*@001629* I 0 e 0 2 BMTH RESOURCES ADMINISTRATION 3 PUBLIC'HEALTH SERVICE 4 5 THIRTY-FIFTH MEETING OF THE 6 NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS VOLUME II Conference Room G/H 8 Parklawn Building C L,O S B D S E S 9 I 0 N Rockville,, Maryland 9 - - - - - - - - - - - - - Friday, to June 13, 1975 The meeting of the Council was convened# pursuant 12 to adjourrment, at 9:00 o'clock,,.a.m.,, MR. JERRY GARDELL,, 13 ACTING CHAIRMAN* PRESIDING. 14 COUNCIL MEMBERS:--- 15 HAROLD MARGULIES, CHAIRMAN 16 COLIN RORRIE 17 18 GARDELL 19 MR. KEN BAUMT EXECUTIVE SECRETAR 20 MRS. EDITH M. KLEIN 21 DR. HOKE WAMMOCK 22 MRS. MARIA E. FLOOD MISS ESTHER MARTINEZ 23 24 DR. JOHN GRAMLICH 25 (202,) 628-4888 -COUNCIL MEMBERS (Continued), 2 MRS. AUDREY M. MARS 3 DR. RICHARD JANEWAY 4-- MRS- WYNONA R. GORDON 5 DR. ANTHONY L. KOMAROFF 6 DR. BENJAMIN W. WATKINS 7 DR. PAUL A. HABER 8 -1 -- - - - - - - - - - - - - - - - --- - - - - - - - - - 9 1 N D E X 10 REGION: DISCUSSION BEGAN: ENDED: 11 Connecticut 2-5 2-6 12 Kansas 2-6 2-9 13 Louisiana 2-9 2-11 14 'Maine 2-11 2-13 15 Memphis 2-13 2-19 16 Missouri 2-19 2-28 17 New York Metro 2-28 2-86 2-94 18 North Dakota 2-29' 2-30 19 Northern New England 2-30 2-30 20 Northlands 2-30 2-31 2 1 Ohio Valley 2-31 2-32 2 2 Oklahdma 2-32 2-34 23 Oregon 2-34 2-34 24 25 i2O2i 628-4813A JD/ph 2-3 I N D E X (Continued) 2 DISCUSSION BEGAN: ENDED: REGION 3 Puerto Rico 2-35 -2-37 4 Rochester 2-37 2-43 5 South Carolina 2-77 2-79" 6 South Dakota 2-79 2-80 7 Susquehanna Valley 2-48 2-59 'Tennessee/Mid-South 2-80 2-82 9 Texas 2-82 2-82 10 Tri-State 2-82 2-84 11 Virginia 2-43 .2-44 12 Washington/Alaska 2-44 2-45 13 West Virginia 2-45 2-46 14 Western Pennsylvania 2-46 2-48 15 Wisconsin 2-84 2-85 16 OTHER ITEMS: PAGE: 17 Resolution of Dr. Haber re: document of council 2-54 - 2-77 18 Region Bloc Action 2-94 - 2-95 19 EMS,, PSRO and Kidney activities bloc action 2-95 - 2-98 20 Public Accountability Reporting 2-98,- 2-103 21 Adjourned 2-105 22 23 24 25 2-4 P R 0 C B E D I N G S - - - - - - - - - - - - 2 MR. GARDELL: May we get started,, and maybe we can 3 get done a little bit after lunch, which would be nice. 4 I thought this morning we would start one where 5 Dr. Haber is not the primary reviewer so he can get a 6@@ feel for how we are going through the review. Then we can 7 pick up alphabetically where we left off yesterday, and he 8 fall in place# where his name appears. 9 Let me say one thing first, so that everybody under- 10 stands. In the event, and I don't know that this is so be- 11 cause I can't get myself back to it, but in the event that 12 any of the regions happen to ask for less than their annual- 13 ized level of funding that we have passed out to you, that 14 Will become the level. 15 And we will redistribute the annualized level, based 16 on your recommended level, if that is as high as it goes, 17 In other words, be assured that the level recommended by 18 this Council will not be exceeded, let's put it that way. 19 What I am saying is, some of them may be recommended 20 for a level less than the annualized level which we passed 21 out yesterday, which is the one we are working with, and we,. won't exceed that. 22 We won't get there anyway, because we have $44.5 and 23 we are already approved for more money than that. 24 25 NRS. MARS: Why were these figures annualized for 2-5 here, current ltvel'of support figureso, different from 2 those" -,3 MR. GARDELL: These were 18-month budget figure 4 annualized. 5 MR. BAUM: Divided by 18 months and multiplied 6"@ by 12, the last 18-month budget period. -The ones.in front 7 of you are the figures for the June and August douncil cy- 8 clds last year that were based on a full review by a review 9 committee. 10 And it was the last 12 months, and we figured that 11 was probably a sensible level to use. 12 MR. GARDELL: They also exclude arthritis; which 13 was an earmark. Let's take the first one that is not'Dr. 14 Haber's. We did not do Connecticut yesterday. 15 DR. GRAMLICH: Considerable additional.information .16 has leen brought in from staff. -I:--have.resolved many of 17 the questions I raised yesterday, and I therefore suggest 18 that Connecticut be approved at the bloc level as requested. MR. GARDELL: Okay. One million $098,836. 19 20 DR. GRAMLICH: The figure is $1 million $99#830. MR. GARDELL: Was that so short, Dr. Haber,, that 21 you did not get a catch? would you like one or two more? 22 DR. HABER: I think I get the point. 23 MR. GARDELL: What it is, if you have no.quarrel 24 with the application and the amount seems reasonable, we 25 2-6 1 will handle it as a bloc action. If you have any questions, 2 n be.discussed. raise them and they ca@ 3 DR6 HABER: Let me express my gratitude and thanks 4 "to Council and staff.for having permitted me to comment 5 on these. MR. GARDELL: Mrs. Gordon is out of the room. 7 DR. HABER: Kansas is a very interesting applica- 8 tion. Several things need to be commented on, only to indi- 9 cate their importance. The project on remote cardiac moni- 10 toring, the nurse clinician program. 11 But most importantly the organ retrieval program, 12 which I construe to be an extremely important program in 13 view of the growing importance of organ replacement as a 14 way of meeting end stage renal disease. 15 1 have had personal experience with the organ re- 16 trieval program in Kansas, and found it exemplary for the 17 nation. 18 I do have so qualms. I would select Alternative Number 3, but there are a couple of projects that I am not 19 very happy with. 20 I would recommend reducing their costs-or their 21 funding, that -- and the arthritis project, by $26,000. 22 They presented $226,400, so I would give them a flat $200,000. 23 24 Similar to that for the perinatal project. 25 This would then. effectively reduce their funding 2-7 unt3r Alternative 3-by $108,000 for a to 1 of $1.149 mil- 2 -on. lion,, and that would be my recommendati 3 MR. GARDELL: Dr. Gramlich,, would you like to 4 speak to the arthritis, which we handled in bloc form yes- 5 terday,, Dr. Haber. 6 DR. GRAMLICH: Dr. Haber, yesterday-it turned out 7, @-that the arthritis requests roughly equal the amount of 8 funding that was available in total* 9 Therefore, we took bloc action,on them, including 10 Kansas, at the level of $226,000, and that has already been 11 approved. That is earmarked funds that can be used for 12 nothing but arthritis. 13 And it turned out to be the amount available, as 14 it was, 15 DR. HABER: With that amendment, I would like to 16 make my recommendation such that it embraces the actions '17 already taken by Council. 18 MR. BAUM-. So we would add that to your figure, 19 how much? 20 DR. JANEWAY: Twenty-six thousand four hundred. MR. BAUM: So it is $1 million $490 -- plus 21 22 DR. HABER: Whatever would be additional for,the Kansas arthritis project.' 23 24 MR. BAUM: It is $226,400'. 25 DR. HABER: Incidentally, I am delighted with the 2-8 1 news that I hear about the arthritis project an bloc be- 2 causL I construe that'to be extremely important. 3 MR. GARDELL: With that motion that you have I 4 think it becomes a bloc action, then. 5 MR. BAUM.- No. It becomes $1 million $716,400; is that right? 7 DR. HABER: Right. 8 MR. BAUM: I added wrong. It@is $1.149 million, 9 plus $226,,000. That gives you $1.375. 10 VOICE: It comes out to $1 million $175,400; is 11 that right, Dr. Haber. 12 DR. HABER: Yes. 13 DR. JANFWAY: So it is bloc? MR..BAUM: No. it isn't. 14 15 MR. GARDELL: Dr. Haber# the $1.357 in here does 16 include the arthritis, We d@,'@.d not have separate applica- 17 tions. Do you intend to increase it over that, or do you want to stay with what they are requesting, which includes 18 the arthritis. 19 DR.' HABER: The latter. 20 MR. GARDELL: Okay,, then it does become a bloc 21 action. Very good. 22 DR. KOMAROFF: What level of support are we voting 23 on? 24 25 MR. GARDELL: It is either three or four, Tony. 2-9 They are both the same. 2 DR. KOMAROFF: -What about the reduction for the 3 perinatal funds? 4 DR. HABER: That's part of the level I recommended, 5 reduction of perinatal funds to $200 1000. 6 MR. BAUM: They @ave asked $1 million $357,126. 7 Now you want to take how much out? 8 DR. HABER: That amount for perinatal, which is in 9 excess of $200,000. What was thato, $26,000? I'm sorry, 10 $52,000. 11 @@MR. BAUM*. That would give you $1 million $305,126. 12 It is the amount requested, less $52,000. 13 DR. HABER: Right. 14 -MR. BAUM: So the actioni then, is on $1 million 15 $305,126, deleting $52,000 for the perinatal project. 16 MR. GARDELL: We have a motion on board for Kansas 17 which is the figure you finished up with, $1 million $305,12( 18 excluding the perinatal project; do I hear a second? 19 DR. WAMMOCK: Second. 20 MR. GARDELL: Discussion? All in favor? 21 (Chorus of ayes) .MR. GARDELL: No? 22 (No response) 23 24 MR. GARDELL: Thank, you. Now, Louisiana. Dr. Janeway 25 DR. JANEWAY: I had extensive discussions with 2 y staf' following the receipt of a variet f letters'between 3 Dr. Sabbatier and Mr.. Rubel# and those from the 'State office 4 of Comprehensive Health Planning# and Mr. Rubel. 5 it is my recomendation that Alternative Numb6r 3. 6 in the amount of $66Ofl69 be recommended as the level of 7 funding for Louisianaf which is the requested-amount,, in #8 comparison with their current annualized rate of somewhat in 9 excess of $1 million one per annum. 10 This recommendation is made with the suggestion to 11 staff that it use the widest possible discretion and use. 12 of its authority in the allocation of funds for transitional 13 activities, to assure that there is cooperation between the 14 State Office of Comprehensive Health Planning, the A agency, 15 and the Louisiana RMP. 16 MR. GARDELL: Very good. 17 DR. JANEWAY: Dr. Sabbatier,, I think, has done a 18 fine job in bringing that organization back to a functional 19 level. MRO GARDELL: Then we have a recommendation for 20 21 funding the Louisiana RMP application at the third alterna- 22 @ive level of $660,169. DR. WAMMOCK: Seconded. 23 MR. GARDELL-. With conditions that would be inclu- 24 ded. 25 2-11 DR. JANEWAY: It would%be my,inient on that to 2 excude the new activity listed under Alternative Number 4. 3 MR. GARDELL: It does, yes. It is less than four-- 4. but you want to specifically have that one excluded, do you? 5 In other words, supposing they could fund it within the 6 $66OlOOO. 7 Do you want that one not funded? I' s that your in- 18 tention? 9 DRO JANEWAY: I think it is a nice ideal but I 10 don't think it relates to new activities as determined un- 11 der transitional activities in the law. 12 MR. GARDELL: Are we ready for the vote? All in 13 favor? -14 (Chorus of ayes) 15 MR4 GARDELL: Noes? 16 .(No response) 17 MR. GARDELL: Thank you. 18 Maine. DR. HABER: The Maine project is a very interesting 19 20 one. The comments I would make is that this regional medi- 21 cal pIrogram has done a great deal to bring up the quality 22 of care in this relatively isolated section of the north- 23 east. - The Veterans Administration has been heavily in- 24 volved in making grants to the grantee organization, and we, 25 2-12 involved in ing to get a medical school are a]-so deeply try 2 going in Maine, and have the family practice residency and 3 several other worthwhile objectives going there. 4 Although it has been my apparently mistaken belief 5 that everything is harmonious in Maine, that is not the case. 7 There was an acrimonious controversy over a position 8 of the municipal health specialist, in which a great many 9 issues, relating to local versus state versus federal hegemony 10 over the health care process come to fruition. 11 But I really think it is a tempest in a teapot. 12 I would recommend Alternative Number'3 for them, without any 13 change. I would go with the staff recommendation of 14 $1,133,989 million. 15 MR. GARDELL: Do you have any feeling for the new 16 activities at all, since we did not come to a conclusion 17 yesterday as to whether we would or would not consider? Are 18 you excluding those, Doctor, or do they have the alternative 19 of funding them, if they have a high priority? 20 DR.-HABER: I think-it would be the latter. 21 MR. GARDELL: Then it is Number 3,, without any 22 conditions? 23 DR. HABER: Right. I wish the process was not so 24 fast, because there are many fine things in this application 2,5 that I would like to comment on, but in the interest of time" won It. 2 MR. GARDELL: I knowr we all feel that way# I guess. 3 DR. JANEWAY: Dr. H@r,, I would like io ask'a 4 question for my own edification. Are any of the funds in 5 the RMP being used toward the development of a medical 6. school? 4w .7 DR. HABER: Not directly. The basic problem is, 8 'the veterans Administration has'a new law, 541, which per- 9 mits us to establish on our own campus,, to construct and 10 fund a medical school for 90 percent of the first year's 11 costs on a decreasing scale, over a period of eight years, 12 at the end of which time it would have to be fully supported 13 by the state in which it operates. 14 My concern is whether Maine can afford a medical 15 school or not. 16 DR. JANEWAY: That was the thrust of the question. 17 MR. GARDELL: We have a motion from Dr. Haber that 18 Maine be funded at $1 million $133,989t with no conditions. 19 Do I hear a second? 20 MRS. MARS: Second. MR. GARDELL: Do we have any discussion? All in 21 favor? 22 (Chorus of ayes) 23 MR. GARDELL:. Noes? 24 DR. JANEWAY: Abstain. 25 2-14 MR GAnEi;L: Memphis. 2 DR. HABER: Memphis gave me some real concerns* 3' I'note the staff recommendation was for Alternati@e Number 4 1 or 3. I guess I would have to come down on the side of 5 Number 3.' Memphis is obviously very busy. They are proceed- 7. ing in a workmanlike fashion. I think a number of very 4 8 good things have happened there. -Theyi themselves, regard 9 Alternative Number 3 as their first priority and did not 10 believe that Numbers 2 and 4 were viable. 11 It seems to me that that is flagrant disregard of 12 your instructions# but so be it. I.think their projects 13 Are plumped under quality assurance, accessibility of pri- 14 mary care services, training and increased manpower utiliza- 15 tion, regionalization and emergency medical care and preven- 16 tion of disease. 17 They have done some remarkable things; they have 18' helped train a great many people in emergency care. They have established regional community trusteeships. They are 19 20 now funding over 140 separate and distinct activities. in the emergency medical field. 21 22 They have trained 800 emergency medical technicians. That must be having a major impact on primary health care 23 - delivery in the memphis area. I would-dearly love to see 24 some analysis of this. 25 They claim that their target wo uld be 470,000 2 parents,, and they are screening an additional 300,,OOO 3,- -people for hypertension and other related diseases. 4 DR. WARMOCK: HOW is that done? 5 DR. HABER: Through hypertension screening clinics. 6 DR. WAMMOCK: Voluntary basis? 7 DR. HABER: Yes. Hypertension screening is, again, 8 something that has national priority from HEW and the VA as 9 well. It is an area where integration with private medical 10 practice has been rather good. 11 In sum, I would, without enthusiasm, recommend 12 acceptance of Priority Number 3 for a total of $3.28 million 13' dollars. 