were Re hg SANE HSER AEE AE ECM SEIN DS WET ininieaalliimintnepiiorineanpaanbeictinic yi tia ee aaa) DEPARTMENT OF HWALTH EDUCATAON ANG WELFARE — DIVISION OF REGIONAL MEDICAL PROGRAMS 4 MM r wel : y Maryland 2 HOOVER REPORTING COMPANY, INC. Official Reporters Washington, D.C. 546-6666 pt 2 kad DEPARTMENT OF HEALTH, EDUCATION AND WELFARE MEETING OF AD HOC CONSULTANTS REVIEWING REGIONAL MEDICAL PROGRAM APPLICATIONS Conference Room H Parklawn Ruildina 5699 Fishers Lane Rockville, Maryland 29852 Thursday, May 23, 1974 Panel 83 convened at 8:49 o'clock, a.m., Mr. Peterson Chairman, voresidine. PANETT Bs sak (As heretofore noted.) (Continued) AFTERNOON SESSION Pegqional Medical Plan for Western Pennsylvania Motion for recommendation Virginia Reqional Medical Program Motion for recormendation HEY Pacormended Medical Plan for the Metronolitan New York and the Lakes Area Motion for recommencation Motion for recormencdation HEW Recional MeCical Program for the State of Marvland Motion for reccmmencetion HRW Recional Medical Plan for the District of Columbia Motion for recommendation ty cd = 188 THE CHAIRMAN: Now if we are going to get into these Senate type protocol, we're not going to get fourteen regions done’ todav. [Laughter. ] DR. McCALL: I'm not sure whether I accept the floor under those circumstances. I'm sorry Bill is not here. I wanted to point out to him that I find another "“Sunerior" region, but that I'm not one that came in with two volums of elaborate amplification ver s@ -- but just tne opposite. A avarter inch, non- bound, non-color, black and white application that is one of the simplest, clearest, most concise applications that I've yead -- and it's simple for a lot of reasons: One, is the state, itself, and they they have developed the program, but also because this application is a reauest for support for staff, and only two continuation projects -~- with the plan to come in for all of their new programs in July. And that is clearly as stated here, it is a recion that came in rather late in terms of the overall -- 56 RMPs that ultimately was our peak -- so that they came in, develoned their program based on the needs of the recion, developeé their vriorities, stuck with them, haven't had to shift them -- they have a strong staff and reqion advisory groun leadership and an intecrated program that has been consistent, right along. 189 t 4 And I have already mentioned that it's really a staff ae 44 broposal, primarily -- just two continuation projects -- just I think the feasibility of their accomplishina, in the hight of what they say here . what they have done in the past, is axcellent -- and while there is not a lot of information on PAP relationshins -- there is nothing that indicates there is hniy problem now there, at all. Shey are requesting, now, 663,132. the only thing I Would point out there is that there is a siqnificant indirect cost in this that has come up before, about 130 some odd -- or 136,663 which was indirect cost -- but that is an established thing that we couldn't do anything about at this point in time. it merely call it to your attention. Ind I think I'll stoo there. The Peqional Advisory Group is a littie heavy on the brofessional membershiv, but it's there -- I don't think it's a Berious problem. THE CHAIRMAN: Paul? DR. TESCHAN: We have no reason to disagree with anv- thing that has been said. It's a pleasure to read a proqram ! that has not only been able to carry -- not onlv been able to hccumulate funds currently, and arrange ongoing funding -- but mo is able to accumulate funds concurrently in multiples ~- f.e., where they #7ill put in half a million and they will be aw 190 running about a two to three million dollar program ~- that when PMP was going to phase out, the Governor and the State Government were ready to take the staff on. It looks as if they are as far along becoming the follow operation of RMP as any region that we have come across. We have known Charlie, in operation of West Virginia, because it's a membership in the Southeastern Group and we have been aware of this development in the general direction, up to.novw. Thev seem to accomplish more interaction, and starting of more services and developina of manpower, with fewer dollars than almost any group we are aware of. So my recommendation -- if I ean preemot the dignity of my predecessor -- I would recommend funding as recuested. DR. MCCALL: I'll second that. THR CHAIPMAN: O.K. Before we open that un -- as Charlie did indicate, this is a very, in one sense, a very modest application -- a continuation of program staff with funding -- a slight expansion in view there and a counle of projects -+ so that it totals $663,090.09 in round numbers. They do anticipate coming in with a major supplemental application inJuly for $1.2 million. . DR. McCALL: But that, added to this, would put them above the target. We're recognizing that. But I think we are in a position to let them make at 6 191 - the judgment of what they do come in with, in their new committee. > THE CHAIRMAN: All we knew -~ this is one of the reasons -- this is one of maybe eight or ten, where the initia] application is, indeed, restricted to continuation and to program staff -- and all of their new activities will be reflected in the July submission. O.K., Norm, are there any comments regarding CAP or this matter -- I recall West Virginia has at least considered, over the vears, some possibility of disassociation from the a f Q 2 University - a sort of -- MPR. NORMAN ANDERSON: Any Agency Director is a Member of the Legal Advisory Group, and they did recommend avproval of this particular apolication. And as I said, it has been previously approved by the agency, since the work is continuing on schedule. The major thrust of the program we can anticivate in the next application, will be on the State-wide basis, as opposed to the individual project, or community basis. Now I think it probably will be the size that they will get. DR. TESCHAN: They have helped build PAC agencies in an area. | THE CHAIRMAN: Tom, do you have any particular insig: but I'm not sure whether that ever got mucn beycn “ aA Nd cr at 7 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, B.C. 20002 192 snto this as regards West Virginia? MR. SIMONDS: Well I think Norm summed it up very well. That's a pretty good state. : THE CHAIRMAN: Most of West Virginia is still that way, I know. We do have a recommendation -- but are there additional I ' comments, questions, observations. MR. BARROWS: I would like to ask a question, just - a matter of my own information: What qualities, as you fellows see it, accounts for this marvelous support on the part of their constituency? DR. McCALL: The usual fact of strong, capable leadership involving -- MR. BARROWS: On the part of the coordinator, or do they have a good RAG too? DR. McCALL: I think it goes on further than that. MR. NASH: The coordinator, the university, and the force of the medical society -- They started off with -- had the RAGs to start with : and they haven't had to shift. They have been right on target throughout. MR. BARROWS: The university and the medical society are united -- i.e. -- they both agree. Now, I didn't say the relationship was . good between the medical society and the university, but both units support the RMP. { | | | | t t 8 DR. TESCHAN: There's a very important phrase -~- about half of one line in the application that says that, in working | i i 1 with the medical societies in the health delivery area, they have restricted their activities to their legislative franchise. And then the thing goes on. | Well, anybody who reads English in the context that | we have all experienced it, will know exactly what they mean. That says that Charley's been very careful as a non-MD, he's been very careful and he's working with full understanding © with the people who might otherwise take umbrage. MR. NASH: That's right. THE CHAIRMAN: I think I've observed something --~ this isn't just West Virginia -~- it does seem to me that in those states which have, perhaps less in the way of health resources, institutionally and otherwise (and Maine falls into that category certainly) and during the phaseout period, they seem a little more, for whatever.reasons, anxious to preserve what little they've got, including the RMP, than some states where there is almost an embarrassment of riches, in one sense. I don't know that that's an axiom, but I have that impression that in places like Maine and West Virginia, they seem to be, or to have been willing -- and I think they have had good programs there, to try and preserve the RMP with state and other funds, moreso than had it ‘een Michigan or HOOVER REPORTING CO, ‘NC. 320 Massachusetts Avent:2, NE. Washington, D.C. 20002 HOOVER REPORTING CO. INC. | 320 Massachusetts Avenue, NE. Wachinsian TC PAW? 194 Illinois, necessarily. DR. McCALL: But I think also, in addition to that the good leadership, good program -- a lot of needs relative to the resources. THE CHAIRMAN: Yes. DR. McCALL: But also, a rather homogenous noncomplex region, too. You know there has been a lot of competing institutions and people, so that they were able from the beginning to focus it, and then have not only the need to recognize their function but they were productive in it -- and therefore, you can rally when the legislation gets shot out from under you. People come in and say: This is a worth while thing, and -- MR. NASH: There's a motion. THE CHAIRMAN: Yes, there is a motion, but are there any other questions or comments? If not, we have a motion to recommend approval of the amount requested, $663,000.00 which has been seconded. I call for the question. [Approval of the amount requested was put to vote and carried unanimously. ] b 1 195 wt 10 THE CHAIRMAN: O.K., again we are still short Bill Thurman. He's got three black marks now -- but he can afford it, he's a dean of a medical school and he's got enough major insecurities without worrying about black marks from the Chairman. [Laughter.] I wonder, Sister Ann, since Bill isn't here, if we could again improvise, and ask you to review Oregon? Laced This is a region where we only do have a single ‘reviewer, Sister Ann, since Dr. James is not here. SISTER ANN: There is a staff person here. THE CHAIRMAN: Yes, there is a staff person here, Dick Russell, and he's just coming up here. OREGON | SISTER ANN: Oregon is presently at the $767,000. level and they are asking for $1.2 million. They are bringing in three new activities, and a total of eight projects, and they plan to come in, in the July review for a project at the cost of $200,000. The program, from what I can read, and I .questioned a few people who were there on a site visit, and apparently it has been a good program over the years. From the material that is presented in the book I was able to identify a strong program leadership, with staff, with the regional group, that has a good review process and apparently it functions adequately. HOOVER REPORTING CO,INC. =, 320 Massachusetts Avenus, NE. Washington, D.C, 20002 pana car cere 196 The Regional Advisory Board select projects and wt 11 assign priorities, and they do this through three standing committees, by which this is accomplished. It was interesting to me that the coordinator of the program is really in control of three projects with a total of $360,000. You might want to comment on this, this is rather interesting -- it kind of indicates the style of leader- ship in this program. , MR. RUSSELL: Yes. SISTER ANN: There are eight professional staff and — there are three vacancies that they hope will be filled. Credentials could indicate that the staff is well qualified. Their job descriptions are well written, and if they operate within that framework, they should be able to do a good job. In the past, they have had adequate technical review, problem analysis, and documentation of need and technical soundness. “They have also addressed themselves to efficiency and containment of costs -- and this would appear to be on an ongoing basis. : The project, submitted in two ongoing projects (approved but unfunded projects due to phaseout directions) and the new activites not reviewed by the Board -- the methodology for achieving the goals listed on page 42 of the project -- and I won't read it -- if the methodology is HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 wt 12 HOOVER REPORTING CO,INC. 320 Massachusetts Avenue, NC. Washington, 0.0. 