggest that instead of the oronosed 6 level, that they should be funded at a level of a million 7 dollars for the supplemental request that they have come -Li, 8 which is some $473,000 less than they have requested. 9 MRS. SILSBEE: Dr. ir%omaroff? 10 DR. KOT4AROFF: I think a series of projects, 66 11 prO3ects which are described here, can both be'vague in 12 their individual description and disconnected, without anv 13 kind of sense of cohesiveness, and I -- well, that in fact is 14 my feeling about reading this application. We have a region 15 that is a relatively small state in terms of its population 16 which is already funded at a level of two million dollars, 17 and I have kind of a gut feeling that their supplement ought 18 to be closer to $400,000 recommended bv committee than an 19 additional million dollars, bringing our level up to three 20 million. 21 DR. 1',OIIAROFr: I will summarize. As an example 22 of my edginess, I will tell you i-7hv I am edgv. Yesterday 23 there was a question as to whether the RAG had set any 24 priorities among these 66 projects. Ilow, irr-fact, there is 25 a listing of priorities, but you will notice that the ranking 157 rm6 1 DR. KO!.IAROFF: Could I move five hundred thousand? 2 DR. @,771@-IOCK: I se--ond that motion. 3 j@4RS. SILSBEE: The -.iotion has been made and 4 seconded that South Carolina aoolication be approved at the 5 level of $500,000. 6 Is there further discussion? 7 (No resnonse.) 8 MRS. SILSBEE: All in f avor? 9 VOICES: Aye. 10 MRS. SILSBEE: Onoosed? 11 (No resoonse.) 12 MRS. SILSBEE: The motion is carried. 11 14 15 16 17 18 19 20 21 22 23 24 25 rm7 1 TED"IIAS 2 IIR-',. SILSBEE: If we go alphabetically, we come 3 to Texas. 4 MRS. FLOOD: 1,7e are going to Texas? 5 @IRS. SILSBEE: llrs. Flood is going out of the room. 6 lias the Texas pink sheets, or white, been distri- 7 buted? 8 MPS. @4ORGA-N: No. 9 MRS. SILSBEE: Let's distribute them. 10 Off the record. 11 (Discussion off the record.) 12 MRS. SILSBEE: On the record. 13 You will recall that the Ilay-application from the 14 Texas regional medical program included requests for funds. 15 for a series of contacts of which the ideas were smelled out 16 in the May at) lication, but the specifics regarding @.7h p o was 17 going to carry it out and what institution and the amount 18 for each contract was missing bedause that was going through 19 their local review process at the time that it @-7as aoing 20 through the national review Drocess. 21 Council considered this application and decided 22 that in general the goals and objectives of the region and 23 the general management of the region seemed to be sufficient 24 to enable council to delegate to the review committee which 25 at that time had felt that it was going to meet in June or 16Q rmO review committee which will consist of on this, nlus members from the RAG. The concern of the review committee was health 2 professionals revi(@-i,7ing these r)rojects.- If you are familiar 3 4 with the Texas RAG, it is Dractically all health professionals. 5 About 95 percent of them are Dhysicians on the RAG, and thesei 6 physicians are going to be the ones, and this is from the 7 material we have received,.who will be on the review committee. -here is no question in my mind but that there will be health 8 9 professionals reviewing these area contracts. They have 10 sent in their form, which is a six page form. It has to be 11 filled out-monthly on the various contracts and sent in; will be reviewed by their committee. I havein mv mind no doubt 12 that these will be reviewed bv health professionals, and 13 14 I would like to move that the level from June meeting of 15 one million four hundred thousand be returned to the Texas 16 IUIP 17 MRS. SILSBEE: Dr.Schreiner? 18 DR. SCHRRINER: I am a -little bit confused about '19 the back and forth thing and the'old grant. If vou could 20 clarify that a little bit? In other words, are you -- I 21 didn't hear the discussion yesterday on this T)articularone. I- 'Are they proposing any additional new money? 