14 MR. GARDELL: That would become a bloc action, Doc- 15 tor. 16 DR. HABER: I am open to all kinds of argument on 17 that one. 18 DR. WAMMOCK: What will you do with the unfunded activities of $500tooo? 19 DR. HABER: I would suggest that they be phased out 20 21 MRS. FLOOD: I have to express the same concern, Half a million dollars' worth of new activities, beginning 22 23 at the transitional period. I only have the staff summary, but the transition components of this particular region's 24 proposal don't seem to be that strong,. other-than staff 25 sis of will be doing some ongoing monitoring,, and now analy 2 data reports,, etcetera,, which will be of value. 3 Can the staff person, perhaps, tell us if,any of 4 the new activities relate to transition? 5 MR. JEWELL: No. The way I understand it it is a 6 salving of some forces in Memphis. They included and they 7 would not get enough funds to fund it. There is equipment 8 in,here, too. 9 MRS. FLOOD: I just feel that-it is inappropriate 10 to just-bloc action in a particular region which has an 11 annualized budget currently of $3 million $494,000, accord- 12 ing to the new printout we received and is talking about 13 a half million dollars of new activities although approved and unfunded. 14 I'would like to recommend a lesser level of funding, 15 16 deleting.the activities, the new, approved, unfunded activi- ties. 17 MRS. KLEIN: Mr. Chairman, I notice here that they 18 have equipment requests too. Are those a part of the re- 19 quested funding? It is over $300,000. 20 MR. GARDELL: It depends on what the equipment is 21 for. 22 MRS. FLOOD: It's in the $528. Of the $528 over 23 $300,000 was equipment. 24 DR. WAMMOCK: I want to touch another point here. 25 -4cP)t cP'7,'O "Ii)) 9 If you look under the Tennessee grant; they are requesting over $2 million. This grant is $3 million $650 that's 37 $5 million plus. 4 And that is a lot. 5 'MR. GARDKLL: On the other hand,, their annualized 6 level is $1 million dollars greater than Tennessee itself. 7 DR. WAMIOCK: That's right. 8 MRS. MARS: What you are saying is that's going in- 9 to the state. That much money is literally going into the 10 state,, which is too much. 11 DR. WAMMOCK: For the size and the population -- 12 I don't question their ability and capacity to spend it, 13 but I think it's way out of line. 14 DR. HABER: I would temper that information with 15 the knowledge that Memphis -- I don't pretend to be too. 16 well informed about this area,, but Memphis'has as z,,,uch ef- 17 fect in some of the northeastern counties, say, of Arkansas. .18 DR. WAMMOCK: That is perfectly true, but at the 19 same time 20 DR. HABER: Our patterns of patient referral fre- 21 quently go that way in Arkansas. 22 DR. WAMMOCK: It is close to Missouri, too. 23 DR.JANEWAY: It's still a lot of money. DR* WAMMOCK: I would leave that $528,000 for 24 approved, unfunded activities. 25 MR. GARDELL: On the basis that 2 DR. WAMMOCK: They have been approved and unfunded. 3 BLt the budget is all out of balance. 4 MRS.-FLOOD: Mr. Chairman, may I submit for the 51L Councills consideration the funding level deleting the ap- 6 provedt unfunded activities at $2 million $762,590. 7 DR* KOMAROFF: Second. 8 MR. GARDELL: I think Mr. Jewell was raising his 9 hand. 10 MR. JMSLL: I think the record ought to show that 11 the Memphis RMP covers parts of five states. It is not all 12 going into Tennessee. It's Arkansas, it's Mississippi, it's 13 a conglomerate. 14 Even though it is called Memphist and it is physi- 15 cdlly located in Tennessee. 16 DR. WAMMOCK: That is a big umbrella. 17 DR.'HABER: I would like to indicate that Iwould 18 be very happy with Mrs. Flood's recommendation. As I indi- 19 cated, I recommended Alternative Number 3,, but without en- thusiasm. 20 X think the points she makes are well taken. I 21 22 think they have done some very fine things, but I think@the 23 level of funding that she mentioned would be appropriate. I would be happy to concur in that. 24 MR. BAUM: What was your number? 25 (202) 628-4Bi38 21411io, MRS* FLOOD: I have i@,la n $752,590. 2 He i right. 3 -MR. GARDELL: Has the recommend tion been seconded? 4 DR. WAMMOCK: Yes, sir. 5 MR. GARDELL: The motion has been seconded that the .6 amount of $2 million $752,590 -- that excludes the approved 7 but unfunded activities, which are to be excluded specifi- 8, -cally,, because-in all probability they will not get that 9 much anyway. 10 All in favor? 11 (Chorus of ayes) 12 MR. GARDELL: Noes? 13 (No response) 14 MR. GARDELL: Missouri, Dr. Haber. 15 DR. HABER: Missouri was the most,difficult of.al:l. 16 Arid I will need some help on this one.-,I came up with the 17 feeling that again there was a great deal of controversy @18 between the CHP agencies and the RMP, between various levels 19 of state and county and national jurisdictions. 20 it was difficult to dissect out what they were 21 doing. They are obviously doing a great many fine things, 22 and one is reluctant not to go along with their total rec- ommendation. 23 But that, of course, strikes me as being inappro- 24 priate. They do have some good things in trying to bring 25 better care to nursing homes,, which I think is important 2 ir 14issouri, certainly from the VA's stance. 3 They have spent a fair amount in family care, .4 which I think is important. They are concerned with pa- 5 tients' rights. 6 one project dealt extensively with that, a very 7 important area. 8. DR. KOMAROFF: What are they doing? 9 DR. HABER: They are elaborating something like 10 a Patients' Bill of Rights, and educating people as to what 11 those rights are. 12 DR. WAMMOCK: The RMP? 13 DR. HABER: Right. I think.one of the things 14 let me just say that if I had to defend that concept, I am 15 surprised it is questioned, but I think one of the thin gs 16 that the REgional Medical Program has done has been to edu- 17 cate patients as to what to expect. @18 1 think that is one of the most significant-. things 19 that the RMP has done across this country. In the process 20 it has raised expectations on the part of the consumers in 21 health care. 22 It may be in some areas it is inappropriate, but 23 I think, generally speaking, that that is a desirable thing. I think that one of the most important things that we can 24 25 do in preventive medicine is to educate people'on what to ,4ci):c P@l,j)'Oi-fillq (201111@i(it!l 2-21 expect and how they can take carelof themselves. 2 'DR. WAMMOCK: I would agree with it wholeheartedly 3 but I am not sure -- I sat in on a meeting on the same 4 thing last weeko dealing with the process of the-education 5 of people about those problems. 6 DR. HABER: My concern is that preventive medicine 7 in this country is not going to@get anywhere.until we have 8 people who are enlightened about health care. I think we 9 would'certainly be on the side of educating people. 10 DR. WAMMOCK: I am going to.ask you something about 11 educating people. John Gunther wrote a book, "Death, Be 12 Not Proud". It was premiered on ABC, about two and a half 13 months ago, at prime time. 14 The principal actor in that was John Hillt who 15 also had a son who died with a brain tumor. For the eddca- 16 tion of the publice this was emphasized in the press and TV 17 and so forth and so on. 18 I have asked many of my friends in different meet- 19 ings I have been tot and only one or two fingers have been 20 up who saw that movie. 21 I don't watch movies on TV, but I was posted about 22 this, my wife told me this was coming up and I read the 23 book in 1949 when it came out. - Mr. Gunther is a very eminent man. He wrote "In- 24 25 side Asia", "Inside Europe",, and so on. I just emphasize that a health problem,, as far as I am'concerned and as far 2 as -education is concerned but I don'tiknow how many 3 people saw that. 4 I am going to find out from ABC whether five mil- 5 lion or ten millio n people saw it. But I thought it was a 8 wonderful', educational program about the health problem, 7 Dr. Haber, and I could not agree with you more heartily 8 about the situation. 9 But the question is, look at the trash that is on 10 there. 11 DR. HABER: All 1 am saying is education itself 12 can be good or bad,, and I have no argument with that. We 13 do a lot of bad things in education in many other fields. 14 I would not like to convey the impression that I 15 am in favor of bad education. But I think that until the 16 p@blic is enlightened about what health care is all abouto 17 I don't think we will ever get off the ground in preventive 18 medicine. 19 I think the whole issue of smoking is a case in 20 point. 21 DR. WAMMOCK: That's right.@ 22 DR. GRAMLICH,. Dr. Haber, I noticed there is a 23 large staff in Missouri, around 70 at'..the present time. 24 They are recommending supplementation of that staff in the neighborhood of 90 to 91. 25 Did this"catch your attention? 2 DR. HABER: Yes, it did,, and I do#lt think they 3 should increase their staff. My.feeling is, I would indi- 4' cate that Alternative Number 3 is the one that I would want 5 -to see. 6. DR. KOMAROFF: That gives them.a million'dollars 7 more. than they are currently spending. 8 DR. HABER: With the reduction to $3 million dol- 9 lars.-total..'spending. I am told by staff that Missouri is 10 in the throes of all kinds of political problems with res- 11 pect to the operation of this. 12 The director, himself, has been in Japan, Would 13 you,enlighten us again oh that? 14 MR. POSTA: Dr. Wrigley has been on sabbatical for 15 about a year. He is due back in later this month. Jim Watts, 16 his deputy, has been on board 100 percent of the time.- How- 17 ever, the records you have there show Dr. Seitz has been on 18 board as the Acting Coordinator for about 20 to 25 percent 19 of the time this past year. But Dr. Wrigley will be on board when this new 20 grant would be in effect, July 1. 21 14R. GARDELL: Your motion then, Doctor, was for 22 $3 million eight 23 DR. HABER#. No. 24 25 MR. GARDEL: Number 3. 2-24 DR. EIABEI: Number 3, with the reduction of 2 $883,000, a flat $3 million. 3 MR. GARDELL: Are you specifically reducing the 4 new activities, or are you reducing the amount requested? 5 DR. HABER: I am reducing the amount requested, 6 but that, then, is to be used to prevent the introduction 7 of new activities. 8 MR. GHRDELL: No conditions, The motion has been 9 made that Missouri be funded at $3 million. Do I hear a 10 second? 11 DR. WAMMOCK: Second. 12 DR. HABER: Can I ask Miss Murphy if she has any- 13 thing further to say about this? 14 MS. MURPHY: No. 15 DR. KOMAROFF: I just wonder how often in the pro- 16 ceedings so far we have appr.-,:)ved a level that is higher than 17 the current annual operating level for a region? If we have 18 done that a fair'.amount of the time,, then it seems to me we 19 are not implying that this is a particularly good region on 20 this action. 21 DR. WAMMOCK: This is going to come up again and 22 has come up. We are approving $250,,OOO more. 23 DR. GRAMLICH: But they will only get 40 percent of that, approximately 24 25 MR. GARD"ELL: I know that colors my thinking in 2-25, everything you do. I can't help but have it color my think- 2 ing, and I am sure it does yours# too, 3 That is why I am saying, if you have any specific 4 conditions that you want to put on it,, those would have 5 to be included in whatever share of the funds that they get. 6 It could well be that what we need to do when we 7 finish here and before all of you take off is to get some 8 sort of guidance from you that, if any of these activities 9 are transitional in nature# depending on the wording of 10 the supplemental appropriation when it is finally passed, 11 if it allows new projects for transitional purposes, that 12 you would have no objection to them. 13 But they are new. We have al,ready said, 'We don't 14 care if it is in program staff', but we are talking-about 15 projects no-4. 16 DR* WAMMOCK: Dr. Haber referred to in fighting in 17 Missouri, and there is a comment here that deals with that 18 situation, that is made by the reviewer here. 19 *The CHP comments received from'.Archt St. Louis,'. 20 Missouri were unfavorable',- 'The RMP-plans to-respond to the remarks. The RMP had sent the application to'CHP A 21 agency, who, in turn, fotv&rds related projects to appro- 22 .23 priate B agency. 24 'Unknown to RMP several B agencies have'not been contacted. The program plans to check into matters and 25 2-26 % ights rectify any overs 2 DR. HABER: When you read the response on the" I 3, time of the RMP they, in turn, indict the B agencies as being less than supportive. They point out that they have 5 invited them to meetings where there has been no attendance, 6 It is difficult to say who Is the culprit in this 7 thing, but I was merely commenting that th6re.was a.differ- 8 ence of opinion. 9 MR. GARDELL: I think, again, we have to go back 10 to the resolution that we talked aboute where we will'have 11 to concern ourselves with reconciling any differences that 12 would appear to exist between the RMPs and the reviewing 13 agencies. DR. WAMMOCK: I think this is an unfortunate sit- 14 15 nation for them and for us. 16 DR. HABER: I do have someipecific instructions 17 in line with staff recommendations, or recommendations from Region 7 RHA. 18 19 They are that Project 164@not be funded; that 20 Project 166 not be funded; and that Project CO 65 -- I'm sorry, CO 54t not be funded. 21 MR. GARDELL: Do you have any reasons for that, 22 for guidance, Doctor? 23 DR. HABER: It does not look like it is an appro- 24 priate area for them to develop -the model HSA under 25 12 2-27 1. Project 166. The 164 is in' propriate, because it would ap 2, -icate, according'to the Re ional Director's note,, it comp.. .9 3 would complicate the transitional process, 4 Co 54, the communications for transition@s-eems to 5 be gratuitous to put it mildly. MR. GARDELL: One of the things I would like to 7 the comments we get from the reveiw- remind you of is that 8 ing agencies are not required for us to act upon. .9 In other wordsi what it has to do, Doctor, go back 10 to the RAG,, and they have to consider it. If they decide 11 to fund it anyway, they have to provide us with justifica- 12 tions as to why they have funded it'. 13 All I am cautioning you is that we are not required 14 at this point, and that is why we have a resolution hot to 15 live with the comments that we have. 'DR. HABER: In line with your request for further 16 17 instructions about it, I thought that would be a point. 18 MR. GARDELL: The Administrative office comments 19 are regionally decreed upon, not by law, 20 DR. KOMAROFF: I am not clear whether you want to 21 specifically prohibit those activities or merely make sure @22 that the message gets through to the region that the region- 23 al office and the CHP agencies were concerned. DR. HABER: The latter. 24 DR. KOMAROFF: Am I to understand that the new 2.5 2-28 activities for $878 are specifically excluded? 2 DR. HABER: Precisely. 3 DR. KOMHROFF: Okay. 4 MR. GARDELL: You are still of the opinion that 5 these three activities ought to be specifically deleted, 6 Doctor, or did you change that? 7 DR. HABER: No. I said that ought to be furnished 8- -for their guidance. 9 MR. GARDELL: Very good. We have a motion for 10 Missouri to be funded at a level of $'3 million with guidance -11 regarding three of the activities and exclusion of the new 12 activities in the amount of $888,000, the balance# so it 13 comes out to a flat $3 million. 14 Do I hear a second? 15 MRS. MARS: Second. 16 MR. GARDELL: Any nore discussion? All in favor?-, 17 (Chorus of ayes) -18 MR. GARDELL: Noes? 19 (Chorus of noes) 20 MR. GARDELL: Three. New York Metro,, Dr. Watkins 21 is leaving the room. 22 DR. KOMAROFF: Before you leave, Ben, I am still 23 waiting for staff information on New York Metro. Can I pass 24 again? 25 MR. GARDELL: 'Just don't let us forget you. North Dakota. 