20002 198 followed, it's very adequate. The three priorities are ones that were established by the Federal Government -- the availability and accessibility and improvement of following, and containment of reduction of costs -- it would appear that they would be able to carry out the projects in the allotted period of time. and the CHP relationshps appear to be good -- although as I looked at the letters and concurrence on the last project, I noticed that there was no return on about 50 percent of them, which kind of conflicted wth some of the other impressions that I got. And these are the main things that I picked up. THE CHAIRMAN: I think Sister Ann was the only reviewer, but I think perhaps you will want to elaborate on this -- MR. RUSSELL: Well, let me respond to Sister Ann's questions, because I think they are very pertinent questions: The one that you didn't quite understand the 50 percent return -- was this of letters? SISTER ANN: Yes, that's right. MR. RUSSELL: Oo. K. This is a matter of procedure as part of the oregon structure. They have a CHP subcommittee and all the project applications come through that subcommittee -« so they do have input there. wt 13 HOOVER REPORTING CO. INC: 320 Massachusetts Avenue NE. Washington, D.C. 20002 199 — i And in the applications for Oregon, I think it was only nine of those did not respond formally. But the CHP relationships are -- SISTER ANN: Yes, that is very good. MR. RUSSELL: Now in terms of the staff, they do show two professional vacancies. Now those vacancies have been filled. They, you know, knowing that it is sometimes difficult to recruit just on short time, they are using interns from the Ten WICHIE program -- The Western States Commission for Higher / Education. And these young men are on board. SISTER ANN: I think there were five they were going to bring in -- is that right? MR. RUSSELL: Well there were only two vacancies on page 53 -- SISTER ANN: Yes, but five interns were going to be hired into those vacancies. MR. RUSSELL: No, I think there were only two as I understood it, and those two are filled. Now the three projects which Sister Ann referred to which show the coordinator as project director -- which, I believe would be a CHP priority as 1,. if I remember correctly. The other is an emergency medical service consulta- tion. Yet he is not project director, per se -- it's that these funds are controlled through the Program Staff budget 200 and all of that money will be subject to Regional Advisory i wt 14 '| Board review, and approval. You are right, the Regional Advisory Board is aware of them -- I sat with them for their four-hour meeting to look at the applications, and they have been very much involved, and it has been a very strong program. DR. TESCEAN: How many of the new activities are going to be processed through, or managed by the University “of Oregon? Just in round numbers ~-- one out of ten, or ten out of ten or -- there are a number of these projects who will be managed through the University. MR. RUSSELL: Very few, if I remember. DR. TESCHAN: Well, when I seé the list here -- look | -- it looks as if they were managed somewhere else. i "A hundred thousand dollars to CHP priority" was the > title, and I was interested in what it was. SISTER ANN: But that, then, is when it was under [Dr. Rhineschmidt] and that -is under staff -- $900,000 and then there's another $150,000 somewhere -- it's total $360,000 under his direction, so he keeps it in the program,himse 1 i DR. TESCHAN: What do they plan to do with that? Can you tell from that? SISTER ANN: No, I can't tell from the application, but apparently the staff is going to address itself to the HOOVER REPORTING COLINC. - 320 Massachusetts Avenue, N.C. Wasrington, B.C. 20002 wt 15 201 management of it, but I would think that CHP is going to be involved in the planning, and I think the various agencies in the -area. are going to be involved in providing the services. MR. RUSSELL: What : this is -- this is, you know, in keeping with the emphasis being placed on the particular relationship -- DR. TESCHAN: That signal, I got. I wanted to know the content -- I can read this myself. MR. RUSSELL: And they have a number of activities that now are in the developmental stage. These will come in as projects -- go through the advisory group interview, and then will be approved and awarded to individual CHP agencies. DR. TESCHAN: I gather the decision is exactly what the content would be -- it's open ended. They wanted to get some staff resource to move in that direction and to have it earmarked for committee for that purpose, to get the signal to you all and to the rest of us on that. [Reads from the document.] what they are saying, you see, the law is that they have to do this and most CAPs or many, would say: This in our experience has not been ready because they didn't have the basis to make the judgment. SISTER ANN: I got the impression that the majority of the funds for these programs, that it's really kind of a HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NUE. Washinginn DC. 20002 ‘thrust into the future as well beginning in the present, and | wt 16 HOOVER REPORTING COLINC. 320 Massachusetts Avent: NUE, Washington, D.C. 20002 202 i | i i 1 it really would be very difficult to kind of link chese programs together in the kind of a model that their Federal Government | talks about at the present time. Is that right? Does that reflect -- MR. RUSSELL: Yes. THE CHAIRMAN: Paul, with respect to the University of Oregon and the Medical School, I recently, on a flight, was | sitting next to somebody from the University of “Oregon, and I had the -- apparently, you know -- Oregon is a "different" state you see in many respects. They are trying to keep people out, and they led the way in gas rationing -- but also, its University is one that -- they are at the end of the line in feeding at the Government | trough . They get less money in terms of Federal grants percentage-wise, than any other medical school in the country. And the Dental. School won't even accept percapitation grants and that, you know, is almost unheard of. So it isn't surprising in one sense that despite the fact that the University is a grantee here, that very many... —- RMP activities now, or in my recollection in the past, has been university-sponsored. ‘DR. TESCHAN: You really must have a first rate coordinator out there too. : MR. RUSSELL: Not too long ago there was a management. assessment -- this was by a management program -- and the best 203 wt 17 i. can remember, the only recommendation was that the grantee ought to buy some curtains for the RMP Office. MR. SIMONDS: Well, that's a little exaggeration. [naughter.1] | | a DR. HEUSTIS: Well, while you folks feel sorry for “the university, I know that they are getting $163,000.00 in indirect costs. -- MR. RUSSELL: I didn't say I was feeling sorry for ‘it, Al. THE CHAIRMAN: I seldom have bled for a university. SISTER ANN: But you know, for a university grantee, they get the lowest amount. DR. TESCHAN: What's their rate? . SISTER ANN: oh, I think it goes up to 60 percent in some cases -- DR. TESCHAN: And how low -- MR. RUSSELL: 40 percent for salaries and wages. THE CHAIRMAN: Well, this is an application for, ‘again, in round numbers $1.2 million. They have estimated that they will be in with a very small supplemental, roughly $200,000.00 in the July request -- but this is their major request. The total of those would be, again, almost theix target level figure of 102 percent by our calculation. HOOVER REPORTING CO,INC. 7. - 320 Massachusetts Avenua, NE. wt 18 wt 18 HOOVER REPORTING CO,iNC. 5 320 Massachusetts Averve NE. Washington, D.C. 20002 204 Any other questions, or any other comments? Sister | Ann? SISTER ANN: I recommend that they get the amount that they are asking Hr -- $1.2 million. Their target is just 102 percent. I believe in rewarding good programs. DR. HESS: Was that a motion? SISTER ANN: Yes. DR. HESS: tll second it. | THE CHAIRMAN: We have a motion and a second, to approve, or recommending the funding at the level requested, $1.2 million. Is there any further discussion, comments, questions? In that case, the question. DR. HESS: Let's vote. [The motion was properly put to vote and carried unanimously. ] wt 19 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, D.C. 20002 205 THE CHAIRMAN: Again, unanimous ~- we're just continuing the complacancy of yesterday afternoon. DR. HEUSTIS: I think the Chairman should find a better word than "complacancy." THE CHAIRMAN: Everything, in the eyes of the beholder, Al. | Well, we are still missing Bill Thurman, so we're going to continue to extemporize. DR. HEUSTIS: If they ever subpoena these tapes, I would just hate to have anybody think we were complacent. THE CHAIRMAN: Well I don't think they will find very many explicatives, or, on my part, many "inaudible" portions. As long as we are on the West Coast, and if John and Al feel up to it, we might want to take one tenth of our MP, namely, California, which in terms of population, past funding, has roughly come out that way. Al, do you want to lead off? Or John? Again, I don't know -- DR. HIRSCHBOECK: No, Al does. [Laughter. ] DR. HEUSTIS: You see, I have a voice problem, this morning. CALIFORNIA DR. HEUSTIS: Well, California is submitting two applications for this year, and the one that you have before yo t u | 206 is for approximately $8.3 million, of which about $1.6 million wt 20 is for the program staff. : | And they would estimate that with the July application they would come to $14 million and you can note, if you care to look on your white sheet that the RMP are prorated figures : at $12.5 -- so there are approximately $1.5 million ahead of what they were advised to do. They served the area of California with two regional | , offices, both of them (note) located near major airports, one in the northern part of the state and one in the southern part of the state. The Regional Advisory Group has established si goals and six program elements, and they will implement these. The goals are to be implemented through six programs, and they have assigned a percentage of funds, and have determined their priorities in this way to each of the major goals. The percentages are -- the largest, they held manpower at some 25 percent and the least is 4 percent -- with others ranging in between. The RAG is strong, stable, and very interested -- and this is judged by the attendance which has a very well- known committee structure. In addition to the Executive Board, there are three standing committees on program development, one on program \!review and one on evaluation -- and then they have what I like, HOOVER REPORTING CO,INC. | 320. Massachusetts Avenue, N.f. Washington, D.C. 20002 TARA On Onn wt 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, LE. Washington, D.C. 20002 ‘trying to define what our RMP role ought to be in each of the no oO cence: the program element committees in each of the areas -- and their charge is to develop programs and to monitor programs. Here, again, it seems to me that real guidance is provided to people that would request money, in what the money should be requested for. It came through strong and clear to me that the RMP Central Staff plays an extremely important role in actually coming up with the projects and i i general areas -- and trying to define what kind of applications they ought to address themselves to, and they actually have : pretty well defined criterias for the program development and provide actual guidance and request preparation -- I don't know whether they actually write the requests or not, that wasn't stated. It was stated that the nine RMP Area Committees that formerly existed, had been phased out and that the program elements committees had replaced these, and that the -- they were well satisfied with the fact that the volunteers were now doing -- at least I got the impression from the work, that they were now doing a better job than the good job they previously thought that the staff had been doing. The final budget, as requested, has been approved } by the RAG, and first of all, apparently in the process j the reports of the Program Area Committees goes to an Executive: wt 22 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, WE. Washington, B.C, 20002 208 Board, and the Executive Board recommends a division of the funds among the Program Arsas —~ and then the RAG makes the decision as far as the -- within that context, with regard to the applications. I think they have a really well defined review and approval process, which is adequately described and interestingly -- and before I reviewed this, I didn't know that this was exclusive. They used technical experts, apparently from outside the region -- but the technical experts work under the supervision of the Review Committee. The one matter that I felt was defective, and yet I am extremely understanding, because California is a pretty complex state -- and other large states have been having similar problems -- and that is: First of all, who speaks for CHP? And how do they effectively communicate what they think, to RMP? I gathered that RMP has, what I would consider an "arms length" relationship with CHP and that RMP was extremely strong, relatively, and CHP was relatively extremely weak and there was no described CHP development or input into the preparation of requests prior to the RAG action, except for the legal review and comment -- and that seemed as