I. -K@001611-K NATIONAL ADVISORY COTTNCIL 0 ON REGIONAL MEDICAL PROGRAMS NS BOARD MEETING 9-00 AM Conference Room G-H Parklawn Building Rockville, Maryland Friday June 97- 276 2 C 6 N T E N T S REPORT PAGE Mrs. Wynona R. Gordon, ALABAMA 277 Dr. Benjamin W. Watkins, ALBANY 279 Mr. Mike Posta, BI-STATE 292 Mrs. Esther M. Martinez, CENTRAL NEW YORK 301 Mrs. Audrey Mars, ARKANSAS 308 Mr. Edwin C. Hiroto, CONNECTICUT 320 Mrs. Audrey Mars, LAKES AREA 322 Mr. Peterson, MARYLAND 336 Mr. Sewall 0. Milliken, NASSAU-SUFFOLK 341 Dr. George E. Schreiner, NEW YORK METRO 344 NEBRASKA 348 NORTH DAKOTA 351 SUSQUEHANNA VALLEY 352 Dr. Paul A. Haber, MEMPHIS 364 WEST VIRGINIA 367 Mr. Michael Posta, TEXAS 369 Mr. Van Winkle, WISCONSIN 378 Mrs. Maria E. Flood, TRI-STATE 381 ILLINOIS 4og OHIO VALLEY 1 WASHINGTON/AtASKA 418 COLORADO/WYOMING 421 FLORIDA 426 276-A C 0 N T E N T S (continued) REPORT PAGE GREATER DELAWARE VALLEY 428 HAWAII 430 IN,DIANA 433 IOWA 438 KANSAS 443 MAINE 446 METRO WASHINGTON, D. C. 452 MICHIGAN 454 MISSOURI 459 MOUNTAIN STATES 463 NEW JERSEY 470 NEW MEXICO 473 NORTHERN NEW ENGLAND 483 NORTHLAN,D 487 OKLAHOMA 489 OREGON 491 ROCHESTER 495 TENNESSEE MIDSOUTH 497 VIRGINIA 501 WESTERN PENNSYLVANIA 503 3 277 P R 0 C E E D I N G S MS. SILSBEE: May we please begin? I think we have 3. quorum, with Mr. Milliken. Okay, we are going to start this morning with klabama. Mrs. Gordon. REPORT OF MRS WYNONA R. GORDON ALABAMA MRS. GORDON: Since we are trying to expedite things @oday, I411 not display my ignorance by talking too much. The Alabama Project, we are asking continuation for 16 projects, 21 new and eight that have been approved before out have been unfunded previously, which makes 29 new, As you see, the reviewers ha ve given it an above- average assessment. They seem to have good rapport with CHP and they have one consumer and one provider from B agencies, the 12 B agencies on the Council. I did have a question. They talked about the 3tate Advisory Committee to the Governor and the State Board of iealth and this committee, the EMS Committee of RMP was the iucleus for this and does anybody know what -- what MS. SILSBEE: What is your specific question, .Ars. Gordon? MRS. GORDON: Well, actually, pertaining to what we were talking about last night -- ,S. SILSBEE: Umn hmn. 278 MRS. GORDON: -- and so I picked up on the State Advisory Committee to the Governor and the State Board of Health and was wondering what the -- MS. SILSBEE: Mr. Jewell. MR. JEWELL: Are you talking about the EMS Advisory committee, Mrs. Gordon? MRS. GORDON: They said that -- well, that this ommittee was made up primarily of the EMS. MR. JEWELL: Right, that was the nucleus. They are heavy on EMS in Alabama and the tragedy that occurred to the Governor recently. They have established a committee made Up of the health interests in the state which is advisory to the Governor on EMS and that will be umbrellaed into other areas. MS. SILSBEE: But isn't it an advisory committee in the sense that the South Carolina one was yesterday, but I think that is the -- MR. JEWELL: I missed South Carolina. I'm sorry, I don't -- SPEAKER: It is not. MR. JEWELL: It is not. Okay. MRS. GORDON: As You'll note on your critique, @hey suggested that the PSRO project be increased by $100,000 Decause it seemed an excessive amount of money for $151 000 ';O start with and they also suggeste4@@'-'that the project 82 not 5 279 be funded., mostly because it was for making audio-visual materials. I found nothing to quarrel with the suggestion of the committee on the funding, so I would move that we accept the funding of $2,028,389. MR. MILLIKEN: Second. [The motion was made and seconded.] MS. SILSBEE: Mr. Milliken, as the secretary- reviewer, did you have anything further you wanted to add to this? MR. MILLIKEN: No. I agree. MS. SILSBEE: Okay. The motion has been made and seconded that the Alabama application be approved at the level of $2,028,389. Is there further discussion? ENo response. I All in favor? [There was a chorus of ayes.] Opposed? [The motion was carried unanimously.] The motion is carried. The next region is Albany. Dr. Watkins. DR. WATKINS: Yes. The report on Albany seems superior and from a review, I feel this. I see high visibility on new legislation such as PSRO, CIIP, HMO, EMS and our first ,,concern was that these werentt really true., in-depth working I)rograms, but this is what the future is going to be at first 280 6 ight and I think then, combined with the community involvement, ey have several community programs and overall they have ollowed the goals and objectives so that, to make it Very rief, a superior program can't be criticised, so, to be very rief, I'd like to say very quickly, let's accept the recommendation of the committee of $1,066,175 less than their request. [Sic.] MS. SILSBEE: @I-5 that a nOti@On, Dr. Watkins? DR. WATKINS: Yes, I make the motion that way. MS. SILSBEE: Is there a second? MS. MORGAN: I second it. [The motion was made and seconded.] Ms. SILSBEE- Dr. Haber, did You have anything to idd to this? DR. HABER: Well, I would just like to reinforce vhat Dr. Watkins has said. Ilthink, looking at the studies, nos@t of them were good. I had a few comments to make. The feasibility studies with CHP and HMO and EMS look good. The community hypertension feasibility, I think, is @ell-thought-out and we have a favorable'record of having many of these patients to their private physicians. One of the things that intrigues me is that they ?eally ought to move fast in the IFi,10 area because if I remember correctly, this is one of the,regions of the country -here Dr. Issel8ton, a pioneer in the whole field of HI40 concept 7 281 had a group there that -- oh, I guess it goes back 20 years -- when Permanente was still only a twinkle in -- MS. SILSBEE: That is the Rip Van Winkle Clinic in Hudson. DR4 HABER: That's right, and so they, I think, can move favorably in this area and they certain y appear to Pe doing so, although I didn't see Dr. Isselston's name mentioned in this. One of the real good products is the training for the delivery of home care. I think they are doing a very Desirable thing in moving into this area, but I was concerned about the Project 039, which talks about,expanded concept in home health care. They really are very vague about that expanded concept. Is there any enlightenment possible on that issue? Does anybody have any information about it? MS. SILSBEE- Dr. Haber, the Eastern Operations ranch is represented by one person who hasn't been involved ,iith that particular region, so we can get information for you ll)ut right now we do not have it. DR. HABER: Okay. Well, I will desist from further i,lavil. I would second Dr. WAtkin's motion that this be pproved. MS. SILSBEE: Mrs. Flood. MRS. FLOOD: I have a question, Does the contents :)f your packet, Dr. Watkins, containing the transcript of the 282 transcript of the review committee process, in Any way explain cutting back $175? DR. WATKINS: No. I thought that was justa typographical error. MS. SILSBEE: I wasn't able to figure that out, either, Mrs. Flood. I wasn't at the meeting. Mr. Peterson? MRS. FLOOD: Maybe its not really relevant to them. MR. HABER: Maybe somebody missed some figures, s a MR. STEVENSON: Maybe I should have brought my figures down. I don't recall -- it may have slipped -- MS. SILSBEE: You may have rounded -- MRi HABER: I've got my notes -- MS. MORGAN: You think it's just a round-off? SPEAKER: Probably just a round-off. SPEAKER: Maybe we can take up a collection and -- DR. WAMMOCK: It's too late in the morning. MS. SILSBEE: Just for the record, the Albany, the iiew council members, the Albany Regional Medical Program in -he past years has had real difficulty because it had gone in direction that committee and council in trying to get changed finally did and brought in a now coordinator and the program eems to have moved along. This is one where they had to be :)retty hardnosed with them but it paid off The motion has been made and seconded that the 283 klbany program application be funded at '$l,o66,ooo. Is there further discussion? [No response.] All in favor? [There was a chorus of ayes.] Opposed? EThe motion was carried unanimously.] The motion is carried. The next region in our alphabetical order is Arizona and, Dick, do you want to give some background first? MRi RUSSELL: Yes. As noted on the green sheet, there are really three major problems with the Arizona Regional Medical Program. These problems are not new ones. They have been there, I would say, since the Year One. The Arizona Regional Medical PPoo-ram is in non- compliance with the DRMP policy on regional advisory groups and grantee relationships. The crux of this problem is really the ,,rantee. As you all know, one of our Assistant Secretaries Z> for Health, Dr. Duval, is now back in Arizona and he does seem to have undue influence over the Arizona programs. We have talked with the RAG chairman, Dr. Richard -7,lynn. We have also talked with the By-Laws Committee chairman, Dr. George Bach as late as yesterday afternoon. It appears to that the Regional Advisory Group and some of the key core aff are very sympathetic and would like to see the program in 10 284 compliance. Ilowever, the grantee now has other thoughts. Dr. Duval called Dr. Margulie's yesterday and said that he questioned the legality of the policy. Dr. Margulies could only suggest to him that if he chose, he could challenge it in the courts. It was pointed out to him, by the time anything was settled, that it would be a moot question, because it would all be in a different ball game. @le really have no idea what Dr. DuValls response @o his conversation with Dr. Margulies is but Dr. Margulies issued Dr. Duval that we would hold o the policy and, I Delieve, indicated that in all probability a funding recommenda- ,;ion which would just allow the Regional Medical Program to 3ontinue its ongoing activity would probably be in order and -@hey should not really start anything new until we had evidence ;hey are in compliance. Now, the influence of this representative of the ,,rantee has also been witnessed in the Regional Advisory Group Meetings where the -- it appeared the initial attempt of the '.'Egional Advisory Group was to place a high priority on one of I:he Outreach Programs which would go into the rural areas. The representative of the grantee convinced the group otherwise ,nd it was obvious that he did influence their decision more, I:ePhaps, than he should have. There are other evidences that -- I don't think it Js really necessary to go into it too deeply here except that 285 he has advised the Regional Medical Group in some cases when a letter would come back to the Program saying, you now, you hould do this or this is our advice and this gentleman's response has been., he only wrote that because he had to. We really don't have to listen to that. The coordinator appears to be an instrument of the grantee or perhaps some other interest in the community rather than a true program coordinator. The deputy has run the show for a number of years. ,In calling the program and asking for the coordinator, it appears to us that he has not been involved and can give us the type of information that we feel the other coordinators do. So his role has always been very, very fuzzy. MS. SILSBEE: Mr. Hiroto." MR. HIROTO: I seem to somehow managed to have received some of these@interesting ones. Supporting what Kr. Russell has been saying and in referring to the notes -- thE transcript of the reviewing team@ it seems to me that their D-reatest concern of the reviewers relative to programmatic tatters was that, of those programs which reviewers felt were 'nost meaningful to the Arizona RMP would probably be the ones to get the axe and not be put into play, should the request for funds be reduced. I'd like to suggest to the Council that perhaps we @ight earmark certain funds as has been done, I believe in other 12 286 cases and make our recommendations with the earmarked funds included. I throw that on the table for comments because nuch of this conversation of transcripts seems to lie in the area of concern that these particular things aren't agreed on. They call them C001, 002 and 003, "Shall provide a health education program -- medical manpower other served areas and expansion of health service sites," which apparently lare moving in the direction that the ARMP claims they want to DIO. MS. SILSBEE: This was sort of Outreach? MR. HIROTO: The Outreach, yes. MS. SILSBEE: Outreach activities that they have D6en slow to take uD in this region. I would recommend that we approve the reduced t860,000 and earmark -- I think it is $300 and some-odd for the Dutreach Programs. MS. SILSBEE: Mr. Hiroto? HIROTO: Yes? MS. SILSBEE: The request -- and Dick, you'll have 0 -- is for $655)400 for program staff. And the recommendation s for $860,000 and so, in essence, you are suggesting that :;ome of the program staff monies be reallocated into these Activities MR. HIROTO: And they would reprioritize their 13 287 program as well. MS. SILSBEE: Mrs. Morgan. MRS. MORGAN: The proposed staff of 20 professional, isn't that -" it seems like that is awfully high for a few -- vhat -- even if they took all the programs, they have only got six programs and only three of them, I believe, are program-staffed. MR. RUSSELL: I don't have my copy of the Application with me. They are, Mrs. Morgan, trying to move Lnto the Phoenix area, out of the Tucson area to start that Dffice there which was closed after the phase-out. I,,IRS. MORGAN: It just seems like 20 professionals is quite high for a relatively small program. MS. SILSBEE: Mrs. Flood. MRS. FLOOD: I might comment that, traditionally, 4-,he style of the Arizona RMP's has done some good in sp-ite of I;he coordinator and perhaps the emphasis here of increased staff ,eight be one valid approach to trying to accomplish something :)ut I would have to agree with Mrs. Morgan that it does seem -:Ln excessive number of people to work with with only approxi- iiiately $389,000 both for core staff and the program projects .-I.n that health service site, manpower recruitment and the self I:rovider education because, in essence, that is the only course (:f operation, as I interpret the print-out. Now, I didn't look at the application. So I feel 14 288 that perhaps Mr. Hiroto's point is well-taken that you do give them this reduced amount, but earmarking the $389-Plus for their their programs and hoping the staff will produce more and pot increase it [partially inaudible] so that -- DR. WA14MOCK: I notice this is University of @rizona School of Medicine. MS. SILSBEE: Right. DR. WAlfiMOCK: I was out there in March and you know, @hat is a relatively new school and they have been trying to expand it as a result and they are doing a very good job of loing it in several areas and I was somewhat impressed with 14hat the ongoing projects were at that time, although I knew nothing about the RMP program. I was just, you know, impressed very much with iihat == how fast they had travelled in the past few years when, iihat is it, five years ago they didn't have anything out there t all. MS. SILSBEE: That is as far as the medical school s concerned? DR* WAM14OCK: Yes,, as far as the medical school is Concerned. But I know nothing about its relationship lthough I do know that this is the Universtiy of Arizona 'ledical School. MS. SILSBEE: It is the grantee organization that :eems to be one of the issues 15 289 DR. W@IMOCK: They are probably going to be controlling RAG grantee funds here. MR. HIROTO: May I ask Mr. Russell -- MRS. MORGAN: They are responsible for them and they should use them correctly. MR. I-IIROTO: -- what your reactions to that might :)e? MR. RUSSELL: I think one of the -- the basic ,Droblem herb is one of noncompliance with policy and in going 3.long with Dr. Margulies comments to Dr. Duval and having had discussions with Dr. Paul, it would seem appropriate to )rohibit the RMP from moving into any new activities until hey were in compliance. This, I think, Mr. Hiroto, would permit the continuation of some program staff Outreach activities which ,iave, as Mrs. Flood noted, have been very effective. MR. HIROTO: In spite of? MR. RUSSELL: Yes, and I think, in,dll fairness to he deputy and some of the other core staff and some of the IIAG members, they have really tried to respond. MR. HIROTO: Then may I change my recommendation? MS. SILSBEE: You havenyt made a motion yet. MR. HIROTO: Okay. May I make a motion, then, that we accept the reduced funding for the Arizona Regional Medical frogram of $860,000 and divide it -- is that it -- so they meet 16 290 the requirements, the regulations of RMP relative to grantees. MR. RUSSELL: I think that the provision should be that they could not start any new activities until we were ssured that they were in compliance. it. HIROTO: Yes. [The motion was made.] DR. WAMMOCK: That's really putting them in d bind. MRS. MORGAN: Do we request a site visit prior to our August meeting, or would this be of any value? You don't want to go -- MS. SILSBEE: This Regional Medical rogram as peen the subject of a number of site visits. I believe the review committee's recommendation related to the fact that there was this long history of this going out and giving them advice and not seeing much change as a result. I don't know that I think a site visit would be ,lelpful. Now, Mr. Hiroto has moved that the application be approved at the reduced level of $860,000 with the provision that the Region not undertake any new activities until the iAG grantee policy is resolved to our satisfaction. MRS. MORGAN: Do we want to tag that for their )utreach activities? Part of that? programs. MR. HIROTO: I know we are supposed to stay out of 17 291 !,',R. RUSSELL: I think in the feedback, back to the kPIIP, that we could exuress your concerns adequately over this :)articular area. MS. SILSBEE: And again, if they come in with an Application in July, we would be able to -- we can ask for Information about how they do allocate these funds and that .night very well relate to this review n u y. Dr. Janeway. DR. JANEWAY: I am not going to vote on this )articular issue. I would only say that had I been away two years as assistant secretary and come back to Tucson or Phoenix and saw that -- as has Dr. Duval, that -- since they are the grantee, I would want to have some kind of internal reorgan- ization of staff, having known that I didn't have much control Dver them while I was gone. MRS. MORGAN: If he was gone that long, I don't know CD ahy he would want to come back. MS. SILSBEE: Would you please just second it, "Irsi Morgan? MRS. MORGAN: I second it. MS. SILSBEE: Okay, the motion has been made and ;seconded that the Arizona application be approved at the neduced level, based on the $860,,OOO with the condition that ,;hey undertake no new activities until the RAG grantee policy s resolved satisfactorily. 292 Any further discussions? [lio response.] All in favor? EThere was a chorus of ayes.] Opposed? Ello opposition.] Let the record show that Dr. Janeway abstaned. [The motion was passed.] We'll have to skip Arkansas because Mrs. D@ars did @iot know we were starting this early this morning, so she is 3till coming in from Virginia. We'll go to Bistate,. Mike, do you have any REPORT OF MR. MIKE POSTA BI STATE MR. POSTA: Yes, I think I'd better, since this was :t pretty tough review in the ad hoc panel, Bi-State. Although this region obtained triennial status in ,:@he fall of 1972, it has never been considered an average ):;rantee The request of $1,129,608 was scaled down to a recommended $800-,OOO figure by the reviewers, which is, in (:ssence., 70 percent of the request, 63 percent of the target gure. Poor leadership, particularly on the part of the regional Advisory Group, was noted. It was also noted that he Regional Advisory Group reduced its leadership to 15@and 19 293 turned over their leadership to what, in essence, was the Executive Committee. The coordinator has been serving on a 50 percent basis. However, a new coordinator, Dr. Felix, is expected to take over on July 1. Reviewers noted that the proposals do not conform with the needs as identified by the joint RMP/CIIP conference which met in February of 1974. In all due respect to the region, it wasn't until February 7th of this year that the region realized that the court order had ruled in favor of continuation of RMP and further dollars. As a result, the May 1 application only contained two new proposals. One was involved with the poor. To epitomize still further, or to epitomize, period, there was limited discussion during the ad hoc committee con- cerning the possible termination of this program. However, the reviewers expressed hope that the July 1 request of approx- imately *410,000 will reflect on the identified needs of the region,, which has had its problems in the past in dealing with urban St. Louis and rural Southern Illinois. Mr. Milliken, you might wish to continue this a little bit further. MS. SILSBEE: Mr. Milliken. MR. MILLIKE.11: This special information which staff- MS. SILSBEE: Could you use the mike, pleAse? MR. MILLIKEN: The special information that the staff has provided you with yesterday indicates that of the 20 294 May lst, 1974 request for the Bi-State JIMP identifies four project sites in Illinois, three project sites in the St. Louis County, Missouri and 10 project sites in the St. Louis City of Missouri. It seems to me that,, recently, this problem of trying to serve these two disparate areas has improved in that the kind of projects they have are beginning to even out, between the two kinds of situations. It would seem to me that they have moved a little in this direction. MS. SILSBEE: Mr. Zizlavsky. MR. ZIZLAVSKY: I think because the February meeting between the CHP and the RMP joint agencies has led to a common assertion of needs in Illinois as well as in Missouri, they have simply stated that they would be having 31 projects coming in July lst and these would more adequately address the needs and one of these projects would be in line with the Outreach than they have really had in the past. I don't know if we should prejudge it until we see their July lst effort. MR. MILLIKEN: I think another problem for this agency is the need for staff expansion. After reading a lot of this material and the results of the committee's evaluation, I kind of have mixed emotions. I feel that they do need some more limited staff but I do not feel they need the amount of staff they are requesting and I think the question is, maybe staff can advise on this, what, where and how to cut this, 21 295 you know, so that we don't shut them off completely -- confine them to their present staff only, but at the same time, I think we have got to be very careful in how much and what kind of encouragement we give them for additional staff. MS. SILSBEE: Well, with the recommendations like $350.,OOO less than they requested, that additional expanding may be taken care of. MR. MILLIKEN: Yes. MS. SILSBEE: Mrs. Flood. MRS. FLOOD: May I ask if Bi-State is still using the RFP mechanism for getting proposals in from their regions, especially in light of the CHP conference and the priorities for needs that were established thePe? MR. ZIZLAVSKY: One of the weaknesses that they had when they phased out is that they reduced their staff down to about four or five people on June 30th of '73 with a gal under program staff doing about three jobs and getting paid for one was their information officer. One of the jobs that was really left vacant was their newsletter. After this meeting with the CIIP in February, '72, what they did was print this up in their news- letter. They didn't go the RFP mechanism, but they used this through the paper releases plus their newsletter and sent the newsletter out to previous project directors and others. MS- SILSBEE: Mrs. Flood. 22 296 MRS. FLOOD: I have one further question. Dr. Stoneman, the coordinator that is apparently leaving, was part-time coordinator and is the nevi coordinator to be a full- time coordinator or will he also devote part-time and hold a faculty position and private practice, as Dr. Stoneman did? MR. ZIZLAVSKY: No, he'll be full-time. He'll be 100 percent. DR. HABER: I think it appropriate for me to voice an endorsement of Dr. Felix, whom I know very well. He was, as the brief indicates, former director of the National Institute of l,iental Health. He has been the Dean of the St. Louis University School of Medicine. He was the chairman of the special medical advisory group for the VA and we were bidding for his services at the VA and we lost out. We wanted him to be the head of our new geriatric research and clinical center in St. Louis. He elected to go this route instead and I just want to say that he is a very capable man and will, I am sure,, distinguish himself in the program. MS. SILSBEE: Dr. Watkins, did you have any comments DR. WATKINS: Well., based on what I have been hearing, I would second Mr. Milliken. MR. MILLIKEN: I don't know what I said. MS. SILSBEE: Dr. Wammock. DR. WAL@MOCK: I don't get through my thick noggin here the reason for Bi-State Medical Program when you have got 2 3 297 two states, Missouri and Illinois that have got two states here, Missouri and Illinois, that are making applications and you have got a situation where one is across the river and they are trying to work together and it is sort of like a team of horses and I am not sure how you are going to get them hooked up to the wagon and I'm a country boy. MS. SILSBEE: Dr. Wammock, that has been an issue -- has been a concern for a long time. DR. WAMMOCK: I just -- MS. SILSBEE: The medical trade area is the basis or the -- DR. WAMMOCK: I realize it is a medical trade area, but I just -- I think3 you know, it's trying to fit apples and plums and something else in the same bag and peddle out something curious and I rather suspect that this requires, I mean, some of the inherent difficulties that are arising in there when you have got another state which is going to come up shortly is Illinois. They've got Missouri coming up here. Why can't they just do it, each in their own ballpark? MS. SILSBEE: Well, being an old St. Louisan3 they just don't work that way. DR. WAT414OCK: Well, anyhow, it makes a headache for the rest of us. MS. SILSBEE: The motion has been made and seconded that this application be -- 2 4 298 SPEAKER: Wait a second. MR. MILLIKEN: I will make the motion. MS. SILSBEE: Somebody said you made a motion. MR. MILLIKEN: They knew I was going to do it. MS. SILSBEE: Well, will you say it, please? MR. MILLIKEN: I move that we accept the committee's recommendation for the funding decision, 63 percent of the $8003000, 63 percent of the tiger and $329, 80 under the request. MS. SILSBEE: Do I hear a second? [The motion was made and several seconds given.] MS. SILSBEE: The motion has been made and seconded that the Bi-State application be approved at the reduced level of $800,000. Any further discussion? DR. JANEWAY: Could I ask an informational question? MS. SILSBEE: Yes, Dr. Janeway. DR4 JANEWAY: Knowing Dr. Felix, I suspect -- although I have no reason to know this -- if this comes in $329,000 down, the July request is going to be bigger. [Laughter.] Because he is a mover. He is an extraordinarily competent person and I think that some of the cooperation and clerical questions will be solved by that time. MS. SILSBEE: Mr. Zizlavsky. 25 299 MR. ZIZLAVSKY: One of the things that we did was ask the program -- all 53 -- for an estimate of their July lst request, so this was made approximately three months ago and one of the things we have been kind of watching is their making a monthly total and then keeping up with this figure and they've carved the projects down from something around 31 to 24 in their own review process and I feel that those 31 projects were about $721,000 and it is down to $410,000, so we'll keep your comment in mind when we receive the uly s applications so you may receive a surprise. SPEAKER: Good. MS. SILSBEE: The motion has been made and seconded for the reduced level of $800,000. All of those in favor? [There was a chorus of ayes.] Opposed? [There was some opposition.] The motion is carried. Good morning, Mrs. Mars. MR. MILLIKEQ: There was one further thing that staff recommended, that on the RMP request by 1,4ed,, Incorporated on the EMS that the request be approved but that funds not be release until RI@,IPS staff and regional EMS staff attempt to arrange, possibly through a joint staff Visit, some sort of unified planning capability. 26 300 MS. SILSBEE: Is that a result of their meeting the other day? @'i,R. POSTA: That was a request by the IIEW Region VII office and also during the discussion with the HRA group on Monday and Tuesday we did learn that the arch program, the CIIP "B" agency in St. Louis had been approved for a planning grant and I think that the rationale here is to be sure that there is more coordination with the funded EMS activities in that area. MS. SILSBEE: That really does not require Council action. The next region -- we'll give Mrs. Mara a chance to pull herself together and skip Arkansas and go -- I,,IRS. MARS: I'm sorry I'm late, but I thought I was early. Nobody told me. MRS. MORGAN: We decided that after you left. MRS. MARS: Well, I know, but somebody could have CALLED ME. MS. SILSBEE: Central New York. Mrs. Martinez. Mr. Skolbff is the operations officers for Central New York and Mr. Nash, As I said yesterday, could not be here. If you need any additional information, direct,them up to that end. 2 7 301 REPORT OF MISS ESTIIER M. MARTINEZ CENTRAL NEW YORK 14ISS MARTINEZ: My general impression of this proposal was that it was somewhat weak. I thought the development was a little -- DR. WAI@EDOCK: Louder, please. MISS MARTINEZ: I have a couple of comments to make of some things that I noted. In looking at the membership of the RAG, 23 of the 53 RAG members are also CHP members or staff persons. Isn't that a little heavy and isn't there a conflict of too much influence of the CIIP into the RAG area? c-IR. STOLOV: I think that is the figure. I 11 check it while you go on to your next point, but they have four CHP agencies in their region and one of each of the four is represented on the RAG, but not the 23 capacity, but I'll check that if you'd like to go on to the next one. MISS MARTINEZ: Well, I know that at least that the executive director of each CHP agency is on the RAG, but there are also quite a few other persons who are either on the boards or perhaps a few more that we are familiar with. Let's see -- you'll have to forgive me if I am a little bit -- I haven't done this before. I was wondering if proposal number 022C is primarily for equipment? The radio communications -- is it? MR. STOLOV: 23C? 2 302 MISS T@ARTIi@,JEZ: 22C. MS. SILSBEE: It is the EMS. MISS 1/lA,@TINEZ: EMS Radio. MS. SILSBEE: Miss Maritinez, that is on activities that have been going on before and it is primarily equipment, but it reoresents a partial payment. The hospitals are putting up money also. MR. STOLOV: The review committee did discuss this. 4,IISS MARTINEZ: You are talking about 22C? MR. STOLOV: Right, 22C and in its deliberations the review committee noted that the region is using matching funds at the rate of 50 percent local, 50 percent RMP. They also noticed that the RAG was astute enough to give a low priority to putting equipment in ambulances and sticking to their original plan and aliving it a high priority to putting CD a central communications systems in the hospitals. So in the event of gettina an award, there is a least likelihood of getting the low priority ambulances passed through the RAG. I checked the RAG's members and to the best of my knowledge, I think they made an effort to show that there was also membership from, say, the medical society and a gentleman being on the CHP board but brginally when the RAG was formed, these Gentlemen were chosen by their primary goals, say, representative of the medical society but Vic Murray wanted to show also that there was some representation on his volunteers on other agencies in the community so you were 2 9 303 right on the 23 but officially the representation is from four of the agencies but Mr. Murray lists the people on his l@.AG as representatives, primarily from the medical society, but some did have it, as you pointed out, a representation on the other bodies. MISS MARTINEZ: Is that ususal, to have that large a representation? MS. SILSBEE: I think that it would represent -- these are neople that are serving in two capacities and the representation is not because they are CHP but because they are particular individuals who happen to be active in two a rrencies. MISS 14ARTI14EZ: Okay. "4ow, there is a number of the -- number 44. I can't remember exactly what it is now, Council for Coordinated Health? Is that it? That the function of that grant seems to me to be a county function. P-IR. STOIOV: 4044, it's a home.care health service project and your question, is that it appears to be a county responsibility? May I ask MISS MARTINEZ: That one and the Well,Baby Clinic, particularly the Well Baby Clinics because, at least in my state, that is a county function. Now, is there any reason why the county isn't doing this in the Central New York? DR. SCHREINER: Maybe I can answer that because I have been up there on a site visit. It is very hard for 30 304 traditional -- those of us who live in urban areas -- to appreciate there is a place in our state with a population density lower than the Mesa area of Utah. MISS MARTINEZ: I don't -- DR. SO@HREIN8R: But it is and there are two counties that a Well Baby Clinic started in a county where there were no doctors and two nurses for an entire county. There wasn't a single doctor in the county so this started as an RidP program and I am not -- I haven't seen the continuation of the project, but I assume it is the same clinic being extended that was started up there several years ago. MS. SILSBEE: Mrs. Martinez, I wonder if you could describe what the review committee recommended and see -- and think in terms of whether you have any recommendations? ,MR. STOLOV-. Well, could I just -- MISS MARTINEZ: I really -- MR. STOLOV: I just didn't want to leave