22 23 MRS. SILSBEE: No. vlbll, they are. I was going 24 to ask !Cars. Morgan if she would mind rewording her motion. We gave them an award for two million three hundred whatever 25 161 rmlo it was, and we restricted 1.4 million dollars pending the@ 2 satisfactory review, so in a sense they can't spend that 3 1.4 million. 4 DR. SCIIREITIER: It is cal led internment. 5 MRS. SILSBEE: Internment for a reason. The action@! 6 of the committee yesterday would release one million dollars.i 7 of that. Another four hundred thousand, presumably, would 8 come back here, and they would not be allowed to spend it. 9 MRS. MORGAII: May I change mymotion to state 10 that we released to Texas R-MP one million four hundred 11 thousand dollars of impounded funds to them? 12 DR. PAHL: We remove all restrictions. 13 MRS. IIORGAII: In other words, restrictions are 14 remved from Texas. 15 DR. WPJTMOCK: The restricted funds is what you 16 meant, and not impounded. 17 MRS. MORGAN: Had this one million four hundred 18 thousand dollars been,released in- June to Texas, they we're 19 not planning on coming in-on thi@ cycle four, any money at 20 all. 21 DR. SCHREII-TER: So this comes out of the 84, not 22 out of the 20. Thatis what I wanted. 23 ?IRS. IIORG2UT: It comes out of that money. 24 @IRS.'SILSBEE: The money that has &Iready been 25 awarded. 1 6.3 rml2 VIRGI:IIA 2 MRS. SILSBEE: :@lo,.q we go to Virginia, and Dr. @latkins. 3 DR. ',,7Aj'KI7.,IS: I have no problem with Virginia. 4 5 This is Virginia, and Dr. Perez has changed the face of the whole program. !4iss Martinez had a question. 6 MRS. SILSBEE: Miss Martinez? 7 IIISS @IARTINEZ: In thinking over the project 8 descriptions, I notice that a great nanv of the projects 9 10 are reallv supportive or extending grants to CHP's for 11 planning, for the normal planning of ChP programs, whichI am not sure is terribly wise, even if it is legal. In any 12 13 case, I think the committee recommended nine sixty-three? MRS. I-IORG@4: It is nine sixtv-three eight sixtv 14 MISS i4AR7LIIIE'"7: And I would like to reduce that 15 16 sum somewhat to seven -oh-seven seven fifty-nine. I just 17 went through the projects, and eliminating things like number 18 48 which is a arant to a CIIP age@cy for a 19 M @TZS. SILSBEE: Miss ii-artinez, in terms of what you 20 are recommending there,, have you, are vou aware, that a 21 message was sent back to the reaional medical programs @-concerning the need to do -- or to get geared up for health 22 23 resources planning and that this should be done,in collaboration 24 with the CHP agencies? MISS @IARTINEZ: No. 25 6 5 rml4, 1 I-IRS. SILSBEE: All in favor? 2 @"OICES: Aye. 3 MRS. SILSBEE: Onposed? 4 (No response.) 5 MRS. SILSBEE: The motion is carried. 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 16 7 rml6 1 DR. GRZU.ILICII: May I open up one more small subject7 2 DR. PAHL: T.-le have that as well as Mr. Oaden's 3 resolution. 4 DR. GR7LT-ILICII: I mean. relative to this project, 5 specifically !.IississiT)pi. 6 MPS. SILSBEE: Yes, sir? 7 DR. GRAI--ILICII: There is a very strange request 8 and it is kind of -- the review committee didn't pal, an 9 awful lot of attention to it, a two million dollar, roughly 10 two million dollar request for hypertension screening and 11 treatment prog.ram including one million dollars for salaries,l 12 and included in that salary scale was 82 public health nurses 13 who presumably are already on deck, so that the @-T funds 14 as far as I can determine from the grant requests, be used' 15 simply to supply what is now being spent by the state health 16 department. Included also is $500,000 nlus or minus for 17 drugs for treatment of some possible 11,000 hypertensives. 