though at minimal, CHP ought to in some way formally be consuited about what they thought their needs and priorities were. Nm Qo \O t 23 Of course, the whole problem may be that they don't have any need for priorities that have as yet heen developed -- but that is rather reading between the lines rather than reading what's there. | DR. TESCHAN: Well, they have had seven years time to acquire -- DR. HEUSTIS: The staff is well seasoned and exper- ‘ ‘ienced, although substantially cut. They used to have approximately 50 percent of the total awards that went to staff and it's now down to 12 percent. The past results that I found, seemed to be impressive both with regard to the numbers trained and, I guess I have i 1 to interpret some of these figures, I'm not quite certain how meaningful some of this is, as far as the meaningfulness. We talked about new medical power resources created -- or "new medical people power resources created" and the number wasn't really very impressive. I think it was a little better than 2,000. But the access to care -- it seemed as though the two major provider systems that had been started and now were expanding with other funds -- they have given attention to urban Indians, and they have done some work with the California Council of Free Clinics -- all helping the under- privileged. HOOVER REPORTING CO, INC. 390 Massachusetts Avenue, N.E. | : 24 210 The record of continuations, the projects without RMP funds, was impressive. They said that out of 76 ongoing projects, or 4 total of 81 projects that had terminated since July, 1960 -~ 70 percent had continued with other funding sources. In the first year, it said that following the RMP discontinuance, the projects that had previously been funded over three years for a total of RMP funds, in the amount of $7 million ~- in the first year of going along with other funds -- the people came up with $4.5 million to continue what was going on. I thought that that was rather an impressive figure. The continuations supported by all kinds of money, including voluntary funds, university funds, hospital funds, State Governmental funds ~~ In the proposed program, they are trying to set up a network of what they call “Health Services, Educational Activities" to cover the entire state ~~ and yet some 14 of these formed ten of them are incorporated and four are developing -~ and these are supposed to improve the quality of health care for coordinated state-wide system for health, manpower, training utilization and health education. And again, it mentioned that over a hundred colleges and 120 hospitals (seemed low) and clinics were involved in this with some 200 people on the boards of wt 25 HOOVER REPORTING CO, INC. .|- 320 Massachusetts Aven, NE. | Washington, D.C, 20002 ell of directors of these organizations. In high bloodpressure control programs, they have a state-wide plan, and I thought it was interesting that of the 36 applications that had been received, the project said that sixteen were selected for funding. Then I think the others were, of course, pretty much - there. Again, as I indicated before, the thing that probably bothers me the most, and yet probably shouldn't bother me too “much, knowing what the facts of life are -- are the relationships between CHP and the Regional Medical Program. THE CHAIRMAN: Oh, I think Staff may have something to contribute to that -- we spent four days in California -- | DR. HEUSTIS: It is very difficult for a person with just the information we have, to evaluate the real meaning- fulness of the CHP comments -- whether they are just bemoaning the fact that they haven't been recognized and want to say some things, or whether they really have a beef and maybe the staff could be helpful there. But before we get to that, as far as my assessment was concerned, I have rated on the Review Sheet, all of the items from -- on the first page, program leadership, program staff, the RAG and the performance and objectives -- in the "good" to "excellent" category. wt 26 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, B.C. 20002 “But the column that I checked was the "Insufficient Data" On the second page, I had to break down the three items in the proposal, thinking that they were congruent and that they were addressed to areas of emphasis, and because I dién't know about the CHP input of plans, and because there were criticisms, I rated that down to "Above Average." And then on CHP relationships, I thought these were -- very -- I couldn't make the determination, and if I had to vote I would have to vote that these were certainly "Poor." and then the overall assessment of the program was "Above Average." . , And the recommendation was made that as far as the funding level, that we ought to know more. about CHP. And then. I should say after that that we need to have staff comments. THE CHAIRMAN: Well, thank you. | You have raised the matter of CHP. Perhaps I would : comment on that before we ask John, and then Rebecca can complement some other things, as relates to California region. Relationships with CHP there, are uneven, but even CHP relationships one to another, are uneven. Let me explain that: There are twelve B agencies in California and r think the relationship of the California RMP, with most of the medium-moderate sized ones (Fresno and the northern counties, Empire Valley, which is Sacramento) we met with, during the 213 course of our four-day visit, Rebecca and Sandy and I, met nt 27 with six B Agency Directors and the A Agency Director. The relationships -- I would describe those agencies as "Fair to Excellent." Much of this has been as a result of the Health Service Educational activities where the State is blanketed by those which have been sponsored by the California RMP -- again, the development has been somewhat uneven, but in many instances, one finds that these health service educational activities, most of which are now incorporated as private non- profit groups, are in a very real sense, the health planning arm, or at least an important adjunct of the lecal CHP agency. Relationship, on the other hand, with the three major CHPs in terms of population areas -~ Bay Area, Los Angeles, and SanRiego -- are arms length to "awful." MRS. SADIN: Well, LA was all right -- THE CHAIRMAN: Well, yes, LA -- at least the word we got was that LA wasn't doing anything, so that they weren't getting into anybody's way. | But some of that is a matter of personalities, I think. We found, for example, that in the Bay Area, the Director of the CHP (and that's sort of a federated CHP, as there are nine counties, and each of them with one exception I believe)-- ( DR. HEUSTIS: Yes, but it seemed to me that in HOOVER REPORTING CO, INC. > 320 Massachusetts Avenue, N.C. | Washington, 0.0. 20002 214 wt 28 addition to the B Areas, that every county had its own CHP, and to kind of sort out the comments it became very complicated. THE CHAIRMAN: . Well, the Bay area is an interesting CHP -- certainly the most vacal, outspoken, bidder, director we ran into, that was Don Ardell in the Bay area. He was having problems with his eight County Directors, and they sort of meet apart from him. Correspondingly, those B Agencies, and perhaps the B Agencies in general, but certainly the larger ones -- I'm not sure it's constructive, I think there was some destructive tension going on presently between the A Agency. and the area wide agencies out there. I think the RMP has, on the whde, pretty good relationships with the A Agency. Now part of that may be the fact that the A Agency is, comparatively speaking, poor so that it has been getting some money from the State EMS Office, or from the RMP, to do some of the things that it really hasn't been able to get State funds or State positions for. But the picture is a mixed one, but certainly based on our site visit, Rebecca has thrust in front of me here both our report to Dr. Paul and our feedback letter to Paul Ward -- while we did have some recommendations about their HOOVER REPORTING CO, «NC. |) 320 Massachusetts Aversse, NE. i Aico AT INA wt 29 HOOVER REPORTING CG, °XC. 320 Massachusetts Avenue, NE. Washinstan HC 20002 { 215 | relationships, I think there are more that have to do with details, that they really ought to do a better job in insuring that the letter, as well as the spirit of the law is followed. If for no other reasons, the defensive purposes. They were kind of sloppy in logging in things, and showing that they -- you know -- somebody wants to get you over a barrel --_ But we felt that on balance, that the requirements for CHP reviewing comment were largely being met in substance as well as technically. We did, also, have a chance to witness at the RAG ‘meeting we attended, that there. are several CHP representatives on there -- one from the State CHP and the area-wide agencies have a California Conference of CHPs -- it's kind of their "trade union" and they have a representative on the RAG and at the RAG meeting we attended an alternate member was sitting -~- the fellow from San Diego -- and they certainly, not only spoke out, and they had some objections, but the RAG took them under advisement to the extent that they deferred -- they were going to look into the matter and either accept them in whole or ignore them -- and I think, you know, that even that slight demonstration suggested to us that in the RAG councils they have the ability to make themselves heard. So it's kind of an uneven picture, Al, I don't -- wt 30 HOOVER REPORTING CO, (iC. 320 Massachusetts Avenve. NE. Washinaton, D.C. 20002 216 at least from what we've -- DR. HEUSTIS: From what you have said previously -- what comes up with what I get out of the thing -- I had written down a summary of the comments that had been made, and that | was marked in red -- and I admitted that the ones that I thought were important, and I had imported negative comments from | six of the twelve areas -- at least what I thought were impox- * tant negative comments of the six -- MR. BARROWS: I don't think we can charge them with the responsibility for resolving these intramural conflicts within the CHP. THE CHAIRMAN: Oh. no. MR. BARROWS: But we can grade them on their effort to relate to CHP -- and would you regard that effort (and this should be a positive one) as "Good" "Average" Weak?" ! THE CHAIRMAN: I would have to ask for Rebecca to comment too. My judgement, I guess, would be "Average" to "Good." I think there are some situations where my impression is that California RMP feels that it has walked the last mile. For example, when the Area Offices are abolished, that was a kind of a structured cross-over situation. When they abolished all their area offices and with them the area advisory committees, and came up with the Program Element Committees as a substitute -- there became a number of vacancies wt 31 HOOVER REPORTING CO, INC. | 320 Massachusetts Avenue, N.E. Washington, B.C. 20002 217 on various B Agencies -- you know our slots targeted for the RMP, we found in the Bay Area that an issue of longstanding -- the B Agency Director wants an RMP person, but he wants a consumer. But it just so happens that in that part of California Paul has only got some providers on his RAG, and you know, I think there is a real personality kind of conflict. But I think on the whole -- and one of the suggestions we have in our feedback letter, was that they should consider the possibility of having a fairly senior staff person as kind of a liaison with the Conference of the Agencies -- they have met with them, and again, this is not a monochromatic picture at all -- DR. HEUSTIS: Have we any kind of a written ‘agreement that has been either tried, or achieved, as to what each of them have thought they were supposed to be doing and what their responsibilities were -- DR. TESCHAN: The answer to that is: Yes, as I recall. Now whether it is current or not is more to the | point, but I recall that there was circulated to the coordinators some two to three years ago -- and this was the first example of a written memorandum of agreement as to what RMP and CHP roles were going to be and how each would interact with them. I'm quite sure Paul Ward was -- wt 32 HOOVER REPORTING CO,INC. 5,‘ 320 Massachusetts Avenuc, NE. Washington, D.C. 20007 | i i i DR. TESCHAN: I thought it was a marvel. As a matter of fact, when we got around to signing a statement in Tennessee, we used 218 that as one of the bases of ours. MRS. SADIN: But I think it's uneven -- the t t relationships are uneven. The only this -- I think we just need it, to mediate. suggestion I could think of and we discussed need a Rabbinical Council -- you know, you I'm @wfully sorry, Sister Ann. [Laughter.] You know, in the old days, they didn't need lawyers -- both parties just went to the local Rabbi, and I kind of thought that's what they needed. [Laughter. ] They are getting the review etc, etc, etc, but in some areas. They are applications, all 76 projects -- doing, you know, the legal