this hanging on the Onandaga County one. It is only $24,000 for a coordinated home care service, so this is what iqP4P usually does. It is a facilitator. They are adding a few extra dollars to get the thing moving. MISS MARTINEZ: Yes, I think one of the weaknesses of this proposal is the lack of development in it on future funding and support. I don't think that is really brought out in most of them. I think this is going to be supported by such and such an agency, it is going to be for a certain -3 1 305 period of time so it sort of leaves me hanging. number 58 -- number 56 I'm sorry -- For instance, i gives you the impression that the people who are now being observed by this clinic will be like hanging at the end of a certain period of time because there is no mention -- in any case., what I did was, I sort of subtracted the proposals that I wasn't particularly impressed by and I still came up with a higher figure than the review committee and maybe you,can explain -- I can up with $706,879 as opposed to $600,016. MS. SILSBEE: Do you want to make a motion to that effect? MISS MAR"LINEZ: Well, does someone want to explain to me how they arrived at 615? MR. STOLOV: Perhaps Mr. Peterson is more familiar with how the review committee came to that. MR. PETERSON: Oh. I think in this region, as in many of them that were considered., while the review committee went through somewhat the same process that you did, Miss Martinez, examining the projects and the like, far more frequently they made some kind of overall assessment in terms of past track record and the like and from checking the Minutes or transcript on this particular discussion, this was one of the sort of class actions in a sense -- oh, let's reduce this about 20 nercent rather than explicitly reflecting a let's subtract this project, halve this one -- some of that 32 306 went into the thinking so in one sense it was an 80 percent kind of region, I P-uess. 14ISS MARTINEZ: Okay, well, I'd still like to make a motion at this time to fund it @@706,379. I subtracted -- MS. SILSBEE: I don't think we need to go into this, but would you repeat the figure? MISS @.IARTI'liEZ: $706,379. MS. SILSBEE: Is there a second? [The motion was made and seconded.] MS. SILSBEE: The motion has been made and seconded that the Central 1-lew York application be approved at the level of $7o6,359? MISS MARTINEZ: $706,379. MS. SILSBEE: $706,379. Is there further discussion Mrs. Flood. MRS. FLOOD: I only have one question. Mr. StoloV, is there still a report out as of the last phone call that they would be coming in for the July- August review at $1,150,000, which is the proposed figure at the bottom of our green sheet? MS. SILSBEE: Mrs. Flood, that represents an estimate that was made in early May. l,qe haven't gotten an pdate. That probably represents, though, some total of @wuhat started through their review process. I would doubt 3 3 307 that it would be that high. All in favor -- DR. SCHREI14ER: I just might comment that they had made tremendous progress setting priorities and I am particu- with larly happy to see them coming in/the coordinated programs in the North Country. There are two, the new ones. Some of you may not know that there are over 5.,OOO Indians on the Regis Reservation who never signed a treaty with the United States so they get no health care from the Federal Government and they are dependent on New York State, which has been zero up to this point on the care that has been provided. At least they had a dental but it had not even had the cellophane taken off -- the plastic -- and so it looks to me like they are getting down to work and I think Miss Martinez was very generous and I'm happy to -- I think that they will spend it well. MS. SILSBEE: Thank you. The motion has been ma and seconded that the application be approved at $706,379. All those in favor? EThere was a chorus of ayes.] Opposed? [There was one nay and the motion was carried.] The motion is cArried; Mrs. Mars, are you ready to go back to Arkansas? Y@1,RS . MARS Yes. 34 308 REPORT OF MRS. AUDREY MARS ARKANSAS MRS. MARS: I site-visited Arkansas a number of years ago and at the time I was very impressed with the pro-rag They had an extremely outstanding coordinator by the name of Dr. Silverbladt who, unfortunately, has resigned in the last few months. I think rather Unexpectedly. He was a very ambitious individual for his program and a Very active person. Fortunately, the new coordinator has been there for the last four years and is a very capable person. He was there, I know, at the time when I site-visited the program. They have a close cooperation with the CHP agencies, both the A and B. There are eight agencies -- eight B's and one A that are funded. The planning and development districts are the grantee organizations for the agency so that if the agencies are disbanded, they -- there still will continue to be a monitoring force for the ARMP activities. They have imporved their relationship with these agencies in the last years and some of the APJ4P proposals now have a B agency as a sponsor and their technical assistance in the development of a project has been invaluable to them. The entire application of the Arkansas RMP was submitted for comments to each of the agencies and all eight 35 309 responded. There were very few differences of opinion between the A and the B agencies concerning the projects but the CHP B agencies and the RAG agreed in any unfavorable comments that were made. Four of the six of the projects that received unfavorable comment were withdrawn by RAG and two were sent back to staff for administrative changes to be made before the approval. They feel that the projects proposed will be supported by other aspects of the health care delivery system when the ARMP funding is no longer available. ARMP has a very well-organized monitoring and evaluation division. It monitors ongoing project activities in relation to their stated goals and objectivet., maintains a constructively critical posture. The division of physical affairs keeps accurate, up-to-date records, working in close liason with the monitoring divisions. The subregional system has been developed exten- sively. For example, they have a contract with the Arkansas iieague for i'lursing and for the development of a quality assurance program. In nursing homes they have a hypertension screening program, quality assurance programs with the hospi- tals and others. There is very good involvement with the RAG. They have been successful in securing funds and political support in order to obtain state funding for programs as well as from 36 310 charity sources. The quality assurance is being stressed. This certainly is very necessary in a state such as Arkansas. They have emphasized continuing education as one of their major thrusts. The ARMP coronary care network in Arkansas is the outstanding one now. Kidney disease control program has become completely self-supporting. The expansion of their recovery room services for the ch:Ddron's hospital project is a very choice example of multiobjective activity. It will provide an improved and expanded primary, secondary and tertiary care and will interact with operations of many health care systems and services of health funding. There is no conflict or duplication of activities being funded with the IISA funds to@Arkansas. They have 58 RAG members, the coordinator meeting with them, of course, makes 59. The RAG is well-distributed between members of the public, the health professional and private and public health service. Volunteer agencies are represented. There are teachers, lawyers, judges, politicians, nurses, higher education, insurance, doctors, health agencies, dentists, hospitals all represented, so it is a very good composition. And they all seem to take a very active interest. The program has stayed -- the RAG has stayed the 37 31 1 same, despite the projected phase-out and Arkansas is planning on applying for another $800,000 in July. I am perfectly happy to accept the review committee recommendation of $1,500,000. The new coordinator, I think, will be able to do a firmer staff organization. This is needed. They do need more people on their staff. It really is not as complete as it should be And some of the programs should be reconsidered, such as their sickle cell, in light of the year's period time 'which some of these programs just cannot be completed or successfully carried on so I move that we accept the review committee's recommendation of $1,500,000 to the Arkansas program. [The motion was made. MS. SILSBEE: Dr. Janeway. DR. JANEWAY: I will, in order to get on the floor,, second the motion for approval of the recommendation of the committee. [The motion was seconded.] I have a philosophical question. I think we are dealing with the only game in town, is one thinIg I read in this I have two questions, one of which is rhetorical and one of which I'd like the advice of the staff, and that is, I think we are beginning to see here a fairly sizeable role of the 3 8 312 CHP B agencies and the implementation of health services which, from a management standpoint bothers me that planning control and implementation should be functionally in one organization. That is rhetorical because there is nothing we can do about that, I think. The other is, perhaps, just to get educated. I wonder about providing support for the Arkansas Health Statistics Center when it is clearly stated in the proposal that they wish the funds for one year to demonstrate to the state legislature that this is a valuable project. One wonders if the planning funds for this couldn't be derived from state sources., but I don't know what was cut out and I just wanted some guidance from staff on it, but I second Mrs. Mars' recommendation. MP,. POSILA: Doctor, to respond on the statistics part, the legislature did not meet this particular spring. That request to the state legislature for additional dollars for an agency statistics will be presented in the next session. The request to the statistics center here was not approved or was cut down and that was the reason for that. DE. JAIQE!IAY: I'm glad to hear it. MR. PETERSON: I think there is one other small item, Dr. Janeway, in the way of history on this one. Arkansas has a great deal of federal money. They have a statewide experimental health services delivery system project and I 39 313 happen to have been on a site visit to it about six weeks ago and it does appear from looking at it through that end of the tube that the establishment and the initial operational support of this is sort of being traded off between the experimental health services, the R@@IP and as Michael pointed out, they do have the legislature which still only meets every two years so you'd have that kind of a problem. That does not necessarily justify it but t oes explain, perhaps, why there is some ES-RMP coordination. It is a new operation established less than two years ago. DR. HABER: Can someone give us a word of explanation about that expansion of that burn center? MR. POSTA: Yes, sir. This was considered a number one priority by the regional advisory group that met. Originally, when they got together, the title of this was a little bit different because the first initial request was for total equipment. When we negotiated with them and they approached us with this particular idea, we said there was no way that the review groups would support a program of this type if it was solely for equipment. As a result, they revised it, went back to the drawing board and came in with mostly soft money. There is a little bit of equipment in it but this is to be funded through diiildren's hospital and it will be an add-on, if you will, to their emergency medical services system. 4 0 314 HS. SILSBEE: The motion has been made and seconded that the Arkansas application be approved at the level of $1,500,000. Is there further discussion? [No response.] All in favor, say aye. [There was a chorus of ayes.] Opposed? [There was no opposition and the motion was carried unanimously.] The motion is carried. P4R. PAHL: Before we proceed with another appli- cation, Mrs. Silsbee has been giving me a little chore to do here which I am happy to do, particularly because you are doing so well this morning, but I think we might have a frame- work for todays activities because a few individuals have indicated, you know, what their schedules are and our interest as well as yours is to be fair to all regions, so I think if I outlined for you what we see to be the framework, you can continue to do as well as you have this morning. If we spend about 10 minutes per application, simple arithmetic will show that if you work through the day, including the lunch hour, you will be finished around 4:00 to 4:30. That is no breaks and work through the lunch hour. "low, I know that in some.instances you will have to eave for good and sufficient reasons. What we don't want to 315 have happen, and I am sure what you don't want to have happen either is to have, at the end of the day, either a rush so that those regions really don't get adequate attention, or, insufficient people working into later hours so that, again, the regions are not represented by primary or secondary reviewers. So, with that understanding, I would like to suggest that, keeping in mind these facts, we decide as a icouncil how we wish to manage our operations now., rather than get rushed at the end of the day, which we know we would be. So we have to make a decision, therefore, either to ,observe I'@'irs. Silsbee's kind of time framework and that could be done by having the staff present a few highlights and then the principal reviewer only add that comment or two which would substantively change the recommendation of the review committee. If it is an endorsement, the review committee has i:done its work. If there is a reason to highlight something which would result in council discussion or perhaps a different recommendation, that is, of course, what we should do. If that is the operation., then I think one can see completing the work in fairness to all regions through the day. If not., we should make our decision to either work into the evening hours or stay over till tomorrow, but I do think it is unfair not to give this framework early in the day and then have people drift off ldter.' 42 316 Perhaps the council should just decide how it wishes to manage its affairs so that Mrs. Silsbee can be guided by your decisions. MRS. SILSBEE: Mrs. Morgan. MRS. T,,ILORGAN: Judy, I am sure there are certain regions which, having not gone through everything, had every- thing to go through, that have been flagged as problem areas. It seems to me you could -- staff could mark these off and maybe we oui-ht to hit these earlier while we have a fresh thinking MR. PAHL: There are a few that we have identified MRS. '@@ORGA,'I: Right. MR. PAHL: -- some of which you have been discussing and that is ghat I say, you have been doing very well this morning. MRS. T40RGAN: But I think if those were flagged and you started to do those, then maybe within the next hour we'll have a much better idea of what -- after we have gotten rid of some of these more difficult ones, what our tiinefrarne is going to be. MR. PAHL: We have, indeed, already identified a few. You handled, perhaps, five of them and there are perhaps six regions that we would take up -- Dr. Haber. DR. HABER: I was just going to modify that suggestion. Is it possible for you to present to us a list 4 3 317 of those things that are likely to be noncontroversial to be voted on en bloc, giving us some time, therefore, to spend on the controversial ones, rather than spending an equal amount of time on each? MR. PAHL: Yes, we have identified those. Just taking up for a moment, let me say that you must recognize that this council is handling more at this meeting in the way of total applications than any council has in the last four lyears because yesterday you had an arthritis discuss on bo in the morning and the afternoon with 43 applications and this council, in terms of RMP application, at this meeting is handling 53 applications, not the normal 17 or 18. So both you and we are under the same kind of impossible time pressures and my comments here are not meant to state that any of us, as staff, are in any way dissatisfied or frustrated, but we are indicating to you that knowing schedules and in fairness to regions., we have to work within that framework. I would suggest, Judy, that what we do -- for example, Dr. Schreiner has to appear on the Hill here for testimony -- either this is the real world and we want your advice for the regions and we will try to get through as many of these before you have to leave and I think what we ought to lalso do is take up those regions where we know we need the council discussions as we have with some of the others that we have been handling this morning and then we can pace 4 4 318 ourselves during the day. DR. HABER: Especially those problems first:and then we can see how they work out. MR. PAHL: That is correct. The other thing is, at an appropriate time after some other coffee is brought in or so forth, staff will be glad to bring in coffee or if you want sandwiches brought in .or depending on how you wish to run your day, but -- MRS. MARS: I just want to get a sandwich, that's all. MRS. MORGAN: Yes., we are not going to work all day without at least a sandwich. MR. PAHL: Yes, and I think a little later in the morning, but I wanted to say we do appreciate that you have an unusual workload. You are doing very well but we also have to recognize fairness to the regions at the tail end of the day when everyone is tired. MRS. SILSBEE: Well, in the memo that I sent out to the council, I identified about 11 regions that I@thought needed some special attention. You have already dealt with four of those, so the remaining ones are the ones that staff identified, that need kind of deliberations of this council and in terms of the coriunittee's recommendations, Connecticut, Lakes Area, Maryland, Nassau-Suffolk, New York Metropolitan, Texas and Wisconsin. 4 319 14ow, that would be my agenda. Then we also have, DP. Haber has to leave at noon. r. Schreiner leaves at 11:30 and Dr. Janeway is going to have to leave this afternoon at about 3:30 so we have got quite a bit to do in two hours, really. I wonder if it would be helpful in terms of IT Dr. laber and Dr. Schreiner, who leave this morning if I could ask them the regions that they reviewed. Dr. Haber, you had Memphis and Washington-Alaska, as I recall, as primary. DR. HABER: West Virginia. MRS. SILSBEE: West Virginia. Are either of those going to require any changes in the committee recommendations? DR. HABER: Memphis might. MRS. SILSBEE: How about among yours, Dr. Schreiner@, DR. SCHREINER: Yes, well, I can, handle them pretty fast. MRS. SILSBEE: Okay. Since the next one on the list is Colorado-Wyoming, our record should show that Dr. Gramlich is not here today. MRS. MORGAN: Do we want to do that., or do we want to do the difficult ones? I'd say., let's go to the, difficult ones and then get Dr. Schreiner's and Dr. Haber's and then come back to these. MRS. SILSBEE: Okay, very good. Connecticut is 46 320 a difficult one. Dr. Watkins. DR. WATKINS: No -- MRS. MORGAN: No, that is Ed's. DR. SILSBEE: Oh, Ed, excuse me. MP,,. HIROTO: It may not be that difficult. REPORT OF MR. EDWIN C. HIROTO CONNECTICUT MR. IIIROTO: Inasmuch as their application is for continuation of only one month of pro@rams and one year for the staff and there is a considerable amount of conversation that occurred between the -- amongst the reviewers -- and since the July application will probably bear the brunt of' the review, I would recommend that we accept the surveyors' recommendation and recommend $510,000 with, really, the bulk of the review to occur at next cycle. MRS. SILSBEE: Is there a second to that? [The motion was made and seconded.] Okay, any discussion? DR. WAMP@OCK: Well, there is a sentence down here that says "The RAG chairman's response to CI-IP comments_, as well as CHP comments themselves, indicated that the RP4P-CHP relationships remain a problem.' MR. HIROTO: Yes. MRS. SILSBEE: Yes,, that's true. MR. HIROTO: They are. 4 7 321 DR. WAlli7ilOCK: Well, there's nothing new about it, huh? I,-IRS. SILSBEE: There is something the council can do about it. DR. IIAMMOCK: Yes, well, I mean, I just -- MRS. SILSBEE: It was a problem and it is not just something that has emerged. The motion has been made and seconded that the Connecticut application be approved at the reduced level of $510,000. Is there any further discussion? [No -discussion.] All in favor. [There was a chorus of ayes.] Opposed? [There was no opposition an d the motion: was carried.] The motion is carried. The next one is Lakes Area a,problem and ",Irs. Mars is the primary reviewer. MRS. MARS: I seem to get all the tough ones. MRS. MORGAN: That's because you do such a good job i)n them. MRS. SILSBEE: Mr. Peterson, I wonder if you would stepping up here, because you chaired that particular j-)anel and Mr. Nash is not here. MRS. MARS: These microphones seem to be making a 4 8 322 funny noise. REPORT OF MRS. AUDREY MARS LAKES AREA MRS. MARS: Again, I think that the funding reduction here is too drastic. I site-visited this program a number of years ago when it was in very bad shape. At that time, the grantee was taking a tremendous percentage of its money. Dr. Ingall., who is one of the most capable of the coordinators, I believe was chairman at one time of the steering committee of the coordinators, is the present acting coordinator and has been for some time and at that time he was about ready to resign. I think that the site visit helped Considerably and all suggestions that were made at the time were followed. .The program was completely turned around and I would not be surprised, but if we reduced the funding to the degree that 'has been recommended here by the review committee$ that Dr. Inr7all would not resign, which would be a pity that he would not be able to see the program through to its termination. He separated the program from the grantee and formed a nonprofit agency to act as the grantee and has a five-mernber board. The program covers seven counties in New York State and two in Pennsylvania with a population of over three 49 323 million people. They have two CHP B agencies and these agencies have representation in the RAG. The criticism that I would make of the RAG is that it is heavily weighted by the medical profession, perhaps too much so. The two programs which the review committee, let's say, brought to attention and which apparently deserved it greatly and were of particular concern to them was the request for the funding of the telephone lecture network. This is a very unique project. This is an area where, in the wintertime, snows pile up to 12, 14 feet and I guess at times, 20-feet drifts which means that there is practically no communication in this area. This telephone lecture network is far more than that. It is their only means of communication. It is a continuing education program and it is just a unique and valuable dispensable program to the area. It is an expensive program but I felt that every penny that is put into it is worthwhile. The other program that they were concerned about was the continuation of the cancer registry. This is the fifth year for that and as all of you know, cancer registries are not as much use or cannot be proven of use, really, until five years has been completed. So that I felt that despite the fact that we have been trying to get them out of this tumor registry, inasmuch as they are 50 324 still in, it seems to me that the continuation of the registry at this point would certainly be worthwhile and, undoubtedly, it will be taken over by the participating hospitals at the end of this five-year period. The complaint seems to be that we should give a strong message to the practice of continuing support projects beyond three years. Of course, this has been our policy, but, nevertheless, there have been other programs throughout the @RMP funded over a period of five years' time and there is no absolute set rule, I do not believe. Is that true? To that degree, that if a program ii8 worthwhile, that it cannot be continued for a longer period. I-IRS. SILSBEE: Council policy is to encourage three-year funding. MRS. MARS: Right. MRS. SILSBEE: And to have, at the initiation of the activity, some plan for take-over by other resources. MRS. MARS: Exactly. So that with the tumor registry, the plan is such that the participating hospitals will take it over and I think eventually that as PLMP withdraws its support for the telephone network, I am sure that this likewise will be taken over. So that I really felt that this was more or less something that did not justify destroying a program to say that we are going to give a strong message to -- for the sake of this money which is already being put in. You 51 325 are simply scuttling program that it just doesn't justify doing that. The staff, my criticism is, does seem excessive in number. They certainly need to eliminate some of their staff and replace them with people who are more competent. The CHP relationships seem good. They and the RMP did not agree on all of the projects that were presented, but the staff and the RAG took heed of this. The total dollar request for the 11 approved projects is $780,453 and five new projects were presented in their application that require $26o,ooo. The funding that the review committee has suggested is $400,000 below their current annualized funding and as I say, at this late date to deliberately try to scuttle a program for the sake of teaching them a lesson just does not seem to make sense to me. This program has done a great deal of good to improve the health pattern in the area and I feel that it certainly is an average program, although the review committee rated it below average and I think that it could hold its head up against any average program, so to sppak. So I would like to suggest that instead of -- and I will move --- I not only suggest but I will move that instead of the $1 million committee recommendation against the $2,072,000 they requested., at least to give them the $400.,OOO which is now the funding 52 326 is less than their current annualized figure. So I move that we recommend $1,400,000 funding. [The motion was made.] MRS. SILSBEE: Mrs. Gordon. MRS. GORDON: Well, I can@appreriate the value of the telephone network. We don't have drifts 12 feet high, but we do have somewhat the same problems with communication and that sort of thing. Ilowever, I agree that it is a shame to scuttle it at the last year. But it would seem that they @could have put more emphasis in -- toward getting other fUndingi It was a valuable program to them and there should be those who are willing to support it. MRS. SILSBEE: Mrs. Gordon., I believe that a part ;of that support is that there are a number of hospitals in the area and they do -- it is a matter of gradually getting all of the hospitals to take up their portion of the cost. There has been -- costs for this project have gone down over the years and it is used as a method for having committee meetings in-the winter and a network in., oh, emergency medical service relay from one hospital to another. So it has been more. The term telephone lecture network, that doesn't really tell the whole story on that. MRS. I,,IARS: It should not be termed that, really, because that is too ambiguous, I think. It does, as I said, so many other things besides that. 5 3 327 MRS. SILSBEE: Mrs. Mars has made a motion to -- for $1.4 million. Is that seconded? Dr. Ilaber: DR. HABER: I second it. [The motion was seconded.] MRS. SILSBEE: Mrs. Flood. MRS. FLOOD: On the yellow print-out, does the symbol "C" at the extreme right signify funding beyond,the three-year support or funding beyond '75? MRS. SILSBEE: Beyond '75. MRS. FLOOD: They are requesting funds here, then, for fiscal '76? MRS. SILSBEE: Right. There were two projects, I believe, because they were asking for two-years' support. MRS. FLOOD: Then may I ask who the sponsors are of, for example, the telephone network? MRS. SILSBEE: That is the grantee organization which is a nonprofit organization. I-IRS. FLOOD: Well, it was my understanding that there would be no funds allotted ast June the 30th o@ p f 1975 for any core staff. llow, how can it be a grantee project and they request funding beyond that fiscal year if it is going to take four staff to operate it? MRS. SILSBEE: Mrs. Flood, in this particular organization, is as a nonprofit organization, they have other sources of funds. I believe they have gotten funding from 5 4 328 other Dlaces. l@. Pahl. 14R. PAIIL: I'd like to speak in general terms. @@his is as good a case as any, but there is a general problem which runs through a number of applications, so my comments are really not to the application under consideration, and that is, how does the RMP manage its affairs when it makes its awards for activities which will extend beyond the termination ,date of the RD4P in question? Since RMP's are to terminate on June 30th, 1975, the question is a proper one. We have been interested in addressing this question now for two years because of some nterest.in proposed phase-outs last year and possible termination of the program this year. In practical terms, there is no resolution at this time to that question. Some grantees will be able to manage affairs beyond the life of the IU4P because they happen to be institutions that have a life of their own and are willing to absorb the cost necessary to monitor those ongoing activities. On the other hand, it would be fair to say that the large majority of grantees are not for-profit institutions or are medical societies or schools that do not literally have the funds to pay the staff to monitor such activities. lqow, staff has recognized this situation for the second year running and, actually, I have discussed this 55 329 matter in recent weeks with Dr. Margulies and have proposed to him that the agency sent out to all RMP grantees a statement of federal policy which basically would say that it is the established Drdctice of the government -- and I can give you any number of examples out of personal experience -- that it is the established practice of the Federal Government to provide for the monitoring and survei lance of activit es which extend beyond the life of a program when that program has been terminated by the government. For example, the chronic disease control program was absorbed into the Regional Medical Program and there was no more chronic disease control program but we in our organ- ization have spent the last three years managing federal commitments and contracts in the kidney program area and part of my staff has been doing work that was obligated to three years ago. We had a series of HEW regional offices. There is a decentralization thrust to put appropriate functions in these regional offices and there will continue to be head- quarters staff either under the title of RMP, Health Resources Planning, [IRA or some organization. I have in my briefcase a statement which has been drafted by RMPS and will be forwarded to Dr. Endicott for official consideration as an agency statement for RMP grantees which merely provides assurance that although we have not 56 330 identified the manner in which the government will assume monitoring responsibilities, that this problem is both recognized and the grantee, in good conscience, can let contracts for periods beyond June 30, '75 whether the present grantee is in operation or not. I hope that addresses both this and a number of other issues. MRS. FLOOD: Well, but you are clarifying the concern we have for management of phase-out projects by contract mechanism, but here we have a grantee who intends to continue projects themself beyond -- MR. PAHL: Well, there is a clearcut statement by the administration that no costs may be incurred by an RMP beyond June 30., '75, regardless of what the applicant wishes. You can't stop the applicant from stating whatever he wishes to do but there is a clearcut statement in all of our instructions that costs cannot be incurred by RMP's beyond June 30, so this situation falls -into the very one I am mentioning. lie cannot go beyond June 3bth. That is the administration policy. Therefore., he falls into the class that I am talking about, if the project is to be continued then either the individual regional offices or some head- quarters program, whether we are the same name or not, will have to assume that responsibility or we have to make 5 7 33 1 arrangements for some other organizations to take on that responsibility and, as I say, we are trying to develop a policy. It is very strange that I cannot send to any grantee a xerox copy of anything out of ITEW as to how to manage such an activity Yet the.Federal Government does terminate programs all the time and there is no grants-management policy in this area. So we are attempting to develop one and hope the Agency will respond. MRS. FLOOD: Then I must inquire regarding the tumor service registry here, if this, then, is fifth and sixth year support? MR. PAHL: Yes. I-IRS. FLOOD: And in that case, it was the same status for the telephone network. MR. PAHL: No, that is a different thing than either one of them. MRS. SILSBEE: No. MRS. FLOOD: Fifth and sixth yeari No, tumor registry MRS. SILSBEE: Is fourth and fifth. MRS. FLOOD: Fourth and fifth. Can you tell me if the budget reflects decreasing funding in the sixth year of the tumor registry or if there is full support again in the sixth year? 332 MRS. SILSBEE: I can't. In terms of the way in which they put this money in, in one lump, we don't know what the costs for the fifth year would be, but they put it to- gether as a total. I-IRS. MORGAN: Except for Texas, I didn't know we supported tumor registries for six years. DR. WA,',fiMOCK: This is $200,000 here for a rather broad area and I'd like to address myself to the importance of a tumor registry, because this has been a project that has been promoted by the American College of Surgeons since almost the day of its inception. It is called the clinic act v ties record and it is the only way that you can have any control over survival, not only survival, but quality of survival, because, actually, what we are talking about is erad cation, paliation, et cetera and so on and if you do not have any kind of mechanism where you can look back and see what you have taken inventory [of], then you do not know whether you are making any progress, so everything goes for naught and the average individual doing any kind of clinical work says, I have got a case of carcinoma of the colon, it is cured. But, hell, if he looks at 100 cases he finds out that 95 of them are dead and they died all on the surgical table or something like that. So this does have -- this is a nitty-gritty proposition and some people do say that the tumor registry is not worth the salt that -- 59 333 MS. SILSBEE: This is an issue, Dr. Wammock, that the council has dealt with. DR. WAMDIOCK: Well, I realize that. MS. SILSBEE: And in general, they feel that it has been the experience that once you pick up the support of cancer registry, you have got it -- they go around seeking one grant program after another, so council has been discouraging -- DR. WAIUIOCK: I recognize that and I just wanted to name that particular area there. I would not question the councils position. MS. SILSBEE: Dr. Janeway. DR. JANEWAY: Isn't in general this "- I could ask our administrator -- roimbursible per dium cost, the,. patient care thing would be a medical record, includible in the administrative costs of running a hospital. DR. WP14MOCK: That has been ebate . DR. JANEWAY: Well, it has been accepted in North Carolina. DR. WAIU@OCK: I'd say some people here are considering it. I mean, I'll rephrase my statement. MS. SILSBEE: If I could make a statement about the way in which the committee arrived at the recommendations which, in looking it over, they did arrive at this differently than they did most of the actions. 