2 MRS. GORDON: North Dakota last year was annual- 3 ized at $5D5l5Ol. They are short on their minorities,as -4 far as their employees and staff'goes, and their-Council, 5 which is something I just wished to mention. 6 At this stage of the game I don't know if we ate in 7 any position to do much about it. They foresee closing shop one year from now. 9 They are only going to have three activities,.and 10 one of those is arthritis, which is earmarked. Sp I recom- 11 mend that we bloc them,, with their Number 3 request. 12 DR. WAMMOCK: So moved. 13 MR. GARDELL: With some sort of indication of cbn- 14 cern for the lack of minorities? 15 MRS. GORDON: Yes. 16 MISS MARTINEZ: ),fr. Chairman, I believe when Ire- 17 viewed New Jersey I forgot to mention that# not the lack of .18 minorities in general, but the lack of Spanish-speaking '19 minorities. 20 New Jersey has a very large population-now and 21 there really is no excuse. I believe I mentioned it at the last Council meetingr as well. 22 MR. GARDELL: I don't recall whether the advice 23 went to them or not. I assume it did. 24 25 MR. NASH: I don't know if it went into the advice 4ciltc P@, 'o,-Iilg COI)II,cf,ty 2-30 let,-er or not 2 MR. GARDELL'* We will do it again. Northern New 3 England is our next one. Mrs. Flood. 4 MRS. FLOOD: Northern New England has a current 5 annualized budget of $1 million $266,460, and is requesting 6 under Item 4, Budget 4,, $1 million $51'7,,480,, with'-the new 7 activity designation being.@entirely transition activities. 8 There is concern expressed by staff, and'I found 9 it obvious in the application., The coordinator has listed 10 himself as the Project Director for five different projects. 11 He has assured staff that he has eligible agencies 12 and institutions to assume these responsibilities, should 13 the award be given. The project reflects some well-planned 14 thinking for the transition period, and I would recommend 15 a bloc approval for Northern New England, at Level 4, inclu-- 16 ding the new transition. 17 MR. GARDELL: All right. My favorite Northlands. DR. 18 WATKINS: Northlands has a very tightly run program. Three new projects connected with the 93-641 HSA 19 bills. It is asking for roughly halft which is $963,760p 20 half of their previous current level of supports which was 21 $1 million $850,459. 22 I am asking for a bloc on that. -23 DR. WAMMOCK: Second. 24 MR. BAUM: -At which level,, four? 25 2-31' DR. WATKINS: Four. 2 MR. GARDELL*. Ohio Valley. 3. DR. JANEWAY: Ohio Valley is currently operating. 414 at an annualized level of support of $2 million $i73t321. 5 Their alternate Number 4, including $108,,568 for hew acti- 6 vities is $1 million $216,149. 7 Although I have some minor misgivings about cer- 8 tain of the projects, I recommend a bloc. 9 DR. KOMAROFF: What are the new activities? -lo DR. JANEWAY: They are all related to transition. If there is a second to that, I would like to make one phil- 12 osophicdl comment. 13 DR. WAMMOCK: Second. 14 DR. JANEWAY: I wonder if it is not an error that 15 we made before. This project, 4844, computerized time 16 oriented data base for renal failure, which strikes me as a 17 scientifically related project that should have been peer 18 reviewed,, through a scientific council on its merits. 19 In reading the discreet activity summary it is 20 a continuing activity, and there is nothing we can do about 21 it. But careful reading of it indicates to me,,and I pre- 22 sume it has been handled thusly, that it should have go ne through at least a clinical research practices committee. 23 24 Or,, a committee on human subjects before it was 25 included as a project*. MR. @ELL: That went to the kidney programs @2 Dc tor,, and we will be guided by thei: pqponse to us. 3. DR. JANEWAY: Thank you, 4 MR. GARDELL: Oklahoma,, Mrs. Mars. 5 MRS. MMS: Oklahoma has acted as a resource to '6 the Governor in the HSA planning. In.factl I think he is 7 taking great advantage of the fact, and he is asking for 8' @$60,,OOO for support of the transition period* 9 Their proposed application activities represent 10 more or less a continuation of program elements,,..which do 11 have the most potential in the transition and organizational 12 period. 13 Also, it their request there is $100,000 support 14 for two approved, unfunded BHP B agencies,, as well.as 15 $).00,,OOO to the CHP A agency,, through another project. are justified in the amount 16 I don't feel that they 17 that they have requested, and I would like to recommend 18 N@er 2. but spread over the period of 18 months. In other 19 words, to June. 20 And not confined to December 31st,, of $1 million 21 $252tl4l. I feel that a great deal of the money.,4.-hey are @ i 22 asking for can be obtained from other places, so -,.o speak. Naturally they had a glowing report from the CHP# 23 24 since they are supporting them, more or less. So@that is 25 my recommendation. 2-33 DR. WAMMOCK: You wanted to go t@ June of 176? 2 MRS. MARS:' Yesf you see, ordinarily,, Number 2 3 would end at December 31st. MR. BAUM: That's $1 million $252,,142 through 5 June 30th, 1976? 6 MRS. MARS: Right. 7 MR. GARDELL: By questioning the support7,of the 8 CHP agencies, federally and non-federally supported, I 9 think this is the first.time that it has come up, Idon't 10 know what kind of a precedent it will set in future review. 11 But it seems to me in some of the areas in the 12 coordination of the two programs out there,, or three program@3,, 13 however many are involved in trying to develop an appropria-,-e 14 health planning activity for the state, remember that the 15 CHI? agencies are not well funded either. 16 That has been one of our expendituresp'clnd we de-. 17 cided a long time ago it would be, so that is for what it 18 is worth. 19 Do you want any conditions put on thist or just 20 reduce the amount? 21 MRS. MARS: No. just reduce the amount. They can do what they-please about it. 22 MR. GARDELL: We have a motion on the floor for 23 Oklahoma to receive $1 million $2520 141 for a 12-month 24 25 period. Do I hear a,second? MRS. GORDON: Second. 2 MR. GARDELL: is there any discussion? 3 MRS. FLOOD: 1-just wish to request 'FlarificatiOn. A- This funding level does not exclude funding, whatever they. 5 manage to apportion to either the A or the B agencies or 6 the Governor's office? 74p@ MRS. MARS: No.-it does not. They can do what they 8 please about it,, as far as I am concerned. 9 MR. GARDELL: All'in favor? 10 (Chorus of ayes) 11 MR. GARDNER: Noes? 12 (No response) 13 MR. GARDELL: Oregon. @14 DR. WAMMOCK: This is a very small and concise 15 report. I would call to your-attention that.the annualized 16 level is $1 million $3l8lOOO. 17 They are requesting under Number 3 $901,186 and 18 1 recommend they are going through a transitional stage here to HSA. 19 They have some Emergency Medical Service going on. 20 I will notread this, but I think it is a very goo program 21 and I would move that it go en bloc. 22 MR. GARDELL: Very good. Let's take a coffee 23 break. 24 (Whereupon,? a short recess was taken). 25 (202) 6 2 B-4888 14R. GARDEI;L: can we reconvene? Can we move on to Puerto Rico? 3 MRS. FLOOD: Puerto Rico is listed in our.books 4 as annualized figure of $742,572 but-the actual print-out 5 reflects a lower annualized figure, $705,972. They have 6 a reduction in arthritis that was approved at previous level 7 of funding, not approving an expansion of.funding. 8 There is one concern expressed by staff review#, and 9 also upon careful analysis of their documents. They have 10 a plan to expand their current staff levels. 11 I would request that they be advised to carefully 12 analyze the types of staff that they are going to expand 13 to, or perhaps not expandt and readjust the types of staff 14 that they are utilizing for the transition, as it is docu- 15 mented, 16 But they intend to ar.,ply to become the IISA for 17 Puerto Rico;. But I would recommend bloc approval. 18 MR. GARDELL: That's $889,852? 19' MRS. FLOOD: That is correct. It will carry, auto- 20 matically, the deletion of the arthritis reduction. 21 DR. WAMOCK: I was in San Juan and they are work- 22 ing hard on their program there, and I think they are de- 23 serving of this pitiful sum, and I would echo that. MR. BAUM: Can I comment on that? I will take off 24 25 my hat as Secretary, and put on one as a staff member. APIIC Rcl;ol.lilz Coi,il",-Illy 9 2-36 1 Dr. Rabura (ph) who is a coordinator of-the program 2 in Puel--o Rico was in here several weeks ago, In Puerto 3 Rico there is no CHP B agency. The RMP there clearly intends 4 to become the HSA for Puerto Rico. 5 They have to divest themselves of their association 6 with the university, and become an independent organization. 7 But that may partially explain the reason for his increase in staff, because they appear to have a clear track to be- 8 9 come the HSA,, and I gather Puerto Rico will be a single 10 area, 11 MR. GARDELL: Mrs. Flood, that is all in the staff 12 review. Would you still like to have us alert them 13 MR. NASH: This problem, as I see it, with the staff 14 in Puerto Rico is that they already have on board more 15 staff than an HSA for the population of Puerto Rico would 16 be able to support. 17 MR.'GARDELL: I see. So really instead of'inereas- 18 ing them what they will have to do is be more selec tive 19 and reduce. MR. NASH: Right. 20 MR. GARDELL: That's a good point, and we will guide 21 them accordingly. 22 MRS. FTOOD: That was the only concern. 23 .24 MR. GARDELL: The motion is that it be a bloc action but with guidance with respect to the assignment of staff to 25 2-37 1 RMP and Ultimately to the HSA,, should they be accepted as 2 one, 3 MRS. FLOOD: That's good'. 4 DR. TIAMMOCK: Second. 5 MRi GARDELL: Any more discussion? 'All in favor? 6 (Chorus of ayes) 7 MR. GARDELL: Noes? 8 (No response) 9 MR. GARDELL: Mrs..Klein? 10 MRS. KLEIN: ster seems to be a very fine 11 program, and they are requesting funding some $500,000 below 12 their current funding. 13 I think that it is -- would be subject-.to.;'bloc ap- 14 proval at the three level, $805,492. 15 MR. GARDELL: That isn't bloc, then. B10C would 16 be Number 4. Number 4 incluees new activities 17 MRS. KLEIN: Staff questioned those new activities,, 18 but I thought we were authorizing bloc action at Number 3. 19 @MR. GARDELL: Only if there was not a Number 4. Number 4 is considered -- that is the gamut. 20 MRS. KLEIN: Then I would recommend that we approve 21 it at $805,492 which is the Number 3 item. 22 DR. WAMMOCK: I second. 23 MR. GARDELL: Are you going to give us any guid- 24 ance on the new activities? 25 2-38 MRS. KLEIN:' They:_seem to contemplate the new acti- 2 vities as being justified by the Number 4 authorization. I 3 don't know whether it would be necessary. I feel as a mat- 4 ter of philosophical approach that these programs for the 5 various regions should be given the greatest freedom to 6 utilize the funds as they wishe 7 I don't know enough about it to recommend that. 8 MR. GARDELL: I just wanted to make certain. 9 MRS. KLEIN: If someone else feels that qualified-- 10 DR. KOMAROFF: Do the new activities relate to 11 transition at all? 12 MRS. KLEIN: Yes, to an extent they do. 13 MR. GARDELL: Largely related to primary and chronic 14 care in a variety of areas. one of them relates specifi- 15 callyr and that is for $9,800. 16 MRS. KLEIN: The sta.4f comment was that it may not 17 be in the best interest of the newly formed'HSA. So I 18 would imagine that some of them would be continuing programs. 19 If somebody else feels differently, and knows a little bit 20 more-about Rochester than I do 21 MR. GARDELL: I just wanted to say, for discussion 22 purposes, that I have not seen a clearly accepted definition 23 of what is transition. We tend to think of it in terms 24 of something that would-be helpful in the development of 25 an HSA or a'state agency* or the designation of an area- 2@39 1 which has already been done. 2 Those kinds of things. But in addit on to that, 3 they' are talking about transition in the appropriation lan- 4 guage at the moment, transition being the kinds of things 5 that are worthwhile saving for the future. 6 Just as we were speaking a few minutes ago, there 7 are a lot of good things that the RMPs are doing that'should 8 be continued by somebody. 9 This is considered transitional, as well. Sd:l 10 am just saying to you -- I am confusing you I know but as 11 far as I am concerned,, transition means a lot of things to 12 me, 13 And it could well be that some of these activities 14 which-are not necessarily geared for the new agency are the 15 kinds of things that should be continued by a new agency, 16 not just in the development of one. 17 Hopefully,, someday needed federal funding would 18 come under 19 MRS. KLEIN: How would you then interpret the com-' 20 ment by staff, the funding of 23 new projects at a cost of $544,578 may not be in the best interest of the newly-formi-A 21 HSA? 22 MR. GARDELL: Let us ask the staff. 23 MR. BAUM-. Frank? 24 25 MR. NASH: Is Moe Robbins here? He was staff p"I-loriiii@i cloll/7cioly 2 40 reviewer on this. This particular region.probably has the 2 closest working relationship to CHP as anyone.in the country. 3 The records the advisory group for CHP and the 4 ,staff are almost one and the-same, and will probably become 5 the.HSA for that area. 6 Therefore, I think the projects that they propose 7 have been reviewed by CHP and RMP. If they did rot feel it 8 to-be appropriate for HSA, which they intend to become, they 9 would not have included it in this application. 10 DR. JANEWAY: On the other hand,.if the'Motts were three rather than 2. they could have worked Hill Burton in 12 this as well, and gotten some construction money 13 MR. NASH: The CHP agency was the Hill t.urton agency 14 for that area. 15 MR' GARDELL: We are going to have a very,active 16 case of incest here very shortly, aren't we? Then the rec- 17 ommendation is that the Rochester RMP be funded at the level 18 of Number 3, which is $805,492. 19 DR. KOMAROFF: Second. 20 MR. GARDELL: Any discussion? 21 MRS. FLOOD: I would like to comment that looking 22 at their application, there are some projects that do fall 23 into the broader category that you mentioned, worthwhile meri.. 24 torious projects that merit new development and continuation 25 over and above what we might technically have called ,4,iize iVeporlioig Coi)zpciiiy 'transition"# writing by-laws and developing the true struc- 2 ture of an HSA. 3 The staff mentions the $9#800 projectr but,there is 4 a project, 097, for $34,360 which is entitled "A Hospital 5 bata Finder'. There is an 098i "Case Finding Profile". It 6. is difficult without going into the 15s to evaluate all of 7- them. 8 But I would have to share some concern for a program. 9 We realize they don't get this money,, and I think'that is 10 what tempers us all in these decisions. 11 But should a flash of lightening occur and someone 12 decides in the next six months to'give the Regional Medical 13 Program,, the whole Regional medical Programs, another $50 14 million, you will give Texas this one, and another', and 15 another, up to some levels of approval. 16 We have been sort of blanketing, and I.%-ould have 17 the feeling that this might be interpreted as a statement that 18 we don't feel that some of their newer concepts are meritor- 19 ious at this point for Rochester. 20 Even though they may be brothers together, it's one 21 of the only ones we have seen where they all seem to be 22 happily working together. 