part of it and in comments and submitting the things, it's a relationship thing that's the problem now logging in, as you can see in their of the comments that are sent out and all i { DR. HEUSTIS: 76? MRS. SADIN: Well 75 -- not that's a lot of projects for review and comment -- and they just sent me another whole batch from the LA a dossier.] DR. HEUSTIS: That came in late. -~- and this is all just LA CHP [Displaying wt 33 HOOVER REPORTING COLINC. | 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 t | 219 MRS. SADIN: Yes, that came in late. [Laughter.] So it is -- you know, one of the things we suggested | and this is the letter sent back to Paul Ward -- and one of the things that we suggested is that they have a senior staff 2 person as liaison, to spend more time and pay more attention to that problem. DR. HEUSTIS: Well I am satisfied from what I have heard, that I would change my recommendation from "Insufficient Data" to at least a "Satisfactory" relationship. THE CHAIRMAN: Correct. me, Rebecca -- but most of the program elements committee do have a CHP representative on them. This is really their program development thrust. Now -- DR. HEUSTIS: Yes, it is pretty good. THE CHAIRMAN: Well, I wonder if we want to hold -- withhold other staff comments, and let John as a second reviewer, take a look at California -- we have spent an awful lot of time with CHP but given the fact that they are probably 10 percent of the CHP in California, also. At least, in terms of family, I wouldn't think that was far off. DR. HIRSCHBOECK: Well, I won't repeat the comments | which Al made because I think they hit the target right along the line in most instances. | I am troubled in one way that in reading this over, I didn't see what really happened when the areas were dissolved 220 wt 34 and they were put into two. | Is CHP, again, is it moving into the area-wise approach here that existed with: the regional setup? I think that because of this, maybe this is one of the reasons for some of the problems that they are encounter- ing there in relating to the CHPs. ! The other point that bothered me is this enormous “project that Dr. White is in charge of -- it's how many millions? Altogether, I guess he's asking for -- | a state-wide consortium of colleges and universities and hospitals and this enormous arrangement seems to me really going too far. At the practical level, I don't know how they are going to work this out, but if this is the way to go in California, maybe it should be allowed, but I have ny druthers about that enormous approach to dealing with area- wide health education aspects. MR. BARROWS: Resolving that at Berkeley -- DR. HIRSCHBOECK: I guess so. [Laughs. } I have made several visits, Site visits, to other agencies in the California region, and there is one for the California RMP and one in their Review Team consulting visits, and the thing that impresses me out there is that things are HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Whaehinatan PE Oth? I wt 35 HOOVER REPORTING CO. INC. 320 Massachusetts Aven, NE. Washington, D.C. 20002 eel so different in different parts of the State -- that to try to resolve a problem on a state-wide basis becomes extremely @ifficult and this is recognized initially by their setting up a CAP region. And now that this has gone, I am uncomfortable. It's like setting up a Regional Medical Program for a whole nation, and doing it in one -- as a sub-set of another nation. ‘I don't think -- DR. McCALL: That is difficult to do. We tried it. [Laughter.] DR. HIRSCHBOECK: So that my overall evaluation is: Sure, the leadership is good. | The problems are difficult. The program and staff is good. The Regional Advisory Group -- I might differ a little with Al on all these -- he has perhaps read it in a little different way. I had the feeling at least that the Regional Advisory Group- wase not really involved in the actual process of evaluation as much as other RMPs are. | .In other words, they take the word of others very readily, without being, themselves, directly involved. Now I may be all wrong on that but I sort of sensed that wt 36 HOOVER REPORTING CO. AC. 320 Massachuseits Avene NE. Washineton. 0.C. 20002 222 Past performance and accomplishments ... objectives and priorities -- I think these are well defined. Feasibility -- here, again, the whole idea of true regionalization on a state-wide basis, I think, is very difficult. In general, I would say "Average" or "Good." "Avarage" would be my overall evaluation. MR. BARROWS: Let me ask a question: One of the things -- California, as you both pointed out, is not only vast, but extremely complex. One of the very unique complexities is the strength of the foundation movement. Now nobody has commented on how this program relates to the practices of the community -- which happens to be an unfortunate bias of mine -- have they been relating to these foundations at all? This is including the interplay between ~- DR. HIRSCHBOECK: Well some of their projects are involved in the quality insurance. DR. HEUSTIS: They mentioned particularly some of the foundations have picked up the check for some of the projects which had gone on -- THE CHAIRMAN:: Great. : , DR. HEUSTIS: Now how extensive this is, I don't know t | 3 4 | ' t wt 37 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Wachinstan DC 20007 1 { : i | programs? 223 or how wide. MR. BARROWS: Good -- well boy, that's the acid test to this hard-earned -- DR. HEUSTIS: Whether this was two foundations or twenty foundations I couldn't -- I believe my notes are not clear. PROM THE FLOOR: Could you tell roughly how mahy grantees there are, other than their sponsoring grantees -- DR. HEUSTIS: You would have to help me there. DR. HIRSCHBOECK: Let's see the agencies other than -- central staff that are handling the money -- as grantees. | MRS. SADIN: They have subcontractors -- or contracted, that is, most -- for instance, all of the health service activities are contracted to the independent facilities. They are calling their shorts -- And almost all of what. they have, when they | | | develop a program element, they have sent out RMPs, you know, : throughout the state, and in which they really outline what they want -- and then they contract it out. They have in their access, which is going to be coming in in July, they have had something like -- from their RMP they have something like 250 -- isn't it? I think it's 250 letters of intent, which is the way they go about this business. 22h wt 38 In answer to some of your guestions on the definitions of area offices -- one of the things the CHP -- or some of them, told us -- was that well now that they don't have the area offices in California, that we could kind of take their place in terms of local input. And when we mentioned that to Dr. Mitchell, he said “Yes, do you think this is the first time I have heard it?" They have never communicated this to us. [Laughter.] Some said that they missed the area offices and some of the agencies said they were glad they were gone. You know, it was kind of a 50/50 kind of thing, almost through- out the state. | The result of the definition of area offices really -- you know they had something like a three-months visit when HEW audited them and this was the latter part of '72 -- that was a fact that one of the strongest recommendations was that they not have all of the area: offices. And I think Paul ward took the opportunity to follow the advice of the HEW auditors, and they now have a northern field -- it isn't just a central office, they have a northern field office and a southern field office. THE CHAIRMAN: © Yes, but these are quite different from the old areas. These are essentially administrative HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Waohinatan Al GACNI | wt 39 HOOVER REPORTING CO..dC. || 320 Massachusetts Averse, NE. Washinstan. B.C. 20002 I 225 or for program development, and monitoring purposes. MRS. SADIN: Right. DR. HIRSCHBORCK: One» wonders whether they shouldn't really make two RMPs instead. | MR. BARROWS: Right. From a management point of view \ this is too damn big for one -- MRS. SADIN: Right but -- MR. BARROWS: But we can't do anything about it. THE CHAIRMAN: I think that represents, though, a very conscious, deliberate, decision made at the time RMP came along and involving what, at that time, were a lot of the influential people in California. At that time you will remember, Breslow was the State Health Officer, and Brown was the Governor, and they made a conscious decision and they wanted a "state-wide" RMP even though it might be juggled. They came out exactly the opposite from New York, which now has six or seven RMPs. So they didn't blunder into it, and I'm sure, like any decision, it had both then and in retrospect both its plus and minus qualities. MR. BARROWS: Well, there's not much we can do about | history now. What's the recommendation? SISTER ANN: I was interested in your comment where you said the technical experts work under the direction of the | 206 | i Review Committee of -~ would this be inhibitory to the technical wt 40 experts? | DR. HEUSTIS: Are you talking to me? | SISTER ANN: Yes, you indicated in the report, that the technical experts work under the direction of the review committee. What's the purpose of bringing in these technical experts? DR. HEUSTIS: Well, I think the purpose of bringing “in the technical experts, as I understood it from a person that made a site visit too, with me one time when we got into this discussion -- is that this is to get rid of the local bias and the local conflicts of interest and the local antagonisms between the centers from which the experts come. SISTER ANN: Then you said that they work under the direction of -- | DR. HEUSTIS: Well, the "direction" -- perhaps if I said the overall direction or overall supervision -- DR. HESS: Or "they report to" <-- MRS. SADIN: I started in on that -- to review particularly the manpower, and they do bring in top experts and they have to counteract the ones in California -- and I think what was meant was that the recommendations go into a review -- but it isn't -- | DR. HIRSCHBOECK: But this is exactly the point I was. tryingto make a little while ago. I think that the distance | HOGVER REPORTING CO, INC. | 320 Massachusetts Avenue, NE. ! Wachinatan AP Fh? | 2e7 wt 41 between the RAG and that technical review process, is at least at the time that I was out there -- it seemed to be a larger gap than really should be. That the RAG should be much more closely involved in the actual review of the project itself and not just take the report with the badge of an expert pinned onto it. : MRS. SADIN: I don't know if they changed it since we've been there, but they now have a member of that RAG present at every one of these -- which helps tremendously, and he reports back. THE CHAIRMAN: They have two standing committees: A review committee, and; An evaluating committee. Under the Review Committee, the technical experts operate in a panel fashion, sort of. They look at the new projects. The Evaluation Committee, on the other hand, doesn't have that close line of the smaller committees, and they are the ones who look at and then forward to RAG. And then, both of these standing committees are RAG people, on continuation, so that they have that kind of relationship . And what goes through RAG, if it's a continu- ation of the Evaluation Committee -- if it's new, it goes to the technical panel. So it's the overall "umbrella" supervision HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. ‘| Wachinaian Te FANN H wt 42 HOOVER REPORTING CO, ‘NC. °|° 320 Massachusetts Avenue, NL. Washington, B.C. 20002 t 228 of the Review Committee. SISTER ANN: And then lere, too, on page 3 of the staff Comments, they have 70 _ requiring surveys, four kinds of positions -- they are adding the 19 -- but one of the concerns is the proposals are not being monitored and evaluated on a systematic basis. And ‘here, I just wondered if adding more and more “people would complicate the issue. MRS. SADIN: There is some urgency to this. In fact, they have added evaluations to their staff, and they are asking -- part of the 70 is for more. But we had, after their supplemental application we sent an advice letter back to Mr. Ward. We had suggested that such a vast program would merit that they spend more time on surveillance and monitoring. And when we were there in April -- if anything, they had gone the other way. They are sending the people in the Southern Field Office to the Northern Field Office and require a monthly progress report. So if anything, they have gone overboard. So they are monitored -- all their people in their Field Offices are monitored -- every single contract -- and this is the contracts mostly, so that they have a condition written into the contract. 