18 Ilow, the review committee's attitude is, it is a poor state 19 and they have got lots of blacks and they need all of this, I 20 but there was no Particular attention paid,to the construction 21 of the budget which included apparent substitution oo P-T-IP 22 salaries for what are now state Health department salaries. 23 That is one item. 24 The other item is, if the treatment to be applied 25 to the suspect hypertensive or to discover hypertensive which 168 rml7 is to be administered to the county health officer in each 2 county. No@v, this poses a loroblem of practice of medicine, 3 if you will, by rl_"-IP funds. If the council feels this is 4 appropriate, this is fine. All I want to do is bring it 5 to the council's attention to make sure it is considered 6 appropriate. This has to do with Mississippi only. 7 MRS. SILSBI-'E: I's-there discussion on this ooint? 8 DR. KOIIAROFF: Can staff enlighten us as to wheth(irt 9 this will supplement the resources of the state health 10 department, or merely supplant them? 11 MRS. I SILSBEE: Mr. Van Ilinkle, there are two 12 issues here, in case vou couldn't hear. 13 MR. VA,@4 I heard. I was trying to hide. 14 ",Iy answer is, no, I don't know. I read the application. 15 Ile did ask that they include the full, when they sent in, 16 not the center form 15. That is all vou i..7ould have had. 17 I presume that Dr. Vaun looked at it, being the -primary 18 reviewers He did not discuss tha't; however, as far as @19 practice of medicine, we have been in the habit of doing it 20 for years on demonstration projects. I doknoxq that thev 21 proDosed to take these over and continue it after this first 22 year funding. The Government has put already a line out of 23 its budget to suonort it, but I do not know if these nurses 24 are on bid, or if they intend to hire new ones-. I just don't 25 know. 1 6 9 rml8 P-IRS. SILSBEE: Dr'. Komaroff? 2 DR. KO,"@lA@OFF: I looked ' at that application 3 .last night after our discussion, and I had the impression 4 that it was an unusually well documented request, but probabl@t 5 -that was going on was that I'@T money was offsetting certain 6 expenditures that were part of the state department of public@, 7 health this year, but that the quid pro quo was that the 8 government was going to take over the support of the program 9 in future years, and that that seemed to me a reasonable 10 bargain; consider the importance of this problem in that 11 state medically. 12 DR. GR2UiLICH: I am satisfied. Thank you. 13 DR. PAHL: T-have two items of business before 14 we adjourn. 15 16 17 18 19 20 21 22 23 24 25 a @,all amount of difference, only r3Ol,n@@. 2 D P @'.'7-L I f L'Ilcre is a di-@-'ere-ice, v.-e @,.,ill 3 --itlier take it out of j-dith's salar-,,, or c,-i,.,e it to her. -iese 4antist4 4 @-7e have one of t, @c data -ratic 5 aides on sale, or something, and IL--'.-ere is voltaae fluctua+--4---- and during one of my afternoon tele-.oho-.e calls- I foun@- 6 J-dith sitting nol:ing these keys. %t the same time, doina 7 everything in lonq hand because with voltage fluctuation 8 you don't end with the same digits'vou should. So, I think 9 we better go back to lead nencil and naper. 10 I gather the correct fiaure is @,27,349,054. 11 Another one of 'the rumors. 4- 12 1 have received information also, again, I don knoi@7 whether it is a rumor or not,but @resumably it has 13 been announced out of the !,!!,iite Tiouse tl-at, as .,ou knoi-7, -h@- 14 --e @-iill he announcement either at 01:00 -- and now some peonle '15 say 8:30 - and Congressman Ford is to undergo his inauaerat4-on! 16 at 6:00 u.m. tomorrow. I auess we all learn as to 17 go to airports whether this is rumor or.direct. This was 18 given to -ie as a statement. 19 '.he other item of busi-n'ess @.,,hich I think we are 20 on more firm ground ab out is to reconsider the resolution 21 that !lr. Oaden introduced, and i-l-hich @.,,e tabled until -you had an opportunity to look over. 22 The su,-m-iar-v material pertinent to the resolution. 