23 I would like to move that we consider at least,a 24 slight increase over Item No. 3. perhaps not up to their 25 total request, giving them an approval for some flexibility IT (202) 6 2 8-4 888 in new activities. 2 At least in philosophy even if they@won't get the 3 dollars. 4 MR. GARDELL: Mrs. Klein, you have already made your 5 motion. Does this affect your motion in any way? 6 MRS. KLEIN: I don't have any objection to that. I 7 would be glad to withdraw my motion, if my second-will with- 8 draw the second,.in favor of this new motion, 9 DR. KOMAROFF: Yes, 10 MRS. KLEIN: I do think it's agood program, and it 11 should be encouraged. My only feeling was that when:they 12 specifically.labeled the new activities and we started out 13 with the philosophy that we were not going to authoriiel-- 14 MR. GARDELL: We are not sure that we can in which 15 case that will have to be the advice to all of them who have 16 requested new projects. 17 But don't concern yourself with it at this point. 18 MRS. KLEIN: Well, fine,, I would be happy to withdraw 19 my motion in favor of Mrs. Flood's. 20 MR. GARDELL: Mrs. Flood, you have a motion. 21 MRS. FLOOD: I have some figures here and I am try- 22 ing-to pick out a basic figure that includes some of the new 23 project start-ups that really relate to things that need to 24 be continued. 25 I get about $256,000 of relatively meritorious 4,ine P",I.,O,.Ii,lg Co,,Il@)a"y 2-43 projects that should be carried on, Iwould like to add to 2 the $80r, 3 MRS. KLEIN: it's $1 million $61t 4920 4 DR. WAMMOCK: That puts it in Category 4. 5 MR. GARDELL: What is the figure nowt Mrs. Flood? 6 MRS. FLOOD: One million, $61,492. 7 Two hundred and fifty-six thousand dollars' worth of new activity. 9 MR. GARDELL: Now we have a motion on the floor to 10 fund Rochester at $1 million $61# 492. 11 MRS. KLEIN: I will second the motion. 12 MR. GARDELL: All in favor? 13 lChorus of ayes) 14 MR. GARDELL: Noes? 15 (No response) 16 MR. GARDELL: Time is @-unning on us and I wonder if 17 we could go to West Virginia for Dr. Haber and then we've 18 got Miss Martinez with Virginia and Western Pennsylvania.' 19 DR. JANEWAY: Do you want to sandwich in Washington 20 and Alaska at the same time? 21 MR. GARDELL: I don't care. I am real flexible; 22 just like you. Let's just start them right now, and then 23 we'll finish the others if we can. The first one of concern 24 would be Virginia.. 25 Virginia is first, and Mrs. Mars is out o the room. MISS MARTINEZ: Virginia has a very heavy emphasis 2 on PSM and Quality Assurance programs and also hypertension 3 It has an arthritis program for $4OoOOO that was previously 4 approved. 5 I understand that will be funded separately, so I 6 won't consider that. Of the new program activities for 7 $243,000 approximately, $lOOfOOO of that is for HSA-type 8 transitional activities. 9 The rest of them nurses' workshops and hospital edu- 10 cator workshops. Their last yearis budget.was $1 million 11 $858,000 and they are asking $2 million $669,000 and I really 12 cannot find much justification in the proposal for the in- 13 creased staff and -- core and professional staff increase, 14 I would move that they be funded, at the Number 2 15 levelf but over the annual period. 16 MR. GARDELL: So the raotion is that Virginia Regional 17 Medical Program be funded at $1-million $975,047, with no 18 conditions. Do I hear a second? 19 DR. KOMAROFF: Second. 20 MR. GARDELL: Any more discussion? All in favor? 21 (Chorus of ayes) 22 MR. GARDELL: Noes? 23 (No response) 24 MR. GARDELL: Thank you. Washington/Alaska is next. 25 ,4,ipze 2"45 DR. JANEWAY: Washington/Alaska is currently fund- 2 ed at in annualized level of $2 million $558,169. After 3. 'the resolution of a minor misunderstanding and skirmish with 4 .,.A task force in the Alaska portion of the program,, which 5 staff assures me has been satisfactorily resolved, I recommend 6 bloc funding at the maximum requested level, which-is N umber 7 3# $1 million $545i879. 8 it is a good program,, that is designed to phase out, 9 and it is a pity. 10 DR. WAMMOCK: I second the motion, 11 MR. GARDELL: Our next one, then,, will be West Vir- 12 ginia. 13 DR. HABER: West Virginia has given every indication 14 that it intends to become the HSA and much of the thrust for 15 the coming year would be to educate people on what an HSA 16 does, and to prepare, 17 I would recommend that we accept their alternative 18 Number 3, with, however, the deletion specifically of two 19 projects which I construe as conceivably unnecessary at'this 20 point. 21 One is Project CO-10, the Health Manpower Statistical 22 System. They ought to have gotten that under their bell-- a 23 long.time ago, and 015, a legal project. This would reduce 24 the amount by $76,322, or I would recommend that they be 25 granted $1 million $129,686. 2@46 MR. GARDELL: We have a motion that West Virginia 2 be funded at $1 million $129#686, less two activities, CO-10 3- - c and 015. Do I hear a second? 4 DR. HABER: That figure already subtracts those 5 projects. That figure is the total I would recommend.-' 6 MR. GARDELL: Yes, I understand. 7 MR. NASH: West Virginia,, I believe,, ha(f an MIS Pro- 8 ject"that was disapproved by the EMS Service. 9 MR* BAUM: 14e'll have to take bloc on all of that. 10 MR. GARDELL: Yes, we will. 11 MRS. GORDON: Second. 12 MR.. GARDELL: Any further discussion? All in favor? 13 (Chorus of ayes) 14 MR. GARDELL: Noes? 15 (No response) 16 MR. GARD.ELL: Western Pennsylvania. 17 MISS MARTINEZ: Western Pennsylvania has a situation 18 similar to Greater Delaware. It has $80,000 for the Mahoning 19 Shenango, That should really be earmarked specifically, 20 $80,000 should be earmarked specifically for report.' 21 As for the rest of the project, they are funded at 22 $1 million $666,000 and they are requesting $1 million@' 23 $305,000. Some of the projects -- one is for arthritis# al- 24 most $88,000 and there are two, possibly three proposals 25 that I have some concern @ ut. fine P'llot-liit@i C.1111.7.riily one is nurses in training. Another is an educator 2 programs. Another is a tumor bank. I would move for level 3 Number 3. There is also an EMS, Quality.Assurance and EMS 4 that I am concerned about. 5 I would move for funding level Number 3.with the 6 provision that $80,000 be set aside for the project for Ma- 7 honing Shenango. 8 MR. GARDELL: The motion has been made that Western 9 Pennsylvania be fu'nded at $1 million $777,650 with an earmark 10 o.fl,$80,000 for the-Mahoning Shenango project. bo't hear a 11 second? 12 DR. WAMMOCK: Second. 13 MRS. FLOOD: This does not exclude them from enter- 14- ing into a list of new activities with the funds they do 15 receive? 16 MR. GARDELL: That's right. I have not heard -t',hat 17 condition. Do you want it in? 18@ MISS,MARTINEZ: No, but now that it has-been men- 19 tio-ned, Iwould like to make that condition. I'don't see 20 those new activities as being transitional. 21 MR. GARDELL: Okay. No new, because.they are not 22 transitional in nature. Did-you have any feeling,as-to 23 actually they were really new or just pursued previously 24 you can't tell? 25 MISS MARTINEZ: They have no on the right side 4,itic Repol-tilici of'the 15,, it had absolutely nothing, so I'assume they have 2 not got:en started. 3@ MR. GARDELL: All right. 4 MRS@. FLOOD:' Staff says one previously approved but 5 unfunded. 6 MR. BAUM: Yes, $35,000. 7 MR. GARDELL: Do you want to exclude that one,, also,, 8 is M s Martinez? 9 MISS MARTINEZ: Yes, 10 MR. GARDELL: So all of them would,come under that. 11 All in favor? 12 (Chorus of ayes) 13 MR. GARDELL: Noes? 14 (No response) 15 MR. GARDELL: We have, also, a request to jump again 16 and this time it.is the Susquehanna Valley. 17 DR. WAMMOCK: I feel highly complimented and honored 18 that I have got this back in my lap again. This was one of 19 the projects last year that we banged up against the wall and 20 almost tied the noose around its neck and cut it off. 21 The current level of support is $710,000, but in 22 their latest figure it is $691,000. They are requesting 23 $2 million $770,000. 24 This involves a county region of eight counties. 25 That is almost in mid-Pennsylvania, I would say. They went 2@49 to long lengths to describe the requested $859tOOO for new 2 activities. -They were approved for $139,000 but it was un- 3, funded,, approved activities# unfunded. 4 This is a large and extensive description of activi- 5 ties and so on They are going through transitional activities 6@ which seem to be favorable. Comments from the CHP are favor- 7 able. 8 Activities requiring special attention, a regional 9 arthritis service'program for $139,,000,, regional organ procure- 10 ment program of $52,000. 11 The staff has researched.this area out many times 12 last.year and many times this yea r. I think before making 13 my move here on this,, I would remind you that the annualized 14 budget was $691,,000.. 15 -1 would remind you that last year we almost tied 16 the noose. But before I render a judgment here, I woul@l defer 17 to staff, for their comments on this. We have had some dis- 18 cussion back and forth about what is and what ain't and what 19 should and what could and maybe. 20 MR. STOLOV: First,, I would like to correct, for 21 the record, Susquehanna Valley is a geographical area of 22 27 counties. That was from a CHP letter that I think you 23 were referring to. 24 DR. WAMMOCK: That's right. 25 MR. STOLOV: Other than that, I think your 2-50 description is most accurate. The only point that I wanted 2 to make for Council is the point-that we made on the staff 3 review summary sheet. 4 It is our belief that this is the only region of 5 all the ones here today that is somewhat of a separate case because they were somewhat on probation. 7 They were brought up for what is termed a "Dutch 8 Uncle", Dr. Pahl, and they have turned around their program 9 to an extent that they have asked their staff to continue 10 developmental efforts in the region, despite all the signals 11 that they got. 12 And I think this is another reason why we got a high 13 inflated our of the $2 million $700,00.0. I just thought 14 that whatever we had to say was succinctly written up in the 15 staff review sheet. 16 But again I feel that this is the only RMP that 17 was on the downswing, when they got an annualized level, but 18 definitely turned around as a result of our speech. 19 The Director has instilled on the staff and gotten 20 high morale and has excellent 30 out of 34 RAG members 21 attended his program, and their application was one of the 22 best out of seven that I have reviewed, whereby they stated 23 their high,,medium and low-ranking priorities, and in prior- 24 ity order. 25 This also gives us a lead as to how we can look at them. 2 Very few did thisp and I thought that this was a 3 plus. 4' DR. WAMMOCK: No matter which way we look at thisf 5' vities of $859pOOO. Unfunde they have requested for new acti 6 and approved activities, $139fOOO. 7 equestin $2 million $770,OOD. Under Number 4 they are r 9 8f IT funded activities f you take out the new activities and the un 9 y cut it into one-halff $1 million $350,000. that would roughl 10 To make arithmetic simpler I would just reduce it 11 to $1 million $350,000. I feel 40 percent of that will cut 12 them down to a pretty low level of activity. 13 1 would like to hear an expression from some of the 14 ncil about their reaction to this. Re- other members of Cou 15 member, they almost got the death knell last year. 16 they have worked diligently As Mr. Stolov has saidf 17 to revitalize the programf and even if we 90 to $1 million 18 $350,000 we are going double their annualized fundingf and 19 that will be quite a job in comparison. 20 MRS. GORDON: They are going to get the $139fooo 21 anyway through arthritis. That was approved yesterday. So 22 whatever we decide ont there will be that, plus the 23 $139,000. 24 MRS.-FLOOD: Some of these projects, for example 25 the North Central Pennsylvania Neonatal intensive Care ,4,ipze Reliot,lipi Co,,,Iaity 2-52 project and many others, there are some broad statements 2 that say, OFunding will have continuation", and that's all. 3. I am a little concerned about strong expenditures now, with- 4 out visible statements as to the continuation of dollars for 5 some of these rather broad-scoped programs. 6 DR. WAMMOCK: I think this reduction here will cause 7 them to take a look at the things that they will be positive 8 about what they are going to do,, and not dealing with the 9 possibilities. 10 I would add to this reduction here the $139,500 which would make it $5,440. 12 MRS. GORDON: Are you'adding or subtracting? 13 DR. WAMMOCK: I am adding. 14 MRS. GORDON: Whatever we approve, they get an addi- 15 tional $139,000. 16 DR. WAMMOCK: That's what I was going to say.' If 17 you add the $139,000 to the $1 million $350,000 that would 8 bring it up to $1 million $489,500. 19 MRS. GORDON: That's not what we want to approve. 20 DR. WAMMOCK: Mrs. Flood here is raising objections 21 to some of the projects here,, and I could wholeheartedly 22 agree with her, because if you read some of these things you 23 have to read these in detail to come to some sort of solution 24 as to whether they are valid projects, or whether they are 25 maybe projects or iffy. -411,le )?CPO,.Iiitq Co ... /.kill/ i@,2-S3 But this does give them an opportunity. If you cut 2 them do!,n to $1 million $489,000, 40 percent will be a rather 3. low reduction. 4 I would move on that basis, $1 million $350,1000 5 plus $139fOOO for arthritis. I would tell you that we agon- 6 ized last years and I agonized when Igot this and looked 7 at it. 8 MR. GARDELL: We have a reco ndation that the 9 Susquehanna Valley RMP be funded or approved at the level of 10 $1 million $489,500. Is that seconded? MRS. GORDON: You don't include the arthritis in 12 thatt do you? 13 MR. GARDELL: Yes,, I did. 14 MRS. GORDON: You shouldn't have. 15 said $1 million $350,000. MR. GARDELL: He 16 DR. WAMMOCK: The arthritis program was approved 17 yesterday. 18 MRS. GORDON: What I am getting at, yesterday when 19 we took up North Carolina,, we took arthritis out. 20 MR. GARDELL: Because it's an earmark, Ithat's right. 21 So we are back to the $1-million $350,000 because they will 22 get the $139,000. 23 DR. WAMMOCK: All right. Thank you very-much. 24 MR. GARDELL: Let me change that.' The motion is 25 that the Susquehanna Valley be recommended for a level of $1 million $35OgOOO, and that.the new activities not be in- 2 cluded. 3 MRS. FLOOD: I would second that motion. 4 MR. GARDELL: Discussion? 5 DR. JANEWAY: I rarely find myself in disagreement 6 with my good friend Dr. Wammock, but it is a little bit diffi- 7 cult for me to see, even with a lot of discretion'given to .8- the RMP in that area how they are'going to fulfill their con- 9 tinuing activities within@those limits,, when the amount of 10 monies that would be available for program'staff administra- 11 tion would only be available for six months. 12 If they are going to go ahead-and authorize 12,months of activity,, it seems to me they would almost categorically 14 have staff supervision and phase-out time for the staff, 15 If the activities are ,approved, I cannot, in this 16 circumstance, see the logic for @he reduction. 17 DR. WAMMOCK: You mean reduction in half? 18 DR. JANEWAY: No. If you are going to delete new 19 activities,, you could bloc them at alternative Number 3, which 20 would allow them to have the staff support in order to contin- 21 ue the activities that you have already concluded are worth- 22 while to be continued. 23 I find myself in a logical dilemma, and therefore 24- unable to support your motion. 