229 wt 43 DR. HESS: I see. | DR. TESCHAN: I would like to say that the evaluation effort of what public accountability of funds really means in terms of output benefit -- that whole concept was jelled for all of the RMPs in the country by the initiative of Paul Ward and that staff in California. And a good deal of some ‘of the numbers you are seeing, John, and all the rest of us are aware of how that ultimately became generalized in order ‘to get the data together, to show to various critics what the numerical impact of these activities was. I am interested that you consider that some of it became a little bit more compulsive than others -- but I understand the atmosphere in which such compulsion can be generated -- so that I even have some tolerance for that as well.. MRS. SADIN: “In terms of the H.E. -- Doctor, you asked a question about the manpower. When we said "supplemental funding" in July of '72 California of course as usual, got the most money in the supplemental funding for manpower control -- they started out with something like 10, plus the Central Coordinating one. They now have something like 15 and they just about cover the state. Some are in the planning stage but most are now independents consortium with independent boards. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, 0.C. 20002 230 It's interesting though, that at conferences like wt 44 | the schools of Allied Health Protection -- and they have had some -- there's a national conference in Boston this year -- | they had Dr. White speaking in some of the consortia of the directors. The people at the conference were so excited about it that they then sponsored their regional California conferences -- they have done some exciting things. | But it is a lot of money, though. : DR. HIRSCHBOECK: Well, I would like to see it | sometime, to see how it functioned. It sounds good on paper but I would like to -- DR. TESCHAN: Well, John, the thing that bothered us is that each one of their nine regions was about as big as one-point-some million -- as most of the other RMPs we are talking about -- and to see Paul Ward, in one application, with a dissolution of area offices, just boggles my mind. And Ken's point of “management, how do you get ahold of it?" I am surprised at the HEW Audit. We know a little bit about the origin of that, or have suspected some of the origin of it, and I'm wondering whethe acceeding to it -- the fact that it has some budgetary require- | ments -- isn't a "giving in" to what would in Ken's view be sound management -- since we would have insufficient data to male { i HOOVER REPORTING COLINC. |, : 320 Massachusetts Avenue, NE. 1) | Wachinatan THO 90009 Ui , , 231 wt 45 or to be able to make that judgment from here. | MRS. SADIN: Well, some of the things Dr. [Hirschfeld] has said -- nobody knows this is going to happen --~ they had more than a norm -- they recognized that -- perhaps not ... DR. HESS: You are dealing with a state of some twenty million people, and $2 million for health, education -- though it seems a lot in one lump sum, is not a disproportionate amount for the population. THE CHAIRMAN: Al, you've been trying to -- DR. HEUSTIS: Yes, I've been trying to push -- and I would like to make a motion. THED CHAIRMAN: Fine. We have a request here for a little over $8 million and we have an indication that California will be in -- and this is a request just for continuation and program staff. Roughly, they are at the $6 million level for all new activities in July. That would total, if my figures are correct, almost $14 million. DR. HEUSTIS: If you would then look at another column you would note that if they did that, they would then come to 111 percent of the amount that you requested for them. And because both John and I have rated this as "Above Average" it seems as though, in conformity with our HOOVER REPORTING CO,INC. 326 Massachusetts Avenue, NE. i| Washington. D.C. 20002 i 232 wt 46 policy of rewarding the people that do well, and taking away from the people that don't -- INDEX I would therefore, move that it be funded at the MOTION requested level, some $8,170,374.00 [The motion was properly seconded. } THE CHAIRMAN: All right, we have had a motion to | approve at the requested level of $8.170,900 -- DR. HEUSTIS: 374. -- it's a separate item. THE CHAIRMAN: $8,170,374. Are there any further comments, or any additional questions? SISTER ANN: Excuse me. Are there any things that you feel we should look at, or that you think should be looked at, serious enough that by reducing this funding (since they are coming in in July) might be an impetus for them to look at the funding? Are there any points or things that bother you about the region that maybe could be looked at? : DR. HESS: But the point is, there is no time for them to look at anything. DR. HEUSTIS: I guess the answer, as far as I'm concerned, Sister, is that I thought it was a good program with good management and that the CHP Situation bothered me HOOVER REPORTING CO, INC. 2; 320 Massachusetts Avenue, N.C. \ Wachinatan Tl 7000? i 233 / but that has been resolved satisfactorily for the moment -- wt 47 they still ought to work on that, but at this time I think I would say "no" to your question. SISTER ANN: As I read those notes here and the Staff Summary, I'm not all that impressed with the good management, and I think part of it is because it is such a difficult region -- and as I have heard it reviewed from time to time, and the management hasn't been its strong point. But as Dr. Hess says, there is nothing that can be done about it now except in terms of a recommendation. MR. BARROWS: I feel as you do. We can't reverse history. I would certainly not recommend this as a model program for the new House Resources Agency ~~ it's too monstrous. SISTER ANN: Well now I would think thatwould have to come through -- it would make me much more comfortable if that came through as a ~recommendation. MR. BARROWS: But I don't know what -- it's bigger than both of us. MRS. SADIN: The target that's figured though, you know, which is, I guess, less than what they -- less than the $14 million -- they have communicated over the telephone and they have allocated percentages to each program analysis -- and. of course if that came down to -- say $12 million instead of $14 million -- the man had written 25 percent of 12, etc -- HOOVER REPORTING CO,iNC. {)° 220 Massachusetts Avence NLL. i\ Bachinntan AE 20K? |} THE CHAIRMAN: They have pretty well -- you know, I we 3° | assume there is some ability to make adjustments at the tail & end. of the process. But they have gone through a process by which the RAG has said in effect: One way of expressing priorities is that we'll put essentially 25 percent of our money into the access program -- now whether that is X-plus $2 million | | or X-minus $2 million -- so I do think we have a notion -- | both here and looking at a new application, of what the -- or where the cuts would come. DR. THURMAN: Yes. Question. 2 THE CHAIRMAN: All those agreeing with the recommend= ation to fund at the level requested indicate. | [The motion was properly put to vote and passed | by a vote of 6 in favor and 3 opposed. ] THE CHAIRMAN: In that case, I guess that's by default. I can't think of any better solution. There should be one, but I can't think of it. O.K. for California. HOOVER REPORTING CO, INC. - 320 Massachusetts Avenue, NE. Washington, D.C. 20002 (202) 546-6666 wt 50 HOOVER REPORTING CO, INC. ||. 320 Massachusetts Avent, NLC. Washington, D.C. 20002 235 THE CHAIRMAN: O.K., Bill, since you guaranteed us, last night, that you could dispose of Puerto Rico in ten minutes, we'll take you up on that. And then after Puerto Rico, we'll see if the group wants to take some coffee. You and Joe -~ rit call on you first, since you are on the site visit -- well Maybe you were too, Joe, were you? COMMENT: No. PUERTO RICO DR. THURMAN: “gust a reminder of the fact that a site visit was asked for by Council, as to whether or not Puerto Rico would get any money at all -- whether they should be discontinued. Mr. Nash was on the site visit with us and the most important thing about the site visit was that we had a multi- lingual team, and I think that resolved all our questions because in our meeting with the Puerto Rican group -~ i the Coordinator now, he was the Associate Coordinator before -- he has the respect for the program and control of the people. They continue to have real translation problems, even during the site visit and even though we were multilingual. “Some of the concerns that came out were only handled by a girl who was even more fluent than the Site Team was. The RAG is very strong. It's very representative despite the differences involved with Puerto Rico, and poor t wt 51 AiG , i Song ae nly HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E Wlanhkinadan DT SOD | 236 transportation -- and despite the phaseout as concerned that part of the program in toto, the RAG has continued to work quite well. The real strength of the program as far as the future is concerned, is that 70 percent of all health services in the island are public, and the grantee being the University of Puerto Rico which is also a public agency has forced the staff to flow from agency to agency, but nevertheless, has worked quite well. I think the most eloguent thing that we heard was several testimonials that came from consumer groups about what Puerto Rico and the medical program had meant ~- the delivering of health services to the underprivileged groups in the continuing organizations. The projects were just superb, when you really under- stood them (which is not true on paper, and this has been our problem the whole time.) They have an operational VSRO which is phenomenal in every sense of the word. They have a very good plan for their EMS and they are working hard at the geographical spread. I think that this program, having gone down there thinking it wasn't worth supporting for another day -- the Site Team came away totally satisfied that it was an excellent “program, and I would recommend approval of their request. 237 wt 52 DR. TESCHAN: Second. THE CHAIRMAN: Joe. MR. de La PUENTE: Well I have many good things to: say about them. I have discussed with friends of mine who i ) i structure, which is quite monstrous -- and they speak of Puerto lived there and who have been living with the government | Rico RMP as "La créme de la creme" as far as entered into our conversations -- with living over there. And under the circumstances I have written -- I wrote a lot that has already been said, but in summary , this application represents tenacity in the face of austerity in that a viable program is being presented. It is possible to enhance the staffing pattern with the introduction of a physician who possesses some training in the field of epidemiology, and this is tremendous. It is apparent that the Regional Advisory Group has continued their efforts towards program development and review. Their track record in terms of the number of programs that are eventually adopted by the community appears to be better than average. Most of the present priorities appear to coincide with the needs of the Island. Special attention should be paid to assuring the dissemination and application of findings for additional sites in Puerto Rico. HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, RE. 238 wt 53 But I certainly, strongly concur with the present recommendation. - THE CHAIRMAN: Thank you. Yes, Al. DR. HEUSTIS: I am impressed by what was said. In fact I was so impressed by what was said that I looked over into the next to the last column on this tabular sheet, and I noticed that Puerto Rico is one having the honor or distinction (or otherwise) for requesting the lowest amount of the allocated funds, for any group. THE CHAIRMAN: Yes, the lowest percentage of that so" called target figure. DR. HEUSTIS: Yes, the lowest percentage. THE CHAIRMAN: Yes. DR. HEUSTIS: Now, with the obvious need, and I say "obvious" need, it's from what you have said after a one- week visit -- and whan I was there under different circumstances and not for RMP and quite sometime ago -- Is this because they were tired, or because they were. discouraged, or because there was a lack of understanding on the part of what RMP was looking for? Why this low figure? DR. HESS: I don't think that's a good measure, at all. HOOVER REPORTING CO, INC. : 320 Massachusetts Avenue, NE. | Washington. 