6 0 334 Instead of looking at the request and deducting those items that they really were concerned about, they looked at the current levels and deducted so, in a sense, I think the recommendation did need to be looked at again. We have a motion -- MRS. MARS: May I, before we -- I just wanted to tell then a little bit about this network, I'll only take a second, as to what its activities were, just to give you an idea that it is far more than just a lecture network. There were., however,, 187 one-hour lectures on 14 scheduled series. The total attendance was 16.,743 people and an -- there were two new lecture series were developed in medical librarian8hip and food service. There were 600 previous network presentations that were reviewed. There were special lectures offered in anatomy and physiology, emergency medical technicians certification, interpersonal relations, secretaries, alcohol problems, third-party payments. They provided audiovisual support at 33 teaching days and conferences throughout the region. MRS. SILSBEE: Mrs. Mars, I -- MRS. MARS: So these were things that it did do, which you can see, it is far more than just a lecture series. MRS. SILSBEE: The motion has been made and econded that this application be approved at the level of 1.,4oo,ooo. 61 335 MR. HIROTO: May I ask a question before the question? MRS. SILSBEE: Yes. HIROTO: What is to ensure that this $1100,,OOO in addition would be used for the purposes you feel are so important? MRS. MARS: Waii,,it isn't for that. It is simply this is their annualized money. They used this money. I can't say as to whther they are going to put it -- where they are going to put it. I,IR4 HIROTO: That was the Prior yearls? MARS: Yes, yes. MRS. MORGAN: Question. [The question was called. for.] MRS. SILSBEE: All in favor of the motion, say aye. [There was@a chorus of ayesil Opposed? [Two voices were raised in opposition@and the m6tior was carried.] Two. The,motion is carried. Now, do you want to take a quick break at this point? [General assent is signified.] Okay'. the next problem area is Maryland and I wonder if you, as chairman 6 2 336 DR. WAMMOCK: Oh. my aching back. MRS. SILSBEE: This won't take long. Mr. Peterson chaired that particular session. Mr. Mank is not here. I wonder if you would just make a brief statement, Mr. Peterson? REPORT OF MR. PETERSON MARYLAND MR. PETERSON: Well, I think anybody who read the transcript, as I am assuming Dr. Wammock did, it was summarized very neatly by the review committee after considerable discussion because, as you see,from your green sheets, they, ir effect recommended phasing out the Maryland RfvlP. They said -- I think I am almost quoting verbatim in the way of summary., this,is a region which has been almost since its inception plagued by an ineffective coordinator, an inactive RAG, a self-serving grantee and we could overlook all those things if they had done anything. ELaughter.] Finally, and I think that whoever has got the verbatim, I am not saying it any stronger than the review committee summarized it -- finally, we don't think this is worth preserving as a building block for whatever comes down the road in the way of health resource planning. I think those were the conclusions they arrived at. Whether those lead to the recommendation is something else again. This was one of two regions which they did recommend 6 3 337 phasing out on the third morning when my group reconvened briefly. I, in effect, opened up Maryland and Nassau, since they had had a night to sleep on it, as well as looking at all the other actions taken and they decided not to reconsider or at least revise their recommendation of the earlier day on Maryland. DR. WA14i@OCK: I'm going to fool you today, very decidedly. This program was not approved by the review committee. Therefore, I concur. It is difficult to under- stand what they Are trying to accomplish. It is not very well organized. Period and that is it. [Laughter.] SPEAKER: Motion. SPEAKER: Make the motion. DR. WAIOIOCK: I move that we sustain the reviewers' comments that it not be approved as a solvent program. SPEAKER: Second. [The motion was made and seconded.] MRS. SILSBEE: Dr. Watkins, you were the secondary reviewer. DR. WATKINS: I concur. MRS. SILSBEE: Now, this is a major step for this council. SPEAKER: Sure is. MRS. SILSBEE: Dr. janeway. 6 4 1 338 DR. JAITEWAY: Just one question. We are not dealing with a very o-reat number of people at the moment. Is there any provision when something is phased out with regard to the peonle on board so that they Are not cast adrift? MRS. SILSBEE: That will be negotiated by the staff. .,he intent -- DR. JA'.4EItlAY: You know, because there is some kind of personal element in this and we have to think about it. , 'T i,iR. PETERSON: It was made explicit, although no figure was arrived at that while they recommended pahse-out and there was a zero figure, it was with the understanding that staff would need to negotiate if the council concurred to see how much money would be required for a timely but orderly phase-out. This involves considerations of how much funds do they have on hand that would remain unexpended as of June 30 and other considerations so while it shows as zero, the intent was not to preclude some negotiated award to permit the phase- out, again, if council should concur. DR. WAMMOCK: They only described one project in here that I could find of any sort, I mean, that was in the -- 'i',IRS. SILSBEE: Well, Dr. Waininock, essentially this is more or less of a continuation application. There were other things. They are coming in with the July thing which has had -- been under development. I have to -- I was not present at the committee review. I have read the transcript 65 339 and I must say, from the standpoint of being responsible for the -- all the regions, that this region has not had the n of staff work -- it was not gone to see whether the regional advisory -- there is a new chairman now. We don't really know, so in a sense, this region is being looked at in terms of the situation as it was a couple of years ago and we don't know whether it has.been changed or not. MR. PAHL: I'll make my comments off the record. MRS. SILSBEE: Qk,ay. MRS. MARS: Well, is there a.ny program there that could be taken over that would be worthwhile to be taken over by, say, Delaware, in order to supervise the phase-out of it, or MRS. SILSBEE: I don't think in this particular situation that would be a very valid way because Greater Delaware Valley doesn't really extend. They have trouble enough with their area as covered. SPEAKER: Question. [The question was called for.] MRS. SILSBEE: The seconded that the Maryland Regional Medical Program be jhased out'. While no dollar amount is recommended., it is Understood in this motion that staff will negotiate to make 3ure that this is done in an orderly, judicious manner. DR. WAI@4MOCK: That would be included ii MRS. MARS: How long will it take to phase it out? 66 340 MR. PAHL: Off the record, please. [Brief off the record.] MRS. SILSBEE: All in favor of the motion. [There was a chorus of ayes.] Opposed. [There is no opposition and the motion is carried unanimously. I The motion is carried. MR. PAHL: Off the record, please. [Brief off the record.] DR. WAMMOCK: -- it would take, really, too long to describe and everything here, I can see nothing that sustains the continuation of that kind of project and I would compliment the staff on doing a very difficult situation [sic] because I recognize that when you phase out something, that is a blow, either above the belt or below the belt or around in general. I don't care what you want to call it. !IRS. MARS: Thank you, Dr. Wammock. MRS. SILSBEE: Nassau-Suffolk is the next program that was a problem. SPEAKER: I wonder if we could have the staff with us on thit? MRS.,SILSBEE: The Nassau-Sutfolk Regional Medical Program originally was part of New York Metro and then it broke off and became the Nassau-Suffolk Program. It had the 67 341 unique organizational pattern of having the executive director serve as both the coordinator of the Regional Medical Program and the director of the CIIP B agency. The staff was under this one man and the advisory councils and so forth were sort of intermeshed. That has been a problem for us. Last year, they divorced. The B agency and the RMP went their separate ways and since the phase-out, the original coordinator, who was the -- kind of the man who developed the B RMP relationship has departed. His deputy was coordinator for, oh, about six months. lie left and we now have the third coordinator in the course of this year. The region has not had its review process verified. There is still a problem with the by-laws for the Regional Advisory Group. The reviewer for Nassau-Suffolk is Mr. ',,,Iillikeri. REPORT OF MR. SEWALL 0. MILLIKEN NASSAU-SUFFOLK .a. MILLIKEIT: Well, I concur completely with the committee recommendations. I do have a problem. In looking through the material that was taped., I was trying to find some indication of what appropriate phase-out cost might be. The closest I could come to a figure on that was $240.,OOO but I do not find any documentation@as to detail@s on 6 8 342 that., so I am not sure how reliable that is. MR. PETERSON: I don't think it is necessarily reliable, Sewall. It reflects, I think, some sort of a guesstimate but here again, I think'the clear intent of the review committee was to leave to staff the termination from negotiation with IJassau-Suffolk, if the council should concur, what would be required in the way of additional funds. itain, it is not only determining how much money is needed for a timely, orderly phaseout, but how much money would they have still on hand as of June 30 and I think, again, whether a quarter of a million dollars or $150,000 that is something that would need to'be worked out. The figure was spun off, I believe, in the trans- cript, but I don't think anyone would hold to it because we have not really looked into it until the council takes action and that reflects final action rather than a review committee recommendation. MR. MILLIKEN- Well, based on the same concept Of the one we just deleted, it is My motion that we accept the committee recommendation and terminate this program. [The motion was made.] MRS. SILSBEE: Is there a second? SPEAKER: Second. EThe motion was seconded.] MRS. SILSBEE The motion has been made and 69 343 seconded that i4assau-Suffolk Regional Medical Program be terminated. While no dollars are recommended, it is under- stood that staff will negotiate a figure that will allow for an orderly phase-out. Is there any further discussion? DR. HABER: Yes, I'd like -- MRS. SILSBEE: Dr. Haber. DR. HABER: Will someone give me a reply to the question, if the RI"IP has not complied with the RAG grantee policy, in what respect has it not complied? MRS. SILSBEE: Dr. Haber, the board of the grantee organization has -- it is on the regional advisory group in toto and we have been concerned about the dominance of that board. Now, they have been sending in various changes in this and it is my understanding at the present time that the numbers of the board that are now on the RAG are somewhat fewer. There is a jurisdictional dispute between the grants management branch and the eastern operations branch as to whether they have completely complied. Since that was just one issue in this whole appli- cation, I didn't think that it was a major thing at this point. We have had the motion made and seconded to terminate the program with the full knowledge that money will 344 70 come forth for orderly phase-out. All in favor? [i@here was a chorus of ayes.] Opposed. [There was no opposition and the motion was carried unanimously.] The motion is carried. We do New York Metro next, Dr. Schreiner. REPORT OF DR. GEORGE E. SCHREINER NEW YORK METRO SC INER: Yes, th s s a large -- MRS. SILSBEE: Oh,, let the record show that Dr. Watkins will be out of the room. DR. SCHREINER: I won't say anything until he leaves. There were two reviewers, one who was in on the site visit and one working from the application. I reviewed the transcript and also the grant request here. This was rated by the review committee as average. The projects were given a grade in the 40 percent range. I think this is a situation that is perhaps -- brings to mind something Mr. Rovell said yesterday and that is, we have to be careful not to be prejudiced too much by past performance. New York, as you heard in the speech yesterday, is a very complex place with 10 million people, the medical 345 71 schools, 200 hospitals and there have been a number of conflicting wheels within wheels in terms of internal politics. I think it is a remarkable achievement, actually, that in the past two years or so there has been a semblance of coordination and there has been some rallying around the new grantee and the new director and the RAG has been much more representative, as far as I can see. Taking one program alone, which I happen to know very intimately and that is the transplant situation, there were 12 transplant units working in' the 'City. I think there were, at one point, nine typing labs., three of whom were using totally different semantic systems, @It was a real Tower of Babel and there still is a considerable competition in this area, even the Better Business Bureau got in the act to try to settle things with regard to transplants, I was told time ago by one of the directors. Now, the one that looks like it is going to survive, to me, is the one that is being sponsored by the Regional Medical Program associated with the Blood Bank. Very recently it has come to my attention that there is still another competitor in the field trying to turn the Medicare Social Sbcurity reimbursement into a commercial enterprise so I think it it very important that we not let this little game go down the drain because there are a lot of hawks waiting on the fence waiting to rush in if this is 72 346 not supported. So I think that the committee request is -- I would normally consider I mean the review committee's request for $2.5 million I would normally consider quite a fair and adequate allocation in relationship to the outlining of the projects but the two things that have happened recently, one is, Dr. Koontz arriving from California, who is one of the country's outstanding transplant surgeons, which really mobilized a good core of people around him and a very expanded program. The other is that I suspect that they will probably be asked to Pick up about $96,000 in ongoing stuff from @lassau-Suffolk in the organ donor procurement programs that ties in, that they will be asked to pick up some of this, so I would, unless the staff has some strong objections, I would like to move that we up this to approximately .$2.9 million or even $3 million. I would make A motion for $3 million, for this area and believe that it will be well-spent and some of it will be allocated, it should be emphasized, to try to, strengthen this transplant program, which looks like it is about ready to fly. They did 250 transplants last year in the metro- politan area there so they would do 500 to 1,000 if it were adequately banked. [The motion was made.] 3 347 MRS. SILSBEE: Mr. Milliken. MR. MILLIKEN: I agree, concur. [The motion was seconded.] DR. JANEWAY: Is Koontz [inaudible.] DR. SCHREINER: Yes. hey had done -- just as an example, they had done no transplants -- well, they had done two - transplants in four years before he came and he did 30 the first six months. MR. MILLIKEN: I second the motion for $3 million. MR. PETERSON: I think there are a couple of things that ought to be, perhaps, laid on the table for the benefit of the others. Many of the projects in this request were for two years. Thus the request was a $6 million-plus one but it reflected in large part sort of a two years of activity and I think the review comrnittee's recommendation has to be seen in that light. The second thing was, as Dr. Schreiner, I am sure is aware, and if you have glanced at the transcript -- the review coruiiittee, in making its particular recommendation, in effect said -- and I don't remember the exact words, but that given what had happened in the way or turnaround or the kind of health care jungle that New York City is, that certainly, looking at the July application or the council if additional funds proved to be available, that this was a region that they might well view more generously. I think that -- those are 7 4 348 not the exact words, but that thought was very clear in the review comrqittee's considerations, which included on Bill Thurman who had previously site-visited. the rec,,ion and been quite impressed by the kind of turning around that was occurring in New York. MRS. SILSBEE: The motion has been made and seconded that I,.Jew York Metro application be approved at the $3 million level. Is there further discussion? [There was no discussion.] All in favor. [There was a chorus of ayes.] Opposed. [The motion was carried.] The notion is carried. DR. SCHREINER: Shall I go on to the rest of my MRS. SILSBEE: [i@ods head yes.] REPORT OF DR. GEORGE E. SCHREINER 14EBRASKA DR. SCHREI14ER: Nebraska I only have one specific question to ask of staff. Nebraska was given a 95 percent rating, above average, and there was very little that I found wrong with it. Is it appropriate to ask the staff who were the technical reviewers on the renal -- tIR. POSTA: 14T. Zizlavsky, do you have the names? 75 349 I am sure Dr. Bauer of was one of them, but I don't recall the other two. MR. ZIZLAVSKY: [Inaudible.] MRS. SILSBEE: We can't hear you up at this end. MR. ZIZLAVSKY: All three of the kidney consultants ad hoc technical reviewswere completed from out of state, provided the Nebraska RMP with negative comments. They allowed $10,000 or $15,000 flexibility. MR. POSTA: Dr. Schreiner, consultation from staff here to the coordinator, we had recommended that he contact Dr. Flanigan in Arkansas to get three certified reviewers that had been approved by DRMP in the past. Dr. Bauer was one but I don't recall the other two. DR. SCHREIIJER: Yes. The reason I am not really totally prepared to accept their evaluation because one of these individuals was very vocal and so evangelistic about home dialysis that he never approves anything that involves satellite dialysis anywhere in the country and in this kind of a situation where you have long distances involved between places and no real back-up, I am not really sure that every- body can be put on home dialysis and this was probably the basis for his comments. The -- part of these areas have depen ded on Minnesota for back-up in their satellite dialysis and I sort of iiew this project as a beginning attempt to try to go it on 76 350 their own and get units in various areas that are quite rural and with quite a low population density. Therefore, I am going to move that it be approved in the $950,000 level, putting back some of t he -- the only project they criticized was that particular project and I'm putting back some of them. [The motion was made.] MRS. SILSBEE: The secondary reviewer on Nebraska was Mrs. Klein. MRS. KLEIN: [Inaudible.] MRS. SILSBEE: Could you speak into the microphone, please? MRS. KLEIN: I couldn't find anything that I disagreed with in the dommittee's report and so I would concur. MRS. SILSBEE: Would you second Dr. Schreiner's motion? MRS. KLEIN: Yes. [The motion was seconded.] MRS. SILSBEE: Okay, then., the motion has been made and seconded that Nebraska's RMP application be funded at $950,000. Is there any further discussion? [No discussion.] All in favor. [There was a chorus of ayes.] Opposed. 7 7 351 [The motion was carried unanimously.] The motion is carried. REPORT BY DR. GEORGE E. SCliREI@JER NORTH DAKOTA DR. SCREINER: The next one is North Dakota, which was rated average and below average and given a rate of 75 percent. The projects are interesting. I think that from a critics point of view, one could question some of the priorities which they have established but, nevertheless, they have established them and they are their priorities and they are going to do them, I am sure, well, and I think the people out there have impressed everybody with their general honesty and integrity so I think the committee's recommendation on this -- which was somewhat of a reduction in the requested amount of $77LI -- the committee reduced it to $582 and I redid from the project and came up a couple of thousand,,dollars away on the basis of this report and I think that the committee's recommendation is just about on target here so I would approve the recommendation of the committee. I'Lhe motion was made.] i,IRS. 8!LSBEE: lqrs. Gordon. MRS. GORDON: Second. EThe motion was seconded.] 14pis. Q@ILSBEE: The motion has been made and 7 352 seconded that the '@orth Dakota application be approved at the level of q')582,517. Is there further discussion? [!\To discussion.] All in favor? [There was a chorus of ayes.] Opposed. [The motion was carried unanimously.] The motion is carried. Susquehanna Valley? REPORT BY DR. GEORGE E. SCHREINER SUSQUEHANNA VALLEY DR. SCHREINER: Susquehanna Valley is a real problem, although it wasn't on your problem list. [Laughter.] All of the programs -- the request or the recommendation for $400,000 or suggestions [inaudible owing to side conversation in mikes] -- that I gather -- as I add up the program, the most you could get out of the programs would be $96,000., so we -- the taxpayers are being asked to spend $600,000 in order to administer $96,000 program. I personally think this is immoral. MRS. SILSBEE: Dr. Schreiner, did you see the memorandum that -- DR. SCHREINER: Yes. 79 353 !,IRS. SILSBEE: -- the July application. DR. SCHREINER: It didn't impress me. 14RS. SILSBEE: Well, I didn't expect it to impress you, but I do think, in terms of the way in -- I think the background of this region is, it is a cautious region and the fact that they could very well have just taken off a lot of their projects that they were all ready to o-o with a year ago and sent them in in this application so that you would see more activity per staff -- but they chose to go back through the whole process again and reevaluate them and for that reason we don't see the program part of this region. DR. SCHREINER: Well, everybody knows the RMP has a short prospective life and it seems to me that they are so unrealistic that they don't realize that one of the reasons RMP has been in trouble is the amount of money spent for staff in relationship to programs and to start all over again to build a great big staff without any programs at all, it seems to me that the normal direction would have been to go out and scratch for some low-budget programs. If you,can twist my arm a little bit, I might be willing to give them $200,000 but there is a lot of sentiment on the council. I personally think we,ought to seriously consider discontinuing it. MRS. SILSBEE: Mrs. Flood. MRS. FLOOD: I would like to inquire if historically 80 354 this particular program had utilized staff effort heavily or whether they founded independent outside agencies, institu- tions, et cetera? I-,IRS. SILSBEE: Jerry. MR. SHOLOV: Yes. I believe -- you were asking whether they were using the money for force studies? There is only one force study in the application in front of us for a unified health plan in this application. SPEAKER: He didn't understand. MRS. FLOOD: Well, yes, there are many programs, RMP'S, that use heavy staff to actually carry on programs or projects throughout the state, rather than -- and carry them as core staff functions to provide full projects in the core staff base and I just needed to know if this is their traditional format? Otherwise, I would have to agree with the doctor that this is a heavy investment in staff just to monitor some projects that they hope to, you know, send to us in the July review. MR. SHOLOV: May I just comment that the only investment that they have in the current staffing project is funding a B agency directly and, again, they only asked for $50,000 for one unified planning staff and this application is what you see in front of you. MRS. SILSBEE: But, Mrs. Flood, traditionally, it is a mixture of staff and project activities. The 14 people 355 now on board have just come on board. They had three up until recently. DR. SCHREINER: Yes, the total project, outside of program staff on the yellow sheet only add up to about ,@6,000. The July projects that we know about are such things as the Fulton County Public Health Nursing Service, the Huntington County Home Service, the Center County Home Service, the North '-Oenn Home Health Agency. It sounds to me pretty much like county health-type projects. There is one for consumer health education program and there is a dental program which is $81,000 with the $16,00 in direct costs. It just sounds like an enormous build-up of staff for a very, very thin program and I am not very enthusiastic about it. MRS. SILSBEE: Do you have a motion that you wanted to makes DR. SCHREINER: Well, I'd like to -- I would either move for $200,000 or move for zero and a phase-out and T was trying to see if there was any strong sentiment on the council or staff for phasing out. MRS. SILSBEE: Dr. Wammock. DR. WAMMOCK: I read this several times and I can't solve the problem and I concur in the fact that the budget here for staff was extremely large and that sort of turned me off, I am sorry to say, right then, although I did 82 356 leaf through it. If you want to take into consideration the location of the Susquehanna Valley and what their medical needs are, they are not available to them like they are in some of the other areas. Now, I think that, certainly, some consideration must be given to whether -- what will stimulate them to activity and I would say this would be a token, whatever we do with $200,000 or $300,000 will stimulate them to what they could do for that particular area and perhaps that is what we might do here but, in essence, it is really a poor program and I have one of two choices -- to give them something or just wipe it out. I would be more inclined to show a little bit more compassion by giving them some stimulus Under the circumstances. DR. SCHREINER: In that case, I'll move for $200,000. EThe motion was made.] "MRS. SILSBEE: Is there a second? DR. WAMMOCK: I'll second it. [The motion was seconded.] MRS. SILSBEE: Mr. Stolov. MR. STOLOV: Mrs. Silsbee referred to a memo given to Dr. Schreiner on the reading of the Susquehanna grantee RAG chairman and coordinator we had with us. My only point, did everyone at council hear this? It was brought up in this 3 357 meeting that the commitee's concern was exactly that of councils and that is why they did meet with us. We did discuss this with them and that is in the memo. My only addition to the factual on this is that they do have 14 people on board now and they came on-board as a recruitment by the newly-appointed coordinator and some of these people are already experienced in RMP and the $200,000 recommendation made was for a reduction of staff at this point and that is my only point right now. MRS. SII,SBEE: The motion has been made and seconded that this region be -- its application be funded at $200,000. Is there further discussion? TT,. CHAMBLISS: I would simply, in an effort to make sure that the council is aware that this region has been advised about the level of staffing. I would simply want to reendorsb what Mr. Strolov has said. We have had a very @ecent conference with the leadership of that program and I 3hare with him the view that if the level of funding as is now I)efore us -- is now on the floor -- that level is accepted, I"hat it would probably cut into the existing staff that that @i,egion ha I do Peel that part of this was taken into account 'Y the review committee when it reviewed the application. MRS. IIARS: i Are you saying, Mr. Chambliss, that 84 358 if this is cut to $200,000 that, really, there won't be enough staff left to,stimulate any type of program? IdR. CHAMBLISS: I do, because we did admonish that region early on that they were too low of staff. We have a specific letter in the files saying, build up the staff. That was right after phase-out. And they built it up and I must admit, with you, that they have gone beyond that, but I think what I see the council is considering now may get them back actually to where they were when we advised them early on that they should increase the staff. Now, I do this only -- only so that council may have before it as many facts as we have here on staff'. DR. SCHREINER: Now, I appreciate what you are saying. I think this would be a real concern, for example, if we were looking ahead to three years of project development, but I think you have to ask the question, build up staff for vihat? I mean, there has got to be a program that goes along with that build-up and in this case I can't find the program. MRS. SILSBEE: Well., that is because the program is going to be primarily contained in the July application. Dr. Janeway. DR. SCHREINER: It is not that impressive in the July -- I've seen the July projects and they don't require 14 people, you know, for a county nursing service, a home 85 359 health nursing service to sponsor does not require all that staff monitor strength. MRS. SILSBEE: Dr. Janeway. MR. CHAMBLISS:I am very sorry, and I apologize for interrupting. If I may just further illuminate this council, in a letter we sent to that region, we even suggested that they go out and get former RMP staff members and bring them on to augment the staff and we further suggested that it might be worthwhile to bring on three to four part-time physicians. liow, that was a region that was operated without M.D. staff -- M.D. on staff. So I can report to you that they did go out and employ three part-time physicians as we had recommended and they are now on staff and I believe that what you are now considering may wipe out the staff that they already have on duty. MRS. SILSBEE: Mrs. Flood. MRS. FLOOD: I feel strongly that this particular region has been'victim to what we frequently on a site visit call the "yo-yo effect," and quite markedly. Apparently they took quite seriously their phase-out instructions and then were reticent to tool back up because of what you have described as a conservatism of the region and now are following what they interpret as a directive from DRMP. But if we can have some insight as to what their core personnel budget is today, with the ekIisting staff that they have on board now. 86 36o Can Mr. Stolov shed any light on this? MRS. SILSBEE: I just did a calculation the other day, in terms of even the committee recommendations. It is, in salaries alone, about $189,000 on an annual basis. That doesn'@,t allow anything for projects, rent, telephone, travel for the council the regional advisory group or any of the committees MRS. FLOOD: Then I would have to add my voice to the expressions of concern of Mr. Chambliss and Mr. Stolov now before us, that with a $200,000 funding level, we would, indeed, then, be better off telling them to close up shop because, in essence, we are doing that. We are criticizing them for lack of programs that is broad in scope and has sufficient projects in it and then on the other hand., we will turn around and cause to discharge recently-acquired personnel and the first to go will be the high-priced part-time docs and they will not gain any, you know, impact on developing programs. MRS. SILSBEE: Dr. Hammock. DR. @qAi",!..,IOCK: They have a total of 26 staff and 11 vacancies here that need to be filled. MRS. SILSBEE: The $189 was of the staff that is now on duty. DR. WAMMOCK: Yes. Now, the other thing is this. I read this thing through very carefully and I said that the 87 361 original budget of "@700,000 when the staff is $322,000 was too far and the statement was made, a description of the project that it is'perhaps thIe most outstanding achievement of the SIIFP over the last few years has been its grassroots involvement and that is where it is, it is grassroots level. Apparently they have made some progress in primary care units. They have Drovided a neighborhood health center for some 1,200 blacks -- 12,000 blacks, according to this report in here. Apparently, they have not made an adequate survey of their needs in their particular area and also as related to the total program of the State of Pennsylvania. Their endeavor to develop manpower for the primary health care in and rural areas,/provision of information on existing services in rural areas, consumer education and use of services and et cetera. Their endeavor to increase manpower availability for the Drimary health care in underserved urban areas, accessibility and so on. They put some emphasis on heart disease and nothing that I can see is related to stroke, renal disease or cancer. This program, it seems, is not well-designed. That is the substance of it here. But if you pull it down to $200,000, that will completely iiipe it out, I believe. That is nothing for a group of Deople in that area there. I don't know, 88 362 somewhere I have the population of that area. Here it is here- MR. STOLOV: 2.3 million, 27,000. DR. WAMMOCK: How many? @@PEAKER: 5.23 million. DR. SCHREINER: I think you have made some good points. 