25 DR. WAMMOCK: I am throwing this open for discussion. "2 -5 5 .It is a complex problem here., This does require a lot of 2 thinkirg and planning here, and that would bring it up to 3 sit $910. 4 MR. GARDELL: That's $1 million $910,257 with 5 specific instructions not to fund anything new. 6 DR. WAMMOCK: That's right. 7 MRS. FLOOD: They are currently supervising the 8, ongoing activities with the 11.4 full-time equivalents. Theii 9 staff costs do not only represent a 12-month budgets but it 10 represents an expansion of staff by an additional seven slots. 11 MR. GARDELL: Ma inly to the new activities, from 12 all indications. 13 MRS. FLOOD: Yes. It is a little hard to follow, 14 But is there any way to tell us what their annualized staff 15 costs are for the 1104? 16 DR. WAMMOCK: There area, pages.and pages of corres- 17 Pondence here from various and sundry people. I don't want 18 to get into this because it becomes,very complex and very 19 complicated. 20 MRS. FLOOD: There is no doubt that they have@come 21 a long way from last year .22 MR. STOLOV: I did an analysis of the new projects, 23 On Page 34 of the application they have ranked their projects 24 in numerical order. From-12 to 18 in the 'high priority and 25 one and two in the medium priority are new projects, if that 2;-56 will guide your decision. 2 DR. WAMMOCK: We have not discussed I intended 3 to pull this page out# the high priority, medium priority 4 and low priority. 5 The high priority is HSA transitional activity, 6 program staff activity. Data system for ambulatory patients, 7 continuation# North Central Pennsylvania Neonatal Intensive 8 Care, Community Medical Service, Family Community Medicine, 9. Dental. 10 MR. STOLOV: When you recommended new activities, 11 did you mean new projects? Because the HSA transitional 12 activity is a program staff activity and is highly important 13 to their thrust in the region to develop.an HSA. 14 DR. WAMMOCK: That is what Dr. Janeway was fussing 1 5 about.. 16 DR. JANEWAY: I cheat,,sd on you. I was a secondary 17 reviewer on this, and I read it. 7 18 DR. WAM40CK: I knew you were the secondary re- 19 viewer. I wanted some help, to tell you the truth. 20 'MRS. FLOOD: Here is their personnel budget for 21 core staff, which totals $271,600 less fringe benefits. 22 To me that reflects that $298,895 is an annualized staff 23 budget for operational levels today. 24 The 561 of column 3 reflects additional proposed 25 staff necessary for discreet staff activities. 2 '57 MR. GARDELI#s Mrs. Flood,, one and two are six monthc 2 don't forget. MRS. FLOOD: This budget here says 100 percent of 4 the timet 12 months. 5 MR. GARDELL: But one and two alternatives are for 6 six months of program staff support. We went through that 7 yesterday. 8 DR. KOMAROFF: She knows that,, but there is still 9 a discrepancy. 10 MRS. FLOOD: If that is true, why does their total add up to 12 months' salaries, unless this particular execu- 12 tive administrator is making $60,000 a year. No, he is 13 making $30,000. 14 one hundred percent of his time is $30,000. That 15 core staff'budget page adds up to $27 1,600 of direct cost, 16 so to speak,, personnel. 17 I find it hard to match this with the Form 16 for 18 core staff, with this out to the one year annualized. I 19 don't know where it comes from. 20 DR. WAMMOCK: We come back to the point that HSA 21 transitional activities are Number 1 high priority. This 22 might reflect this program staff administration here, I am 23 not sure about that. 24 Doctor Janeway -- when you look at this, the 40 25 percent idea will still cut them down, so'I would go with N@er 3. 2 MR. GARDELL: Do we have a feeling here that we 3 Can move toward? 4 DR. WAMMOCK: Dr. Janeway suggested he wanted to 5 fuss with me about it, and I have no fuss with him,, because 6 it is only $600,000 difference. I would accept the Number OW 7 3. 8 MRS. GORDON: Less $139,,000. 9 -DR. WAMMOCK: Yes. 10 MR. GARDELL: We have a motion on the floor that 11 we will have to withdraw; won't we? 12 DR. WAMMOCK: The.original one I made, I withdraw 13 that. 14 MRS. FLOOD: And I withdraw my second. 15 MR. GARDELL: Now we have a motion for $1-million 16 $910,157 less the $139f5OO. 17 DR. WAMMOCK: Right. 18 MR. GARDELL: Do I hear a second? 19 DR. WAMMOCK: I would second that motion. 20 DR. JANEWAY: You made the motion. 21 MR. GARDELL: I know you are enthusiastic 22 MRS. MARS: I will second it. 23 MR. GARDELL: Any discussion? All in favor? 24 (Chorus of ayes) 25 MR. GARDELL: Opposed? DR. KOMAROFF: No. 2 MRS. FLOOD: No. 3. MR. GARDELL: I think we have taken care of the 4 real problem regions. What I just wondered is, Dr. Haber-, 5 wanted to discuss some discussion regarding a resolution for 6 the Council to consider. 7 I wonder if we might do that before he leaves the 8 room. Dr. Haber? 9 DR. HABER: My resolution, please permit me to say, 10 that the prose here is amenable to any correction'.' The 11 basic thrust that I would like to let a resolution on is to 12 the effect I mentioned yesterdays 13, I would hope that opportunity would be sought so 14 that Council can, with some deliberation and hope-fully with 15 some small resources, develop a document embodying its exper- 16 iehce and views of the impact of the Regional Medical P@@..-ogram. 17 I think that is essential. I know Dr. Margulies 18 indicated yesterday that an evaluation would be made.- I 19 think that is highly appropriate and necessary. I do not 20 think that any other group can say what.Council can, and I 21 hope would want to say. 22 If I can briefly read this and give some.idea, but 23 I would not defend this prose against any other suggestion. 24 Be it resolved, in order to distill and preserve the experience 25 of the Regional Medical Programs for guidance and evaluation, ,4,in c 2"60 as the nation moves closer to National Health Insurancet 2 the co ,Icil wishes to express its desire to develop a docu- 3 ment relating to,, but not limited to such issues as, A,, the 4 interaction of different levels of jurisdiction in health planning. 6 B,, the heightening of health care awareness among 7 patient populations. Ci the involvement of minorities and 8 disadvantaged groups in health care planning. D, the iden- 9 tification on a local, state and national basis of health 10 care needs. 11 D, the involvement of academic consumer and provider 12 groups to express their views in health care needs and prior- 13 ities. 14 Notwithstanding the,fact that other evaluations will 15 be made of the effect and impact of Regional Medical Pro- 16 grams, such evaluation will be incomplete without the input 17 of Council which has helped to conceive, develop# monitor 18 and preside at the transition of RMP. 19 Councills feelings, experience and viewpoints can- 20 not be adequately expressed by any other group. I make no 21 defense of any language here. The basic thing that I am 22 t@ing to promote would be that staff seek the opportunity 23 for Council to express its views in some document, dither 24 as an appendix to the evaluation, or as a comment and so 9-5 on, It would seem to me that as a minimum, one more 2 meeting might be required, at which time Council could have 3 reacted to the evaluations that other groups are going to 4 be developing. 5 I would hope'that staff would be available and I 6 know this is difficult to work with Council to develop that. 7 This does not have to be an exhaustive thing. 8 But I think too much hard information has developed 9 heret which is not vouchsafed to any other group. And I 10 would be dismayed to see that experience lost or dissipated 11 and trying to recapture it in three years would be difficult, 12 MRS. MARS: To whom do you expect to present@this, 13 to Congress or to the Secretary? Where would it go, in 14 other words? Unless it has the attention of Congress,, it 15 is useless. 16 DR. iMBER: I think through the Secretary to-f,-he 17 Congress, because I think that this ought to be available 18 to whoever is going to draw up the implementing rules-and 19 regulations about 641 or the National HeAlth Insurance. 20 If we feel that one-of.the -things you don't do is 21 set up competing agencies in the state, where the resources 22 are limited, I think we ought to be able to say that.- 23 This brief catalog that I have made is obviously 24 incomplete. I think the Council ought to be thinking about 25 what lessons we did learn. To me it is A tremendous 2-v62 tragedyl it is unfortunate,, that at a,time when RMP really 2 seems -.o be running smoothly,, when the methodology seems to 3 have been worked out, some of that may be lost in the trans- 4 ition. 5 I would hope that the experience can be distilled, 6 and I think this group can do that. 7 DR. WAMMOCK: Dr. Haber,, do you recall'the resolu- 8, tion drawn by this body August 8th of last year? 9 DR. HABER: It seems to me I do. 10 DR. WAMMOCK: This was the National Advisory Coun- 11 cil, and.it was drawn by Ogden. Shall I read it? 12 MR. BAUM: Go ahead. 13 DR. WAMMOCK: Resolved that the Congress, in adopt- 14 ing H.R4 16204, or similar legislation, give-to each state 15 the statutory financial support to maintain a separate Health 16 Syste.-ms Development and Demonstration agency on a statewide 17 basis, or similar independent commission, appointed in a 18 publicly accountable way, reporting to their statewide Health 19 Coordinating Council, and devoted exclusively to such work. 20 And be it further resolved that the comments@;pre- 21 ceding this resolution and the resolution itself be trans- 22 mitted to.the members of the House Interstate and Foreign 23 Commerce Committeet and the Senate Labor and Public@Welfare 24 Committee for their consideration. 25 That was a continuation of so me of the efforts of 2@63 the RMP program, is what the intent of this resolution was. 2 I think Dr. Haber -- I just bring this to his atten- 3, tion, because Dr. Ogden -- Mr. Ogden spent a good @it of 4 time writing this thing up. I think you are perfectly in or- 5 der,, but I wanted to remind you of this particular resolu- 6 tion. 7 MR. GARDELL: Is that resolution in thii form of a 8 mot ion, Dr. Haber? 9 DR. HABER: Yes. 10 - MR. GARDELL: May we have a second before we have our discussion? 12 DR. GRAMLICH: I second that.. 13 MR. GARDELL: Ken has a comment with respect to 14 Mr. Ogdenis resolution, 15 MR. BAUM: I thought I would say,, for the record,, 16 that that resolution was transmitted to the appropriate com- 17 mittees in both houses, as specified. We never heard from 18 them, but it was sent to them. 19 DR. WAMMOCK: Well,, we are not going to hear from 20 this one also, I am sure. 21 MR. GARDELL: Dr. Rorrie, do you have any reaction 22 to this resolution? It obviously would go first through 23 the Bureau and then HRAT etcetera, which I am sure is,the 24 route that the other took. 25 DR. WAMMOCK: It would have to go to these other -4,ine Repoi-litiq Coo@tl;ciiiii 2-64 committees here. 2 DR. HABER: 1 think, Dr. Wammock, I would disagree 3 -with you. I think that this resolution, if Council approves 4 it, might have a very salubrious effect on the health plan- 5 ning process. 6 If we have learned anything we ought to be able to 7 point it out. If future legislation ignores that, My own 8 experience with Congress is that they would be very loath 9 to ignore it. 10 If we have learned something that they could incor- 11 porate in a hew legislation, I think they would be anxious 12 to do so. 13@ DR. GRAMLICH: I am not in opposition to what you 14 are talking about. I am just trying to help us get at the 15 situation. 16 DR. HABER: I am obliged to you for reading the 17 previous resolution, but it seems to me the purposes are 18 rather different. One, it was to continue the existence in 19 some fashion 20 .DR. WAMMOCK: I go with you 100 percent. 21 DR. HABER: I think right now what we are saying is 22 whatever we have learned, let's passed it on. 23 DR. RORRIE: As Dr. Margulies said yesterday,, the 24 PAR group is going to do a study evaluation, and there is 25 no reason why your evaluation in that study could not be '2-65 incorporated. 2 Quite frankly,, we don't have the staff resources 3 to do the type of stuff you are talking about. I think if 4 theL PAR study is already going to do thato you ought to be 5 incorporated in that. 6 They ought to be instructed in their plan of--, 7 action to involve you in some facet of their study. 8 DR. HABER: That would be highly acceptable to me. 9 The thing I would hope might happen is that a group of 10 these people might be convened at some time,, or the whole' 11 Councill and just say, "Can you develop a 10-page document 12 and pareel.it out?tl '13 This could be an appendix to the PAR study or'the 14 PAR could relate to us. I just think Council obviously has 15 a different perspective than staff mightp or PAR, or any 16 outside group. 17 Some of these people have been intimately involved 18 with the RMP for the last decade, I am sure, and their exper- 19 ience should not be lost. 20 DR. GRAMLICH: In order for this to be truly effect- 21 ive it would have to be fairly soon. 22 DR. HABER: Absolutely. 23 DR. GRAMLICH: You are talking about something 24 that would be accomplished and presented within a six-month 25 period? PR@ HABER: 'Exactly, six months, 2 MRS. FLOOD:. we have not really gotten to the PAR 3 ,proposal and resolution in Councills deliberations. Even 4 though it is a very laconic explanation of how they antici- 5 pate to address this particular accountability reporting 6 there is, under their Goals and objectives, under Goal 2, 7 a mention of integrating socialp historical analysis of 8 RmPs, using invited articles by key federal, Congressional, 9 and Executive representatives. 10 Members of National and Regional Advisory Councils 11 and others, whose experiences qualify them to make judgment- 12 al analyses. 13 Potentially I could foresee that by an instruction 14 from the Council when we address the resolution for-the PAR 15 program that we might be able to incorporate the functioning 16 of this Council'A wealth of knowledge or broad experience 17 that we have garnered heret or at least our experiences into 18 A portion of the PAR group's study. 19 DR. GRAMLICH: Disagree, 100 percent. This level 20 of information if supplemented by or incorporated in'the 21 PAR'report, oner it will be lost in a mass of information; 22 ands two, it will be too late to do any good. 23 DR. HABER: I think there is no harm, and I would 24 advocate doing precisely what Mrs. Flood said, but I must I 25 agree with Dr. Gramlich that, first of al'l, we can't wait ... .. .. .... @247' two years. 2 And, secondly, when an outside group comes to you 3. ,for advice and your experience, there is a question as to 4 how that is expressed and to what extent that is dealt 5 with. 6 They have other priorities that they deal with, WW 7 and whether they would adequately express the views is prob- 8@ lemmatic. 9 I would think that Mrs. Flood's suggestion should 10 certainly be incorporated, because I would want Council to 11 have as much effect on their own document and in the docu- 12 ment of PAR. 13 But to my mind,, it may not be sufficient, andI 14 would hope that we would take it upon ourselves to develop 15 our own view of this. 16 MR.GARDELL: That was the question running thro%@igh 17 my mind, Doctor,, howtyou would accomplish this. Iknow you 18 did suggest possibly, another meeting of the Council#, maybe, 19 for this purpose, 20 Again, we are not at liberty at this point to say 21 whether that can be accomplished or not. But I was wonder- 22 ing who you had,in mind that might work with the group to 23 develop something from the Council, if you want to have it 24 separate from the PAR report. 