0.C. 20002 manna car eens 239 wt 54 DR. THURMAN: I think I had better respond to that. I agree with you, I don't really think it is. It's not a matter of being tired, it's not a matter of being fed up, or anything else. This program has been going and again, we didn't understand how well it worked with all the other health affairs and activities. Now they have wanted to avoid an outward appearance “of affluence, and that's why they were so well accepted, as Joe points out. Again, I would just emphasize that -- not in talking to people who are getting anything out of it, but in talking to the little people -- and these people were able to speak in Spanish to the people involved -- it really is the cream of the program and they felt that they can use this money wisely and not jeopardize the future of anything else -- and they would only ask for the money they think they can use well. DR. HEUSTIS: Now in view of this, do you not wish to retract the statement that you made yesterday about the people "always asking for more than they need?" ‘DR. THURMAN: No, these people have asked for more than they need. I would never retract a statement, like that. [Laughter.] HOOVER REPORTING CO, .AC. 320 Massachusetts Avene NE. | Washinatan fit finn? i wt 55 HOOVER REPORTING CO, INC. 320. Massachusetts Avenue, N.C. Washington, D.C. 20002 ! 2ho DR. HEUSTIS: For the moment I thought I had you, but I couldn't go further -- DR. THURMAN: No, I am going to defend the sheet, a little later on, with the fact that I think it's useless, so I only bring that up -- No, the only place that -- the place that I would criticize their budget, if you still look at the core of the staff program -- as to what was indicated earlier -- they just pick up all the staff, and they didn't really, physically pick them up, they just moved them to other budgets within the medical science campus, and try to find a place for them ~- and then they kind of Elow them back. | | And that "flow" is very worth while for the very reason you bring up -- that these people will be able to do an awful lot with a very little bit of money. So that we are approving more money than they can truly use right now, because they are funded through other mechanisms. So that I'm not defending my very dogmatic statement too much. [Laughter.] DR. HESS: The point is: How many people are there in Puerto Rico? DR. THURMAN: Higher than New York City -- per square | 241 foot -- it's the most densely populated region in the United wt 56 States. | MR. NASH; About 2.5 million I guess. DR. THURMAN: But a higher density than New York City, per square foot of ground. And yet the most of the island, you couldn't set foot on if you wanted to, because of the trees and the water. MR. NASH: Dr. Heustis, that figure may change -- 69 percent -- depending on what comes out of their application that they will submit. DR. HEUSTIS: I didn't care to explore that any more -- but it just seems as though where there was need -~ was there a language problem. But I think my question has been satisfactorily answered. MR. NASH: All right. THE CHAIRMAN: We do have a motion, and a second, on this one -- to approve in the amount requested, which is $696,862.00. Is there any additional discussion? All those in favor -- [The motion was regularly put to ‘ yote and carried unanimously. ] HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C Washington, B.C. 20002 i i i ee wt 57 . oe CHAIRMAN: O.K., it's ten o'clock. What is the pleasure of the group? Do we want to take on another one or do we want to break for fifteen minutes and have a cup of coffce? Do we have another ten minute one? How about the Mountain States of Idaho, Montana, Wyoming, and Nevada? COMMENT: Is that always that same four states? It's always been a little unclear in my mind. ‘What i've read now sucqgests it's sort of a northern half of Wyoming -- it doesn't really make much difference as Wyoning has been RMPs "Poland" -- there are three RMPs to plot over; in the mountains: Colorado, Wyoming, and -~- the THE MOUNTAIN STATES DR. McCALL: They have got a table of staff and a priority aroun, and a priority setting on a oriority | basis, they have handled that in a high, medium, and low grounina in this application -- which is a good application -- clear : and I think it presents a picture of the reaqion pretty vell. They have had recaion review certification visit and management assessment visits which came out as, I think pretty much all "nluses" from that req@ion. Assessment of their past performance and accomplish- ment has also been pretty good. wt 58 243 The current proposals seem to be in accoré with their stated objectives and priorities, and I think they are feasible. The CiP -- there are four A Agencies and seven B Agencies that have to be dealt with by this Reqional Medical . . Program, and they have received in this application, comments. S I, a - : i 1 t from all four A Agencies, and four of the seven B Agencies are included. The Idaho A Aqency disapproved one of the projects the physical assessment field -- nurses ~~ and the B Agency had negative comments on about four projects -- but were no an in depth studv or critique of those ~~ it was just one sentence comments. I state that to sav that I don't have any wav to evaluate the auality of the CHP review and relationsnins there but these were -- the extent of the negative type comments that would need dealing with by the RP = and from the applications, I would feel reasonably comfortable, althoudn I would warn the Statf to comment on these if they would wish to deal with them. This application contains 27 projects. 11 of these are for continuation, and 16 are new -- making up in dollars an eleven continuation of about $1.5 million; and the sisteen new ones, at $640,009 -- the staff budget being some quarter of a million dollars -- the total request $2.4 million. pat 59 eR ae euu They intend to apply for agapplement of some $220,009.00 in July. I rated this "Above Averace." THE CHAIRMAN: Thank you, Charlie, and Joe. DR. HESS: I generally concur with that. It is | evidence to me that the people who put this application together think clearly, concisely, and are well organized, and are usina appropriate procedures, They have attempted to reach out and provide good service to all four states, and they have offices in cach of the four states, and seem to have qood workina relationshins with the state governments, and the CHP and so on. Just to comment on that one vcroject that we have neqative comments on -- given a little oriority in the listine so I think that may be a result of the CHP Review. I think the CHP comments on that particular one were relevant but that was taken account of. The only real question I had about the budeet was the rather large amount of money going into EMS from PMP, I have no doubt that in that area of vast distances and so on that an ENS system is an important element to get orcanized and goina. But there has been a substantial increas in 2MP | “¢ 1 money going into that and I suppose that it would be appropriate to sort of flag that as an issue and ask them to take a close wt 69 look at that when they cet their grant award. DR. McCALL: Mavbe it would be appropriate to have a staff comment on that. DR. HESS: Yes, I was going to sav, that was somethine I meant to point out -- and because of the distance, of course | it might well be justified, but you can't tell. THE CHAIRMAN: Yes. Some of the -- while a good part of this is continu-~ ation, some of that continuation is really expansion, and it's. largely in the EMS area. | Dick, I don't know whether vou would want to comment | on this, or whether there are any policy issues. 4QP, RUSSELL: At this point there are no nolicy -- there does not amnear to be any nolicy issues, but we have ( flagged this to make doubly sure. In terms of the BUS program in the Mountain States + area, all of these nrograms started out with assistance from Mauntain States in terms of very small contracts. Like, Nevada, for instance, started out with $17,909. and as a result --vou can see. Montana, is the same way. Idaho. So this is one of their big, major program -- we do have some concerns about that larger -- DR. HESS: This is one of the things that impressed m 61 245 me about their management techniques; and that is that they used the contract mechanism as a device for getting thincs done that they have identified and perceived as a means and | they have immediately taken the initiative -- as opposed to waiting for it to come in. and I think this reflects very sound, sophisticated manacement on the part of RMP. DR, McCALL: Just. one other thing, one point that I think maybe the Staff might want to comment on, too. It is noted that they clearly show the allocation of collars and programs -- and obviously, there is a strong staff, and hey have generated and involved in a lot of this anc seem to be involved with and mentioned in these projects -- the grantee acencv. In many of the activities, I am nretty sure that somebody knew the region better than I did, myself -- and that this was acceptable within the region -- it wasn't too much ceneration. MR, BARROWS: Is this mis expenditure, for preparation for a system for the purchase of hardware? MR. RUSSELL: It's preparation of -~ rather than the purchase. THE CHAIRMNI: Sandy Flythe, and Dick russell were both out in the Mountain States, I quess this was probably Maren, or earlish, on a review verification of the management. wt 62 I guess it was combined: Neview Verification of Management Assessment -- so perhaps Sandy and/or Dick would have some comments as it relates specifically to CHP and also the ability to manage projects under the aegis of program staff -- which I think I heard Charlie raise a question about. MS PLYTHE: Basically, the Cup relationship within the region are good. There is one problem, perhaps, but they are working on that, trving to get that worked out -- but generally, the relationships are cood. CIp is -- in fact, CUP has generated some projects within the recion -- relationships are basically good. Which is, just really, the grantee -- thev have no responsibility whatsoever as far as the projects are concerned, Staff and prodaram staffs, basically, are resnon- sible for monitoring that sort of thing -- which is just grantee. MR, RUSSELL: I would ~- you know, we spent reallv a whole week anu covered, I think at least tvo counties every dav, and this is what it takes. Before we went out, we had some concern, really because we didn't understand that program that well -- as to how one managed the proarams in four states from that Reqional | i Office -- and we were very much impressed with the communication | : i wt 63 c4O among the staff and the whole setup. We kept looking, and looking, and looking for something wrong and we really couldn'i find it. And I talked with Rod Mercker, who had the Management Assessment -- and his impressions were pretty much the same as ours. DR. HESS: Well I ended un, based on what I read in here, giving them "Good" and "Excellent" ratings-in nearly every catedory -- and I think it was one of the best organized and managed TIMPs. MR, BARROWS: What's the number? MHP CHAITMIA: Well, the number is our -~- in the e 1 i i { case of the Mountain States -~- they are asking for $2.2 million -~- no, I'm sorry -7 P24 million. They did indicate, as I think one of the reviewers said, that they will be in for a very (by comparison) modest supplemental additional amount of $209,009, DR McCALL: I recommend $2.1 million. DR. HESS: I had written down $2.2 [Laugnter.] So we are pretty close, DR. TESCHAN: $2.15. {[Laughter.] THE CHAIRMAN: We have a motion of recommended fundi: level of $2.15 million. Ts there a second? [The motion was properly seconded. ] i { i i { i i * re at 64 249 DR. THURMAN: May we discuss this? THE CHAIRMAN: Certainly. DR. THURMAN: I have no disagreement with everythince that both of them have said about the management. But on some of these projects and the funds for them are absolutely unreal. Now if you will turn back to the Staff Sheet here in our little grey book -- and we have already heard the concern expressed about EMS -=~ and t share that concern -~ $181,000.00 for Nevada which is for working on the EMS Program on which they have been working for ten years. Now EMS in Montana and Idaho both, make up to $350,090.00 not to mention Nevada's share. But look at some of these other projects. Area- wide, they would simoly scare you to the tune of $270,009 and as I listened to this motion, we are talking about a little over 8,000 versons at the most. Now vou figure that 8,000 births -- and you are going to have roughly 120 children that may need intensive care a year -- and you divide that by the two hundred some thousand dollars and it's an astronomical figure. Well, we move on down to the breast cancer -- which regionally continues to be funded at $30,676.00 and that's an old project, again. wt 65 nN wm Oo And the Recional medical audit system development project, $177,090.00. Let's see, there is one other here that rocked my boat, but I've forgotten which one it was -~ But I just, I really have no disagreement with the management and I know the difficulties of communications and organization -- but the I am going to move to a funding of these projects, I think mountain state now and -- [Laughter. ] TUR CHAIRMAN: They need a medical school. DP. THURMAN: They really need one. DR. TESCHM]: Sounds Like the staff and the RAG are awfully -- MUR CHAIRMAN: Joe, I think vou want to say somethins. DR. HESS: Well, I was going to say that one judgment here about numbers of