1would be inclined to change my motion to $800,000, which I think will give them a warning that their job is not to build staff. I!m.afraid they have been told to build staff and not to build programs and -- or at least they have not heard the admonition to build programs. I think if we do this, they can come back in in July with projects and we can look at them fresh and at least it will be enough to keep the thing alive, so I'll amend my motion and change it to $300,000. [The motion was amended.] MRS. SILSBEE: Will the seconder., Dr. Wammock -- DR. I,,IAMMOCK: I'll second that motion. [The motion was seconded.] DIMS. SILSBEE: The motion has been made and seconded that the Susquehanna Valley RMP be funded at $300,000, that the application be approved at that level. Is there further discussion? MRS. MARS: Could we put an amendment on that that not all the $300,000 be used just for staff, but that programming be included? 89 363 SPEAKER: That won't be necessary. MRS. SILSBEE: I think that will be taken care of in terms of the advice. Is there further discussion? SPEAKER: I call for the question. MRS. SILSBEE: All in favor? EThere was a chorus of ayes.] Opposed. MRS. FLOOD: Tlay. [The motion was carried.] MRS. SILSBEE: One opposed. The motion is carried. Nowl I have an announcement for the staff. There are going to be sandwiches brought in for the council members and if any of the staff wants to get their order in, Mrs. Handle is right over there and it has to be done right away. Do you want to take a -- SEVERAL VOICES: Yes. ELaUghter.] MRS. SILSBEE: All right, ten minutes. [Brief recess.] MRS. SILSBEE: Dr. Haber has two I would like to have discussed before he has to leave. Memphis. 9 364 REPORT OF DR. PAUL A. HABER MEMPHIS DR. HABER: The reason for wanting discussion of Memphis was that I'd like some elaboration of this problem of the escrow funds. In general, I heartily concur with the ad hod cotqmitteel@s recommendations. I think that the project is well-conceived. The staff is vigorous. The domment was made that this @roup did not consider the future bleak and I guess one of the consultants said they seemed to be suffering from unfounded euphoria. @.Jay@e that is another word for failure. ELaughter.1 But I think thatthe individual projects looked very impressive to me and I was pleased with the relations ip with the CAP and with the establishment of their regional advisory group, well-staffed, competent people, highly interested. I will have a couple of words to say about some of the individual projects but one of the disturbing th ngs that came out in the ad hoc committee's review was the disclosure that some $800,000 is being held in escrow in two projects, I believe -- one of $300,000, one of $500,000 for an umbrella trusteeship which is euphemism for something. [Laughtez,.E I don't know what. Would somebody enlighten me on that? DR. WAIli,'IOCK: What's that word you used? 9 365 'DR. HABER: lluh? DR. T;IA14MOCK: What's that word you used, euphemism? DR. HABER: Yes, it's a euphemism something. I don't know. Maybe it's that hole in the mattress they talk about. MR. VAN WINKLE: No, I don' t think so. This is another example of what you discussed yesterday on a couple of projects. It really isn't any different. They have set forth these thrusts that they wanted to carry out. They don't have them -- the individual activities before you at this time. They will have at a later date. They will be coming in with those. If these funds are allowed and the review committee had decided that at that point in time they could look at them. They didn't have sufficient information to consider them and that was the basis for their reduction. DR. HABER: I think that is fair. Let me comment on some of these. There is one project, C008 for analysis hypertension which I think is good. A couple of activities smack of public health concerns. One of them on the trends for registering of vital statistics. That seems to me to be kind of not entirely new and innovative and clearly a function of the public health officer or commission. MR. VAN WINKLE: Is that 13? DR. HABER: Yes. And I would say the same thing is 9 2 366 on 33, improving the quality of the death statistics without, I think, going through the business of this, apparently they said it would be a single individuals project. , On the,o'u-her hand, some of these activities are, I think, very exciting, health services education activities, the 021, the high-risk for infants with the special intensive care unit for the infants. I think that is really great. Some of that stuff gets funded at ll'TCHD but as a planning activity, I think that is grbat., And the post graduate intensive care and the hypertension control I would certainly agree with. One thing that bothers me is that 052 multiphasic screening evaluation -- it seems to me that has been done and redone and reredone and there ought to be some general rules that are known by this time where we don't have to keep plowing that ground over and over again. The project 056 for the neighborhood health counselors, expanding the nursing role I think was good and 057, the Yalobusha Grenada Leflore chronic disease detection center sounds very good to me. So I would move concurrence with the committee's recommendation for funding at that level described by them. [The motion was made.] iilRS. SILSBEE: The motion has been made and seconded that the Memphis RIIP application be approved at 9 3 367 $2,600,000. Is there any further discussion? ["'4o discussion.] All in favor say aye, [There was a chorus of ayes.] Opposed? [There was no opposition and the motion was carried unanimously.] The motion is carried. All right, West Virginia. REPORT BY DR. PAUL A. HABER WEST VIRGINIA DR. HABER: West Virginia was a delight to review because everybody gas universally approving of it. One can only envy them their relative paucity of resources, I suppose because in total darkness, a candle looks awful bright, but apparently this group has been very highly motivated, has worked very well, has brought additional interest and money into the state. There seems to be, as the reviewer, great concurrence of the effort on all levels of the state, the medical school, the governor's office, the local boards, RAG. Out VA director of the VA Hospital Board is a member of the regional advisory group and everybody is very complimentary of them and I do not dissent from that. I would move that they be approved at the present amount of $663,132. 9 4 368 ':,Il@S. SILSBEE: Dr. Janeway. DR. JAITEWAY: I will recommend approval but I would just mention in passing -- thought I'll second the motion -- that the distribution on the program basis between staff cost to program cost is quite similar to the situation that existed in the Susquehanna Valley. But I find nothing wrong with this, I second the motion. [The motion was seconded. MRS. SILSBEE: The motion has been made and seconded that the West Virginia application be approved at the requested level of $663,132. Is there further discussion? DR. WAMMOCK: You are talking about the salary here. The request was for $3,085,000. Has it been recommended? SEVERAL VOICES: @"4o, you're in the wrong state. .1'@IRS. SILSBE17@:@ We are in West Virginia now. Ts there further discussion? Ellio further discussion.] All in favor, say aye. [There was a chorus of ayes.] Opposed? [There was no opposition and the motion was carried unanimously. 95 369 The motion is carried. @,!elll @o back -- pardon? CD MORGAI,'4: We never did get to Texas. MRS. SILSBEE: Okay, we'll go back to our problem areas. Or at least, we'll relook at the committee recommendations and let the record show that Mrs. Flood is out of the room for the Texas application. Mrs. Morgan. REPORT OF MR. l@ICHAEL POSTA TEXAS MRS. D,'IORGAN: Mike is going to give it. MRS. SILSBEE: Mike, do you want to give an introduction to Texas? MR. POSTA: Well, I have a real long one here, but I'll try to keep it short. Let me just proceed as quickly as possible. Texas did submit a unique request of $2,333,551 but the real problem, as the reviewer saw it, was that approximately $1.4 million of the request calls for a series of open-ended contracts which would concentrate in the implementation of five programmatic areas, RFP'S, and that is, request for proposals for future contracts were submitted to the various consumer provider organizations throughout the state. On the day of the ad hoc panel review, those 370 reviewers were notified by telegram that 62 applications responded to -- responding to those RFP's had been received by the Texas Regional Medical Program. The total amount of the responses totaled $6.2 million. In the same telegram to the regional advisory group, they requested the review committee to approve the Texas program in the sum of approximately $1.4 for the implementation of the contracts to be reviewed by the June 28th regional advisory group. Considerable debate took place during the ad hoc group and they decided that they, in all due conscience, could not approve open-ended application of this sort without seeing the specific 15's and 16's on each. Now, we have been notified just this morning in two of the programmatic areas that the RAG has been meeting this week and, for instance in the area of the manpower thrust, 18 contracts had been received. The consultant RAG members and staff have selected eight of those, of which five to six will be funded and they range in the neighborhood of close to $Iioo,ooo. The access committee, which was another programmatic thrust, received 14 contracts and it had selected seven and together those seven people about $520,000. I think that the question before the council as recommended by the review committee is to allow the review 9 7 371 committee that meets on July 17th and 18th to take a look specifically at the contracts and the forms sent in with bud,-ets so that they, in turn could approve them in order for the contracts to start as quickly as possible. If you did not approve that, this counc 1, meeting in August, would have to approve them and it would probably be September at least before these contracts could be initiated. Their track record in the past, through evaluation, is that the longer the contract has been funded, the better the staff is in carrying out the particular program. MRS. SILSBEE: ,Cars. Morgan. MRS. DiORGA14-. I site-visited Texas on, oh, 18 monthly ago, something like that. At that time, Dr. McCall was the coordinator. Very ambitious, exciting person to know, really. Dave Ferguson, who is now the present coordinator, was his deputy and had been his deputy for some time. Texas has many problems. In the first place, it is a huge area. In:the phase-but, it closed down many of its subregional areas. As a matter of fact, Maria Flood was the subregional director of the El Paso area. In doing this, I think they centralized their area into Austin, which makes it just about impossible to cover the entire state from Austin, right now. They have had many problems since RMP started in Texas. It started in the Houston area, where it was 98 372 concentrated with about seven., eight medical schools right in that area and I believe now Texas has something like 10 medical schools to work with. There has been a problem with the RAG. In act, they aid not have minorities on it, et cetera. They have attempted to correct this all along. It has been questionable as to how much went into their attempt to correct it, but they have tried. I believe at the present time the RAG is very active. Dr. Eastram is still the RAG chairman. He is enthusiastic about the RMP and does do a fine job. I believe, in fact, that they have.not the minorities we'd like on it and whatnot, is immaterial at the present time with only a year to work on it. They could put all the minorities on it in the world and it is not doing to change the fact that they have only got A year to work on it. The biggest problem I see is in their request for proposals and all their work in Texas is really done by contracts. We do have a record here. The current status is, well they received 111 contract proposals, I bIelieve, according to this, which means they have got plenty of people who are willing to do it Under contract proposal. The whole thing is, we do not have their proposal. I recommend that cominittee's recommendation of $1,100,000 be approved at this time with the idea that these 99 373 contracts can be approved at the review cycle and let at that time,,prior to the August council. MRS. SILSBEE: l@iould you like to reword that in terms of the maximum that you would approve and then the balance of the pending review committee approval? MRS. MORGAN: And then $1.3 million for the sake of argument could be approved if all of these contracts are approved at the present time. It is $1,298,599 were what they were asking for contracts and there would not be -- there was not if we had approved the $2,333,551, there would not have been an application in July for any more funding at all. MRS. SILSBEE: So, is your motion approved at the $2,33,551 level with delegating to the review committee the approval of $1.,298,599 for contracts once the specifics are available? MRS. MORGAN: Right. They are 15's and 16's. [The motion was made.] MRS. SILSBEE: Dr. Schreiner was the secondary reviewer here. Does anyone on the -- this motion has been made. Is there a second? ">PEAKER: Second. MRS. SILSBEE: Any discussion? Mrs. Martinez. 'I.LRS. MARTI14EZ: Yes. I'd like to suggest that no matter how short the year is and no matter what the level of funding is, that we make a successful effort to [inaudible] RAG 10 0 374 because, especially in Texas, I don't think there is any excuse for that. "Q-PEAKER: Say that again? DR. TANEW.AY: I don't want to be obstreperous, but I think that that motion subverts the intent of the review committee. Their major complaint was that it was open-ended. Now, it seems to me that one either gives the authority to the RP,IP to grant these without further review or if grants at the level that is recommended by the review committee and forces them to bring a flushed-out plan in contract proposals to the council for review committee consideration and then cancels consideration in August and does it in two steps, or that you just say, okay, regardless of what the review committee said, we know you are a good outfit, even though it rated average to below average and we said, go ahead and we'll review them after the fact, after you have already obligated the funds.. .,,@ow, maybe there is a technical way to do it or an administrative way to do it, and if so, I'd like to be enlightened. POSTA: I-ly only retort. I don't think I'll zero in specifically on your comment, is that the review committee considered this region to be a good one, triennial status, developmental component in the past, good, capable staff. The grantee was changed in December, 1972 to a private, nonprofit organization and the regional advisory group at that 101 375 time advised the regional staff to pursue the contract route and that is what they have done for the last year and a half and the whole purpose, I think, here is to get these contracts going as soon as possible. I don't think the review committee had any intentions to usurp the council that meets again and I am not, again, saying that I am specifically answering your concern. I would say this and I might be out of order and the chair can rule me out. I do think that several other applications that you have reviewed today did have, in exxence, openended contracts but they were not in -- not nearly the size of this Texas application and that is why the reviewers put their foot down and said no on this particular issue. MRS. SILSBEE: Dr. Janeway, it seems to me that Mrs. Morgan's motion doesn't take away the review committee's responsibilities, in essence. it would be approval at the requested level with that $1,298,000 conditional -- not to be released until the review committee looked at the 15's and 16's that made up that balance, specific information. DR. JANEWAY: Well, 'if that is the intent of the motion, I less unhappy with it MR. P40STA: Well, lot me say my understanding @@DR. JANEWAY- I wasntt worried about anybody usurping the council.' I'm worried about the council going in 102 376 there and saying to a review committee, we are going to fund them 100 percent anyway and you have got to look at it -- MRS. MORGAN: No, no -- if MR. PAHL: I think that/the motion, perhaps, was made in such a way that the council recommended $2,333,551 with the delegation of authority to the review committee to exercise its discretion within that ceiling funding level following the receipt of information, I think this would accomplish what you want and save the Texas program a few weeks time, if you feel you wish to delegate that authority to them within that funding level. !,IRS. SILSBEE: Mr. Peterson. MR. PETERSON: Am I reading something wrong, or is it perhaps misphrased, I thought, from looking at the green sheet several times, the figure 1298 has been evoked. That is additional money they would be coming in for is it not? MRS. MORGAN: No. sir, it is not. MRS. SILSBEE: Texas had opted to come in with one application in this time and that $1 million represents the difference between the 1.1 and the requested amount. MR. PETERSON: I see. MRS. SILSBEE: 01-lay, let me restate the motion now 50 we know what we are talking about. The council moves to approve the Texas application up to the amount of $2,333,551 delegating to the committee the 10 3 377 approval of the balance for the contracts with 15's to 16's to come in in July. Is that clear? Is there further discussion? MRS. MORGAN: Just a note. There is a letter from Dave Ferguson that they will have all their 15's and 16's available July 10th. MRS. SILSBEE: Further discussion? [No further discussion.] All in favor. [There was a chorus of ayes.] Opposed. [There are three nays.] MRS. SILSBEE: Maybe we had better raise hands. All in favor. [,There is a show of hands.] Opposed. [There is a small show of hands. The motion is carried-] Three opposed. The ayes have it. The motion is carried. !low, Wisconsin is next. Mr. Van Winkle, did you lwant to give a brief overview here? MR. VAN !,,III-@XLE: Very brief. 10 4 378 REPORT OF !,!R. VAN WINKLE wiscoilisill@, ,,IR. VAN 'I"LE: The reviewers felt that this region had had a very illustrious past history but they certainly felt that they are in a crisis of leadership at the present time. Their current coordinator was the-- was previously the evaluator on this program. The reviewers found little evidence that the RAG had accomplished much during the past year, although their past performance has been quite good. Their CHP relationships, as in the past, are still good. Their overall objectives and priorities are extremely vague. Both staff and committee felt that this proposal was a series of poorly conceived, fragmented project activities. some very researchy in nature, others, such as the major push in mental health, not in keeping with the usual DRMP goals. Or, I would say, with Wiscbnsin's goals and we weren't too sure that this was appropriate for funding and except for the evidence of past performance, there is little evaluation of what is currently going on in the region. In looking at the large variety of new activities that they came in with, if you have the application, you Will note that they are basically centered around the University of Wiscon sin and Marquette -University. They don't seem to get outsi(le;iof Madison and Milwaukee and they just seem to be 105 379 pulled together, put in a book and sent forward. MRS. SILSBEE: Mr. Ifiroto. IT@i. HIROTO: It is apparent that this RMPS is having difficulty realigning themselves with their new leadership and the RAG is somewhat weak in creating the leadership necessary to create the proper point of view and attitude for it. It seems to me that the committee's recommendation is really a stab at a number hopefully coming up with something that is reasonable for what has been going on and to provide them with that support and, hopefully, that they will be able to come up with a clearer program in the next cycle. I just got that out of a conversation. MRS. SILSBEE: Reading transcripts? MR. HIROTO: Yes. MRS. SILSBEE: Mr. Milliken, did you have any comments about Wisconsin? MR. MILLIKEN: Only that I agree with the committee recommendation. MRS. SILSBEE: Is there a motion? MR. HIROTO: I move that the recommendation of $2 million be accepted by the council. ,MR. MILLIKEN: Second. [The motion was made and seconded.] MRS. SILSBEE: The motion has been made and lo6 38o seconded that the Wisconsin RMP application be funded at the $2 million level. Is there further discussion? [!lo discussion.] All in favor? [There was a chorus of ayes.] Opposed? [There was no opposition and the motion was carried unanimously.] DR. JAIJEI,@IAY: Madame Chairperson, could I ask a question off the record? MRS. SILSBEE: Yes. [Brief off the record.] MRS. SILSBEE: All right, we have got Dr. Janeway all cleared up now. There is one region that was site-visited and I wondered if Maria Elena, if you didn't feel you wanted to hold as many of the committee here to hear your recommendation? MRS. FLOOD: If it would be feasible. MRS. SILSBEE: So I didn't have it listed in this memorandum, but because there was a site visit, it was obvious they did have concerns and the site visit was on Monday And Tuesday and Dr. William Thurman, Dr. James Musser and Mrs. Maria Elena Flood were the site visitors, along with Mr. Stolov and Mr. Nash. Now., we have copies of the hastily-prepared site 107 381 visit report and Mesi Leventhal will distribute them to the council. REPORT OF MRS. MARIA ELENA FLOOD TRI-STATE MRS. FLOOD: Yes, I think it would be of help to the members of the council to have copies of the site visit ,report. I might comment that the committee has some problem@, with this application, as you can see by the recommended funding level that they suggested to us and their concerns were deep-seated enough that not only were th ey concerned about the funding level, but they were concerned that there was perhaps inability to truly interpret what Tri-State was attempting to address in their applications and, therefore, there was a reservation made for a site visit if it could be launched prior to council meeting. With that relative short notice to both putting together a site visit team and the burden it placed on staff and also, I suppose, the burden that it probably placed on Tri-State, this visit was undertaken on Monday and Tuesday of this week. As Mrs. Sislbee pointed out, the visit team was chaired by Dr. ',,Tilliam Thurman and Dr. Mark J. Musser and myself comprised the other two members. We were also accompanied by Mr. Nash and Mr. Stolov and a representative 10 8 382 from the regional office in Boston, Daniel DeMates. There was outstandin- attentance at the session of the site visit and listed on the site visit report you will see the people that appeared. In the report, I would like to cover the Tri-State region in a two-part approach and I might make a note that there is no Crew Hampshire component, either in our review nor in the present application before us for consideration. The I,,Iew Hampshire component, along with other applications for project proposals, will be submitted for the next review cycle. The Rhode Island segment of the site visit was primarily to evaluate two very expensive projects and both of these caused concern at committee level and not all questions were answered by the documents before them so we addressed ourselves primarily to these two high-cost projects. One is called the RIIISEC and that is a term given to the Rhode Island Health Science Education Center and this is [inaudible] type of a project. @he request in the programs proposal is for funding to include monies for Fiscal '76 and this raised some flak. There had been intention also that there was a large amount of unexpended funds available to this particular project at the close of Fiscal '74 but upon request, we obtained information regarding their present unexpended funds 10 9 383 for RIHSEC project and where information had reached the RMP that there might be in the neighborhood of $300,000 available to RIliSEC unexpended at the completion of the second year of their funding "- they were originally funded, I might point out, for close to $600.,000, $598,000 -- we have received reports, documented, that they only have an unexpended balance of $14,953. Now, we try to ascertain why there seems to be this large a discrepancy and we feel strongly that it was a lack of reporting mechanism from RIHSEC to Tri-State and the information received at DRMP was from the TPi-State Regional Office and there had been some recent encounters, as our site visit report says, from questionably effective -- or I think I could use the word, mediocre -- studies in the last 90 days and they were $39,000 to the Rhode Island Health Services Research, Incorporated and $9,000 to the Rhode Island Medical Association for a component part of the consumer education program. DR. 1,@IAMMOCK: Huh? MRS. FLOOD: Yes, sir. The area health education activity in Rhode Island had entered into a contract with the Rhode Island Medical Society in the amount of $9,000. DR. WAMMOCK: For what? MRS. FLOOD: For a continuing education segment. DR. WAMMOCK: [Inaudible.] 110 384 MRS. li7LOOD: I might say that one of the problems with the RIHSEC development had, in the leadership of RIHSEC, there was, at its head, a particular person who., because also of what we term the "yo-yo effect" of stability of funding, had been ineffective in gaining the stability for TiIIIS@z'C's development that had been expected of him. Frankly, little was done in the first two years of this operation and the responsibility rested with the board of directors of RIHSEC and they still had not fully addressed this. Rather that discharge a weak director when they became aware that they were way behind, sponsors of this particular project, they relegated him to a secondary role and he is still on board. The on-site visit report and, hopefully, the advice letter to them will recommend that some remedial action be taken very quickly. The decision to replace the director of RIHSEC was made in @lovember of '73 and only in May of' '74 did they find a replacement for him but they did, as I say, keep him on in a secondary role. The new director of RIIISEC is a very capable individual with knowledgeability of both regional medical program activities and the concepts of an area health education center. He seems to have rapport With theleadership in the State of Rhode Isldnd. lie is recognized and respected n all of the dif ferent associated with the hospital 385 association. We had representation of the medical association. All of@them hang all their hopes on the indivi- dual, Robert Laughton, who is not an unknown name to the RFPA or RMPA had been at one time the deputy coordinator of Tri-State In the very short time that he has been there, it is evident that he does not intend to reflect the same pattern of inactivity of the RIHSEC project as had been the history for the past 21 months before his arrival. Now, the site visitors had to take this Tri-State visit in two segments and to address myself to the RII-ISEC segment of their proposal, the visitors felt that they should be approved for the continuation funding of RIHSEC for Fiscal '75 at their previously agreed-upon budget level, but approved at a level of only -- let's see -- $100,000. Is that correct, Mr. Stolov? l,4R. STOLOV: Yes, $100,000. MRS. FLOOD: For the fourth year Of funding for RIHSEC, Fiscal '76. This would force the RIliSEC Board of Trustees to face the realisms that they must become a self- supporting entity and that the participating institutions and agencies would also support the same positions. We did also state that we would require that the progress report of the PLIHSEC activities be submitted at the end of the six months? period -- December 30th of '74. There seems to be a great deal of hope in Rhode 112 386 Island that with the new leadership, that this project will indeed reach the goal that it had been charged to reach. Therefore, we were in support of its continuation funding but with the limitation for the fourth year. Now, the next project for Rhode Island's segment of Tri-State was a rather interesting one and I think I used the word yesterday -- and there is no way to express it except to call it blatantly political. This project was based -- and the project pro- poser PAHL- Maria Elena, perhaps before you go on, we have been handed a table, a budget table on RII-ISEC and so forth and it has a question and if you would just make that a part of your presentation'? 14RS. FLOOD: All right. Is the form that I have the same one that you received? MR. PAHL: Oh, I guess we were just given our copy of what has been handed to you. "IRS. FLOOD: Well, they gave us a print-out of this Rhode Island and then we found a mathematical error. ELaughter.] !',IRS. FLOOD: In addition. So, apparently, then, he mailed the corrected copies in to the RMP. MR. PAHL: Okay, thank you. MR. FLOOD: Now, if I may go on to the next one, 387 the title of this particular project is called, "Planning for Health Services in a Time of Economic Transition" and the applicant is the Governor of Rhode Island, the Honorable Phillip Noel. Now, this was a relatively interesting approach and we pressed very hard for the rationale behind having this project based in the Governor's office and there are some particularly interesting aspects to Rhode Island at this time with the closing of the naval facilities at Quonset Point and Newport -- I think. There has been a tremendous economic impact on the community. The application is actually a little behind times in its request because it proposes to do an analysis of what impact these shut-downs will have on the health delivery system in one segment, and that is after the fact because those particular facilities have closed down and the impact is already there. But the second segment of the proposal was to address the impact that the Governor's drive and his whole Bureau of Economic Development, or whatever you want to call it, has undertaken to bring new industry into the Quonset area and develop the entire area into an industrial complex and anticipating already having gotten some obligations from some industry and also major insurance companies to move its major offices there, they will have, an impact, they estimate, 114 388 of about 50,000 employment -- or rather, families coming in from the employment, 50,000 persons as the result of the families employed in these two new attracted industries to this area. This does, indeed, present some problems for the health care delivery system of Rhode Island. We question severely that the planning for this project proposal in Rhode Island had been done by the Governor for the people of Rhode Island and not with the people of Rhode Island and there shows obvious lack of understanding by representatives from the Governor's office as to the realisms of the health delivery system, the capability of the health professional associations and societies to participate in meaningful planning endeavor of this type and analysis of the needs. The Tri"State RMP has been urged to carefully monitor this particular project to assure that these component parts are included in the Governor's office. It gave a feeling that the Governor was really just trying to develop a staff capability in his office for future economic planning and analysis and using health care as one of the keys for it. Ilonetheless, we again approved the concept of funding this at the discretionary level that the Tri-State RMP placed on the application and I might point out that even though it is at a $250,000 price tag at this time, the 115 389 the original application to Tri-State was $472,000 and the Rhode Island RAG -- they have sub-RAGs for each state -- cut the project funding to that level. There is a desperate need in Rhode Island for this type of activity. The question arose as to why hasn't a comprehensive health planning agency perhaps addressed this long ago were easily answered by a totally ineffective comprehensive health planning agency. There is only the A agency for this state. There are no B agencies either seated in the state health department and the Governor's proposal showed a stark lack of knowledge as to available data and statistical information. The state health department, indeed, has exdellent information and could be utilized if their original proposal was going to generate all of this information. They wanted to do impacts on heart disease because of the stress and strain and ulcers of having no jobs or being insecure about one's job which, of course, there was some information already and by staff of DPJIP here -- Mr. Stolov and Mr. Nash's able assistance in garnering documentations and I believe Mr. Stolov contacted in the short time from committee to site visit something like 17 different departments and agencies to gather data and information that could have been utilized for the preliminary stages of such an analysis. He got stuff from the Navy Department, Department of Labor, of many, 116 390 many segments of HRA and this bibliography was provided to Mr. Kevin McKenna, a very angry young man who is an admin- istrative assistant to the Governor in charge of this particular proposal. Still, there was a rallying of support for the need of this by the community leadership of Rhode Island and the Rhode Island Regional Advisory Group had given this project its approval at the reduced funding level and vie will [be] in concurrence to continue the funds and potential for this project.