25 DR. HABER: One way in which this could be done 2-68 if funds are in such-short supply is by rcAilt although that 2 would lot be preferable, 3 But I should think if we asked for volunteers, if 4 one of the staff people could contribute his time to shep- 5 herd this effortl that would be fine. 6 I would be happy to work with him, and I assume ail- 7 most everybody on Council would be interested. .1 don't 8 'know if everyone would have time, but-I think to develop 9 some kind of outlines and proportion out the work and sayi 10 "Could you look into these areas and express some opinions about them"? 12 Or just solicit independent things that could'be 13 put together. 14 DR. WAMMOCK: To finalize this thing, I am in agree- 15 ment that something be donet and it ought to get to the 16 proper source within a short period of time,, rather than 17 laying someplace on the shelf. 18 Dr. Haber has read his resolution," would,you read 19 that again for us pleasd? 20 Dr. Haber re-read his resolution). 21 DR. WAMMOCK: What I was getting at is the latter 22 part, the emphasis you are placing on the role that the 23 Council has played with RMP. 24 MRS. MARS*. As far as the evaluation and Assessment 25 a good bit of it will be very repetitious, If you look at 2-69 this RMP report heret all of the impact is expressed that 2 you ar- trying to more or less put into your resolution. 3 1. I think it would be a very expensive thing to take 4 staff's time at this pointr when we have a very adequate 5 summary here. DR. HABER: Mrs. Mars, Iwould have no objection 7 to Council saying, "We think this is great' if that is-what 8 iCouncil thinks. What I am tryin to say is,that when the 9 9 federal government develops advisory councils# it, presumably 10 is reaching out into the public body,, as opposed to the bur- 11 eaucracy to get some advice. 12 If.Council,says, "We think this is the be-all and 13 end-all of analysis and nothing further needs to be said"# 14 that's important. 15 To me that is a validation, and in the veterans 16 Administration we do it all the time. The thing that ve,,tes 17 me as a bureaucrat is the fact that we lose the opportunity 18 to crystallize the view of advisory bodies. 19 MR. GARDELL: Let me say one thing, Doctor, just to 20 correct for the record. That is not a bureaucratic, and this 21 is not uncomplimentarily meant, it is not a bureaucratic 22 document. 23 That is done by that group, without our guidance, 24 because we told them that we were not able to do-it. I think 25 Mrs. Mars' comment is one for consideration. I also think 2r7O Mrs. Flood's is one,,'from this standpoint. I feel that:, 2 with tie wrap-up contract, and with the two reports that we 3 .have to date, certainly the Council would not want to dupli- 4 cate. 5 I don't think it would, want to duplicate what 6 PAR has already done or is going to do. I think what I 7 hear you say is that you would like to have the 'Council have 8 a separate position to make, independent of anything else, 9 going on to show what its feelings are toward RMP activities. 10 DR. HABER: Yes. When I say "bureaucratic, for- give me, but what I am talking about, some documents are 12 generated by full-time federal employees. There are some 13 documents that are contract. 14 And I assume PAR is the following. There is some 15 body of thought which relates to the consultant group which 16 has been very carefully chosei. 17 And I think that is-not the same as the other@two. 18 If the Council comes out and says "This is a great document 19 but we have nothing to add", that's fine. That, to me,@is 20 an independent decision. 2 1 MR. RUBEL: I would urge the Council that if you 22 do if you would like to have a separate document come 23 from you, and I don't hear any objection to that opinion, 24 I would urge you to do it on your own,, because I really don't 25 know of any staff that might be available to help you. 2-71 And I think it would be better actually coming from 2 the.Co@.incil,, independent of any input from staff. 3 DR. WAMMOCK: What Dr. Haber is trying to'do is to 4 write an epitaph on the programs so that we can say,, "Well,, 5 we were there'. 6 MR. GARDELL: -1 don't disagree with that. Dr. 7 Janeway? 8 DR. JANEWAY: I wonder if it isni-t a little bit- 9 Cry$- presumptuous of the Council, one, to try to.develop a 10 tallized position, since each of us views RMP and its im- 11 pact from a different viewpoint. 12 Presumablyp alsor.we would be using this"to try 13 to make input to the regulations that apply toa new law. 14 I,think that that information can very well be input just as 15 well by a request that, if the Congress and the Department 16 chooses, that members who have served on this Council night 17 testify or aid in the development of the regulations that 18 would apply to Public Law 93-641, which could be done much 19 less expensively, and perhaps get the point across just as 20 well within a meaningful time frame. 21 1 seriously doubt that without extensive and expen- 22 sive staff support anything other than a ddlphic document 23 could be derived from this Council. 24 Many of these people who served extended terms on 25 the Council are now no longer on itt and in order to get 4,itte P%eliolltilig COJII/7((IIY them together or to have them have the sense of what one 2 would to come up with seems to me to make it an imprac- 3 tical approach, 4 Although I agree with the intent of it, Dr. Habert 5 I Just think it is impractical, and there are mechanisms 6 for having your voice made known in the development of the 7 regulations. if there is an experience that you wish to 81 impart. 9 DR. KOMAROFF: I agree completely with what Dr. 10 Janeway said. 11 DR. RORRIE: As I mentioned yesterday we are going 12 through a process right now.of attempting to take a number 13 of policy issues associated with Public Law 93-641 and sol- 14 icit a number of viewpoints from different perspectives. 15 Anyone who wants to contribute ideas which would 16 then be incorporated in the regulations. I would be more 17 than happy to pass out the list of issues, and I have copies 18 of them here. 19 We would be more than willing to have you participate. 20 in meetings again with us, or solicit individual comments, 21 with respect to these issues. 22 1 think there is an adequate mechanism, in terms of 23 what is going on right now. I would agree with Dr. Gramlich 24- with his concept that if-you are going to-make any impact you 25 have to make it now, 2-73' You can't make it-six or eight 'months from now, 2 becau-ts the regulations will be coming out. Now is the 3 .time and here are the issues. 4 If you want to contribute your comments in terms 5 of your past experiences and how we can strengthen a number 6 of areas in terms of 93-641 we would b e happy to receive 7 your thoughts and incorporate them in the deliberations. 8 DR. HABER: I am a great believer in the British .9 system of commissions. Somehow,, the British seem to be able 10 to do this better than we can in this country. 11 The closest thing we have to a commission on RMP 12 is this body. The fact that some members have left is no 13 baro unless they have departed this world they are accessible 14 by phone and by mail and their views can be solicited and 15 incorporated. 16 I don't construe this as any multi-million dollar 17 project. I would think the resources and time required is 18, relatively limited, except insofar as the members of the 19 Council are willing to work at it. 20 I would hopefully -- I would embrace Dr. Rorrie's 21 suggestion that we can work with him and so on. I think the 22 availability for testimony to Congress, if you will forgive 23 me, is, in itself, a presumptuous idea. 24- Congress, presumably, has gotten'the testimony 25 it needs already, before the Act was passed, I would suggest ,4,ine P-lilot-liizg 2-74 as a minimum that YOF consider this further, and that in ;.k 2 some fashion the members of the Council be solicited or 3 permitted to express their views. 4 And that this be amalgamated in some document, if 5 even that be only to assure that Council agrees completely. 6 DR. GRAMLICH: This can be stated very simply,, and 7 I think we tend to confuse it a little bit. Really, what 8 Dr..,Haber is suggesting, that a.-document,, a small document 9 be compiled by this group which simply states the mistakes 10 we have made and how to avoid them,, so we don't do it all 11 over again. 12 MR. GARDELL: That's a little bit along the line 13 of what I envisioned. 14 DR. GRAMLICH4. That's over-simplified, but it can- 15 not be incorporated in this because of timing and because 16 there is no one in this group who would be able to assemble 17 the.information from the Council. 18 Only the Council can do this. If it is going to 19 be of any value to anyone, it will have to be done as a 20 joint effort, and not as an individual effort. It will 21 have to be done rapidly, and I think very briefly. 22 DR. HABER: Amen. 23 MR. GARDELL: We have a motion which goes a little 24 bit deeper than that. Would you like to,modify the motion? Withdraw the other one and modify it? 25 2-75 Or can we live with what we have? 2 DR. HABER: I would like to make the motion as broad 3. and simple as possible, and I would modify it with what 4 Dr. Gramlich has said. 5 MR* BAUM: Let me comment for a minute.'- When it 6 comes down to holding another meeting of the Councilt I get 7 involved, as Executive Secretary. We also get involved with 8 something called the Federal Advisory Committee Actt and it 9 tends to be very complicated and provides very complicated 10 rules for the ways in which a public advisory group can take 11 action. 12 You cannot take action by mail,, at.least I would 13 think that you can't. You have to take action oil everything 14 except grant awards in an open session. 15 The open session has to be advertised so many days 16 in advance in the'Federal Regi.,7ter, and all that sort of 17 thing. 18 'I think the interpretation is that if you get a 19 subcommittee together you have to go through the same thing, 20 and hold an open meeting. 21 So if two people met to write something'for the 22 Council, presumably we would have to call a meeting for 23 that. This introduces some problems of logistics, and calling 24 a meeting and having an open session, orat least'having a 25 room where the blue sheet or other interested people can 2-76 come in and sit and listen to the deliberations. 2 If you are asking us to hold another meetingr then 3 we-have got to go through all of the formal procedures to 4 do that. 5 One thing we could do would be to solicit the views 6 of Council members individually by mail. You'c'ould write 7 us any views you have, and then we could compile'them in some 8. -way:.in some logical order. 9 Possibl circulate them, and if you thought as a y 10 group of individuals that they were worth publishing, we 11 could probably put them together in some sort of a document 12 as a compilation of individual views, but not necessarily 13 the views of the Council. 14 Some people might not want to'say anything. I thoug@,t 15 I would advise you of the logistical and technical complica- 16 tions of doing 'anything again as a body under the Federa.'.@, 17 Advisory Committee Act. 18 DR. HABER: I would be perfectly happy with that sug-, 19 gestion. my thesis was that much of the spade work could be 20 done by mail or something like that# but that a co ening of nv 21 the group for one day to consider what had been developed 22 would be useful. 23 I would be less inclined to say let the individuals 24 express their opinions. I think those are valuable, but 25 this does represent,, I would hope, the considered opinion of 1411?IC P%Cporiiil 2-77 Council,, which is the advisory group which has been dis- 2 banded. 3. To'me it seems a shame to have it go out of exist- 4 ence without some document of its own that it can' point to,, 5 as a crystalization and distillation of its experience. I 6 can't say any more than that. 7 MR. GARDELL: I think with some of the,constraints 81 that Ken has indicated to us, and with the study going on 9 by PAR, etcetera, I think we have enough of a sense of the 10 desire of the Council here to make sure that youi,.feelings and thoughts with respect to experiences gained 'with our 12 program are-such that they should not'be ignored,'-but should 13 go down for posterity or whatever assistance they'might be. 14 Would it be acceptable to you that we table this .15 resolution# and you leave it ir our hands to do what we can 16 e? As to pull you into the picture at the appropriate &m 17 Dr. Rorrie has just said, you have your opportunity for input 18 in the regulations, which is one of the things you mentioned. 19 Would that be acceptable to you,, not,ignoring your 20 resolution? But I think we do have some problems-in trying 21 to carry it out as presented. 22 DR. HABER: I recognize that, and,I am not trying 23, to make life difficult. I would only hope that this invitation 24 be when you said express to you that you meant the Council. 25 2-78 MR. GARDELL, Right. okay,, thank y@ou. Very good. 2 we hav one more resolution to consider, and'iwe have a few 3. regions to go. Should we finish these up in a hurry? Would 4 you rather go right through? 5 MRS. GORDON: Yes. 6 MR. GARDELL: May we have South Carolina? 7 MRS. MARS: South Carolina-is a program that had a 8 great many irons in the fire. It had'61 projects in all 9 going.' Many of these are going to be dropped. As a matter 10 of fact, 31 of them will be dropped. 11 There are 19 that were commented on.by the CHP. 12 Of these, 14 were favorable, and the other five were cohsid- 13 ered to be purely statements of statewide nature, This nec- 14 essarily must influence the thoughts on our funding. 15 They -had initiated transition activity as early 16 as No-v,@er,, 1973,' They have aided the Governor as to area 17 designation and channeling existing resources under the new 18 program. 19 They are requesting $1 million $752,889, which is 20 less, about $355tOOO less than their current annualized 21 funding., 22 They plan to fund five formerly state-supported agen- 23 cies through the transition period out of this money. There 24 is an arthritis program, of course, in this. They want to 25 increase their,staff, which seems to be quite unnecessary. 2-79 1 Therefore,, I recommend that we fund them at the 2 rate o-' their Number 2, but to be spread over through the 3- year to July lst, 1976# at $1 million $455,871. I'will say,, 4 in defense of the program, that they seem to be the only 5 agency that has been @ble to pull together various agencies 6 in the state to work with the Governor. 7 They have made considerable impac.t there, so that .is my recommendation# Number 2, to be spread over through 8 9 the year. 10 MR. GARDELL: There is a motion on the floor that 11 South Carolina be funded at the amount of $1 million 12 $455,871. Do I hear a second? 13 DR. JANEWAY: Second. 14- DR. WAMMOCK: One comment. Remember last year there 15 was some discussion about the role that the Governor was 16 playing in this program. I just bring that up, if you remem- 17 ber. 18 I don't remember the exact nature of the p roblem, 19 but there was a problem there. 20 MR. GARDELL: Mr. Jewell, is there still a problem? 21 MR. JEWELL: No, sir. That was Project No,' 170, 22 and they have married each other and 23 MR. GARDELL: Okay. All in favor? (Chorus of ayes) 24 25 MR. GARDELL: No? ,4,11te Rlporliitj collij-)Ciiltl 2-80 (No response) 2 MR. GARDELL: The next one is South Dakota.. 