veople has to be modified hy the distances and the distribution of vopulation in those areas and it's my judgment or estinate, that with the population spread out the way they are, it's going to be more costly per person, to cet some of this more sophisticated services organized and available than it would be in a densely populated region. So I would make some allowance in my mind for the geographical distribution of the population, you know. so that doesn't unset me too much. wt 66 e251 SISTER ANN: I have a comment to make on the use of medical services -- because the regions intending to ~~ being in Salt Lake right near the University of Utah, where they have funds for the Reqional Medical Proqram for just the same kind of service and are crying for, you know, people to use the service. and for an air transport being available in terms of this service, and with the birth rate goind dewn -- I think that is a very -- if we just knew how this program overlanned with the other nroqrams. But this one vrocram, I know is going to »e competi-: tive and neither of then are qaha to be aple to use their fund: effectively. DR, THURMAL: We could almost buy each baby a plane for this monev, and let's fly tnem in. {Lauchter. ] Mp, BARROWS: That's a tough thing -- but vou're opening a whole new thing there when you start talking about numbers of people and the other vorovlens. But in connection with these costs, is it true, or is it not true, that these people have further to go in these things -- and. they don't have the present resources that many other regions do? DR. HESS: Well, there's no medical school in the ar#e nor in the reqion -- and they are trvina to relate -- you know wt 67 .up their secondary terciary resources in the region. they are trying to relate you know, they are trying to build But for medical schools, they tried to relate to Utah, to Oredon, Seattle and to Denver. Those are the four, I guess. DR. THURMAN: They now have a medical school for -~ associates -- DR. HESS: There's one developing there, ves -~ and that's the first one in the region, and it's just qetting goinc. THE CHAIPMAN: Well, we've heard some comments ~- regarding budget funds, and particularly as it relates to neo- natal projects. Dick? MP, PUSSTLL: I would like to respond to Sister Ann's concerns about the Salt Lake inter-mountain program. We have, we in DPMP, have sort of put the screvs to the inter-regional executive council ~-- the three coordinators: ¥ou know, that Council was formed to avoid the tyve of prosicmn! you are talking about, during the phaseout, for some otner reasons, it just didn't get off the ground. It's back in action, now. We have a complete listing that came in just a couple of days ago, of everv community listed, and which RMP is programmed there. We are very concerned about the effectiveness of that committee wt. 68 and we think we are going to see some improvement in there, in their action. DR. THURMAN: Yes, and you know ~- MR, RUSSELL: In terms of transportation there, we have found on two trips, that to get to Helena, Montana, one must go to Portland, Oregon and spend the night. That's about the only wav you can qet there. DR. HESS: Actually, what they are trying to do is with this $116,090.00 is Geveloo local resources and train people on the local level to be able to provide the higher DR. THUPMAN: But that's a criticism of manaqement. Ti shows $116 there and $207 on our sheet -- and 117 somewher? SHE CHRIPMAMT: You are looking at the yellow -- DR. TESCHAN: Could this be a typogranhical error? DR. THURMALT: Anyway, it would be less than a hundred babies -- at the most it would be 129 with 8,900 expected births in this vonulation -- and that would, of course, not be every baby. iro WE CHAIPMAN: Well maybe we have -- I don't know --~ Dick and I were huddlina here -- maybe we have an arithmetical error -- but the yellow sheet which you have in your boos and which I gather Dr. Thurman was looking at, is a staff output. j wt 69 254 DR. THURMAN: And I'm looking at this too -- it does show 116. THE CHAIRMAN: Yes. DR. THURMAN: But even at 116, this project is glittering in gold because -- we have intensive care over all the country -- and | DR. McCALL: And they can qet intensive care every place else, too. DR. THURMAN: But if you look at -- a lot of this is -- if you look at the staff sneet and get hung up on that, vou are talking about $1.5 million for continuation of eleven projects and some of those -~- the last time this came up for review were -- DR. McCALL: $690,000 for the eleven -- | | i ! j i THE CHRIPMAN: You're talking about the continuation. DR. THUPMAN: In the continuation they are asking fox $1.5 million for that. THE CHAIRMAN: Lf there are no more comments or { i i t ' i questions, the motion on the floor is to approve $2.15 million for Mountain States. All those in favor. (The motion was reqularly put to vote and carried with 6 in favor and 3 opposed. ] rh WwW An THE CHAIRMAN: i think it would be good, if it were the concensus of the group, though, in reporting your recommendation to Council -- and assuming they agree in the feedback to the Mountain States PMP -- that to indicate that ; there was some concern with the dollars invested in some of | these projects and singling out neonatal, among others, as a good example of that. DR. TESCHAN: I think we ought to have a decision now as to what the actual number is. Tf there are three or four -- we have several differant readines and there ought to be a way to tell the -- J “3 a tet nat wm icp) oy iH ct oe fot ink we have to accept their amolication as the -- DR. TESCUAN: There are two places in the application. One is the 16 that you are looking at and I want to know -- THE CHAIPMAi: Well now I can see -- 16 shows $234,000.00 and that includes indirect costs. DR. THURMAN: They multiply one vear by two. MR. RUSSELL: Where are you getting the 116 from? Wnat page is that on? DR. HESS: Page 105 DR. THURMAT: And page 199. ® Mow I don't mean to get hung up on the intcnsive care i wt 7} 256 There are an awful lot of high priced and an awful lot of continuing projects, and I thought I would just go along with the advice -- DR. HESS: Well again, this is an area-wide thing that covers four states -- and that's roughly, $ 25,000.00 per state for developing this care -- and I don't think that is excessive at all. OUR CHAIPMAN: Well, there is some incongruity, I think, between the application they have prepared, and the fidures on the Form 15 and 16 -- which obviously don't agree. the figure that we have translated to the print- out here is the Form 16 figure. DR. THURMAN: Yes -7 MR, RUSSELL: I'll see if I can find it on the other sheet when .. . [Laughter.] THE CHAIPMAN: Well are they asking for two vears? DR. THURMAN: No -- MR. RUSSELL: If I could call your attention to page 21, Consolidated Budget Request -- 21 of the Application. Because I think this shows how Mountain States Programs -~ it's right in the middle of the page. The 116 - 231 is budgeted as a discreet project activity -- and add to that $91,738.00 which is the rest of the Regional Program -- the cost of that. wt 72 think it is thouqn. 257 That brings the cost up to 207. DR. McCALL: That is what I questioned. That was the additional budget allocation on the staff -- looked like about 45 percent of program activities - THE CHALPMAN: Well, I think that one of the thinds we have seen, or at least I have seen, and I suspect this is the case in Mountain States: some of the more sovhisticated regions (if that's the adjective to use) in California certainly in this class at this juncture, from the nanagement standnoint -- California is pudacting a cood deal of its program staff as sort of a project item and each of the program elements -~ at least from my first hand observation there, that seemed to be a reasonable form of vrogran budeeting so that a Chuck thite, who literally spends, if not full tine, a major vortion of his time on health services ecucational activities and ~ - and one or two otner oeople who are -- tue wav they are set up, the people who monitor a narticular program element they are sort of the cost of that prodram alement -- as a separate vroject -- and there may be some of that here, also. Mm, PUSSTLL: There may be some of that. JI don't his is the case: say, for example, that thev are coing out into a programmed area and they will call a project like "area wide neonatal" vou know -- that is a program thrust wt 73 258 that's a project -- they may have two or three funded activities -- a contract, or an agreement ete -- affiliations -- So to save time, they have budget set aside like you know, FMS -- if they need to support a Governor's Confereng on neonatal or whatever, then that money is considered a "regional" budget rather than tacking it onto an individual project. DR, THURMAN: But I think I hear what vou are saying but that says that they have cot $54,900.90 -- if you go all the way pack, to ao to consultants to put on the regional program. But vou cet hung un on one program, or one voroject, and that shouldn't be. Tt's the philosophy tnat I am speaking adainst, to ao overfundina of vrojects for which there is no validity and the overfunding of continuation projects. $1.5 million of the $2.1 or the $2.4 that they nave requested for continuation projects -- some of which are six and seven vears ago -- and that is not good management. Did vou move that the staff and -~ that they should pay particular attention to this? MR. RUSSELL: yes, we will clarify this before it aoes to Council. - DR. MEUISTIS: I will sunvort this. MR, RUSSSLL: We'll clarifv this, O.K.? THE CHAIRMAN: O.u. And this is a prize item for -& eo Council, that the Committee, while it did vote a recommendatior of 2.15 -- it had some sicnificant concern in this reqard and hopefully reached out and provides the Council with some additional clarification so that they might take a critical look at this region, perhans differently than they will for most, because thev are accepting your recommendation. DP. HEUSTIS: The amount of money for each of these activities -- it would be helvful to the determination as to whether this was accurate or not. m. RUSSELL: Yes, well I think I would have to voint out nere that when we looked at some of these activities, it was as a “continuation” and this means that they are continuindg in that oroqram areca. NR, MCCALL: Yes, but the same activity -- that's tne -- Mp, PUSSELL: Wo, no, it does not mean the same MP, BAPPOWS: Are we on that break yet? THE CHAIPMAN: Yas. {Lauqhter. ] 1 back bv a cuarter of eleven -- re Let's nlease he would certainly like to polish off at least two more regions before lunch. [The assembly recessed for coffees at-10:39 a.n.] 260 [Proceedings were resumed at 19:59) wt 75 THE CHAIPRMMI: I thought we would jumo to the Tri- State, at this juncture -- that will take care of the last of the regions where Dr. McCall is a reviewer, and that will let him, without any problems, get away >v midafternoon for -7 i per his earlier understanding. | | | So we have Sister Ann and Charlie on this one. I don't know whether you two have ~- I saw you huddlinse at coffee -- I don't know whether you had agreed as to who was aoine to lead off, or ~- TRI-STATI eUNn CHAIPMAMH: Charlie -- Massachusetts, mnode Island, and “lew Hamosnire. DR. McCALL: Right. Tais is three states fron 7-1/2 million veople -- and 5.6 of that 7.5 million being in Massachusetts: 749,999 in Wew Harmnshire: and 959,990 from And at the outset, I think I would also point ovt in this particular application, as far as additional nev activities, New Hamnshire is not in this application, but they were a little slover in getting their review and thinas in -- and vlan to come in the supplement -- which will be in the July 1 avplicatiocn. So the "tri state” is really, as far as this is concerned, a “bistate" of Massachusetts and Phode Island for this varticular application. wt 76 - ee mM ON ft ot 's also mavbe a little bit helpful vy b- cr T thin! jnitially to look a little bit at the past history of this region, because in my judgment, in addition to a counle of volicy questions, it's not our -- the major question is not going to be avality of staff and program, as much as tne unding level -- and it's in this reqion which we've had a bh 7 ather exponentially rising level of funding from one 1.2 hy o million to 1.9, to 2 million -~- and then jumping to ¢.