- !low, if there are no questions about the Rhode Island segment I will transfer to the -- DR. WAIIMOCK, Now, this is the Governor's idea, is that right, because of the phasing out of a project there,, of closing Up and bringing in new industry and he thinks they are going to have some 50,000 people and he doesn't know what they are going to do as far as their pulse and respiration are concerned? [Laughter.] MRS. FLOOD: That is correct, Dr. Wammock. Let me explain that Rhode Island has a specifically interesting problem in that its entire economy, practilly, was based on the services ancillary to and the employment potential of the naval bases and they are gone. DR. jANEWAY: It sounds like it is based on 117 391 FJIP, now. SPEAKER: That's right. FLOOD: They are now gone and besides being gone and their effect on small business on the island of Newport, they have had a close-down of 93 small businesses in the past six months. Also, these people that were employed, Civil Service employment, have not found positions and we have a large segment of retired naval personnel in that part of the country that utilized the naval health resources and now do not have easy accessibility to the health care and are relying now on their champus coverage into the private sector. TiR. CHAI@IBLISS: I would raise the question, and I think it is rather fundamental. I have looked over this project and I really would like to ask you, would this not, in fact, an economic development type of activity as opposed to a health activity. I throw that out simply to get more discussion from council so that we can be fully aware of your views regarding this problem. IvM. HIROTO: I might refer the Governor to the Chamber of Commerce. DR. WIUIMOCK: I think it is unfortunate to drag the Governor into the situation because we had this situation yesterday afternoon with another project which was continued upon approval of this by the Governor for ethical funds and 118 392 we debated this for an hour yesterday afternoon and here we Come along with another state with the governor involved in this and this looks like it is an economic problem and not originating in the regional medical program. The Tri-State situation here., you've got -- what is it, three states involved.in here? MRS. FLOOD: Yes, sir. DR. WAMMOCK: We had headaches yesterday with problems. We have got some more this afternoon coming up and it is difficult for me -- and guess I got a single trolley- car line or whatever it is, to absorb all of these things that are put into this and it disturbs me very greatly that when you come to a Tri-l@itate or a multi-state pror-ram involved CD and so on, and yet you have the Governor coming in here -- MR. HIROTO: From one of the three. DR. WAMMOCK: Ifuh? MR. HIROTO: From one of the three states. DR. WAMMOCK: From one of the three states and it makes it difficult to sort it out. If we were dealing with it state by state, it would be simpler to do, Madame Chairman. MRS. SILSBEE: Well, it is a Tri-State IU@IP and in terms of the charges that the committee made to site visitors, you went and got the information and you are coming up with your recommendations and it is up to the council to either 119 393 accept or reject or modify the recommendations. MRS. FLOOD: Do you want to go on to the next state? DR. HABER: I would just like to attest to the economic deprivation and its effect on health care in that part of the country. We operate a small outpatient clinic there and have often wondered whether it should be continued or not and felt, after visiting it, that there was "- that to remove this small clinic would have been symbolic of a disinterest on the part of the Federal Government and in the health care activities. Itlis certainly theoretically possible to divorce that from any other consideration, yet one must remember that this area has been a depressed area and it has been becoming more so. Prior to the loss of the naval operations there had been continued loss in manufacturing industries in that part of the country in @Tew England, Rhode Island particularly, and I think that the people there are very, very sensitive to the removal of any operations. So I would endorse what Mrs. Flood is saying. MRS. FLOOD: Before T go on to Massachusetts, I might add one point that your comment that this is really an economic development proposal might be valid in one comment but the true point of the medical assistance program to try to assist in accessibility and availability of health care does play an important part -- did play an important part in 12 0 394 our considerations and definitely this analysis is needed there. Under whose aegis, council may reach a decision on later, but they have no valid information put together in a coherent manner at this time to address an availability and accessibility problem that they will be facing the major impact of in the very next few months. 14ow, if I may go on to-Mas.sachusetts, we have also two component parts of the Massachusetts segment that presented some problems., One was a proposal offered by the Institute for Governmental Services of the University of Massachusetts. Again, at preliminary review by review committee, it also appeared to be a politically-oriehte d type of a proposal but as we saw one of the most refreshing sights that I have observed in site visits or in deliberations of projects proposed., seated around a table, a warm fellowship -- that is the best I can describe it -- of CIIP's out of the Govern6r'8 office human development resources is where the CHP is seated there -- the University of Massachusetts'. Brown University -- no, not Brown -- SPEAKER: Harvard. MRS. FLOOD: Harvard School of Medicine and the other one -- it begins with B -- SPEAKER: Boston University. MRS. FLOOD: Oh, Boston University. I knew it was 12 1 395 a B -- Boston University -- working in close liason in responSE to a desperate need for the utilization of tremendous resources available in academia in that state to make legislation addressing health care institutes relevant to the realistic needs of that state. It was a fascinating process to watch. I personally, and other members of the site visit I think would concur we'll have to give the entire credit to this blending of the different phases of that state, the political, private education, public education and physician community to the coordinators, Bob Murphy is responsible for stimulating this first agreement to agree to the political entities utilizing the private education system, harvard School of Medidine's research center fbr@Infbrmationitied with Boston University's Reticular Institute with the University of Massachusetts' blending of skills to provide the necessary information for a judgment reaching on long- range planning by comprehensive health planning and the legislators' needs to understand the health care needs in order to develop responsive legislation. We were very impressed by this project and we urge that it be considered not to be withheld in their total fundin-. DR. HABER: I would just like to Add a comment to that because if Mrs. Flood's observations areltrue, they are 12 2 396 all the more remarkable because several of those institutions have just completed a very blood internecirie battle, the net result of which, two of those medical schools were uncere- moniously kicked out of the Boston City Hospital group and they had a cannibalistic orgy and if they can be said to have cooperated in this endeavor, I would think anything we can do in the way of pouring on some healing balm we ought to do. MRS. FLOOD: I'd like to comment, one added aspect that I think means that the pressure here -- @as review committee looked at this application and saw it coming from a state university, an institute for governmental services, they thought, here we go, another rip-ofP and but when we got there and saw that, in essence, this application was solicited by the regional medical program,,Tri-State, of this agency to be the seat of this unifying endeavor, it changed the entire complexity of the situation. MRS. SILSBEE.- Dr. Janeway. DR. JAIJEWAY: It is my recollection, Mrs. Flood, that at the time of the planning for the new medical school in Wordester that the Governor had an office of health policy. Is that a -- do I mi8recollebt about the Mass government? He had considerable help from the MIT-Sloane School of Management and the MIT-Harvard program at that time as far as their legislative liason and date of production. 12 3 397 Perhaps I am incorrect on that, but I -- MRS. FLOOD: That was not brought to light during the site visit. MR. STOLOV: It might just have been formed at the request of the Governor for that particular formation of the medical school. The best we can determine from the health resources agency which was there was the agency was given this responsibility but he did have strong legislative both the Senator in charge of the health committee and the Housels representative person [inaudible.] So I felt that there was a need and we could check this out but to my knowledge, it didnot surface at the meeting. DR. JANEWAY: I present that as a recollection, as best as I can recall at this point in time. MRS. FLOOD: The recommendation for this project was unqualified approval, although, in executive session, the site visit team did call attention to what we felt might be an excessive budget to the coordinator of Tri-State RMP and this budget was in the process of negotiation and could be markedly altered. Now, there was concern .in review committee that the programmatic concerns of Tri-State might not have been addressed and that their review process might be lacking. This, we did not find. We found careful description of their 12 4 398 goals and objectives and an adequate review process and, certainly, broad participation in the review and in fact, we found strong review by the Rhode Island components as they chopped back at the governor's project, for example, and then it got strong,review processing at Tri-State. MR. IIIROTO: I noticed a discrepancy between your committee's or your site visit of $1,676-some-odd-thousand as opposed to the committee recommendation of $800,000. Was that recommended primarily by the governors program and the rehash, or whatever it is called? MRS. FLOOD: Primarily, it falls into those categories, that's correct. Well., actually, it is three and I am going to cover a one-fourth segment here. MRS. SILSBEE: I wonder if we could hold for a minute? She has to change a tape. [Brief off the record.] MRS. FLOOD: I might respond, on record, if you wish, to Mr. Hiroto's question. The regional request for $1,886,000 in essence, resulted by our reviewing only a cut back of $100,000 for the phase out of monitoring and $100,000 on the bureau funding for the RIHSEC. T.@low, the last component that has raised some concern at review committee was an item that we have already discussed at council and that is the idea of having a contract let for continuation monitoring of ongoing projects beyond 125 399 Fiscal '75 and since the policies have been clarified that this is indeed appropriate, the Tri-State RMP had proposed a request of $275,000 to have a contract given to the Harvard Medical School to monitor the operating projects of Fiscal '76. Our recommendation was that it should be approved., if legal, which is now unnecessary, but for a budget of approximately $100,000. MRS. SILSBEE: Could you clarify? Did the RIHSEC approve it for the two years? MRS. FLOOD: Yes, but with a lesser funding level than they requested for the continuation beyond the regional support, a marked reduction. MRS. SILSBEE: Mr. Iliroto. MR. HIROTO: Yes, I have one other question, indication for the July/AUgust review listed it as $800,000, and you indicated an increase to $1@800,000.@ MRS. FLOOD: Yes, I might offer some explanation. When we reached Tri-State, it was our understanding that the application for the next review cycle would be in the vicinity of $800,000. Mr. Murphy, the coordinator, informed us on our last day of visit, that there are projects flooding in that have merit and are in the review process and that at this point in time, it looked as if they may come in for $1.8 in the next cycle, MR. STOLOV: Mr. Iliroto, there was also $3 million 12 6 400 worth of grants processed -- FLOOD: Thatts right. MR. STOLOV: -- by Tri-State for this next cycle that is coming up. !IRS. FLOOD: They have over $3 million in requests. MRS. SILSBEE: Dr. Janeway. DR. JANEWAY: May I ask you one question? Was Dr. Weiss at Harvard enthusiastic and supportive and is he going to be actively involved in this health policy? MRS. FLOOD: He was effusive. DR. JANEl,4AY: He is solidly behind it. MRS. FLOOD: He was in attendance, solidly behind it, effusive and told us in no uncertain terms that:even if this fails in putting:together sufficient information to be of value, it was strong in its merit of being the first segment in which these multiple aspects'@df Massachusetts community were going to work together and perhaps his testimony, above others, swayed us to cast full support for DR. JANEWAY: It would sway me, too. MRS. SILSBEE: Mrs. Flood, would you like to summarize the recommendations of the site visit.teamq MRS. FLOOD: The site visit team was, in the Tri- State Regional Medical Program, feels that the Tri-State has a strong staff, broad knowledge and especially commands; lir. Murphy for his efforts in tying together many problem 12 7 4ol areas in that region. It has a good regional advisory group, a strong board and advisory subcommittees. The commitment of Tri-State to the entire concept of blending the private community with the public sector was obvious. We would recommend strongly to the Tri-State Regional Medical Program that they function more strongly in monitoring roles, especially in Congress in the State of Rhode Island, but recommend to this council that funding be approved at a level of $1,686,907 -- MRS. MORGAN: 86 or 7? MRS. FLOOD: I'm sorry. Jerry., I'll have to MR. STOLOV: I have 1676. MRS. FLOOD: Okay, $1,676,907. MRS. MORGAN: Is that a motion? MRS4 FLOOD-. Yes, that is a motion. MRS. MORGAN: I second it. [The motion was made and seconded.] MRS. SILSBEE: The motion has been made and seconded that the council accept the site visitors' recommendations and approve the Tri-State application at the level of $1,676,907. Is there further-di.s-cussion? Dr. Janeway. DR. JANEWAY: I feel compelled to make what may be 12 8 402 a gratuitous comment. If the Massachusetts State Governmbn'u is going to have a study of health policies, I would hope that they would involve more than the medical schools and that the Mass. Medical Society has some input and I don't see'anybody from the Medical Society on DR. WAM'i'IOCK: Nope, I didn't either. DR. JAIQEWAY: And I think that is a serious error, if they are not going to have effective representation on that. MRS. FLOOD: That point was mentioned, Dr. Janeway, and I can't recall -- it has been sevei,a days now -- @,ihat the response was. DR. JAIIEWAY: '.Tell, it is really none of our business. As I say, it is a gratuitous comment. MRS. SILSBEE: It is good advice, Dr. aneway and we certainly will convey that to the region. MR. HIROTO: I am still uncomfortable with this project 52. Vlhat happened to the overall Tri-State F34P -- what would happen, if your recommendation were to be reduced by the amount reflected here? MRS. SILSBEE: Is 52 the Governor's Rhode Island study? 1ILq. HII@OTO: Yes. MRS. FLOOD: [Inaudible.] MRS. SILSBEE: Dr. Wammock. 129 403 DR. WAIIMOCK: I didn't get your comment. He asked about what would happen if this 52 was struck out. Is that what you were talking about? MRS. SILSBEE: I didn't comment. I was going to let Mrs. Flood or Mr. Stolov comment on that. MRS. FLOOD: Well., besides a probable very violent temper tantrum on the part of one angry young man in the Governor's office, I am not sure that there would be others who would address this, with the expediencies that the potential is available here. Now, I might broaden the statement We questioned that they were trying to build staff and we offered some counsel and statements about possibly utilizing consultant groups to answer this in a more massive impact way rather than garner staff and strengthen the Governor's office. This was well-received and I don't know if there would be anyone else that would take this up and address it and it is a necessary component of some future planning for Rhode Island. DR. IVAMMOCK: I'd like to call your attention to the fact that I read this as, program staff is $6543000@000 and the budget you have got up here is $1 million. MR. PAHL: We appreciate the budget increase3 Dr. Wammock. That is $6543000- DR. WAD@UIOCK: That is a lot of money. 130 4o4 MR. PAHL: It is, indeed. DR. WAMMOCK: And the other thing is, that item 52., here, health service time of economic transition. That may not be the only state that is going through economic transition. Maybe the other states are going through economic transition and I think we have to take this into consideration from the standpoint of what role will the RI@IP play in this when we are trying to provide health care services. MR. PAliL- Well, I am glad you made your remark before mine, because I want to merely say Prom the point of view of the program staff that I believe page 2 of the site visit report points out the weaknesses and the strengths and from what I listened to the discussion of the site visit, if we can divorce ourselves from the' Goverhor's office for a moment, I think that a good bit of discussion has centered around an appropriate role for IUDP, perhaps in this area and I think you could make your decision, not on the basis o whether this happens to be the Governor's office or not, but there has never been a consideration in councils prior to this one. This has been an unusual council in that twice now we happen to have situations which involve the Govbrnor's office and this puts a different complexion on the RMP program than we have ever had in the history of the Drogram. In this case, I think the site visit team has done 131 405 an exemplary job in trying to weigh very accurately real strengths and real weaknesses and I think this council should decide whether it is in the interest of the RMP program to approve or not approve this project. You have heard all of the discussion and I think now comes the decision on the basis of what you believe to be the merits of the funds in this area. I viould feel that we could support your recommen- dation whichever way it happens to be. I frankly have a personal feeling about this but I think it .is the coIuncil s job to take whatever action appears appropriate. I do not see where a Tri-State RMP or Rhode Island RAG has to do one thing or another and I don't think you have to do one thing or another, either. I think you should decide on the basis of the merit of the situation, I-IRS. SILSBEE: Mrs. Flood. MRS. FLOOD: I'd like to comment on the high staff costs. They are all very well-paid people, but of outstanding capability and their numbers are not extraor- dinarily high for the area they serve, but they are still the most capable people with well-pai-d positions and that does account for high staff budget. MRS. SILSBEE: Looking at the print-out on just the T)rograrq staff line, Dr. Wammocl-@, in and of itself does not tell you much because, particularly their contract costs 1 32 4o6 and so forth that have built into staff activities, so we have to look at the -- DR. WAII@ll,'!IOCK: I recognize that part of the situation., but I mean, it doesn't trim the astronomical part of the total. Plus the fact that this is a Tri-State situation and I come back to the question as to what Dr. Pahl said, that this is the second time that we have been confronted with this, a governor participating in a program. MRS. SILSBEE: Is there further discussion on this point? MR. STOLOV: May I ask just one question? I am unclear about what Dr. Pahl says and that is in terms of, does the council feel that they are holding an economic project? Because Dean Thurman, I think, and the s te visit team were able to get the full-blown project and review it and the majority felt the project was dealing with the health aspects only of a thrust out of the Governor's office, using every agency at the Governor's disposal to deal with it because of the eight percent Einaudible] Dr. Haber mentioned, these people no longer have health benefits and we checked that area about what is Medicaid doing in the state and they said, everybody who is now employed gets divorced and the families are separated and we can then take care of them on Medicaid but in essente, the proposals, the majority of the proposals in Tri-State are for people who are not directly 3 3 407 dealing with the health care delivery system but using the method the Hill-Burton Program the health department -- the state health department currently sitting in the Governor's office, the definition of how they plan to go about it through subcontracts and one of the subcontracts was with the local group in Newport, $50,000. Again, all of this has to be negotiated, but to pull together the Medical Society, the hospital community and give then, $50,000 to plan their health needs in the community, well, I hope by the title in the computer print- out you are not misled by the economics of it because Dean Thurman, I must say, focused in on that quite well. MRS. SILSBEE: Mrs. Flood., did you have something further? MRS. FLOOD: Well, no, my response to the comments of Dr. Wammock was the true personnel costs at this time are really closer to $300,000 than the rest of the, you know, contracts for staff costs. MRS. SILSBEE: Well, the motion has been made and seconded that the Tri-State application be approved at the level of $1,676,907. Is there further discussion? ETherewas no discussion. All in favor., say aye. [There was a chorus of ayes.] Opposed, 134 4o8 DR. WAIIL@OCK: No. [The motion was carried-] li!RS. SILSBEE: The motion has been carried. Now., the sandwiches are here. Are you hungry? Would You like to take a break? [General consensus.] [Whereupon, at 12:00 o'clock noon, a recess was taken for luncheon.] LEW Rle 4og AFTERNOON SESSION (12:25 P.M.) MS. SILSBEE: We would like to get started again. 0 There are a couple of announcements I wanted to mk(@. For the record, Dr. Merrill was not present during the Tri-State review; he is not here today. And with regard to the Arizona application, after we got all through with discussing It, we noticed that the Arizona RMP did have an arthritis application, so we are in- terpreting the sense of your review that that does not apply to that earmarked activity, in the program applications. Now we will do Illinois. Lee,did you want to give any real brief remark? Dr. Janeway, you did a review. MR. VAN WINKLE: I would just as soon he Lead off and if he wants me to respond to any question, would be glad to. DR. JANEWAY: If I can find It in my book. DR. WA MMOC K: I tcomes right after "Hawaii." DR.JANEWAY: In order to get,the topic on the floor I move approval of the recommended level by the committee of $2,816,935,' which is LOO percent of the request pr6sented to the Ad Hoc Review Committee. MRS. MORGAN: I second it. MS. SILSBEE: Dr. Wammock.. secondary revi6werp do 410 you want to say anything? DR. WAMMOCK: I came across this business of public awareness of venereal- disease that sort of worried me a little bit. And really, there is not much about it; I though,-, it was a well prepared situation and there is no point in nit picking, anything of that sort, so I would second it. DR. J.ANEWAY.- In brief comment on the topic,, I think that in the general guidelines for following it, it is a superior program. I think that one bit of potential difficulty that ought to be made available to the Council is the fact that@Dr. Creditor and Mrs. Creditor are both Leaving the program. And since that represents the coordina- tor and the grants manager, the Illinois RMP, I think it is a difficult task to replace them. Dr. Creditor has a reputation for strong Leadership and advanced planning and'has a very interesting monograph on the subject. From the standpoint of proposals, I would make only one comments in my review, which I noticed was covered in the transcripts also, is that the hypertension control pro- gram that they visualize themselves to me rather ambiguous considering the amount of time that is available in order to carry out the project, but it is worth while and well designed. I am not sure they canattract the, staff and get the computer base and all of the mechanics necessary to complete 411 3 the project as they see it. But I nonetheless recommend 0 approval as the committee recommended. M@S MARTINEZ: (Inaudible) DR. JANEW.AY: He is going full time at the University of Illinois@,,,. Medical Branch. The Dean there is a reliable person. If he said it is going to be a generous 25 percent, it will be, and I have,k'n'own him for sometime; he is quite interest--a in the RMP program, I am sure that will happen. DR., -W-AMMOL;K: I would like to ask one question here if I could find the page. It is an amount of $1@.b,000 for POMR medical care evaluation. This is a demonstration of the usefulness of the model system in other settings at Michael Reese Hospital, and assessment for adaptability to do ambulatory care setting,,,,. MRS. MORGAN. What number is that? ,UR. W-AMMC(;K: Page 90, page 90. It is 33 is what it iso project 33. L)evelopment test and feedback method for the sys,tem evaluation ol' first year of the project ttn6 promotion use for system at the institution. It is going bo oo done in one hospital, si@8,000. Thau is a good 8ize "chickeni'eed." I)R. JANEWiiY-. They have bit ;into, the,,-,plate,,on@-the system on the computer, capital P, capital H. UR. WAMMOUK: Yes. 412 L)R. J.AN-EW.AY: Mnd I think they nttve been using the POMR throughout 1IL4nol@ for inpatient and medical audit purposes, The extension into ambulatory care is a necessary one in my opinion, but considerably more difficult in its lm- Plementation than inpatient. DR. WAMMOCK: Yes, that is what worries meg imple- m,entation on the outpatient basis. DR. JANEWAY: That is where it is going to be at, though, to use an old Western Pennsylvania phrase. DR. WAMMOCK: "Where it's at." MRS. FLOOD: This particular project will be seated in one facility as a tezt? DR. WAMMOCK: Yes. MRS. FLOOD: May I ask an additional question. Let me clarify, Dr. Mort Creditor will now be,25 percent of his time will be coordinator of IRMP -- period? Or-- DR. JANEWAY: My understanding of the proposal Is that this will extend through December of 1974 and it is not a 25 percent spread- it is 25 percent generously, but it will presume to terminate at a year or so. It is more time actually. Is that your understanding? MR. VAN WINKLE: Yes, yes, it is. MRS. FLOOD: I have some real 413 irc 5 MR. VAN WINKLE: They do have a search team at the present time. MRS. FLOOD: They do have a search group formed? MR. VAN WINKLE: Yes. MRS. FLOOD: Definitely this has' been the power behind the successes of IRMP, and if they don't address the -- sufficient transition time, you know, to replace the coorclina.- tor, they would face a lag I think in putting all these pieces together and perhaps a crucial time when they must enter wind UP* MS. SILSBEE: Dr. Wammock. DR. WAMMOCK: Another project on page L07, that pro,lee 41, PSRO evaluation of technique in Chicago. Quality of disease information of Cook County physicians, It bugs me a Little bit, it Is a form I am sure of continued education in some one form or another, but it costs $135oOOO. MRS. MORGAN: There are a lot of physicians here,, though. DR. WA MMOC K: I recognize thato but if you analyzed how many attended out of the total-- DR. JANEWAY: I think the number is going to go up. DR. WAMMOCK: You think it will go up? You mean just for political reasons? DR. JANEWAY: No, no. Reality. 414 MR. HIROTO: If they want to stay licensed. DR. WAMMOCK: That is all have. MRS. MORGAN: Question. MS. SILSBEE: Motion has been,made and seconded that the Illinois application be approved at the requested amount of $2,816,935. Is there any further discussion? All in favor say "aye." (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. Next one is Ohio Valley. DR. JANEWAY: Madam Chairperson, the Delegation from Ohio Valley (Laughter) DR. WOBMCK: Want to get the Council on this? DR. JANEWAY: In order to plade@@the topic on the floor, I move approval of the committee recommendation of $2,205,636, plus $100,000 for project 27-D. MS. SILSBEE: Hold it just a minute until Milliken gets out of the room. (At this point Mr. Milliken withdrew from the room.) MS. SILSBEE: All right. Excuse me. He is out. 415 DR. JANLVAY: Thank you. I move approval ol' the committee recommendation for the Ohio ValleyMe in the amount of $2,205,636 plus $100,000 for project 27-D, to fund Toledo, Lima, Dayton Region. MS. S BEE: s there a second? MRS. bMRS: Second. DR. JANEWAY: I am a little bit less enthusiastic about this proposal than I was about the Illinois proposal. I think that leadership in my opinion remains to be demonstrated, both in the coordinator of the program and in the RAG. I think that with the phasing out of other programs in Ohio, that they face severe political difficulties in brin@- ing other regions, other parts of the state into the funding mechanism, because it appears to me that the great majority of their programs are divided a third, a third, and a third; thei the participating medical schools. There Is no fault in the direction of the great majority of their proposals but I do think they underestimate the difficulties that they may face as they get more vocal from the regions that have not been in, I am not quite sure how this is going to be resolved @,within the framework of the proposal they presented. Although the overall program Is presented in a 416 3 well printed form, it is difficult to follow exactly what the accomplishments of the region have been to date. And Iihink there is going to have tobe a lot of salting out in this re- gion before they accomplish what they say they are going to do. Inherently I think in a program that crosses state boundaries is this type of problem and they have jus@ in miti- gation of what I said earlier, done quite we II in hand ling the fact that it does involve three states, MS. SILSBEE: I should explain to the Council that Toledo-Lima-Dayton part of the application, because last year when we were phasing out, two of the programs that formerly covered Ohio, Ohio State program and the Northeast Ohlo,,were phased out. At the time that these applications were being pre- pared Ohio forces began to wake up to the fact that there was money to do some things that they wanted to do and under the terms of the court order, the money has to go through the 53 existing regional medical programs, so we suggested to various people in Ohio to go either to Ohio Valley, which covered the@lpart around Cincinnati, and Kentucky and part of Indiana, or to go to Western Pennsylvania or to Michigan, and so in this particular round of applications, Ohio Valley. RAG agreed to take this on. And Western Pennsyl,,van@ia applica- tion you will be looking at later was to try to Co portions of 417 activities in Ohio without taking on the whole state. Lee, did you have anything to add? NR. VAN WINKLE: I would explain in the recommenda- tioh that the 100,000 was explicit for this expansion into Ohio, and I understand since the committee met that these people have applied and this will be forthcoming, whichwould eventually. probably 'raise this Level to $2.3. DR, 0 JA NEWA Y: My only problem with that is $100,000 is j@ue,t for starters. I don't think we are going to have any difficulty with that. It is when that area gets organized, what are they going to do? MS. SILSBEE: I think these are for specific pri- orlties In the Ohio Valley program. MR. VAN WINKLE: That is correct. MS. SILSBEE: Health education services$ that type of activity, And they have made it quite clear to Ohio they are not interested in a lot of different ki:nds of activities. So these are related to the goals of this particular regional medical program, MR. VAN WINKLE: They have no intention of helping to form a new medical school. MS. SILSBEE: Okay, the motion has been made and ed tIhat the Ohio Valley application be approved aline second level of $2,2O5i636, plus another $100,000 for the Toledo- Lima-Dayton, Ohio, area. 418 Is there further discussion? All in favor? (Chorus of "4yes.