23 'Ir. Ogden, I think i.,e have distributed this to each person. 24 Perhaps, vou would lil-,e to r@.ake some comments. 25 IIR. OGDEN: I hope that manv of vou have had an 172 1 onnortunity to loo'j- at the Tnaterial headed "Su.=,.ar,,, of t@e I.ational Health Policy Plannina and I"esources Develo-ment 2 It@l.ct of 11)74." 3 Dr. l'omaroff, is sitting next to me here, 4 has n@-obably gone through it a little T--.ore carefully than 5 many of vou and underlined the areas and I .,,ill call on 6 him just in a few moments for his comments. But, in acina 7 through this piece of legislation I found no iDlace where I 8 could find anything that fitted the function of any existing- 9 regional medical program, save perhaps some of the programs 10 v7hich are in fractions of states, such as some of those perhaps in the State of l@,ew York. 11 If the Governor of the state were to decide the 12 1 health service area, for example, @%Tas '-"Iassau/suffolk - perhaps I 13 1'.7assau/Suffoll- P-'-IP could become the health service systems 14 agency in that particular area. But, this particular piece' 15 of lcaislation while it seems to encompass Fill.-Burton-almost 16 completely and you %.7il 1'find that comes ur) on Pacre 5 o.-i the 17 description of the health resources development the only place that I find 'UIP perhaps even suggested is on Page 6 18 under Area Health Services Development Fund. '19 @.Zow, remember here-we are talkina about a health 20 svstem agency. @7ow, health system agency is a non-.profit 21 private operation on a local or area-'7ide '--asis. But, this. 22 lis a nealth service area nonulation of less than half a 23 -li-llion. it is not permitted. It can be up to a-bout two 24 million, as I recall lir. Rubel's comment yesterday. But, it would encompass-the health service area would encompass anv 25 1 73 4 standard metropolitan statistical area, v7hich is entirely 2 ,.!itli a boundr-,7 - it cin cTo over state lines, I:)ut there are 3 literally, I understand, 100's of S,'ISA's in the United 4 States. So, that what we are looking at here is an area health services development fund which is aoing to be a 5 A 6 localized thing, and indeed we find that the grant that can be made for the development within one of those on pace 7 2 - no single grant or contract may exceed $75,000 be made 8 for more than two years. 9 It simply taliled about the area health services 10 development fund. This is why I have proposed this resolution. 11 That this piece of legislation - it be suggested that this 12 be amended to give each state the'statutory and financial 13 support to maintain a separate health s-,rste-is development -4 So, t.-iat at least we hava 14 zigency on a state-i.!ide basis. something similiar to the P,.!-,IP's we have today who can perform 15 16 a state-@@iide mission or function. And, indeed, i,,-c could leven say, goincT beyond state lines. nut, I suspect the 17 1,r,incl of legislation we are seeing coming up here is-croing to 18 be limited to state boundries' and national health insurance. 19 may indeed have in it have some sort of state-wide function 20 mechanism. 21 So, I pronose this resolution and in it, the -second Part of it I have said, "The comments that proceeded 22 the resoltuion and the resolution itself be transmitted to the 23 members of the licuse Interstate and-TLoreicrn Commerce Committee 24 and by that I meant to encompass the com,,,@nts that T made 25 in the letter from Senator I'@lagnuson to Senator ':\ennedv, which .A 5 1 '1'4 I read to ,-ou earlier and v!hich should an-,oear n -ranscrin- 2 O.L the -iinutes o@- meeting. I can aive vou J@- -.a L@- letter L ? if ou would life to ;'erox it. I %,,ould like to ',a7,7e it baclz. 