3- MRS,,..FLOOD: South-Dakota is currently budgeted on 4 an annualized figure for $790,125. They are, quote, Oas 5 staff views theme also a good small program'. 6 They have accomplished quite a bit in the state. 7 Their funding request is most reasonable, and pioperly ad- 81 dr@'sses existing continuing activities, and also will pro- 9 vide transition concepts developing in that state, and I 10' would move for bloc approval on Column 4, $612,525. DR. WAMMOCK: Second the motion. 12 MR. GARDELL: Okay. Tennessee/Mid-South,, Mrs. Mars. 13 MRS. MARS: The Memphis program has not reached 14 out truly into the state. The Tennes'see/Mid-South has made 15 an emphatic thrust in primary care, and in the regionaliza- 16 tion of health services throughout the state. 17 Their development of new and innovative health per- 18 sonnelf such as nurse practitioners, physician assistants, 19 midwifery and dental hygiene, has been very meaningful in 20 this rural and mountainous area. 21 Also, in the mining area, which is a considerable 22 part of the state of Tennessee. They have done a great deal 23 in public and professional education. This has been a very 24 important component in the transitional activities. 25 They have had many educational conferences across 2-81 the state which has been related to area designation. They 2 are ask.ng support for four B agency projects. The one great' 3. weakness I sensed was,, they just do not seem to have any 4 definite commitments for future funding. 5 So much of their future funding will depend upon 6 legislative support, and of course that is very problemmatical 7 as to whether you get it or don't get it. They have had an 8 excellent arthritis Program going. 9 They had one going actually before the RMP had a 10' pilot project. They have an extensive kidney program. How- 11 ever, they want to increase their staff from nine and a half 12 to eleven People. 13 They also want to increase their professional staff 14 by one. Some of these things seem to be quite unnecessary. 15 I would suggest and recommend, in fact, resolve, that they 16 be funded at the current level of annualized support,, which 17 is $2 million $208,564. 18 MR. 6ARDELL: The level we are using Mrs. Mars 19 MRS. MARS: Is this other, but what was on here? 20 MR. GARDELL: You prefer that one over this one? 21 MRS. MARS: Yes. That's $2 million $208,564. 22 MR. GARDELL: It has been moved that Tennessee/mid- 23 South be funded at the level of $2 million $208,564. Do I 24 hear a second? 25 DR. KOMAROFF: Second. 2-82 MR. GARDELL: Is there discussion? All in favor? 2 (Chorus of ayes) 11 3 MR. GARDELL: Opposed? 4 (No response) 5 MR. GARDELL: Our next one is Texas. Mrs. Flood 6 has left the room. 7 DR. KOMAROFF: Texas is currently funded at an 8 annual level of approximately $2 million. Their maximal re- 9 quest is for $1.57 million, approximately. The application 10 is generally well written. 11 The activities seem appropriate. Good emphasis and 12 fairly detailed emphasis On the Problems of transition, and 13 I move bloc action at Number 4 level. 14 MR. GARDELL: Okay. 15 DRi'JANEIIAY: Second. 16 MR. GARDELL: Tri-State. Now, Dr. Komaroff ha@@; to 17 leave. 18 MRS. FLOOD: Tri-State is operated at an annualized 19 figure of $2 million $40,548, and is requesting $2 million-. 20 $848,640. But within their request were $453,822 of dis- 21 approved arthritis programs. 22 Apparentlyl Tri-State feels that they were approved 23 but unfunded. But after careful checking and Mr. Matt 21 Spear's reviewing of the process at that time, it is found 25 that these are disapproved projects. Rci,,ot-litit.i Coijti.7aiiii 2-83 Therefore,,'subtracting the disapproved arthritis 2 projec;s, I would recommend that Tri-Sti e funded at a 3. level of $2 million $394,818. This provides@them with 4 $354,000 plus, over their current annualized figure, which 5 allows them sufficient staff and operational budget to con- 6 tinue their activities, and they are actively involved in 7 -HSA transition, with a specific request delineating the 8s expenditures to be undertaken in each of the three states in 9 that area. 10 And would give them sufficient dollars to cover 11 these activities. 12 MR. GARDELL: We have a motion that Tri-State be 13 considered at the level of $2 million $394,818, Do I hear 14 a second? 15 DR. GRAMLICH: 'Second. 16 MRS. F'LOOD: I might bring up one point for the 17 CoUncills information. As you may recallf Tri-State pre- 18 sented some serious problems to the Council in the past# and 19 just prior to Councills action last time we had a site visit 20 there -- I would like to let Council be aware that many of 21 the problems in the relationships of Tri-State RMP to the 22 Rhode Island programs have been relatively settled. 23 The part-time coordinator of the Rhode Island seg- 24 ment of RMP has relinquished that position to full-time 25 project director in the RISEC program, and they have appointed 2-84 a full-time Rhode Island coordinatorliwhich is one of the 2 big CCliflicts that this Council viewed as a problem in that 3 area, 4 Except for occasional friendly letters from Gover- 5 nor Noel, we do very well with Rhode Island. 6 MR. GARDELL: We appreciate your assistance in.that 7 matter. Are we ready for the vote? All in favor? 8 (Chorus of ayes) 9 MR. GARDELL: Opposed? 10 (No response) 1 1 MR. GARDELL: Wisconsin. Mrs. Mars. 12 MRS. MARS: Wisconsin has asked for an increase in 13 staff from 15 to 23# and in professional from 11 to 17. 14 They also have in their application $31,400 request for movable equipment. 16 I have no idea what movable equipment is. 17 DR. WAMMOCK: It's not glued to the floor 18 MRS.'MARS: That I appreciate, but I felt that this 19 was really an unnecessary and monstrous request for increase 20 in staff. They seemed to feel that this would increase 21 their core activities. 22 Also, their travel costs were exceptionally high. 23 The main activities are staff discreet activities, in the 24 form of feasibility studies, which are completable in one 25 year or less, and will be made available'to the successor 4,i@ie )Vcijoi-tiizq' Co"zl7a#t!i 2-85 agency. and appropriate regulatory agency for informational 2 use ari implementation to the transition mission. 3 They had at one time reduced their staff, but they 4 did successfully rebuild it in order to carry on their pro- 5 gram activities for this year. Their volunteer committees 6 have continued at full strength, and remain very"'iictive. 7 They have some very good programs goin4. Their 8, burn care services program is a particularly outstanding one. 9 They have had some conferences. A National Conference on 10 Hypertension which was the first national'one, I.believe, 11 in the United States. 12 However,, I feel their request is much,, much too 13 high, of $2 million $951,240. I would recommend that we 14 fund them at the level of $2 million $146,459, which is their annual3.zed current funding. 16 MR. GARDELL: Do you @.,,ave any advice with respect 17 to'the equipment? 1 8 MRS. MARS:. No. I am sure there will be a policy 19 that you will carry out, and it is not necessary for me 'to 20 make any statement on it. 21 MRS. FLOOD: I second the motion. 22 MR. GARDELL: Any discussion? All in favor? 23 (Chorus of ayes) 24 MR. GARDELL: Opposed? 25 '(No response) 2-86 MR. GARDELL: Can we now go to New York Metro? 2 Dr. Wa@-kins?. 3. MRS. FLOOD: There is one item I overlooked that 4 perhaps since we have made mention of it in other areas that I would like.to have staff address in the 5 advice letter. 6 again to Tri-State. 7 Again, we see no minorities, on staff.ox clerical 8 or professional levels at all in the Tri-State Regional Medi- 9 cal Program. 10 MR. GARDELL: Okay,, condition. 11 DR. KOMAROFF: Mr. Chairman,, New York Metro request 12 is difficult to consider without.lookinq at the current fund- 13 ing in that region# which is why I have taken the time to 14 write on the board. 15 They request, as you see from the face sheet, 16 the maximum level of $3.7 million. They are currently fund- 17 ed.at a level of about $3.8 million. But of this current 18 level of the $3.8 million, $2.5 million are in projects, approximately $2 million of which they are discontinuing. 20 It is not quite clear why this year's request asks 21 for $.S million for continuation of the old projects. There 22 are no new projects proposed, but presumably they wish to 23 expand somewhat the activities that are remaining, 24 The big issue is a proposed expansion, which would 25 raise their core staff from a present approximately 19 or 20 2-87 employees to 75 employees in this last year# to carry, out 2 a seri@ts of core-based projects. 3. Vherefore, new activities, but not the kind of new 4 activities that we are prohibiting we may be prohibited 5 from agreeing to. Nevertheless, it seems to me very unlikely 6 that they could triple the size of their core staff in a 7 year. 8 And that even if they could do that, they would 9 accomplish what they intend to accomplish. So I am recomend- 10 ing that the current core staff level be maintained for the 11 next 12-month period, with an increment of approximately 12 $200,000 to the core staff, to carry out some of these trans- 13 itional activities. 14. And allowing them the full request for continuation 15 of operational projects, bringing them to a total of $1.4, 16 considerably below the maximal request and their current 17, operating level, but still, I think, quite reasonable to 18 allow them to'achieve what is realistic. 19 That is, therefore, my dollar recommendation There 20 is one issue about considering prohibition of a specific 21 activ ty. 22 This region, which is based in metropolitan New 23 York, has a project activity which proposes to organize an 24 HSA in a seven-county area, north of the-metropolitan area 25 of New York, outside the boundaries of metro New York. -@s'@no'B agency in this region' but there ,fe is 2 a plan ing group, called NORMET which apparently has been s@PO r.L @.tate money and which has been the facility's 4 expansion agency dealing with requests in that part of the 5 state. 6 The CHP and Regional office have submitted very 7 strong letters recommending that this activity by RMP not 8 goon,, that RMP move into an area outside their boundary 9 to organize them without even consulting the primary plan- 10 ning agency in that area. 11 I would recommend that that funding out of this 12 $1.4 million for that purpose be disallowed, until such time 13 as the staff here receives written assurance from CHP and 14 from the Regional Office that this question of non-collabor- 15 ation has been cleared up. 16 May I ask Mr. Stolov who has been very helpful in 17 organizing these numbers for me to comment and see if that 18 is reasonable in his view? 19 MR. GARDELL: Do you want to have the motion first 20 oh the record, and then have discussion? We have a motion 21 that New York Metro be funded at the level of $1 million 22 $4,00,000, and that the proje be disappro 23 being outside the area jurisdiction of the region, unless ancL 24 until the CHP agency, by chance, might recommend that it 25 be pursued. 2-89 1 DR. KOMAROFF: And the Regional Office. 2 MR. GARDELL: And the Regional office. 3@ MRS. GORDON: Second. 4 MR. STOLOV: May I ask the secondary reviewer-for 5 h 0 comments before I pro eed with any comments on this? c 6 Was--there'a secondary reviewer? 7 MR. BAUM: we only assign secondary reviewers in 8 ;the event that a primary reviewer could not be present. 9 ided Dr. Komaroff MR. STOLOV: The reason --,I prov 10 with the figures, but I did not know his final recomendatior so Iwould just like to say that New York Itetro had an annual- 12 ized level of $3.8, based on past improvement, and appealed 13 to the National Advisory Council. 14 1 believe their RAG Chairman did address the Nation-- 15 al Advisory Council and expressed the needs of.New York 16 City, and how the RMP was attempting to go out with a 17 -borough eight-million or mor five e population area. 18 I @ink the $3.8 is really that $4.5 on an 18-mont h 19 level. !he staff did highlight and does back up the con- 20 cern of putting so much cost or hiring so much core staff 21 to certain projects, and the drop in projects was pointed 22 out by Dr. Komaroff. 23 My only feeling is that some of the core-staff 24 activities are related in part to the transition. They 25 are not directly related to the transition, but the methodology fine is based to come up with .2 increase over the last.year, it 2 on New York Metro having three core staff activities, and 3 this year presenting -- three of which were continuation. 4 1 just wonder how you could explain the two percent 5 increase you are giving over three core staff activities as 6 opposed to their presenting 20 to us. 7 Can you give your justification for the two per- 8 cent above the .24 that you have on the board? 9 DR. KOMAROFF: Just an arbitrary feeling that they @io probably could expand their core staff by what would be 11 approximately 60 percent expansion from the current level 12 of core staff, which is $350,000. 13 That was a reasonable likel hood and that t ey 14 could accomplish the kind of.transitional planning activi- 15 ties within the sum, if they chose to. 16 MR. BAUM: And, againf everybody is going to be re- 17 duced from the recommended level, because we don't have that 18 much money. 19 MR. GARDELL: Right,, and they will'@'be doing some 20 rebudgeting. You are giving us a level, against which we 21 can 22 DR. KOMAROFF: It would be so hard to apply any 23 formula to this particular region that I thought we should 24 give you some kind of ceiling. 25, MR. GARDELL: Right. You really have just one 2-91 condition anyway, and that is CO-24. 2 DR. KOHAROFF:' Right. 3, MR* GARDELL: So with the'@level-..of:funding which 4 you say will be considerably below what they requested any- 5 way it has to be. 6 MR. ST6LOV: I have nothing further to add. 7 MR. GARDELL: Any further discussion? 8- DR. JANEWAY: Do I gather, Tony, that that is a 9 not to exceed figurer and you would hope that that is what 10 they got? 11 DR. KOMAROFF: Yes. I am not only trying to indi- 12 cate a ceiling, but a target. 13 MRS. MARS: This $1.4. 14 DR. KOMAROFF: Yes, I think they could use that 15 well. They have some very good activities. 16 MRS. MARS: Why not ta@',-.e the Number 1 here? 17 MR. BAUM: Then you ought to have a higher figure, 18 Tony. 19 MR. GARDELL: If you take their annu alized level 20 right now, which is $3 million nine, 40 percent of $3 'million 21 nine, if that's the way it turns out -- 22 MRS. MARS: But their Number 1 is $1 million 23 $606,233. That is more than the $1.4 which he is requesting. 24 MR. GARDELL: This was just a six-month figure. 25 DR. KOMAROFF: May I withdraw my last motion and 2-92 the seconder has departed. I move approval@ at the level 2 of $1,)'06,233 but that should be construed is a 12-month, 3, through June 30, 175 recommendation. 4 MR. GARDELL: All right. 5 MRS. MARS: I will second that. 6 DR. GRAMLICH:' If you leave it at $1 million six 7 they will be loped off 40 percent,, and wind up with $600,, 8@ $800, $900" 000. 9 DR. KOMAROFF: They would only be loped,off that 10 much if staff applied astrict formula to this Councills 11 recommended level. I have not assumed that that would be 12 done. 13 I have assumed that staff, realizing that in certain 14 cases we did not vote a bloc'but chose to set aceiling,- 15 would take that into consideration in allocating subsequent 16 funds 17, MR. GARDELL: Yes, you did, 4ut on the other hand,, 18 neither did I'hear from anybody that this level which you 19 voted on should not be funded in an amount less than. 20 DR. JANEWAY: That's the question I-asked. 