@1) MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: The motion is carried. Okay, Washington-ALaska. DR. JANEWAY: Is there anybody here from Washington- Alaska? MS. SILSBEE: No, but we should get Mr. Milliken back, Okay. DR. JANEWAY: I thought you wanted to wait for Mr.ldlliken. MR. VAN WINKLE: He may be difficult to find. (Laughter) MS. SILSBEE: Let's just keep going. DR. JANEWAY: Okay. (At this point Mr. Milliken returned to the room.) DR. JANEWAY: I move approval of the committee recommendation on the Washington-Alaska RMP in the amount of $2,077,311. MRS. MORG-AN: Second. DR. JANEWAY: The program always has been superior in my opinion with very forward thinking leadership and a 419 great deal of cooperation with the University of Washington. And Dr. Van Sitters, who is the dean there, has since he has been dean been quite supportive of the RMP program, There has perhaps been some criticism at the very close relationship of the university -- the medical school with the RMP program. But I think on balance, it has beEn to the betterment of the program and that there Is no conflict of interest inherent in it. The constitution of the R gional Advisory Group does have some preponderance of providers of medical care and particularly people who are related to the medical school environment* Once again, I think that both Dr. Sparkman, whom,we have@seenp and the people who are on the RAG are able to associate themselves and wear different hats at approp- riate times. I am a little bit concerned that although the com" prehensive health planning relationship with RMP has been very good, there is considerable difference in some of the proposals .that were presented this times which strikes me as a little bit unusual since than RMP and CHP in Washington look a great deal like an interlocking directorate to me. hey have advanced planned to the point of prediction almost, I would seem,, It is nothing explicit,but it is implicit In the 20 .2 request. I am also not sure of the integration of Alaska into the program, but I think than is not surprising. They made good'strides in their minority outreach programs and are getting representation on the RAG in minority areas and I think most of the things I would have to say about @it are good. MS. SILSBEE: Mrs. Russel; did you have anything to add? MR. RUSSELL: No, I have not one thing to add. MRS. MARS: Why did the CHP agencyleomplain about this position extender placement program? I would think in Alaska that would be one of the greatest boons that there could be. MR. RUSSELL: Mrs. Mars, I am sorry, I cannot answer that specifically, I don't have copies of those letters with me. But since the comments have come in to the Washington- Alaska Medical Programo the Executive Committee sat down and addressed each comment specifically and have retpon ed, so those issues have been cleared up locally. I am sorry that I cannot answer* MRS. MARS: You don't know,what the basis for-- MR. RUSSELL: No, I do not, (Discussion Off the record.) 421 MS. SILSBEE: The motion has been made and seconded that the Washington-Alaska application be approved at the re- quested levels $2,,077,311. Is there further discussion? All in favor of the motion say flaye. it (Chorus of "ayes. " ) MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. Okay, now we are going back to our original Plan, we are going back to our alphabetical. Colorado/ldyoming would be the application under consideration. The record should show that Dr,,Gramlich is not here, MISS MARTINEZ: I thought this was an extremely well put together program), very well written. Very well coor- dinatecl with other agencies, and they had a very good EEO statement which was unusual on the EEO proposals that I reviewed. About that subject, I am sure it is much too late, bL(t I did forget to make one comment last time when I was reviewing Central New York; that is, their minority representation is extremely poor. They have one black person on the RAG and that is it. And I would sort of recommend that they do some- thing about that. 422 14 And also Just one more aside,, in looking at the form@ itself, that is used for the statement, I would suggest that it be modifiedbc) eliminate possible double counting of minority- females. I don't know if that is a problem herep but I know it was in our states# so we had to change the system. Naw, I am going tb go just very quickly, I am pretty' much in agreement with the review committee's funding level, I@ just want to make very quick note of a couple of proposals I object to. One is C002,, which Is primarily for a conference; C009, the need for that really wasn't developed in the proposaLp it wasn't backed up; COLO is a small allocation,, but primarily for a series of sLides, audiovisual; C013 Is interesting becau e I knew this was going to come up again, It is $104,000 pri- marily as an insurance policy for extension of trouble the way I read it. I may be wrong about that, And there are a few others, such as 04L which the reviewers mentioned also, bone pathology center cancer diagnosis. I don't know if that is appropriate, I should think the American Cancer Society or soihp 7- other group would do that. It is setting up a continuing laboratory for analysis. And 048 is continuation of a program the funding of which was dropped by NIH. I don't know if that is particuLarLr appropriate either. 423 In any cases when I finished Oubtracting,,,I-came up with $1,573,592.. which Isn't too far off. And I woulcin't mind stick to the co=ittee's recommendation If the extra few thou- sand dollars wasn't used on those small programs that are going to just produce audiovisual materials and a conference. MS. SILSBEE: -Ur. Wammock. DR. W.AMMOCK: 04L, bone pathologist center, for the benefit of Dr. Janeway in Boston, Dr, -- MS. SILSBEE: Would you speak into the mike, please? DR. W-AMMOCK: Many years ago a bone pathology register, used to collect slides and send them all around over the country. There is a great need for emphasis on this situa- tion. The fact these are common to us, yet they are rare,, but they are difficult jCor diagnosis., I Imagine it would be quite a problem. I would like to address myself to support this number 4L. MISS MARTINEZ: Could I ask, Is this a pilot project? There was no mention of Its being taken up by-- DR. W-A MMOU K: It would make no difference to me whe- ther it is pilot or not. I think it is a place where patholo- gists,not only pathologists but orthopeclicsi;ldn(l,ouher individuals., even pediatricians, ought to be cognizant o.'L' the fact o:r the problem ot' bone tumor we are- faced with, 42 L5 I am sure if they have started this, they are going to continue on this. This is my impression in Colorado. I am not sure who is on this program, whether George Moffi:tt,,ihas anything to do with it or not. MISS WRTINEZ: Woub they be seeking funds from other sources 'and that wasn't brought out? MS. SILSBEE: Miss Martinez, in terms of the change-- you are willing to go along with the committee recommendation, we can give advice to the region In general terms, particularly the audiovisual and the conference, and so forth. MISS bMRTINEZ: It is only something like $6,ooo. MS'. SILSBEE: But I don't think we should be In the position of saying yes on this one, no on this oneo unless it is a policy issue. MISS MARTINEZ: No. MR. CHAMBLISS: I think I should respond to Miss Martinez's question. I saw it as being appropriate, as far as RMP funded, the answer to that is yes, it is quite appropriate for RMP sup-. port, that being one of the basic categorial cares the program started out with. MISS YIARTTNEZ: It wasn't so much the project as lack of other support. MS. SILSBEE: Would you make a motion? MISS MARTINEZ: Yes. I move it be funded at 425 i6 $1@587,644. MS. SILSBEE: Is there a second? DR. WAMMOCK: I will second it. MS. SILSBEE: Mrs. Flood. MRS. FLOOD: May I raise a question as to whether or not Intermountain, Mountain States, CoLorady/'Wyoming's total applications have indeed,gone before their tri-regional coordinators conference and ironed out their problems of over- lap? I can't seem to locate it. There is such a counsel- ing genetic component in Colorado/Wyomingo as I recall it was either Intermountain or Mountain States addressing the same particular concept of need for that region of the country. MS. SILSBEE: I think they are all related to the one in Denver. It i8,outreach part of it. MRS. FLOOD: But they have,, all three-- now we hashed the Intermountain status of going through-- MS. SILS BEE: All three applications went before the Interregional Council. We have a letter indicating that certain of the ones that were Identified for overlap areas are now going through the proc6ssof being cleared by respective agents. MRS. FLOOD: Thank you. MS. SILSBEE: Motion has been made and seconded that the Colorado/'Wyoming application be approved at the level of 426 $1,587o644. Is there further discussion? MRS. MORGAN: Question. MS. SILSBEE: 'All in favor? (Chorus of "ayes, MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried, Next region is FLorida; Mrs. Gordon is the reviewer, MRS. GORDON: Florida has ranked a superior region, and one of their great strengths seerw to be their record of attracting outside funds for their projects and for the con- of their projects. Their funding agency Is an inde- pendent corporation. They deal in large numbers, both In people and in moneys @They will ask for one and one-tenth million in July, at least that was the forecast, one and a-half million this says* They do have some new programs which are quite expen- sive, but the reviewers seem to feel that in light of their pa3t record, forgetting continuation funds from other sources, that they would continue this good record and therefore they would be willing to go along with the chance of putting this much money in@to start, although they did not recommend full fundin@, but very close to It, about $500,000 off. 427 3 So in light of their past track record, I would 0 move that we accept the committee's recommendation of $2,TrOO,000. MRS. MARS: I second it. MS. SILSBEE: Mrs. Mar4 as secondary reviewer do yoi want to comment? MRS. WRS: I think you might point out they have an exceptional kidney transplant program. This was begun ore there were any special federal funds given, allocated to it, for this purpose. And they developed a statewide plan which described a network per organ, harvesting covering major cen- ters for dialysis facilities, and required supporting services So that Florida is I suppose one of the best covered states actually as far as kidney transplant system, as far as I know. MR. VAN WINKLE: They are very much looking at quality of care right how in that area* MRS. MARS: Yes. So I think they do have some reall, outstanding programs. There was a Southeastern Interregional Symposium on quality care evaluation. So other than that, excep o say they do have some exceptionally fine programs I have nothing ;o add. Ms. SILSBEE: Motion has been made and seconded the Florida application be approved at $2,700,000. 428 Is there further discussion? MR, MILLIKEN: wuestion. MS. SILSBEE: All in favor? (Chorus of "ayes. 11) MS. SILSBEE: Opposed? (No response* ) MS. SILSBEE: Motion is carried. Next region is Greater Delaware Valley. DR. WATKINS: According to the reviewer, above average program. I recall this program was organized around a region-- I remember it myself@ around five Philadelphia medical schools. Also there was asuccession, if I recall.4 of first st),te, Delaware, but there seems to be a metamorphosis of this region4 We find today that It is controlled or run by a new coordinator who is,really oreof the old members and that they have involved communities,, especially the inner city, in several programs, Their biggest drawback was an inordinate astuteness In financial recommendations, being they apparently were sub- sidizing professiorrts of the medical schools, and it still seems to remain a slim question which I believe we will Inves- tigate because I don't think over three years the same thing should exist, so I am sure you are going to Investigate that further. But in general, the program has Improved, the program 429 is following the guidelines it has strong Leadership shows direction. Proposals were reviewed by CHP and the history in general looks good for this program, so I would propose that the $2.3 @ Ilion recommended by the committee be given to this program, MS. SILSBEEK Is there a second? L)R, JANEV.AY: Second, MS. SILSBEE: I)r. Janeway, did you have anything @r the,r t o acid? DR. JANEWAY: No comment, MS. SILSBEE: I have one thing to add to the record, because at the Review Committee, there came a letter from one Of the CHP agencies with a negative comment. This was one that had not yet been to the Regional Advisory Group. They sent it directly in here. So we called to ask what the pro- cedure was as far as the region in terms of Looking at this, and they said they would-- because of the particular project, they would work with the CHP agency before they Intended to move into that area. And if indeed the (b) agency decided they did not want them, they would not go. So it seems to me the region was responding to the conune n ts . Motion has been made and seconded that the Greater Delaware VaLley program be funded at $2,300,000. Is there further discussion? 430 all MR. MILLIKEN: Question. MS. SILSBEE: ALI in favor? (Chorus of "ayes. ") MS. SILSBEE: Opposed? (No response. ) MS. SILSBEE: Motion is carried. Next region is Hawaii. Mr. Hiroto. MR. HIROTO: Madam Chairman, I recommend that the Review Committee's recommendation that Hawaii RMP be funded for reduced amount of $1,100,000 with $305,107 of that amount earmarked for the Pacific Basin, be approved. Comments I would make is I was a member of a review site visit team in January and in April of this year. A new coordinator was named and in the two short months that he has taken over, he ,Is apparently moving towards meeting the many problems that Hawaii RMP had. As far as the reviewers are concerned he is obviouSLy moving Hawaii RMP in a proper area, There is only one I think still remaining concern, which had to do with the kidney tissue typing, and we would, I guess., suggest that they solve their problems. MR. RUSSELL:@ I was at the RAG meeting when that was discussed and the Regional Advisory Group chose to put the progress right back where this belong;4 on the two institutions 431 2 involved, making them guarantee that either two separate programs were needed or coming up with a jo nt plan. MRS. MARS: Has the RAG been changed? Is It being-- MR. HIROTO: There is a new chairman of the RAG, I should have mentioned, MRS. NMRS.- What about composition of it? MR. HIROTO: -As a result of that, they are moving forward, are they not? MR4 RUSSELL: Yes, the by-lawstave been revised. The Regional Advisory Group has been revampedobringing on board consumers, more different types of individuals; the @niedical school, ,school of public health, Hawaiian Medical Society are delighted withthe change In directors and the new direction the program is taking. It is,,a completely different program. MRS* RS: I should hope so, because It was just about ready to be closed down. MR. RUSSELL: No doubt about it. We were very en- @couragecl by the last few months, MS. SILSBEE: Mrs. Klein, did'you want to comment? MRS, KLEIN: I don't have any comment. MRS* FLOOD: I would second Mr. Hiroto's motion. MS. SILSBEE: The motion has been made and seconded that the Hawaii program be funded at the level of $1,100,000, 'with $305.,107 of those dollars earmarked for the Pacific 432 Basin program. Is there further discussion? Dr. Janeway. DR. JANEWAY: Could I ask a qvestion? MS. SILSBEE: Sure. DR. JANEVAY: Did I beat the call? MR. MILLIKEN: Right. DR. JANEWAY: Just for education, how did Hawa I get around to -- Let me ask it this way, is it because of the Pacific Basin that Hawaii has no CHP (b) agencies? MR. RUSSELL: No. MR. HIROTO: Hawaii is such a small area. DR. JANWAY: So is Rhode Island. This is just for my own education; has nothing to do with the proposal. MR. HT-ROTO: You can answer better than I. DR. JANEWAY: If they didn't have the Pacific Basin in their proposal, could they have a single RMP and (,a,;) agency, no (b) agency? MR. RUSSELL: Yes. What you have in this program is you have a Pacific Basin, separate program from that program conducted In Hawaii. As Mr. Hiroto said, the very size of Hawaii and with the population center being in HonoLulul where the (a) agency Is operating, and it itself Is not very strong in terms of being able to move things forward, it has a very 433 24 small staff. At one ti.,ne there was an attempt to set up some not necessarily areawide agencies, but sort of subcommittees out on the outer islands, And that thrqst-- I really don't know how far it has gone. MS. SILSBEE: To answer your question, yes, I think in the Distri-ct of Columbia that situation;was trueo there was an .@(a)lagency, because that was it, and no (b) agency. We have a motion and it has been seconded. All in favor? (Chorus of "ayes,") MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. Just for the record, that is the shortest:discussion we have had on Hawaii in four years. MRS. MAR8: That's trueo very true. (Laughter) MS. SILSBEE: Indiana. Mrs. Klein. MRS. KLEIN: Indiana was rated by the dommittee as average or below average. You can see by your green slips. The comments, in,the comments the committee talked a good deal about the broad general nature of the report itsO-,If, and the factithere were not very many sped ifics in it. And I 434 had to concur with this when I read It, As a matter of fact, being a novices I decided that I would read the comments of the committee first and see if I agreed with them, and attempt to find points of disagreement, as a matter of training myself sort of, The report showed a good working relationship with CHP, but it didn't specify In what mnner these working rela- tionships were carried out, Many of the program s-- and they did have many pro- grams -- were a Little difficult to assess because they weren'; specific in terms of what they were actually doing. They were conducting some sort of study to determine health deficits they called it,, and they were developing pro- grams in quite a wide variety of areas, lnclud ng con inu no- education, Legislation for statewide emergency services, neigh- borhood health centers, state stroke therapy, and hypertension and coronary care units, and quite a number of others too. Most of their requested appropriation was for alloca.- tion of funds, I guess I should say, was devoted to staff. An(i although I think the Ad Hoc Committee was sort of in the mood to cut them,,a good deal because of the inadequacies of the report, they decided that since most of it was for staff and they had so many programs as I interpreted It anywayi that th(sy were doing something, and tha'u- they shouLd@@,,@, be permitted to continue the principal part of the program, 435 6 They dido, however, cut the recommended funds by $100,000, and I have a little difficulty determining on what basis they did. But there were several items they particularl- questioned. One of 6hem was sort of a teleanswer series in medical education, sort ol' dial-a-disease program that the com- mittee apparently wasn't very enthusiastic about. Also they were studying-- wanted to study the pre- vention of organ rejection, and the committee i'elt that that, was a basic science study which could just as well be funded by some other method. .And they also questioned the continuation of the emergency meCiical service program, In any events the committee decided to Out them only $100,000 and considering the wide variety of progra@ that the7 were conducting, I felt thi@ pr-obaolyin my uninformed manner, that;thi6 was sufficien@.cut, and that i,, the reason tha6 I have moved tha'u we adopt the committees recommendation of $ I,, 15 9. MR. MILLIKEN: second, M,S. 6ILSBEE: no you have any@hing, Miss Martinez-@ 4jr, Janeway, uR. J.AI&W.AY: Perhaps it is in the t an r scripts., It doesn't show in the yellow sheets. Steve Beering is now the Dean at Indiana. Have they 436 changed, got a new director coordinator? MR. VAN WINKLE: For sometime Steve has been the coordinator on a part-time basis. Even prior to the time he took over the deanship. But they do have a fuLL-time program director. I guess you get into semantics -- director versus coordinator. But Steve still is maintaining a very active rot? in the direction of this program. DR. JANEWAY: Good. MS. SILSBEE: Mrs. Flood. MRS. FLOOL): The Review Committee apparently ralsed,some questions about the 31S activities. It was also an area for staff concern. But I see no assurances that this was an inappropriate EMS activity in Light of the MS action. Was this particular-- MR. VAN WINKLE: We flag all EMS, not necessarily because of concern but for reviewers' consideration. We saw no problem with the EM activity they are en- gaged in. They have been instrumental already in obtaining legislation establishing a State Commission on EMS., and have very small appropriation to fund that Commission. But what you see the funding here was strictly staff work for RMP themselves. MS. SILSBEE: I think the committee was concerned 437 arc 26 about that, maybe trying to get an idea. MRS. FLOOD: Yes. The green sheet reflects the com- mittee believes the support of EMS activity was below private or at least open to question. But they classify that with-- based on the information presented. I haven't looked at the whole application, but I would guess it was low priority at this point in the EMS, development in that area. MR. VAN WINKLE: As I recall the discussion, they were raising whether this EM activity was appropriate for funding in view of the EMS legislation. They were raising the same question. MR.JEWELL: That is true, MRS. FLOOD: But they really didn't cut funds. MR. JEWELL: Yes, ma'am, I think that Is the reflee- tion;as I read it, Mrs, Flood,, that is the reflection. Because the EMS proposal is $Ioo,oooo There is nothing new in this application. All con- tinuation. MR. VAN WINKLE: ALL continuation, MR. JEWELL: That is reflected In the committees recormenciationt I believe. MS. SILSBEE: The motion has been made and seconded Indiana program application be funded at the level of $1,121,1!')g. MRS, MARS: Question. 438 MS. SILSBEE: -ALI in favor? (chorus of "ayes.") MS. SILSBEE: Opposed? (No respo@ e.) MS. SILSBEE: Motion is carried. The next region to be reviewed is Iowa. A nd Dr. Wammock is the reviewer. DR. WAMMOCK: Well, some people speak from experience and some people from experience won't speak. MS. SILSBEE: Will you speak into the microphone,, please. (Laughter) DR. WAMMOCK: Just once only. I can't do it again. Well, I caught a slippage hereafter I reviewed this@ I find an epistle right back of the green sheet. But the epistle-- this is in all due respect to the reviewers under- stand, has no reflection on any characters* living or dead, past or future; in the first place, this project, the program was very well put together) very well dcc =entedo And as far as review,was rather easy to do. And a reqQest was made for $1,061,349, was so approved by the committee. And I will make reference to the review by members of the staff at a later moment here as I go through this, This program was well organized. A few comments I 439 30 wish to make,, very comprehensive,put together very weLLin very orderly fashion. Most of the activities originate under the aegis of the TJniversity of Iowa. I point this out, it seems to be controlled in that direction, Of course, I take into consideration what goes on in the State of Ohio. I think that would be perfectly legitimate a thing under the circumstances. Family nurse practitioners for use In rural area, I don't know whether you classify this as assistant,,physician's assistant. But you may need to. Primary family care planning program, this is to design two statistical models,, one to explain and predict., the other to Identify-- (inaudible) The other institute, talking about primary care planning, $24,,000, number two is to coLlect and use available demographic health geographic data In testing the model In appIV- ing it to past and present circumstances, or pertinent to IoewEL subregions. Maybe somebody would want to explain all of that to me, I don't quite understand what it is all about* But I will pass it up if somebody wishes to refer to it all tight. The,other plan is a homemaker home health, a train- ing project. This program has been used in other areas and one 44o area I am particularly familiar with, we fourd this to be very beneficial to people who cannot be contained in a hospital over a long period of time, but do need the systems at home. We found this a very good program. We put it in operation many years ago. Politicians in our local area failed to take it up and carry it on, because they thought it would cost too much money to do a program. They would rather keep them in a hospital than worry about that. The other point is the remarks about the uniform record system for quality care improvement. I think I have no particular qualms about that, Hospital cost study, this I wonder about whether this is a part of the Regional Medical Program. This is one of their projects. I say that is about all I have to say abou'k-, this, except for the fact to come over to page 234, maybe the re- viewer would want to comment on this, paragraph hereo we re- ceived on the twentieth of May coordinators-- this is about the,CH (b) agencies. Maybe staff would like to comment on that. MS. SILSBEE: What page was that? DR. W-AMMOCK: Page 234. That has to do with the breakdown of machinery. MR. POST.A: I would like to have Mr. Zizlausky talk to this point. He has gotten additional information 441 32 from CHP. I would Like to say this if I might, siro I would say Iowa is considered a superior region. DR. W.A MMOC K: I apologize. It was above to superior. I enjoyed reading it, real pleasure to read it, because -- some of them, you know MS. SILSBEH@': It pulled together well. DR. WAMMOUK: Pulled together? Trash cars I am talking about the way that the project that was being applied for -- It was presented to the R@ here. MR. POSTA: Mr. Ziziausky. MR. ZIZLAUSKY: That is project 60 you are saying, primary medical services? MS. SI@BEE: Page 234. L)R. W-AMMWK: Page 234 on your transcript. Got the transcript? Or shall I read it for you? MR. ZIZLAUSKY: I don't have it with me. What Is the area of concern about? DR. W MMOC K: It is about the CHP, the relationship with the RMP. MR. ZIZTAUSKY: Fine. What had happened is when they submitted their May Ist application, they were caught in a Lot of the project de- velopment -- last time in this. We approved a, three-day ex- tension here for an application coming in May 3rd. They had 442 not had all the CHP review and comments in, all the proposals were out to CHP (b) agencies. Subsequently we received, and wer@are still getting in comments from the CH (b) agencies on these project activi- ties, and so far none have been negative. DR. WAMMOCK: I have three here which are a part of the project request here. Dated May23rd. And none of these have been negative. MS. SILSBEE: The additional ones that have come in? MR. ZIZLAUSKY: Now, we have additional health plann ng councils who have submitted additional letters for review and comment, and the program staff is negotiating the differences. There aren't any major differences We explained what this one project, project number 6 -- I thought you were talking about project number 6, family services in Iowa, was recommended for disapproval. This was one of the Northeast Iowa,Health Planning Council recommendations. They have ironed their problem out and this is on @the;,yellow sheet. It is the only negative comment, but that :negative comment has been resolved. DR. WAMMOCK: That has been resolved? MR. ZIZLAUSKY: Yes, sir. DR. WAMMOCK: Fine. MS. SILSBEE: Mrs. Morgan, 443 @4 MRS. MORGAN: I think it has been more discussed 0 than I can. MS. SILSBEE: Okay. Do you want to make a motion? DR. WAMMOCK: I make a motion it be approved for the sum of -- MS. SILSBEE: $i,o6l,349? DR. WAMMOCK: -- $I,o6l,349. Again, I apologize for not recognizing the prep6ra- tion and review of this by the staff and calling my attention to this abov e average to superior, I appreciate those-- that gives me, youkiow, a springboard, MS4 SILSBEE: Is there a second to that? MRS. GORDON: I second It. MS. SILSBEE: Motion has been made and seconded that the Iowa application be approved at the level of $L,061,349, ALL in favor? (C7horus of "ayes.") MS. SILSBEE: Opposed? (No respons(a.) MS* SILSBEE: Motion is carried. Next region is Kansa8o and Mrs, Gordon, the record should show will be out of the room, (At this point Mrs* Gordon withdrew from the room.) MS. SILSBEE: Mrs. Morgan. 444 35 MR4 MORGAN: The Kansas RMP was reviewed as being above average to average. Dr. Bro@n has been coordinator since 1966 and has done very well in coordinating with the Kansas factors. ,The Review Committee really only showed two concerns, one was what they felt was an overambitious project, regional- lzation o@-@p'erinatal care, project number 91. The committee also showed concern over lack of docu- mentation that the continuation of these activities after 197-@, we have since -- this was reviewed by committee -- receives from Kansas various Letters showing that these are being con- tinuedo The Berkely project being continued by a lung cancer --;Mary? And Dr. Brown is very enthusiastic the PerinataL project will be continued by the state. They did, during phase out, lose an outstanding black professional from their staff. They do have female pro- fessionals on their staff4 Minorities ar6n't as well repre- sented as we would like to see, but this occurred during phase but when I think minorities were the first to leave the staff when they were afraid of it being phased out. The Review Committee did decrease their request by $1000000, this being to alert them to take a more careful look at the project 91 perinatal care, I move that we accept the committee's recommendation 445 of $LO633,380 to the Kansas RMP. MR. HIROTO: I second that. I have this one question, I would like to know what this community health education program number 51 entails? MS. SILSBEE: Miss Murphy, project 51. MISS MURPHY: That is one of the HISFAls in Wichita. They are expanding considerably. It is an H/SEA project in Wichita; they are expanding it considerably. MR. HIROTO: Okay thank you. MS. SILSBEE: Mrs. Flood. MRS. FLOOD: Mrs. Silsbee$ may I inquire, you said you had received communications from Kansa4 possibly from Dr. Brown, about continuation funding of the perinatal program from the state. Can we know what segment of the state? MISS MTJRM: I have the whole proposal, the cover letter* I haven't gone into it in that detail. Specifically# I think she meant the other, the new projects. Dr., Brown,feLt this perinatal care project, r nO- 0 a diffe coftipo nts f@ it@'would be c rriecl on by different phases within the state. MRS. MORGAN: Not the state legislature$ just the State of Kansas. 446 @7 DR. JANVWAY: That is a fairly common thing for states to support, premature nursing programs, MRS. FLOOD: My concern iso we'.-l,have gotten some fairly strong assurances of continuation funding for those projects that had some concern to the committee. Why are we cutting them $100,000 for an above averaee area? What was the criteria for the $100,000 cut recommended MRS. MORGAN: I don't think the committee felt they could utilize that amount in a year's time. MRS. FLOOD: Thank you. MS* SILSBEE: The motion has been made and seconded that the Kansas application be approved at the level of $1,633o380. Is there further discussion? MRS. MRS: Question. M. SILSBEE: All in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response.) MS. SILSBEE-. Motion is carried. And would someone bring Mrs. Gordon back in. (At this point Mrs. Gordon returned to the room.) MS. SILSBEE: Next application to be reviewed Is Maine. Mr. Hiroto. 447 MR. HIROTO: I move that the review conunittee's recommendation of funding level of $1,76Q.000 be approved. The only comments I have are that the Main RMP is,consiclered superiorlin all respects and they meet all the criIte.:tia and they meet the review requirbmentso and they have obviously been doing a very superior job. MS* SILSBEE: Mrs. Morgan. MRS. MORGAN: It may be noted that Maine was one of the few, probably the only RMP that when during phase out had appropriation from their state legislation to continue that program. I think this speaks well of how high the Maine program is re&arded within the state and I second the motion. MS. SILSBEE: Motion has been made and seconded that the Maine application be approved at the level of 111,760,000. I,- there further discussion All in favor say "aye." (Chorus of "aye.") MS. SILSBEE: Dr. Janeway? DR. JANEWAY: Perhaps I didn't hear it. I may have been sleeping. But did the staff have any explanation, why did they cut it $300,000 If it is all that great? MS. SILSBEE: Mr. Peterson. MR, PETERSON: One of the running threads in, panel B. which considered Maine,, was looking at not only the amount 448 requested but also such factors as what are they funded at presently and to population, and it was pointed out that Maine was a state of about half a million pep@plep thatthis level of funding would give them one of the highest per cap Whether that is a valid point or not is for this Council to consider. But it was on that basipand Indeed Maine was one of three regions which in the sort of wrap-up session went back and Looked at all 25. They decidedo well, iie WILL up this LO percent, We dealt perhaps a Little too harshly with it. Bu that certainly, as I understood it, Was the rationale for cutting Maine somewhat. DR. JANEWAY: Does the staff have an opinion as to whether that will limit their capability for fulfilling these superior programs? PETERSOIJ: I can't speak to that because I was ac,t@ng,in a chairman function, I really in the sense of not that conversant @:with Maine's overall program., I think It is-- MS.,S@ILSBEE: I can't really speak for Mr. N ash, who is not here, but at the present time this'region is ade- quately funded, I don't think it Is going tD be-- it cut back some of their activities but I don't think it will hurt them, DR. JANEWAY: They don't fall peril to the fact the 449 4 0 state government'.was too forthcomino.