4 Dut, I vTill be hannv to hand it to you. 5 I do recommend that we do this. I am au4L-".e concerned that the kind of legislation that i..e'sc-e co7-irg 6 out simply does not recognize the place that re,-,ional medical i 7 i programs have come to serve on the American scene. And 8 certainly many of us who worked with this proaram since its 9 enception eight years aao this Sprina feel that i.-- has accompl4s:- 10 far more than it has been given credit for and that it '.-,as 7 11 the potential to accomplish a great deal that is co4.nato 12 The necessary in order to male national health legislation 13 function when 4t beains to deal with the verv Co:nnl4cak--ed undertaking of delivery of services and the deli-,Terv of 14 care. 15 And, it seems to me that unless the providers of 16 r in @ut @this Station are given an opportunity to make the, 17 --hrough something like IUIP, that the success of national 18 health insurance is jeopardized and I hope that we are doing '19 to be able to have the continuation of somethinglike the 20 regional medical rrograms. 21 1 DR. I" T L: -mhank you, very much !.Ir. There .,as a motion introduced and seconded, I thl'nk 22 1 1 possibly.. 23 DR. Second. 24 DR. Px@l'@L: Thank you, Dr. ',,@laininock. 25 I think there should be room for discussion by 176 7 J@ll:T-" Y: I would support, quite franl:ly, tl,l A c 2 separation of the planni-na function, particularly the 3 strategic Planning -@unction, to use a managerial term, which 4 is implied bv the summary of the legislation - proposed 5 legislation. I thin!: tl-lat to have planning and control - when 6 I say operational control the implementation mode of 7 any kind of management function in the same agency is courting 8 disaster and, although, I e7ould agree with you, Tony, that 9 there has to be a responsive interrelationship, that there 10 is so much to be gained by having the planning function 11 separate from the implementation function. That, I would 12 certainly be prepared to support a resolution of this nature. 13 1-i@y do you feel it would be courting disaster. T.,re vou thinking back to experience between 14 @ll-P 'and CY.P? 15 DP,. j'A'IE7-7AY: ,,@70. I am thinking in terms of the 16 management function and there is room for disagreement in this 17 but if you read tlnthony's book on Planning Control Systems, the possibility of the planner becoming so involved in the 19 plans that the implementation be-c'onLes impossible, or that 20 there is no outside regulation of it. it p@ts too much. ino@qer in one place. 21 Now, there are admittedly some managers who disagree 22 with that and sav the planning control ought to be in the 23 same agency, tf you set planninq or isolate it you develop 24 think tanks that don't,drain anywhere. 25 But, if you put planning and control in the same 177 laacncy, you go to the-opposite extreme @.!here -vou thin),, that 2 ilby creating an infinite nu@-iber of haystacks will give you 3 infinite supply of needles. 4 11,@. EOI IA@TZORF: It cuts I-loth %.!a-vs, but the for 5 tl-,e reason -,7ou just cited, it seems to me that the providers 6 would more likely be attracted to.these kinds of planning agencies, and therefore, the doing of reasonable planning. 7 If there were some - or more tangible operational components 8 that thev could be involved with. 9 I think one of the problems with CHP has been that 10 the providers have found it unattractive because it was 11 so abstract and so unrelated to subsequent tangible accomplish- 12 iments and if there could be some uniting of this operational 13 arm and the planning arm, so that what the operational arm was doing didn't in fact thwart the rational plans ol the 14 region, then it would seem to me to make more sense. 