21 MR. GARDELL: I know you did,, and that is why I 22 ke@t reminding you,, remember what you are recommending here 23 is definitely a ceiling, and in all probability most, if not 24 all,, will receive less than that. 2.5 You already have approved some $90 million dollars 2-93 and we have $44.5 to distribute. 2 MRS. KLEIN: Mr. Chairmant I would like to ask a 3. question about that. In these instances where we "voted 4 for bloc action, what is the significance of that as related 5 to the ones where we actually set a figure? 6 My thinking was that that was a maximum figure for 7 every one of these, either bloc approval, which-is,a mech- 8@ anical approval of the specific amount,, and that the appor- 9 tiotmen-t would be equally at-.a certain percentage based 10 upon a lack of funds. 11 MR. GARDELL: To us they are ceilings which you 12 people have.indicated in bloc form that they are programs 13 asking for a reasonable amount, based on.an acceptable pro- 14 gram, and we will distribute the funds as best we can within 15 that framework and not exceed that level, which we don't 16 do. 17 Historically we have never had as much money as you 18 have approved'in the review of applications in toto. It 19 is really no different, except that it is more drastic this 20 time, as we mentioned in the beginning of the session, be- 21 cause nobody really knew how much money we were going to 22 get when the applications went out. 23 We had to shoot for four alternatives, and that is 24 why we have suggested to,you right at the beginning-that we 25 make the most equitable distribution of the funds that we 2-94 possibly can. 2 if, for instance You want to say to us that You 3 ayt "This ,want to single out onet two or three regions@ and s 4 is the least amount of money that region can get"t that is 5 for you to say. 6 DR, KOMAROFF: 1-think I would like to do that in 7 this case, and just state that the $1.6 is' effectively a 8, ceiling, but if I could ask staff to consider $1.4 as a 9 floor..- 10 I would like them to get no less than that. 11 MR. GARDELL: All right. Would you amend your motion 12 accordingly, please? 13 DR. KOMAROFF: So amended. 14 MRS. FLOOD: I will second the motion. 15 MR. GARDELL:- Discussion? All in favor? 16 (Chorus of ayes) 17 MR. GARDELL: Opposed? 18 (No response) 19 MR. GARDELL: Now we have a couple of resolutions 20 that we can get through rather quickly. And that ought to 21 take care of our business. 22 MR. BAUM: We now get to the bloc actions. Let me 23 read the list of regions that we will be taking bloc action 24 on. As Iunderstand it the bloc action is approval in the 25 amount requested# either under maximum amount for-three or 2-95 four options. 2 The regions are: Alabamat Albany, Central New York, 3 we did take Connecticut todaye Georgia, Hawaii, Iowa, Nassau 4 Suffolk, NebrAskap North Dakotat Northern New England, North- 5 lands, Ohio Valleyl Oregon, Puerto'Rico, South Dakotag 6 Texas# Washington/Alas'ka. 7 We will entertain a motion for bloc action. 8 MRS. MARS: So moved. 9 MR. GARDELL: It has been moved that we accept the 10 bloc actions as voted on by the Council. Do I hear a sec- 11 ond? 12 MRS. KLEIN: I'll.second the motion. 13 MR. GARDELL: All in favor? 14 (Chorus of ayes) 15 MR. GARDELL.-, Opposed? 16 (No response) 17 MR. BAUM: That takes care of that one. Then next 18 we need an aciion on the recommendations with respect to the 19 EMS, PSRO and kidney dialysis and transplant projects. Let 20 me read you a proposal, quote, "Council recommends that rec- 21 ommendatibns of the Bureau of Quality Assurance, the EMS 22 service and the End State Renal Disease Program be accepted 23 with respect to RMP activities in the respective areas of 24 Quality Assurance, Emergency Medical Services, and kidney 25 dialysis and transplant." Unquote. 2-96 we will e n a MO ntertai tion to that effect,, if it is 2 your p'4.easure. 3 DR.'GRAMLICH: What does that mean? 4 MR. BAUM: That means that where the EMS service 5 has recommended disapproval, that EMS project'is disapproved. 6 The Bureau of Quality'Assurance yesterday sent us a list 7' of their review of all the PSRO-related activities. 8 A number of those they wish to attach conditions 9 that they would not be funded without further information 10 being sent to the PSRO service, and without their approval. 11 There may have been a number of others,, but it 12 was that-kind of thing. In essence, it is accepting the 13 recommendations or conditions with respect to activities in. 14 those fields, from the appropriate program here at PHS, 15 .'DR. GRAMLICH: If a given region is funded at a 16 specific level, and has an EMS project knocked out through 17 this process, it could rebudget those same funds for some 18 other purpose'. 19 MR. BAUM: Right. It doesn't change the funds, 20 it just attaches conditions with respect to projects in 21 those areas. 22 Do you want us to add something that says it is 23 understood that this does not change the fundt? 24 DR. GRAMLICH: No. I just wanted to be sure. 25 MR. GARDELL: Conditions will have to be met.before Coittl;atty -97 2 they can expend the funds for those purposes. 2 DR. GRAMLICH:R That is reasonable. 3 DR. JANEWAY: This is only on disapprovalst Ken? 4 MR. BAUM: No,, they have conditions in some cases. 5 The PSRO have conditions on a number of the projects that 6 the RMPs would not fund them without sending further infor- 7 mation in and getting the approval from the PSRA program. 8 We would attach that as a condition in the advice 9 letter. 10 MRS. MARS: Would you mind reading;it again? 11 (Whereupon, Mr. Baum reread the statement that he 12 had read Previously with respect to EMS,, PSRO and kidney 13 activities). 14 MR. BAUM: Can somebody make a motion? 15 MRS. FLOOD: So moved. 16 MR. GARDELL: It has been moved that this resolution 17 regarding the three categorical type activities that have 18 been reviewed by the specific programs be accepted. Do I 19 hear a second? 20 MRS. MARS: Second. 21 GARDELL: All in favor? MRS 22 (Chorus of ayes) 23 MR. GARDELL: I should ask for discussion, 24 DR. JANEWAY: I have one question. On the California 25 EMS where we had some advice as far as the potentiality of the state taking over funding of it, how d that relate 2 to vot.ng 'aye" on this resolution? 3 MR.' GARDELL: It would'be handled the same way. 4 Anything from this Council. 5 We'need a vote. All in favor? 6 (Chorus of ayes) 7 MR. GARDELL: Opposed? 8, (No response) 9 MR. GARDELL% One more. 10 MR. BAUM: We discussed the public accountability 11 'ion is thal reporting. As we told you yesterday, our inforinat 12 the earmark of $500,000 for a continued support of PAR is 13 in the supplemental appropriation. 14 We had a resolution.on this again in your folders 15 yesterday. Since my voice seems to be in such good form 16 today,., Iwill read that one again. What this does, it gives 17 us the authorization to make a grant. 18 We can't make a grant without a council.'a affirma- 19 tive recommendation. Again, it just passed yesterday. 20 Therefore, the application can't be in here, but you did 21 get a summary of the project, and we did pass around the 22 report. 23 It reads, quote: "Action in the Congress.,concern 24 ing the supplemental appropriation ---whereas, action in the 25 Congress concerning the supplemental appropriation for the 2-99 Department of Health' Education and Welfa re for Fiscal 2 Year 11@75 indicates a probability that $500,,OOO will be 3. appropriated specifically for Public Accountability Reportingp 4 and whereas, Public Accountability Reporting has previously 5 been supported through RMP funds. 6 "And#, whereas,, 'the Department of Health,,. Education 7 and Welfare has been advised of intent to apply for such 8 funds in Fiscal Year 1975, be it resolved that: The Nation- 9 al Advisory Council on Regional Medical Programs recommends 10 the approval of an award for Public Accountability Reporting 11 in accordance with Congressional intent if included in the 12 Supplemental Appropriation-when enacted. 13 "It is further recommended that-funds be made avail- 14 able by the Health Resources Administration for an appro- 15 priate-period and amount, based upon review of an appropriate 16 application." 17 I assume we will have to change the first "Whereas" 18 to read, "Vlhereas the Congress has passed an appropriation 19 including $500,000 for this purpose". But otherwise, it 20 seems to stand. 21 MR. GARDELL: I will entertain a motion for this 22 resolution. k 23 MRS. MARS: So moved. 24 MR. GARDELL: It is moved that this be accepted. 25 Is there a second? MRS. KLEIN:' I Will second it. 2 MR. GARDELL: Discussion? 3 DR. GRAMLICH: Who.would get the award? The same 4 outfit that put this out? 5 MR. GARDELL: That has not been determined. 6 DR. GRANLICH: Who will determine it? 7 MR. GARDELL: It will be determined baserd on the 8 application and from whom it comes. There are a couple of 9 alternatives. It could go to Mountain States. It could go 10 to WICHI, and it could go to the RMP. 11 DR. GRAMLICH: What RMP? 12 MR-. GARDELL: Mountain States. It could go to RMP, 13 it could go to WICHI, the grantee. It would be the same 14 group. However, it is just the medium for getting the funds 15 to the.group. 16 DR. GRAMLICH: The safe people. 17 MR. GARDELL,.- Yes. We even entertained the thought 18 of putting that amount through the RMPs who are presently making those funds available to the PAR. But since they 20 came in for a separate, and it is a potential earmark,in the 21 appropriations bill, we thought it best to do it this way. 22 We may go the 910 route. They are trying to do it 23 with the one that has the least overhead# so that more can 24 go towards the work. 25 DR. JANEWAY: What this amounts to in that case is 2-101 a sole source RPP. 2 MR. CARDELL: If it went contract. 3 DR. JANEWAY: It is analogous to a sole source RFP. 4 MR. GARDELL: Yes. 5 DR. JANEWAY: Is that why the resolution does not 6 read "appropriate appli cation or applications'? 7 MR. GARDELL: As I understand it what you have be- 8 for4i you is not the final document. Nevertheless,, we must 9 have one before June 30th because all of this money has to 10 be obligated by then. 11 MR. BAUM: This is very similar to Congressional 12 earmarks iwe-have had before,for construction, for example, of 13 the Childrens Hospital in Seattle, Washington. It is money 14 that remains available until expended. 15 It is a clear earmark in the appropriation bill, 16 but th(y are not applied at the time. We-.have had several 17 of those and this is an analogous one. 18 MRS. MARS: Talking about Childrens in Seattle, was 19 anybody on this Council when we appropriated the money for 20 the Hutchison, Kansas Cancer Center? That is being dedicated 21 on the fifth and sixth of September. 22 so it is. now a fait accompli. 23 MR. GARDELL: Glad to hear that. 24 DR. KOMAROFF: There is no problem with the fact that 25 we are approving something, even though we don't see the 2-102 application? 2 MR. GARDELL: That's what we are really asking for. 3 It is an earmark, and we will 4 have to accomplish it. We know what it is for. It is a wrap-up of the Continuation Of 5 distrib- 6 things done to date, and You have the second report' uted this morning. -7 It is a wrap-up of that, and I think yo' u can glean 8 from the documents You have in Your material generally speak- 9 ing what they are going to be doing. 10 It will Probably end up in the form Of an award. 11 We are asking Your organization to do what Congress has told 12 us we have to do, and under-the law we cannot do it without 13 a recommendation from the Council. 14 MRS. FLOOD: May I raise one technical question? 15 Leadership of the PAR, as it has been done,, has taken quite 16 a bit cf staff time to develop this type of doc ument. 17 Y6t# in the Mountain States application, we have 18 Dr. Smith operating full-time, as Director of Planning, Asso- 19 ciate Director of Planning, for the continuation for the next 20 12 months of the Mountain State's ongoing activities. 21 Will there be sufficient direction at staff levels 22 with,this rather large endeavor that the contract will cause 23 them to undertake to continue this supervision of the. Mountain 2 States' activities? 4 25 @.MR. GARDELL: I don't think the question has been 14,ine l'?tpot'lill(i ("O))'Pcitltj 2, 103 asked# and I think it is a good point. Lat'us check into 2 it. 3 You can be sure that we would insist on proper 4 coverage during the life of the RMP, and one of our roles 5 ti. in transition is to make certain that the activi es pre- 6 sently funded and ongoing by the Public Health Service are 7 monitored. 8 That is part of it. 9 MRS. FLOOD: I can see abouta third of those people 10 going off to do our evaluation, and there is some strong 11 funding in the Mountain States still and a lot to be accomp- 12 lished in the transition period. 13 MRS. MARS: What was the final figure on the fund- 14 ing? 15 MR. BAUM: It was approximately $90 million. 16 VOICE: It was $89'million $730, 407. 17 MR. GARDELL: And they came in for $106. May I 18 just say 19 MR. BAUM: We did not get a vote on that. 20 MR. GARDELL: All in favor? 21 (Chorus of ayes) 22 MR. GARDELL: Opposed? 23 (No response) 24 MR. GARDELL: Let me just say to those of us who 25 are left that we certainly appreciated your coming, Jb/ph 2-104 understanding our pioblemi and I think you did a beautiful 2 job ir responding to it. 3 It-has been a tremendous help to us particularly 4 with the idea that with the new Bureau in and Dr. Rorrie 5 here, and I am sure he will have something to say to you, 6 too, and the Division no longer exists. 7 But still we have $50 million to distribute and 8 we appreciate your assistance. It has been most enjoyable 9 working with you, and we will see you all in the future. 10 DR. WAMMOCK: 31 would like to express to.you our appreciation. I also realize that in the short time allow- 12 ed for development of this,material and how it "s done in 13 such a rapid fashion, and the efforts'of the staff, and so 14 on, in giving us the background, which I think simplified 15 our problem to a considerable degree in trying to.review 16 these in some sensible manner. 17 MR. GARDELL: I think you were very helpful in 18 helping us to'carry out the intents of the law, which is 19 why we are sitting here. 20 DR. WAMMOCK: Let's hope that it is carried in 21 that manner, 22 DR. RORRIE:' I would just echo what Jerry had to 23 say. It was certainly obvious in the time that I was down 24 here that all of you had done a thorough review and we do 25 appreciate that. I think,, more importantly while it is the ending of the RMP and certainly the beginning of a new 2 effort.'we are hopeful that you will have a continuing 3 involvement with all of us. 4 Again, specifically, the whole area of the policy 5 issues that-I handed out to, you. But all of you do have a 6 lot of ideas, and we need all the ideas and help we can 7 get right now. 8 There is an address on there where you can get in 9 touch with us, and we are going to be putting all of your 10 names on our mailing list,, as materials are developed,,'so 11 we will appreciate getting any help from all of you. 12 -Again, thank you very much for coming, and spending 13 the time with us and we hope to see you again soon. 14 MR. GARDELL:. Thank you. 15 (Whereupon, at 12:45 p.m. o'clock thelmeeting of .TD/ph 16 the Council was adjourned). 17 18 19 20 21 22 23 24 25 ,4,ine )Vel-)oriiii@ Coi)ilyapiy