- ? (Lau@hter) MR. PETERSON: It wasnt that forthcoming. MS. SILSBEE: Ms. Resnick. MS. RESNICK: Correction on the population; it is over a million. MR. PETERSON: I am sorry, it is over a million. MS. SILSBEE: WeLl, the motion has been made and seconded that the Maine program be funded at $lo760@000. MRS. FLOOD: I feel like Janeway, probably this is one we are really pointing with pride to and lauding and applauding, and then we cut them4. And although we may feel it doesn"t, hurt them, per- ha@ps our primary reviewer could tell us a little bit about the program strength as it relates to, you know goals and objec- tives. If it is all there, all put together, then why do we buy at this point a particular philosophy that apparently permeated one review committee, and we know has in the past been sometimes brought into play; is the capitation dollar spent in a state, which Isn't valid in my feeling as a way to measure the amount to be spent in a region, MR. HIROTO: I think there are probably three regions that have a superior -- and I may be wrong -- rating, and Maine and Florida, and there was one other, and they all tend 450 to be reduced somewhat if I am not mistaken. MRS. ARS: Feeling of compulsion. MR. HIROTO: I Just went along with the reviewers concepts. IC . SILSBEE: Well, do you want to reach all of this by a. voting on this motion? The motion is to approve it at the recommended leve I the committee gave, $1,76o,ooo. All in favor say ti aye, if (chorus of "ayes. ") MS. SILSBEE: Could we have your hands on that? I think it is weak, DR. WAMMOCK: I am sorry, I was out of the room. MR. HIROTO: May I suggest we go back to these par- ticular ones and review them. DR. JANEWAY: I didn't mean to open up a hornet's nest. I thought the staff had mOre,:@.dpmmen..te,ithan they get on whatever color the sheet is -- itis blue or something like that -- only when it is sitting on top of yellow, I thought it was green. You know, that there would be a comment that there 'was some padding on the part of the budget, or somethings MR. HIROTO: Doesn't say that. MS. SILSBEE: The staff member familiar with this 451 region is not here toOW. That is why I find it difficult. DR. JANEWAY: It is altogether probable they had full and sufficient reasons for cloiting it. I just don't see anything-- MS. SILSBEE! You are right. They originally had approved it at a higher level and went back and it was-- NR. PETERSON: No, they had approved it at a some- what smaller Level and added an,'additional LO percent on. MRS. FLOOD: Felt guilty and came back. MRS. MORGAN: Dr. Thurman was on that. MRS. FLOOD: No, not really, it doesn't. I have,a thing about capitation calculations. I don't think that the dollar spent in sparcely populated diverse climates and terrains can be measured against a dollar spent in a high Impact, highly professional setting, with a lot of availability of services. It bothers me a little, the thought there might have' been this thought taken into consideration when the funding level was recommended . MS. SILSBEE: We have a motion that was half-way voted and for $1,76o,000, and the "ayes'l were about to put their hands up so we could count them. (Show of hands) MS. SILSBEE: Four. All right, the nays? 43 (Show of hands) MS. SILSBEE: All right, we need another motion, MRS. bMRS: I would Like to make a motion that we fund the program to Its full request of $2,o2o,875. MISS MARTINEZ: Second. MS. SILSBEE: Motion has been made and seconded that the Maine application be approved at $2,020,875. All those In favor say "aye." (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response. ) MS. SILSBEE: The motion Is carried. The next region to be considered will be Metropolitan Washington, and the record should show Dr. Schreiner is not here. Mr. Hiroto, you are it again. NR. HIROTO: I am? Oh, my gosh. I have to remember what I read. The committee recommends and I move their recommenda- tion be approved, that there be reduced funding of $1,100,000 for the Metro Washington,, D.C., RMP. They are rated averageto above average. And their estimated request for May of 1974 is assu@4t@lto be $450,000. There are continuation projects requested and four new. 453 Several of these relate to kidney disease. Dr. Schreiner isn't here, unfortunately, MRS. MORGAN He wouldn't have been here anyway,. MS. SILSBEA- He wouldn't be allowed to speak to that. MR. HIROTO: No, he wouldn't. But conversation by the reviewers in regard tothe kidney disease programs tends, to make it seem extremely -- looked @,at with good favor. I don't know why the reduction the $172,385 reduc- tion. MS. SILSBEE: Mr. Stolov, is he here? Mr. Peterson9 MR* PETERSON: I can't really -- I haven't refreshed my memory on this one by looking over the transcript again, Some of the discussion certainly about this region was related to the fact that it had been a poor performer, an under performer up until very recently. It seems to have some heartening change in that regard, and it may be part of a general equation that it wasn't all that good, But, you know, I don't recall on Washington Metro D.C. there was a particular rationale. Here was a group of activities that they had qQes ions about, not the kind of consideration that went into the Maine decision. I do6lt recall anything from the panel discussion. 454 MR. HIROTO: There was a question raised about the $132,000 that was going to be expended for the comprehensive health planning@ but apparently that was okay. That is all that comes to me out of thait review. MS. SILSBEE: ALL right, Mrs. Klein, did you have anything to add9 MRS. KLEIN: No, I don It real Ly. I will second the motion. MS. SILSBEE: Do you move? MR. HIROTO: Yes. MRSI KLEIN: I think the motion was made. I will second it. MS. SILSBEE: All right. Motion has been made and seconded that the Metropolitan Washington application be approved at $1,LOO,000. Is there further discussion? ALL in favor? (Chorus of "ayes.") MSi SILSBEE: Opposed? (No @response.) MS. SILSBEE: Motion is carried. The nextregion is Michigan, and Mr. Milliken is the reviewer* MR. MILLIKEN: I would like to have a rundown by staff on this. 55 46 MRS. @RS: Can't hear you. MR. MILLIKEN: I would like to have staff give some backdrop on this before we get into it. The program has evidently slipped considerably lately and my question is,, alternative bf@ifunding them in a reduced amount or, on the other hands questioning their future? MS. SILSBEE: Questioning their what? MR. MILLIKEN: Their future completely. MS. SILSBEE: Mr. Van Winkle. MR. VAN WINKLE: Well, it was considered by the reviewers to be an average or below average region@, and if you;look at it retrospectively, this region started off with Dr. Hustis as a coordinator who is quite an able one, and after he retired, the program slipped badly. Then Dr. Tupper came aboard and brought it back up to an @,A 'region., At the time of the threatened phasebut,,Dr. Tupper accepted another position at"Grand Rapids,, Michigan, donating a portion of his time on a continuing,ba8is to this program. Judging from the application we would kind of feel that It has slipped under the new Leadership aLso, SewalL. We have some concerns about' what we see in the packaye the same as the reviewers did. The RAG is still intact, Again, we had Some concerns about the process, 456 looking at some of the program activities that are included in this particular proposal. I did raise the concern yesterday about the auto- mated territory peritoneal dialysis, with Dr. Schreiner, a nephr6logist., He'dlidn!t see;,ahy serious problem with this. He says it i,s probably not of high priority in the nephrology field. He sees nothing wrong with its but he didn't seem to think it held very high priority. The main concern I think that the reviewers had was the EMS activity that durirgthe previous four-month period or six-month perico, I am not sure, had been funded at a level about $37,000 and, as you can see in thisapplication, it junpeJ to $750,000. And they doubted seriously, after Looking at it quite carefully, that they could oven begin to carry out what they had laid out for them to do, even in this one proposal, in a one-year timeframe. MR. MILLIKEN: I gather from the committee's recom- mendation, it was felt that there was a potential of at least effectively using that much under the present circumstances? MR. VAN WINKLE: Yes. MR. MILLIKEN: I would then move the committee recommendation be funded at $2,500,000. MS. SILSBEE: Is there a second? MRS. MORGAN: Second. MS. SILSBEE: Dr. Wammock, did you want to comment? 457 4@8 DR.WAMMOCK: I came to about thesame conclusion herc- that has beenalready pointed out by Mr. MiLliken and Mr. Van Winkleo about the project being average or below average. Twenty-four-hour statewide emergency dr ug analysis feasibility study, I don't know about that. Neighborhood pharmacies and hypertension control, I don't know about that. And EMS, as was pointed out already, $36,000 a year previously jumped to $750,000. These were things I picked out actually before I got this review here@ trying to figure out which way we were going* The vocational educational center to plan to develop systems for continuation, regional health calLs, Renal .disease, radio and television spot announcements. And then educational program for automated renal dialysis, renal failure, raised some doubts In my mind, and there a-re 4L projects here. And it looks Like It will take a lot of sweep- cover all those projects. MS. SILSBEE: Do you think that the reduced funding level will alleviate some of the concerns that you mentioned? DR. WAMMOCK: I think it would have to reduce it to some level or other, I would think it would. I am sure that the reviewers have gone over this in great,dlepth much more so than we have had the opportunity to do, 458 to analyze thiathing and review it. But with Milliken's observation hereo I think that we are all thinking about in the same direction that there has been overheating of the stove here, you know, and that something has to be done to out it back. I think the recommendation here-- MR. VAN WINKLE: They cut roughly $1.3 million. DR. WAMMWK: -- $L 3 million -- has got to cut something out. They can't carry no 141 projects. No way they can do it. Did you get a second to t? MS. SILSBEE: Yeso we did get a second. Mrs. Morgan was very helpful to second it, DR. WAMMOCK: Thank you. MRS. FLOOD: My only concern would be the advice notifying them of possibly reduced funding, if we vote this particular way, would be that theybe advised that the EMS component would more appropriately be under the new legisia- tive actions rather than from this source, I would hesitate to encourage them to even use a portion of their now reduced funding to continue this kind of a massive EMS expansion under their responsibility. DR. JANEWAY: Except there are certain things in RMP, specifically say you ought to get into EMS area, directed activity. 459 MS. SILSBEE: But not $73,000 level from $750,000. Now, the motion has been made and seconded that the Michigan application be approved at $2.5 million. Is there further discussion? DR. WAMMOCK: Yes. MS. SILSBEE: All in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. The next application to be considered is Missouri. And Mrs. Morgan is the reviewer. MRS. MORGAN: In the comments here, reviewing committee 'Dr. McPhadrin, who used to be on this Council, was primary reviewer. You can read it and practically feel he is in the room again, (Laughter) He goes on to say he had received additional materia. since receiving the Missouri application, but he hasn't changed his mind a whole lot. It amounts to really coming down that Missouri has had a tendency to go along with what the needs were with the current legislation. It hasdone very well at this4 When it was;computer bioengineering type output, theN, 46c) were very, very heavy on this. And It was extremely difficult over the years to get them to turn off of it. They would far ha,v-e@preferred to stay that way. Finally, it has, in this proposalt,be turned off. There is one question, and this is among theirrumer- ous I believe it is LI proposals of EMS, totaling about $600,000, and they appear to be rather fragmented proposals, none of them are into a statewide unit. Ithink that the recommended funding was lower than what@they 4ad.roqu@$ted of@about $600,000,, approximately the amount of their EMS proposal. They werei rated average by the reviewers Later when they compared it to other RMPIS they rated it superior as far as this goes. YiS. SILSBEE: That means there were two reviewers, one rated average and the other rated it superior. MR. POSTA: And the superior was based on gran,t8man- ship. (Laughter) MRS. MORGAN: And they,have done very well over the years* I agree with the Review Committee in that these many EMS,ProposaLs are quite a bit of money for a Lot of little o rd;inated into a state EMS that are not very well c o statewide organization. And if they used their money made 461 available to thems they should be -- or we should be assured that they are working towards a statewide comprehensive pro- gram. I go along with committee recommendation of $2@364,333. MS. SILSBEE: That is a motion? MRS. MORGAN: Yes. MRS. MARS: Second. DR. JANEWAY: Right on target. MSi SILSBEE: Does staff have any comments? MR. POSTA: I would Like to bring up just one and,, Leah, feel free to add anything to the Regional Office as far as comments* Again, back to the EMS review group, it met on Monday and Tuesday of this week. There were two planning grants b. 'Oroved, about $45,000 eachs one to the (b) agency in Columbia p tight In the center of the state, and one at Kansas City. Now, EMS has been considered a number one priority of the Missouri RMP. They have put in an awful lot of money. It was a concern of the @nel review group on Monday and also from the HEW regional office who submitted their comments to us, that before any further EMS activity lsfunded by the RMP, that the Governort council shouldbe consulted to be absolutely assured of what types of activities would be funded throughout the st ate in this area. 462 53 Leah,, would you like to make any other comments? MS. RESNICK: Except to emphasize that EMS project proposals are really stemmingf!rom their state law -- they did not feel that -- the new legislation would give them enouah time to develop a total plan. And so they wanted to go ahead and try to help the communities meet their requirements as best they could within the coming year. State Law is an emergency medical services standardi- zation law requiring certain equipment and training of atten- dants on vehicles. MRS. MORGAN: Is it funded by the state? MRS. RESNICK: State law is just a regular authority for them to go ahead. So far they do not have money; they are hoping to get it through legislation. Mb. BILSBE.W: Notion has been made and seconded, Dr. Jpneway. DR. J.PNEW@Y: We may be into it again -- I wonder if the primary reviewer or staff had co@nts? I hate to ask about proposals -- CO42, pilot model, new health legislation? MRS. FLOOD: Yes. (Laughter) MRS. MORGAN: Go ahead, I don't have that. MS. RESNICK: The reviewers observed that and made a strong pitch against supporting not only C042., which Is a 463 central program operation but the Liaison district offices which are part of this total plan, and plan pending new legis- lation. DR. JANEWAY: That will be in the recommendation? MS. RESNICK: Definttd.Ly. MS. SILSBEE: All right, motion has been made and seconded the'Missouri application be approved at the level $P-y36@4t333. ALI in favors (Chorus of ayes, MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion carried, I also should say that is one of the shortest re- views of Missouri on the case. Noxt is Mountain Statea. Let the record show Mrs. Klein is out of@the room and Dr* GramLich was not present during the review of this application. (.At this point,Mrs Klein withdrew from the room.) MS. SILSBEE: Now, Dr Wammock. DR, W@MMOCK: Four states: Idaho, @:'M6ntanao Nevadao and Wyoming* I appreciate thib compliment. The overall request was $2,409,356. Committee recommended $2,.50,000. This was above average. 464 55 I am sure the revie wers would like to discuss this program and then I will make some comments along here if I have them-- if I have0t lost them* Yes, there they are, right here. MS. SILSBEE: Do you want the staff to sa something y DR,WjiMMOCK:@ I think It would be appropriate here, because there is a situation, not an epistle here to this sitaqtion, so we are going to take a-- MS. SILSBEE: Okay, Mr. RusseLl. do you want to do it? Or Miss Flythe? MR. RUSSELL: Miss FLythe and I just spent an entire week in Intermountain program reviewing, review process. We were extremely impressed with not only the review process, but the management of the program where one has the regional office, which serves four states, each of those statez having their own office and staff. One just coularit help but wonder what type of management problems might be encountered. We Were very, very impressed with the communications among the staff, involvement of the program directors, involve-- ment of the Regtonalkdvisory Group; as we told the RMP, v felt there must be something wrong and we kept looking hard and harder -- just couldn't find it. It was a very rewarding visit. We also got a much deeper appreciation of traveling in"@ that type of geography in a rural area. MRS. GORDON: In -April, 465 MR. RUSSELL: It is quite an experience* They do have a travel and communication problem which I think they have overcome very well. I would like to ask Mr. MerO,-ker,,,@who was there at the same time, looking at their management review, their manage- ment process; so broad, just fill us in very briefly on the capability of the Mountain States as management. MR. MERCKER: The very first of April we conducted the routine administrative review,,of@,@the:,management of the Mountain States Regional Medical Program. We found their managementto be complex,, but very, very effective and very well carried out. It starts with the Regional -advisory Group,, which is extremely active,, all members participating on site visits,, all members serving on committees. The work of the Regional Advisory Group is tied together-- that is the city work by the Regionalhdvisory Group itself. In the same mnner and paralleling It, the program staff related very, very well to the Regional Advisory Group; there were four states as you know, each one having a state office) program staff, hnd the work of the four state offices is similarly pulled together by a regional office in Boise, Idaho, the central program staff. The"greadtee has good, sound management practices 466 -)7 which,were well implemented by the appropriate staffo some years ago. They had direct control of the program, both the administration, finance, and also the program itself. Thir-L; has changed and they have assigned functions tc the@@'Proc,,rafti staff,, which nO@7 carry out the administration of the p@ogIram.- again, it Is compLex, the structure would seem to be one'that@woulcl be difficult to operate,, but it operates @.extremely'well and they@lhave a high level of interest in manage- ment and they communicate things verv effectively. MS. SILSBEE: Thank you. Dr, Wammock, do you have anything further? DR.WHMMOCK: I think it's a little difficult to be- labor some o-L' these programs he-re. There are over 32 here, anj' the recommendation from $2,,409,356 down to $2,15OOQOO would probably take care of some of these little thi@ngs that I have jotted down her6o Probably correct themselves without any difficulty, mnd don't believe it would be worthwhile,to takml up anybody's time to discuss, It has been reviewed; as I say,it is a four state mechanism and it has been reviewed, given "a ove average.'l There are a few other things here and there. MS. SILSBEE: Louciero please. DR, WHMMOCK: Such as activities of the physical ,assessments skills for@nurses, and so on,, Then the other 0 467 thing was a serious question is raised as to the validity of Regional Medical Programs financing supporting the basic curriculum of nursing schools, another one was shared service projects, shared cost of materials at the Nevada Hospital Association. Here Is one, mechanism of development of activities, community child health abuse, I understand that is a pretty serious problem. -another one related to PSRO. I would move that this program be approved or $2ol5O;OOO. MRS. FLOOD: I will second the motion. MRS. GORDON: Two hundred or one hundred? MRS. FLOOD: $2,150,000. @lthough this region always seems to come up with pluses and not to lessen the glow that all of you had on your recent assessment visits, and indeed their process gives impeccable, if possible I think it also leads to an additional problem that is sometimes not viewed by a survey visit, such as you have just accomplished. hnd that is, from the applicant level or the consumer level: if I will, and they find that this very, very precise process that began with WICHE'lat I'@ the time that it was really control- ling the pro ram, and Hank is ih@-8till@,today, it is a very 9 difficult process to wade through to get a project funded, and they find the system less than responsive. 'Mnd most of the 468 proposers of projects in that region find by the time it gets through that process, they would have preferred to have soLght help from one of the overlapping RMP's and'oftentime8 do. Which in some cases,@aggravates the turf problem. I would urge, I am in accord they have got a good record and the funding Level is probably most appropriate but I would urge that staff work with this fantastic adminis- trative and review process to hussLe the process through, which I think in the long run will help overcome some of the turf problems. MR. RUSSELL: I think this point is well taken,, but I would hafflebo-- havin watched th@ process and the type of 9 programs that are developing, and I will use as an ex mp e what has happened in the area EMS. Recognizing that@i8 a popular program, very much needed one in all three of the state@ we witnessed in Nevada,, Idaho, and in Montana how the approach o.-L" the Mountain States Regional Medical Program, through its core staff working with the communities, bring- ing them In; starting out in Nevada$17,,QOO CHP@, in a very @short period of time thil@l- covered the state and involved a number of the contiLirners. The Mountain States approach i6 one of a programmatic regional approach which I think they have done a very nice job among those L.'Lnese Now, you are absolutely right,lthe process involved-- 469 and this is where the turf problem has created an-awful lo t cf prob lems 0, here is where we saw CHP I s Playing @a-i e RMP against the other. MRS. FLOOD: Yes, sir. . RUSSELL: Thi@ i,- where we recognized the Interregional Council. It Lb referred to as the Inter-tribal Council. (Laughter) But it has not been effective. Ana we felt it was that councils job to get their own RMP in shape to elim- inate thi--i type of turf problem. MS. SILSBEE: But, Dick, what I hear Mrs. Flood saying, and I think this message shouW get back to the Regional Medical Program, that their very fine structure should be looked at in terms of its responsiveness in that it is so long for an I-V to get through the process. I think they shoql@ be made aware this concern was expressed. MR. RUSSELL: We did feed this b,,-,ck at the end of our review process. MS. SILSBEE: I think we need to do that agah MR. RUSSELL: Fine. MRS. FLOOD: I will add one further comment-. It all falls up there in this turf situation aiid,the Tri- regional Coordinatorl@,@ Council, I see th t reviewers questioned a portion of the 470 Wyoming EMS project and again that is right back in the Tri- region -- you know, Coordinator's meeting. ,nnd it will never be fully resolved. But is there any serious concern that this compo- nent section is a complete overlap of services? MR. RUSSELL: I don't think there is really, because we found the e','Lationships between the Mountain States program and the Colorado program to be very, verv good. MRS. FLOOD: Thank you; Those were my questions* MS. SILSBEE: Okay, motion has been made and seoonde that the Mountain States application be approved at the level of $@,150,000. MR. MILLIKEN: Questions MS. SILSBEE: nlL in favor? (chorus of "ayes.1t) MS. SILSBEE: Opposed? (No response.) MS* SILSBEE: Motion is carried. Will someone c-@ll Mrs. Klein in. @t this point, Mrs, KLein returned to the room.) MS. SILSBEE: Next application is New Jersey. Dr. Watkins. DR. W.'hTKINS: Finds itself superior In all respects$ according to reviewers, Original request was $3,970,024, and the recommendation 471 62 is $3,190,000, and sometimes you start to be concerned when I say superior in all respects. The committee concurred this was superior, a super-or program, well utilizes funds made available to it. mimost $800,000 was reduced. It shows therE is involvement in quality of care,, in excess, shows ther,@ is inner city where attention setting quality for standards, and so forth, shows an involvement with the CHP groups, except one CH (b) sent a Letter which was later refuted, so that that is the main questi6n@here,, why it wa@ reduced. Maybe one of the reviewers can tell me. MS. SILSBEE: @Mr. Peterson? MR. PETERSON: One of the chairmen- I think the principal rationale here had two components to it, going up tc the nearly $4 million level requested. There was some ques- tion whether they could hope to mount that Level that quickly and they also saw them coming in at least with air anticipated $6oo, I think it is $600,000, roughly. They certainly did not, a,ki they did in some other things, say here are a number of activities which we think are questionable. It was more along that rationale. Whether it was valid or not i6 something else again,, but there was some real concern about jumping up to almost a $4 million level; aLthougi the staff has hung together fairly well, it has been reduced and that was the principal thin& as I recall It, from 472 3 refreshing my memory with the transcript. DR@.ViTKINS: With that explanation, I would there- fore move $3,L90,000 be given to this programi MS. SILSBEE: Is there a second? f4R., MILLIKEN: Second. MS. SILSBEE: Miss Martinez, MISS MiiRTINEZ: I only have one comment. I thought the proposal was very good. My only comment is in New J6,rsey, which h,@d such a heavy Spanish speaking population,, absolutely none, no Spanish speaking persons on the @ig:in New Jersev. MS. SILSBEE: The record should show there is a PSRC proposal in there to the tune of about $225,000, and I have been trying to reach a man, he calls me vhen@1I am out of the office and I 0611 him when hc is out of the office, with the PSRO staff, anu- that will have to be resolved before New Jersey put any money into that portion, But we will handle that from a staff end. Dr. Janeway, DR. J@NEWiiY: How can an RMP organiikb@6 PSRO? MS. SILSBEE: That,is the question; we can't. DR. JHNEW@Y: It is agin the lawo isnit it? MS. SILSBEE: Right. It is just@la matter of clarification of what that-- and It Looks, from talking with the coordinator., tha'-u is exactly what they,are about to do. Mnd we will just not allow it,, because it::@is against policy. 473 MR. HIROTO: We have h,@d several related PSRO'S. Ms. SILSBEE: Thalv will be generally looked at. MR. HIROTO: Okay. MS. SILSBEE: Motion has been made and seconded that the New Jersey application be approved at the level of $3,l9OoOOO. Is there further discussion? .All in favor? (Cho.L,us of "ayes.") MS. SILSBEE: Opposed? (No response. MS, SILSBEE: Motion@earried. The next application to be considered is New Mexico, anCA lot the record show that Mrs. Morgan is out of the room. (fit this pointi Mrs. Morgan withdrew from the room.) MS. SILSBEE: Mrs. Gordon. MRS. GORDON-. New Mexico was supposed to have a new director as of May lst. I assume that transpired? MR. POSTji: Yes6 MRS. GORDON: -And sometime ago they expanded their @G to 120 members. I Qn(lerstand thi,,. was in response o criticism. MRS. W,IRS: How many? MRS,, GORDON: 120,, Which I fount-I to be just--fanta-,zti'c 474 DR. JjiNEWjiY: hrkansas has 100. Everybody in the whole state. MRS. GORDON: I don't see ho@,7 they can have a mean- in6ful group of tha'u- size functioning. Somebody wants to fill me in on that a little bit? I would be happy to have them. MS. SILSBEE: Do you want that discussed right no@-? Mr, ZizLausky. MR. ZIZU@USKY: Dr. Gay came aboard L971. His criticism vas.a small group had been making decisions. (Laughter) So he decided to increase it and makc it more repre- sentative of all interests. mnd h@ has brought it up to We were kind of watching to see where he was going, and he brought It down to 73 people nowo in the application, One part of the application it states 120; in the othor place., there,arn 73. MRS. GORDON: I sort of gathered attrition made It 730 MR. ZIZ@USKY: They actually sent out pink slips to unatbending @G members. MRS. GORDON: So they are weeding out the nonpartici- pants. MRS. FLOOD: If I may add a point of information, New Mexico is our immediate neighbor anC4 I am a little familiar 475 66 with wha'@ they di@ on that @G and it was phenomenal. BuL they did regional concepts in a sen,-@e. The state is ver,, ,@@diverse in both climate, terrain, attitudes, and service cappabilities,, and so Dr.,Gay's concept was a developments of a sort of subregional @G concept,. They were.all @G members, all invited to the total PI-.G meetings but there were also some specific assignments of responsibility to'b6 spokesman for the southeastern section or northeastern section. And id did, I believe, become a little unwieldy be- cause occasionally,, believe it or not, they darn near puZh@d @a hundred something at some meetings* MRS. GORDON: Then do they have GS i6@: addition to all of these ILG members? MS. SILSBEE: No, I think she lz saying they serve In thc- local advisor@-, capacity,, have functions, MRS. GORDON: Same people then? MS. SILSBEE: Same peo le. p ICS. GORDON: That n),g,kes it a little better. The reviewers seem to feel that most of the projects were actually or as I interpreted@it, program staff projects. But' as I understand It, as r. Waimnock said the epistle @'the DRMP staffdjfi not agree with this assessment, is that correct? MR. LIL@USKY: Severai,Oi@' their project wtivities were people with the universit,.,This was a problem two,years 476 ago. We askpd them tu identify these people as project direc- tors,, provide a project number and @k(- 6ure It haU three-yeax funding, notcome under the arms of the university once the pio- ject ceases. There areas few project activities here which are program staff people, but they are not all project staff people directed to this project. MRS. GORDON: Says something about being physically in the same building, but not-- MR. ZIZ@,USKY: Program director's program staff are physicially located on the University of New Mexico cam- pus, and some are in thesame building. MRS. GORDON: The Executive Committee of RAG met twelve times Last years so I assume from that that the execu- tlive committee had major responsibilities. .6nd, of course, I think with a @G of L20 or 73., or whatever is in between, that you would almost have to have that. They were rated average, with recommended funding of $1@644,754. I gather primarily because they were rather ambitious. Some of their programs, such as the neonatal Infant trans- portation, In New Mexico -- I would question that activity in jQst,about any place except New Mexicoo or some other terrain such as that. Then they talk about project 25, "should have technical 477 review, site visit, by 6ut"6f-state consultatns who are familiar with the R@ project." Could you comment on that? MR. ZIZUUSKY: Yes. MS. SILSBEE: WouLd you speak up a little. NR. ZIZ@USKY: This Project was originally, oh,, about two years ago, originally request6d about $400,000. The site visit team recommended approximateLy at, $LOOOOOO level. The phase-in and phase-out,, now increased their @requcst again, reviewers thought they would,perhaps were quite ambitious for theirreque8t for their activity, and they suggested since everybody -- well, discussion@from the Review Committee was since everybody is involved with this type of activity,, maybe they need some out-of-state-'reviewers to come in and take a good, hard look at it, NRS. GORDON: This is health education and as I read the projects it seemed to be they were going to produce or had hoped@to produce aucliovisuals and this sort of thing on their own, MR. ZIZLHUSKY: Yes. that is correct, they submitted seven or eight audiovisual films,, HEW clearance. MRS. GORDON: Because of the particular nature Of their population, MR. C@MBLISS: I think the Council should know that 478 we had a demonstration of health education to the public from New Mexicoo right in thio room, jind We were less than impressed with the entire approach. We felt that a good bit had been made of it, but little was coming from it, I simply throw that out, just for your information. MS. GORDON: @s you can see, the committee recom- mendation is quite cut, and I assume that this particular project 25 would be-- MS. SILSBEE: EMS project proposal is for $9LI.,OOO alone. MRS. FLOOD: If we took their funding from January through December 31st, annualized it,, what would be their current funding? MS. SILSBEE: It is apprcKimately $1.1 million, MRS. FLOOD: Thank you, MRS. GORDON: So in view of these considerations, I would recommend, I move the adoption of the committee recom- mendation of $1,644,754. MRS. KLEIN: I think I am going to second that, but I would like to ask a question first, if I may. I notice that these reductions-- MS. SILSBEE:, We can't hear you, MRS. KLEIN: I am sorry. jis@was pointed out, the reduction is substantial in 479 comparison with the amount of money requested and it says that the project objectives could not be accomplished within one year. And then on the estimated requ-,st of May 1974, they.haven't requested anything. I was wondering particularly in these emergency medical services in a state Like New Mexico with a variety of topography and problems of transportation, similar to what we have in Idaho I think, if they were not able to attain project objectives within a year, consequently the fonds were not-- the total requested were not granted for that particular pro- ,@'ject number 18?, Would they have an opportunity to come in and ask for additional money if they haven't made this request as @of May 1974 In other words, the funds for that particular projert would be@ cut off at thel@end of the years to which this grant applies? MS. SILSBEE: That Is true. MRS. KLEIN: -knd they won't have anything to go beyond that? MS. SILSBEE: That's right. MS. KLEIN: Even tough they haven't accomplished all their project objectives. I wonder if that is a good idea? MS. SILSBEE: Well that is sort of the basis on which most of these programs have requested their funds. 