15 DR. JANEl,7AY: What I was trying tO indicate is 16 that I vould hope that the planning function would not thwart 17 the normal.operational arm. 18 MR. OODEFI: I think that this, perhaps, could be. 19 corrected by having the development component@also report 20 to the state health planning and development aaencv, which is 21 assumed to exist under this piece of legislation. It has to come into being. But the legislation just simply doesn't 22 spell out sufficiently how that development is going to take 23 place, except for these very local agencies. And, I would 24 like to see drafted into this piece of legislation the 25 provision that there be a separate health systems development 179 10 it gets dissolved -- and I haven't read this -- and if I 2 read it I 'am quite sure I %..couldn't ]'-,no,..., what I was readina. 3 I may have to read it bacluz the third or the fourth tine 4 or the fifth time, and nay not know what I N-7a.s reading. 5 !ly o@-in personal fee-li.-ticr is that I am probably too 6 close to the trees to see the --Forest, or the forest to see @-he trees. Or i%@hatevcr vou call it. Forest-trees, trees- 4 7 forest. @IR. CGDEN: Woods. 9 DR. I thin)-, that, as !,Ir. Ogden has 10 pointed out and someone else, that people don't know about 11 the acod that the RI'P has done and I think it is pretty 12 hard to cret across to people x@,hat P,"@.P is and I am sure that there are a lot of pl,vsicians that do not understand 13 ce-e--ation and the mechanism of the ."JIP nrogram. Some of 14 them feel that it has not been worthwhile, 1--ut I Personally 15 -Feel that it has been worthwhile and I think this resolution 161 here drawn up by 'Tr. Ogden. T @7ant to congratulate him 17 for the foresight and the merit and the courage and the 18 good common sense and judament to'draw this up and I thiny. 19 we need to support this resolution and somehow or another 20 get it across. 21 How effective it -v@ill be as far as Congress is 22 concerned, I don't 1-@now. I ID.,". P@-TIL: Is there further discuspion.or modification' 23 DR. NO!L@PO'.c"F: I i.:ould like to add some language 24 that makes it clear that this health systems development 25 agency will supl)ort.demonstration health services projects. 1 8 0 I don't tlfini-, thz,,t health services is written in. 2 am not sure it is auite clear ho,..., this aaer.--y would be 3 different from the planninQ agencies that are in the current 4 bill, and secondly, I thin'lz @,:e ought to state @-'-,at this 5 separate agency @7ould report to the state health -,)lannin' 9 6 and development agency that is described in the Bill. 7 DR. J,-@l.',IET,,iAY: 1,7ould you read it to us? DR. 1,@n,7.IAROFF: Read the proposed lanauage? I 8 haven't written it yet, but I will. 9 How would this he: "Resolved: That ,-lie Congress 10 in adopting HR 16204 or similar legislation aive to each state the statutory and financial support to maintain a 12 separate health systems development agency i-.,',Lich supports 13 demonstration projects and health services. This agency 14 i,.,ould renort to the state health planning and development aaency, or similar independent --'I am sorry - agency -15 and be devoted exclusively to such work. And be it further 16 resolved DR. I,.7,@IU-IOCK: Dr. Komaroff, I am sorry, but you 18 are getting too wordy there. I-'ile are going to get lost 19 t because I think the first sentence-what vou say - the health 20 -wide basis -- and I svste,is development agencv on a state 21 thin'-, health systcns development agency is very comprehensll%"C. TO me it is. 22 -L 23 D.Z. T,-IAI.rR: 'light I.suggest Health &ystem developmeA-.@- and, demonstration agency. 24 l,'LR. OGDF,1'4: On a state-wide basis for similar 25 181 12 1 independent commissions in a publicly acccun4--able way 2 in reporting to the state health and development agency 3 and devoted exclusively to such ...-ork. 4 DR. 'L70-!!A.TIIOFF: All right. 5 DR. 1,7AI,llIOCK: I yield. DR. PAHL: tliay i..Te have the final @,:ording before 6 we have the question? 