48o iis a matter of fact, New Mexico has not requested anything beyond June 30tho have they? MR. POSTji: No. NRS. FLOOD:. .6t least the printout doesn't show MRS. KLEIN: Maybe they failed to request It on the basis of having requested this mote than adequate funding, in this one. MS. SILSBEE: I think some background on the EMS proposal is in order. Frank,, could yougive an idea how long that has been supported? NR. ZIZ@,USKY: This project activity started July I,, 1972, so we are going into the third year, Essentially the project director put a third and fourth year request into a one-year request. That is why the money has ballooned, youknow, quite substantially. That is basically it. MS. SILSBEE: WoulL, you speakLp, pleaseo Frank? We just can't hear you down here. MR. ZI;LLMUSKY: This is in its third year of fundinS, and they started July Lo 1972. @nd they essentially put a third and a fourth year request together aW this is what the huge expansion of the project in the request. MRS. FLOOD: Could I ask, Dave. Frank Is familiar 481 with what the status is of the Governorts Division of Highway and Traffic Safetyp and their purchase of radio communica- tion6 equipment. Mt one time the Governor was going to allow some funds ava!Labilty for radio communications linkages rom vehicles to land bases, hospitals,, and perhaps even make available equipment to link Into the mass helicopter poten- tlal that is based in Fort Bliss, at El Paso, Texas, which real- Ly serves a greater region in El Paso than it does Texas. @nd if the Governor's office does indeed fulfill this equipmen part of it, what do they want almost a million dollars for;tha; sounds like equipment money? For one year. MR. zIZLiUSKY: I am not familiar with what they are doina, in southeast New Mexico part of the EMS proposal, They have had a very close linkage with the I)epart- ment of Communications, as well as their own L)epartment Of Transportati on. All these people around the Governor's Blue I on Committee, when the state receives their I)e@ rtment of Transportation fundso the project director for New Mexico RNII sits down side by side and they select the sites. -The same thing goes for the communication equipment; they @have just received-- Robert Woods Johnson grant for EMS, for communication equipment. I haven't seen a copy of that grant I don't know where that equipment. is intended to be, the 482 site selection. MS* SILSBEE: Frank, am I not correct tha hey were trying to put in this application those things th@,they might need if the Robert WoodsJohnson money didn't come throLkh and if some of the EMS money did not come thro@gh? NR. ZIZLUSKY: Right. We have learned that the N,g,vejo health authority has also received moneys but a third of it spills over into the corner of New Mexico. Robert Woods Johnson has come through for them. Possibly we have to check it out, but possibly Presbyterian Medical Services also in New Mexico has received a Robert Woods Johnson Foundation grant. if they received the grant, you know, I am pretty sure it is safe to say there won't be any duplication, They may have a little excess, MRS. KLEIN: Madam Chairman$ I will second the motion. MS. SILSBEE: .1',Il right, motion has been made and seconded New Mexico application be approved at the level of $1,644,754. Is there any further discussion? MR. MILLIKEN: Questions MS. SILSBEE: .IL in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? 483 (No response. MS. SILSBEE: The motion Is carried. The next application to be reviewed would someone have Mrs. Morgan come in -- which is Northern New England, which is really the one. (At this point, @MrS. Morgan returred to the room.) MS. SILSBEE: Northern New England, Mrs. Morgan. (Discussion off the record.) MS. SILSBEE.- Northern New England,, Mrs. Morgan. MRS. MORGAN: T never did quite get this through here, what all is included in Northern New England. MS. SILSBEE: It is really Vermont, MRS. MORGAN: It is really Vermont? Okay. The Review Committeeon North rn New E gland did e n recommend quite a cot In what they had requested, even though the region is rated above average to superior, Their feeling is that the program as requested, as proposed, was all a continuation of projects with quite an iftdrease in funding. Program staff was $430,800, almost 47 percent of the total amount requested, Because these were on-going projects, the Review Committee felt that this was a little high, particularly in program staff portion. 48 Th-- committee recommended that the application be reduced to the level of $700,000 with a stipulation that high priority be given to thi@,,i region for increased Level witt, the July application seeing what the new programs were going i;o be, were going to consist of when they come in with the July application. In going through this, it does appear to be a very good program. The coordinator has been there approximately a year, They do have a good review system. I feet they just did not have the time to put in for Ti--w programs, which will probably be doming in in July. Therefore,, I will go along with the committee recommendation of the reduced level of funding of $700,000, which will certainly keep them in operation, ready to do many of their programs, anC with the fact that this region be considered for high priority, depending upon the committee's review for the July application, MS; SILSBEE: Do you move? MRS. FLOOD-. I will second Mrso Morgan's motion an@ for my information the present grantee Is a nonprofit corpore- tion? MS. SILSBEE: The Pres6@nt-- Mr. Gutdello I will nee4 your help. The present grantee as of thi,,@@ moment is still the 485 76 university, is it not? MR. G-RDELL: (Inaudible) MRS. FLOOD: .6s of July I it becomes-,- MS. SILSBEE: That has been an action under way for sometime and has to do with the concern of the Relwional @.6dvisory Group at the high indirect cost rate the university poseso so thiiD doesn't have anything to do with the nev.'-Iook or anything4 This is outcome of that concern. MS. FLOOD: My question was pointed towards that bec,q,u@qe I recall the high indirect rate from Northern New England program and wondered how long this endeavor had been undergone in the process of development, because some @of the vacant position@,, that they reflect in their personnel, core personnels accountant, comptrollers and I wondered why these positions weren't filled if the transition had been ac- complished sometime ago. iind these were the services thaG had always been questioned as being high priced from the uni- versity. But again, it is one of tho@e gold stars type of areas that did a lot for the region 'anel I can do nothing but confirm the recommendations in light,of the high staff costs to await the quality of review for the,secondary application. red of f er@ ad vice f or ng consideration at that time. g trol MS. SILSBEE: The motion has beei4 made and seconded thal'i the Northern New England application be approved at the 486 level of $700,000. DR. W@MMOCK: Qu@stion. MS. SILSBEE: ALI' in -favor? (Chorus of "ayes.") MS. S SBEE: pposed. (No response.) MS. SILSBEE: Motion Is carried. Yes, sir. DR. JANEWAY: Now, sometimes I feel compelled to come to the defense of what is termed more or less perjora- tively indrect cost. And I wished that someone would come up with a name that Is better than "Indirect cost" or "overhead," or whatever you want to call it. Because if you are an honest grantee, grant recipient, the calculation of indirect cost, to use that term, is additional costs caused by reception of the grant, And pursuant to it, And Is demonstrable as a very well accounted item. I understand how everybody feels about -it, I just fe,l,t compelled to make that comment. (Laughter) Because it bothers department chairmen too. MS. SILSBEE: Well, In this particular instance, you would be interested to know that your fellow dean, Dr. Lukenfield, is one of the leading proponents of getting this owt of the university and into a nonprofit organization. 487 78 DR. JANEWAY: He and I share many common idea,@z,but-- MS. SILSBEE: You are right, you can't just make a blanket statemnt. But in this particular instance$ they felt they weren't getting the services somtimes. MRS. FLOOD: That was my only wish to add also -- n) one is unhappy to accept the high perhaps percentage of indi rect cost rating by an institution when it is a grantee if Indeed the: program gets the support it needs. But we do find regions who have fu-ll accounting staffs,, full personnel departments full evaluation -- even planned separate compute'.' systems while their grantee gets this high percentage of in- direct costs for supposed services offered* DR. JANEWAY: That is not right. MS. SILSBEE: All right, having resolved the inclire(,t cost issue -- (Laughter) -- we will go to Northlands Regional Medical Prograi. And the reviewer there Is Dr. Watkins, DR& WATKINS: We come to Northlands and find that the reviewers regarded overall as below average or average. And, of course, it would seem that that was based on the fact that It is low staffing, lack of activity., and prima,ry care, and possibly funding of PSRO. However, this program has a history of excellence 488 in its performance so we are going to say that denotation is not the best, I guess, for this program. However, it does show that there are IL EMS and 4 QMP -- 11 emergency medical services programs and 4 PSRO, or what have you. And run the gamut through the nonspecific programs from clinical pastoral ministry tothe Mayo Clinical based health education. Even with all this and with the fact it seems to la(k someumgination, I would ask that the $1,700,000 as opposed to requested $1,889,395, $1,700,000 be given to this program. MS* SILSBEE: Is there a second? MRS. MORGAN: I will second it. MS. SILSBEE: Do you have a comment, Mr. Van Winkle', MR. VJIN WINKLE: Yes, if I could,, please. The committee was concerned about one activity tha@ they considered to be a PSRO activity. Mr, Wilkins was on the phone only yesterday morning with us, and the foundation for health care evaluation, which was to be the recipient o'i"these funds, has indeed been declared to be a P6RO in Minnesota, and Mr. Wilkins said that th,-@t pcLrticLAIr,,r contract will now be giveiR @o the State Hospital Association to carry out the intent of the contract, which would eliminate, as I understand It, the concern of the committee. MS. SILSBEE: The motion has been made and seconded 489 0 that the Northiands application be approved at $1,700,000. Is there further discussion? MR. MILLIKEN: Question. MS. SILSBEE: All in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response. MS. SILSBEE: The motion is carried. The next application be be reviewed is from Oklahoma, Mrs. Mars is the primary reviewer. MRS. MARS: This program was rated average and below averagot which means there were two reviewers. The latter was based on the review of the applica- before they,had a chance or he had a chance to study the compre 6nsive statement, regarding their concept and objective,,,. Actual@,ly I like their present concep as seemed 1) reach out to the grass roots and worked upwards, Their program thrust and emphasis seems to be on the Under-served rural areas of Oklahoma, and Certainly this should be that way since Oklahoma is a very rural state. The major thrust of the program have been successful -ALL their original continuing education centers are functional They have a teleconference network which will soon be expanded to include most of the state areas for programs go of health manpower development skills Improvement and education. The RAG composition Includes Indians and blacks. They have not neglected their minorities. They have a well-balanced RAG with 54 members. This has retained really a remarkable continuity of membership, which has provided a very high Level of understanding of both health needs and capacity and function of the RMP to meet those needs. They have budgeted for staff increase of seven more additions, which doesn't really seem to be justified. There is apparently do assistant director and der- tainly the director does in this case need an assistant. Also there are some secretarial positions which are vacant at the moment, and which would be necessary even to help terminate the program if nothing else. The fo.ur (b) agencies have been approved@ the individual ProposaLs and the (a) agency generally concurred. On the whole, I think it is a fairly good Program. And I would concur with the reviewers' recommendation for $L,062,237, against their request of $1,382,2480 MS. SILSBEE: And you so move? MRS. MARS: I so move. MS. SILSBEE: Is there a second? MRS. MORGAN: I second it. MS. SILSBEE: Our seconder will second it. 491 (Laughter) is there any discussion? Okay, it has been moved and seconded the Oklahoma application be approved at $io62,237. ALI in favor? (Chorus of "ayes.") MS. SILSBEE: Opoo8ed? (N6 response*) MS, SILSBEE: Motion is carried. The next application to be reviewed is Oregon, and Let the record show that Miss Martine:zl.is out of the room. And the reviewer is Dr. Wammock. Just wait until she gets out, (At this point, Miss Martinez withdrew from the room.) DR. WAMMOCK: This application is, for $i,20L,357, and it is approved and it was assessed as being superior. There is another epistle with this, and I would ,address this to the reviewer for his comments on thiso because I think he has this much better than I do: Mr, Russell do you@@have Qregon9 MR. RUSSELL: Yes, sir. DRO WAMMOC:K: If you would,, pleasep@ then I will com- ment on it or come back to it4 MR. RUSSELL: I have nothing to add other than what i:; 492 @3 in the green sheet. Historically this RMP has had an outstanding record. DR. WAMMOCK: So the green sheet has really covered, in essencel,,,what you have covered in your review? MR. RUSSELL-. With the Review Conunittee, yes, sir, the transcript. DR. WANMOCK: All right. Oregon has continued to be an exemplary, well- managed program with strong Leadership. The region has a viable Regional Advisory Board with a good review process, The relationships with CHP's are good. These agencies are apparently involved in program planning. New staff has and is being recruited to fill existing vacancies. The on- goir)g @ancl proposed activities are well developed and in line with program objectives, I was rather interested in the statement here about how many of the new activities are going to be processed through or managed by the University of Oregon, because a great many of these are around the University of Oregon. Andjust the numbers, I out'l,of 10 or 10 out of 10,, or number of these projects will be managed through the university. NR, RUSSELL: I am not quite sure what you are took- ing at or what the reviewer was looking at when those comments were made; but, of course, the University of Oregon is the grantee. 493 Now, there are a number of program staff activities which the program staff monitor provides surveillances so therefore as a subsidiary of the grantees It shows up Universi y of Washington -- University of Oregon is the sponsor, DR. W.AMMOCK: That is what, In essence, It boils down to. MS. SILSBEE: That's right. It just so happens there are ten of them, staff. I just counted them. DR. WAMMOCK: One individual pointed out here Oregon 'is'tryin-- to keep@the people from coming into Oregon and also led the story in gas rationing. This struck me very interesting In description of one of the projects,, about family and self-help education pro- grams, and I think it worth-while taking a moment to read this., "Citizens frequently make poor decisions regarding common day-to-day health problems. "Injudicious action often Leads to inappropriate utilization of scarce health resources, This problem can be particularly acute in isolated rural communities or In o her health scarcity areas, "Major cause seems to be lack of' practical guidelinel' for making health related decisions# As a result, people are 'prone to seek professional care when it is unnecessaryt avoid expert care when it Is necessary, impose improper folk remedies and fail to employ simple useful and proven home care 494 areas. This not only applies to the rural areas, but applies to the urban areas." I don't see anything -- I felt it was a well prepared document here; the Oregon program. It is easy to read$ to go through, and table of contents, et cetera. I'conie to this peer review quality assurance program again;, that crops up, and also shared service program for hospitals and related agencies in the south coast of Oregon, the only two areas I looked at. But wouldn't make too much of a quibble about that. So I would therefore move that the recommended Sum of $1,20lo357 be approved for the Oregon program. MS. SILSBEE: Is there a 66cond? MRS. MORGAN: I MRS. FLOOD: I second. MS. SILSBEE: All right. Mrs. Morgan, you were the secondary reviewer on that. Would you like to second? MRS. MORGAN: No, just knowing Dr. Reinsctmidt and being familiar with the program, you can rest assured it will be well spent. MR. HIROTO: On this 028 group purchasing, is tha',-. institutional hospltp,,i group? They really didn't have to do that. It is covered under lvledicare-Medicald laws, 495 That is all. MS. SILSBEE: O@av, we will make a note of that. The motion has been made and seconded that the Oregon application be approved at $1,201,357. -Any further discussion? -All in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried. Dr4 Janeway, thank you very much, (Discussion off the record.) MS. SILSBEE: Could someone call Miss Martinez back again. (.At this point Miss Martinez returned.) MS. SILSBEE: The next application for review, you w 11 be pleased to know we only have four more to go. @t's have a slight break. (whereupon, a short recess was taken.) MS. SILSBEE: Would the Council come to order. The next application to be considered is the Rochester application, and the primary reviewer is Mrs. Klein. MRS. KLEIN: As you can see by your I guess aqua coL- ored sheet MRS,$ GORDON-. Now she has got it, 496 87 MRS. KLEIN: -- the reviewers rated this program as superior, add recommended that all of the money they reques- ted be allotted to them. -And I certainly would go along with this, I think the two reports that I reviewed show the difference between a bad report and a good report. This one, even a person as uninformed as I am could be'very wettlr-very@reaclily understood. They set forth their programs with clarity. They @even outlined their objectives and in great details and put a dollar value on each one of them. -And gave a graphic history of the staff. -And had a number of other Informative graphs in this report that I thought were excellent. It was a short report and very readily-- it seemd easy for me to understand anyway. I enjoyed it. MRS. GORDON: Is this Rochester? Is thlb Roche.ster@ New York? Minnesota? MS. SILSBEE: Yes, it Is Rochester., New York* We should be clear. That is the headquarters and it covers that tier of counties below Rochester. MRS. KLEIN: As I say, it set forth its goals and its objectives very clearly and the funding and asked only for really a continuation of very small program and a small staff of I guess about ten people. And just gave them a 497 small increment in salary. And they had several Well defined projects Which were, as I say, outlined ingreat detail in the report. And I certainly would feet that they ought to be allowed this amount. I noticed, too, that they,are asking for about over a million dollars in new funds on the next application probably to institute some new proposals with a good nucleus o a staff. So I would move that the amount that the committee recommended, $361,437, be allowed. MS. SILSBEE: Second? MR. MILLIKEN: Yes. MS. SILSBEE: Mr. MILLikenoas secondary reviewer, do you have some comments? MR. MILLIKEN: No, I have been on a site visitthere. It is very good. MS. SILSBEE: The motion has been made and seconded, Rochester application be approved at @',36L,437.@ All in favor? (Chorus of "ayes.") MS. SILSBEE,. Opposed? (No response.) MS. SILSBEE: Motion is carried. The next region to be reviewed is application from Tennessee Midsouth, that covers Nashville and the eastern 498 89 Tennessee and the area around NashviLles The reviewer is Mrs. Mars. MRS. MARS: The assessment of this program is that of being average.,'-, However, Ithink it is a fantastic program since September of 1973, they completely dissolved their RAG In facto the RAG dissolved'it Pelf. and reorganized itself as an entirely new Regional Advisory Group, This apparently was very necessary if the program was 'going to successfully continue, The significant improvements included were in the bylaw revisions and grantee responsiblities were limited. A definite limitation was placed on the size of the RAG, bringing it down to 36 members, The term of office for RAG members was limited., and there were adequate conflicts of Interest provisions included# So this has changed the whole more or less course Qf,the program. And now they are beginning t o move into an outreach program where the needs were so great@ Tennessee, of course, being again a very rural state, The new chairman Is medical director of the Universi;y of;@Tennessee, and they also have a new coordinator. He was with the program from 1968, but he has now been acting and is coordinatot as of September, I believe, of L973, somewhere in that area. He hasnit been in that position too long. The former coordinator got fired and I think by the 499 grantee, and both the men, the one that was fired and the present one is a University of Tennessee man., so they all seem to get along all right. The money that they have requested to the sum of $2,133,972, seems to be in order. However$ I would suggest that when they request another $850,000 in JuLy and August review, that it be looked into very carefully and examined, before It is granted, They have a good past performance. They did carry cut their priorities in the past. They funded 68 separate activi- ties in the past two yea@ and the budgeb as now in the applica- tion 49 percent is budgeted for continuation activities and 37 percent is budgeted for new projects, L4 percent is budget- ed for staff. There are eight new projects. Six of these relate to rural application health districts, one concerns a disad- vaotaged area, and although solm of these new activities are classified as continuation. Many of them have come about since November of 1973, since the reorganization of the RAG. So that in a way, 1 suppose you can term them both new and continuing projects, I therefore move that we do accept the recommendation of $2,133,972. MRS. MORGAN: I will second, to get it on the table, then I have a question. 500 MS. SILSBEE: All right. MRS. MORGAN: I wonder, on their current staff, how one can be considered full-time professional and still be located as a full-time professional outside of the RMP office? MS. SILSBEE: Lee? MR. VAN WINKLE: Which one are you speaking of? MRS. MORGAN: Under six full-time professionals, one of whom is located as full-time professional outside* Is 'he full-time professional still in the RNP but outside? MRS. MARS: His worki yes. Carries regional through the state. NRS. MORGAN: All right, that is all I wanted to say. MS. SILSBEE: Mrs. Flood. MRS. FLOOD: I notice reviewers questioned the Logic of a cancer program for the timeframe of potential funding. But yet the topic listed in the printout Is that of lung cancer detection and in this particular region of the country, this is a particular problem. CouLd someone expound as to was the project perhaps that of screening detection and planning for long-range care, or something of this natures that it was not feasible wi hin the timeframe? MRS. @RS: Which program are you referring to? 501 MRS. FLOOD: It is numbered 93, Mrs. Mars, and in the printout it is called lung plan, lung cancer detection. MR. VAN WINKLE: Life adjustment, life adjustment to can-cer. MRS* FLOM-. That is, 92 is being questioned; 92 is being questioned MR. VAN WINKLE: Yes o ma I am. MRS. FLOOD: Thank you. MS. SILSBEE: The motion has been made and seconded Tennessee Midsouth application be approved at the level of $2,133o972. Is there further discussion? DR. WAmmock: Question. MS. SILSBEE: All in favor? (Chorus of "ayes.") MS. SILSBEE: Opposed? (No response. ) MS. SILSBEE: The motion is carried, Incidentally, Mrs. Mars, the rejuvenation of the RAG, and so forth, was not done without a good deal of prodding from staff here. MRS. IMRS: Staff here. It certainly needed it obviously, MS. SILSBEE: That has been a problem for some years The next application to be reviewed is from Virginia, 502 and let the record show Mrs. M-@rs is out of the room. (At thl's' point, Mrs. Mars withdrew from the room.) DR. WATKINS: Virginia was reviewed and regarded as average. They are asking for only $1,000,000. It seems that Dean Perez,is still doing the job that he has done before, that is allowing some of his staff to remain-- positions toxemain vacant. It shows a preponderance of similar projects reflect ng some lack of imagination. However, he has followed the guide- ,lines of RMP objectives and authorities. He also, I saw this over there, he also has accom- modated a number of disciplines, Including RN's,, and it shows dental hypertension project, pharamacist, and he does have these on his RAG'S. I saw this when I was there,, In facts he does have even a dietician program. So I would Like to recom- mend that he gets the $1 million -- in fact, that Is my proposal., he gets the $1 million, MS. SILSBEE: Miss Martinez. MISS MARTINEZ: Second. MS* SILSBEE: She seconded it. The motion has been made and seconded that the Virginia application be approved at the level of $L million. Any discussion? All In favor? (Chorus@@of,,"ayes.11) 503 )4 MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: The motion is carried. But I would like to clarify the record, Dr. Watkins, their request was at $1,290,000. DR. WATKINS: Thank you. MS. SILSBEE: Okay, could someone bring Mrs. Klrs back in and we will do the last application, which is from Western Pennsylvania. (At this point, Mrs. Mars returned to the room.) MS. SILSBEE: Yos. MISS bMRTINEZ: Western Pennsylvania, rated as an average. I agree with the rating of the committee. I would like someone from the staff to clarify the concern@that it had with the kidney projects or the Review Committee had with the review projects MS. SILSBEE: The concern was primarily in the wording of the page 15, which made one of the reviewers think thatthey were developing transplant centers in more than one place. This was not the case; they have got one center, and satellite hospitals that relate-- in other kinds of services. So we feel that concern has been alleviated. MISS WRTINEZ: Okay. I do have two other shortcomings-- I hate to sound 504 95 Like a broken record, but they have no Spanish speaking persons on their RAG. and secondly, I noticedsomething when I was looking at the staff, in administration, they have someone, a woman, called "administrative assistant," who receives a lower salary than "executive secretary.11 Now, I think if she Is a secretary or clerk, she should be so named. Because I have seen this happen so often, when,people want to count a woman in professional administra- tio@n e e which has nothing to do with her to give h r a titi salary or duties or anything eLseo That is a question I am addressing to whether that is the case or why the title if she 'it not an administrative assistant. MS. SILSBEE: I really don't know the answer to that but I will be most happy to ask the region that question. As a matter of fact, Miss KettLe, who used to be witA staff@ made a big point of that in site visit one time, MISS YJARTINEZ: Okay. In that case I would Like iu move that the committee recommend $1,370,285 for the program, plus $170,285 for the heart function be approved. MS. SILSBEE: Is that plus or-- MISS MARTINEZ: Isn't it plus? Oh$ it includes? Sorry. Amend that to include,, including the Mahoning,.@@Shenangb project. MRS. MORGAN: Is this to make sure the Ohio project 505 is good? MS. SILSBEE: Yes. MRS. MORGAN: I second, then I will get it on the table. MS. SILSBEE: Let me explain a little bit about the Ohio project. This is one of the activities that was supported in that special ear-mark a couple years ago, health services educationactivities. At the time the Northeast Ohio Regional Medical Program was phased out, that program had been funded for a couple of years, money was provided there. It was moving alony, well, And so for a year we were able to fund it as a 910 activity Because of the court order and the wording of it, we could not continue in that capacity, so we asked Western Pennsylvania if they would agree to fold this into its program and monitor the activity and they did agree. So $L70,285 for that project represents the request of the.,project. Mrs. Flood. MRS.@FT,OOD: I am not familiar with this region., and I@am not sure who the grantee Institution Is, MS. SILSBEE: University of Pittsburgh, MRS. FLOOD: University of Pittsburgh, So there @W ould be no problem in continuation monitoring of projects 25 50@ 7 and 26 into fiscal 76, which their request does reflect funding for fiscal '76? MS. SILSBEE: The action of the committee in cutting back on the funding was to -- they felt that those additional dollars should not be allowed at this time. MRS. FLOOD: Fiscal'76 portion of the fund? MS. SILSBEE: However, in terms of your initial question, the capability of the university to continue, I don't think there would be any problem along that line. MRS. FLOOD: This was the rationale. MS. SILSBEE: They didn't put any kind o restric- tion on that$, but at the 661L,-,r level they were making that s@gestion. MRS. FLOOD; Thank you. MS. SILSBEE: Mr. Hiroto. MR. HIROTO: Yes. I am repeating myseLfo but there Is something, $31,000 in there, about quality assurance, Agair, is that going to make dertain-- MS. SILSBEE: Yes, we will make certain on that. Let's see, you were the secondary reviewer. Did you have any further comments to make? MR HIROTO: No. MS. SILSBEE: The motion has been made and seconded that the application from the Western Pennsylvania Regional MedicaL Program be approved at the Level of $1,370,285, which 507 ,Includes $170,285 for the Ohio health education project. Is there further discussion? @All in favor? (Chorus of "ayes. MS. SILSBEE: Opposed? (No response.) MS. SILSBEE: Motion is carried and that ends the review of the 53 applications. (Applause) DR. WAMMOCK: I have one other comment if I may. DR. PAHL: Go ahead. DR. WAMMOCK: ArticLe about RMP.,"As I knew him, the rise and fall of an idea," and it ends with a quote, mourners are urged not to send flowers but money." (Laughter) MS. SILSBEE: That is from the New England Journal of Medicine. Before closing, I thought the Council might be inter- ested in the overall recommendations that have been made. You have added funds to the committee's recommenda- tions to the tune of about $3.7 million. You added money to Central New Yorko Intermountain, Lakes Areao Maine, Nebraska, New York Metro, Texasi and Tri State. You took money away from Susquehanna Valley. The total difference in the amount of all of these 5o8 actions was $3,648,458. This means that the committee recommended the level of $85,o47,597. MRS* WRS: What? MS. SILSBEE: $85,047,597. The Council recommendati-ohs'.totaled $88,6960055. DR. PAHL: Thank you very much, Judy. Dr-, Watkins, DR. WATKINS: Tell me brevity is the soOL of wit, so I will be very brief. This Council shows aiimix of jocularity, mental agility., and mental alacrity and I want to say I am happy to be back. (Laughter) DR. PAHL: Thank you. MRS. PMRS: Very happy to have you. DR. HL: Before we adjourn, I have just one or two comments, particularly for the new members of Council. It has been a baptism by fire and I am sure it seems like almost ages when I welcomed you yesterday morning to sit on the Council. NRS. GORDON: "Sit" is the word. (Laughter) DR. PAHL: I am glad to see we have solved the long-standing problem of "indirect cost." I will pass that word on to the appropriate authorities in HEW and elsewhere. 509 It is particularly interesting also to see and Listeii to the humor, and I think I will remember about C'Zechoslovakia and sheriffs for sometime. (Laughter) Very seriously, again, I remind You that you have probably worked harder with greater workload than any Council I have been associated with in this program, MRS. MARS: Except for the last one. DR. PAHL: We were somewhat reduced in numb6rs:. MRS. WRS: Yes. DR. PAHL: But you have also set a precedent todayp and I have just been doing some calculating and I think the August Cot inch meeting should run no longer than about wo ours and eight minutes if you stick with the same kind of good activity. But very seriously, you should know thet the recom- mendations that you have made will, of course, be Looked at and I am sure there will be great interest by the individuals who sat here yesterday morningo and indicated to you their interest In the direction of the program and charge you with various kinds of responsibilities at that time, I feet veryo very comfortable. I would Like you to know, to represent both the Review Committee and the Council in its recommendations on each and every programs, I feet that you faced up to some very difficult decisions. 510 101 There have been some good discussions on complex issues. The record is well documented. And I would want you to knowthat I am probably more comfortable at this time than any time In recent months in defending to our own -Administration the quality of the review throughout this entize process. It will be a pleasure to be able to sit with them and indicate just what recommendations have been and why we have reached those. So without holding you furthers I hope that we can see you and others back-August 8 and 9, and we will be most happy to respond to questions and inquiries in the interval should you have any. Sewa,,l L? NR. MILLIKEN: YoQr remark about production, I don't think we could have done It without the unusual staff work that has been done, very well done. MRS. MARS: We owe you a Vote of thanks. DR. WAMMOCK: It has been a great help and I am @sUr@, the constraint of time here has really been some h ng. DR. PAHL: Mrs. Silsbee may Indulge in a predinner hi'hba,li this eveningp@for a job well done to her and the staff. 9 A lot has been done behind the seeneso as you all know, Thank you very much, 511 I declare the meeting, adjourned. L02 (Whereupon, at 3:27 o'clock, P.m.@ the meetino, was concluded.)