7 .'iR. OGDEN: The t-:ay that I have this drafted 8 at the moment reads "Resolved: That the, Congress in adopting 9 IIR 16204 or dmil.arlegislation give to each state the statutory 10 and financial support to maintain a senarate health systems 11 development and demonstration agency on a state-wide 12 basis, or similar independent commission annointed in a 13 publicly accountable way, reporting to state health accounting and development aaenc@,, and devote--' exclusively 14 to such work, and be it further, Resolved: -.hat the 15 comments preceding this resolution and the resolution 16 itself be transmitted to the membcrs of the House Interstate 17 and Foreign Commerce Comittee and the.Senall-e Labor 18 and Public r@7elfare Committee for their consideration. 19 DR. PAHL: Thank you. 20 DR. I-W-L@-IOCK: tir. Ogden, for clarification. Accountable way and reporting? 21 OGDE""': I am sorr\r. P.npoi-nted in a publicly 22 accountable way. That lias to do with 23 DR. T,@;I'L@'LOCK: But you put another word in there. 24 I'tR. OGDEN: I-le inserted the v,-ords reporting to 25 the'state health and planning agency." 182 13 This was Tonv's TDoint, that separate health 2 systems doveloament has to report to somebody. @,7e are 3 going to have it report to the state health planning T-'Iouldn't that be under state, or not? 4 I (@'on't think that this 5 damages the sense of what I am trying to accomplish. .6 !@@!?S. KLEI17: llr. Chairman. 7 Dr\.. PAIIL: Yes, 'kl!rs. Klein. 8 1',!RS. KLEII;: This reporting bothersme as to whether 9 i.@L. should be to the agencv or,as in Idaho, the planning 10 groups report to the Governor, who is responsible for adinii.- 11 tration of all-programs. And, that would keep it on the 12 Istate -- As I understand it, the purpose of that insertion lis to keep it on a state-wide basis, rather than reporting 13 to any federal agency, for example. So, I i7ould like to sc-e 14 15 it made more general, rather than a specific title, because 16 some states don't have that type of agency, or one that is 17 titled that way. I'IZS. LIIORI;A,T: They v7ill have this Bill. 18 OC-,bE'@: Under'this Bill, they will have to. 19 DP. C@R7@.i.LICH: in the resolve, what do vou mean 20 by, "in the comments preceding this resolution?" 21 OCD!717: This was the letter from Senator :agnuson. 22 DR. PAHL: Is there further discussion.by Counsel? 23 Question. 24 TI@. O('jDEL:,7: T-,ait just a moment. On the matter 25 of information. Tony and I have decided that this should be 183 1 4 rerortina to the state-@-.,ide health coorcii-na't4-nc -@cun@il." 2 -!Jose are the people that have the 16 mcml--ers. 3 the i-7rong. groi-i,,) to @eporl@- to. 4 lqe are goina to report to the state-@.-ide health 5 coordinating council. Is everybody terribly confused? Can'@,.,e vote onit? 6 DR. PAHL: I-litli '-hat change, namely, the s,--ate-@-iide 7 health coordinating council. iiith no further discussion, I 8 would ask the Question - all in favor ofthe resolution as 9 last amended, please say "aye." 10 VOICES: Ave. 11 DR. PAHL: OniDosed? 12 (:-'to response.) 13 DR. PAHL: -Lhe motion is carried. In closing, I i.?Ould like to thank @'rs. S4-'sby 14 L and the staff very much for again going throuah an unusually 15 difficult neriod and specifically say that I an not-- auite 16 certain under "-hat circumstances this council -- @.-e may or, 17 may not meet again. T,,.7e have not set a future meeting date. 18 I would, however, like to thank you individually and collective'-- '19 as a council for your guidance and support throual.-Iout a 20 rather difficult period, -and not this particular review cycle. Since v.,e are uncertain what does 'Lace us, 21 -vou to understand that terms of appointment continue until 22 such time as we inform you otherwise because of passaae 23 of legislation or other unforeseen circumstances. 24 But, I do look forward, as I know the Staff does 25 to @-iorkinq with you -again in some way as we enter into 1 84 our new error. Unless there are further comments, I then 3 adjourn this meetind. 4 Than!- you. 5 ("Thereupon, at 3:15 p.m., the meeting was adjourned.,: 6 7 8 9 10 11 12 13 14 15 16 17 18 '19 20 21 22 23 24 25