& million in 1973, prior to the phaseout, with a current six months current level of 1.4 -- I quess that's a six months level of funding. So that at the time vhen they hit this veak of their gcrovth with the bia staff of some 4€ vrocram activities eoing tine -- and I think mavbe, acainst that backdron it looked at the current aoplications and they nut it into a little b iw tter pnersnective. aye had aood, experienced oe me ct m we O A es It means t: leadershiv at the staff -- the staff, as I mentioned, was a rather big staff in '73 but it has become a rather small staff at this point in time, with six full time vrofessionals and five part time -- And there lies also a noint that we may want to focus on a little bit in terms of -- as it has come up previously -- what deals vita oart time professionals and tc wt 77 efficiency of same anc effectiveness. The Reaional Advisory Croup and review vrocess, I think are qood. Thev have had cont review certification and manacement assessment visits also by the Staff. Their progrem and goals of objectives are kind of interesting. They are verv candid in pointing out, as f say that they respond flexibly to national priorities anc £ocus and try to match these to coincide with local needs “ and that, odoviously, may be @ little more fundine strategy than program strateqy and is not basea on an analysis of cata from the region, per se. But it seems to me that the counterbalance of treat is that as you look at the prodran, they are very candid te say that “this is the way ve do it" and yet they co focus Te myere are a couple of ~- when you look at the proposals ve'lve got, in tne anolications, there are at least one or two policy issues to be raised. huddet, some be 3 ct _ 0 wa r Ny rh ch Shey are requesting $216,009 to contract for thas nhysical management anc monitorins in 1976. Well now, that -- that. NR, McCALL: Well I mean, that amownt needs to he wt 738 kept in mind, and that has to be cealt with. Now what is the policy on activity in '76 -- and havine the grantees dissolve a contract with someone else to monitor the continuing activities so as -- t y pnd the Review Committee needs to keep in mind th request is for $210,099.00 ~- and it could qo one way or another depending on what the volicy decision is. and the other is, not only within the monitoring hh thereof that request of a little over £200,990 -- it's Y $205,000, for a fourth year of funding of an [ANEX] a Phode Island Health Science Educational Council, maybe state wide in Rhode Island. And Mr. Lawon, former Deputy Coordinator, has returned to Rhode Island as the Director of also the State Coordinator for the TriState at a 19 nercent part time, as one of the part time people there. So IT think that needs to be focused unmon. Tt seems to me that this s the second year of its fundcinc. He thina was founded --this It was funded initially at $600,900.00 but aot off to a slow start, and I think this is a siqnificant amount of monev which is left in that, that they are using at the moment. And the comments in vour staff -- you might indicate in one visit there, there was some question of the effectiveness of the wav this was going -- and vet since that wy J Oy 7 time and those cuastions vere raised, ‘xr. Lawton has taker wt 79 the leadership cf this project -~- one should make a consideranie point there. So those two issues of the contracting for fiscal monitoring and That fourth vear of that state-wide project on as that Level of £299,900 -- I think ve would want to acdress this. It seems clear that Rhode Island has nad some p: in analvzing its eriorities and objectives, and the activitios: within that state don't really hold together so well as a program, but I cuess that is not too surprising, aeccoraine “ 2. og . to tne stratecv. a Ae far ee CMP -- one state acency is disarnroved -~ | Wao fl Soya : has disapproved a oroiect. And two B Acencies carried this -~ tney neve USC : + 3 *t there was some aqonizine debate amond some about -- that if we are aoind to see activites, at lJeast h 3 a} nronosed ct oO oy e > continuation bevond June 30th nex ato which int at least proqran staffs at this point in time “ 7 QO bp wt 83 268 we are not allowing any program staff funding beyond that date -- and, you know, who was going to monitor the projects. We had all kinds of glib answers, grantces, which is at least conceptually valid -- where there is a grantee that is not a free standing corporation. In those instances, we felt that this hadn't been the first tine that a Federal vrogram had been phased out and the monitoring of activities beyond its authorization anc funding did seem to get taken care of -- not necessarily well, but I can remember the chronic disease program that became a part of RMP three or four years ago ~~ and there was some Federal monitoring of it. So we, in effect, have in a sense ~~ I suppose -~ said “that issue will quat nave to take care of itself, and vere not goindc to -- DR. MeCALL: One aqnestion that occurred to ine that night have some relevance there or grounds is the region -~ at the time this reaion nad the hich level of funding of almost $7 million and multiple activities namad jin the contract -~ they have indicated currently -- there is some, maybe $3 million in these contracts still under Way « Will these be continuing’ into '76? Even not considering new activities, were there things contracted for that long, that there's going to nave 2og rt G4 to be a monitorine of, regardless of what's done here? min CYALTPMAN: Well maybe Prank, or Gerry can nswer that question. rE don't know. Mm, WASH: I know of none by -- except RIHSEC -- the only one hanging on is RRISEC. 1, STOLOV: -- because the exoenditures are nov reaching a point of projected monthly expenditure rate ~~ and they need that money to Carry then over to the nev legislation, so we con © -7 DR. McCALL: Murpny said, "llow did they arxvive Sary to monitor -- . MP. (SASH): T think the answer there is that NTNSEC protect, torre is a lot of money left over from the 1 Gerry, Go vou know? How much was tnat? Abcow CF $400,999.00? ™hoy soent $299 -- a little over 2090 -- so it was at 593 -- a little less than 409,090 -- 333. Shey told me thev wanted the $290,000.00 for a fiscal officer, a book“eener, a secretary and an evaluator _- therv needed some sunplies, some travel, frince benefits for those aroups -- and there is definitely a budget schedule. The coordinator wanted, when discussing this wLEn ne, was very practical when he said, “when they get tneir 270 award notice, half of the Council meets in August." wt 85 Tiere is "x" number of months for these projects to be viable. If the grantee, which is a free stand, has to clese, he really has to terminate his projects around February, for him to close shop in June. So it hurts the project, and at the same time it would not be practical unless they could find out whether the free standine grantee -~- SISTER ANN: Is this going to be kind of an exception in this case? Or is this the beginning of a new policy? MP, NASH: Well as I say -- all the free standing coroorations probably face the same thine. SHE CHAIRMAN: They are the only ones that nave pronosed to deal with it this way, and as I said, Sister Ann, we in staff, after some agonizing discussion to date, decided vou know, that that vroblem would have to se handled in some Way. But that we would permit, on the one hand, prooram activities to continue beyond that point in time. I think, you know, this is an issue quite apart from the unsettled policy -- will it be vermitted -- is something that the group can address itself to. We may not have -- as a result of the decision, we may not have any option, it nay be precluded. On the other e271 hand, the group may have some views upon the desirability of it in any case, I don't know. MR. BARROWS: I don't think there's much dispute in some cases. 1 don't know whether these are the appropriate ones or not, but there will be a legitimate need for continued monitoring beyond the life of the program, and there should he a reagonable mechanism for dealing with that. Does anybody feel differently about that? Now whether these present a legitimate need for continued monitoring or whether this is the best mechanism, I just con't know. DR. HIRSCHBOECK: mMhat's wnat has been the experienc: with the Ohio procram tnat was phased out -- then sowe of heir activities being monitored --~ TIE CHAIRMAN: I don't know if anytnina -- I can't sneak to it, John -- one of the Ohio activites, for examole, there was an [AHECK]-like activity un in the Cleveland area which was continued after the Northeast Ohio was phased out it was continued under a #919 grant, with funds coind directly | to the [AACE] . tT assume, but don't reallv know, that the monitoring that has taken place in that instance has been essentially staff moniterina, you know, from here. There is not a Mortneast OAL RMP, I don't think [Case Western Reserve | which was the grantee in the old Northeast Ohio RMP, has cast 87 eve any long shadows over that. MR. NASH: No, they are doina the evaluations from that activity. By the way, we will see that activity in a later application in Western P,.A. if we get to it today. , “HE CHAIRMAN: Well, we have heard from -- TR. NASH: Excuse me. In view of the PIHSEC thing which concerns me a little bit from Staff -- the fact tnat we have about 400,990. left over from the first two vears and tere thev are asking for $290,000. more -- I don't know whether that concerns any of vou neovle or not, but -- DR. MeCALL: Well yes, it does. THE CUAIPMBA: Well, Charlie did bring to the attention -- perhavs you "vant to elaborate. There was a staff visit -- and this is pre~Lawton -- which involved, I believe vou said Dr. [Marcqulus] and he vas the Director of the procran, is that ridht? rr, MASH: Yes. Ue questioned as to whether that procram was on taraet or not. He felt they were aqoinec back into the traditional sort of health manpower activities rather than follovina the RMP concent. So perhaps with Lawton there, they can get the thing back on track =~ but I just wonder if they really need that much monev, SISTER ANN: Iwas just looking at this 6.8 here 273 on the line.here and the 1.4 next year -- and you would just wt 88 kind of know that they vere overfunding. MP RARPOWS: Sveakina of funding, I have a concern: From these caption descriptions, the real merits arent clear -- at least in the Country Guide -~ but here we've cot tyvo erojects for which they are asking almost a half million bucks -- a stnuéy of health nolicy in Massachusetts for £238,099. Health services in tine of economic transition, 3259,099. Mow I don't know what they are like, but sight unscen I would like to take those on, on an entrepreneurial basis. DR. McCALL: And the last one, that naval base in Pnode Island -- DR. THURMAT: Be careful now, the're going to call you a “Thurman” if you're not careful. [Lauqnter. ] mD, BAPPOVS: I @on't want to anpear cynical ~- or greedy -- MIE CHUBRIPMNI: Who are the snonsors? Mp, STOLOV: The Covernor of Thode Island sponsors the Phode Island one; and “orris[Donnahue], the former President of the Massachusetts State Lecislature and nov with the University of “Massachusetts, was asked to look at tne state policies issue asa transition to the legislation. Mie auestion staff raised in reference to “hode Island -- and we called the ‘07 Regional Office to gat a wt 89 274 better handle on it -- was the need for this in Rhode Tsland for tyvo counties in thode Island -- but the Staff told us that one out of every ten people in Rhode Island were unemp Love as a result of the Defense pullout, and in the two counties one out of every five jobs were hit as a result of this. And half of the jobs were “avy and the other half was for civilian sunport of the Mavy installations. And the covernor is bringing new industry into the area, and there is a vacuum within that area of the health services -- whether it be later nerformed by EMO or prepaid health »oractice or somethina like that. But they felt that this was an area for focusing on at this time. MP, RBBPPONS: Well, with respect to this volicy stuct in Massachusetts, my auestion would be: What in tne hell is CHP and PMP been doing for the past six or seven vears if it's going to take $238,990 bucks to come up with that. I would think that would have been the guts of what they had been doing. THE CHAIRMAN: Gerry, do vou have any -- MR. STOLOV: Well, I can only say that if you read the CIP revorts, both the A and B, they do support the project, thev feel it's a necessary piece of unfinished business that they need in the health planning transition. They did question whether the U of llass was the ~ nm ct 99 275 proper agency Or a governmental acency, since the covernmental agency is close& to where the policy is beinda made. But they did support. This came from the A and B -- and RIHSFC -- well -- THE CHAIRMAN: Well I hear questions being raised at least by Mr. Barrows, about two of these larcae study nrojects. ~ can only speculate, but havine sat in Washinaton, 1 do know that the closing of the Naval base at Newport, there were literallv full nace ads in hoth of the ‘lasnineton vapers over a veriod of -- I sumpose a month -- not everv davo-- you know, sort of oublic ads nleadine with the President not to close the Mlaval base at Newoort -- which eventually was done, of course. md no doubt it had a verv sionificant econom impact. And also, I also hapnenea to know that the Soverncr of Thode Island is the Chairman of the Governors' Conference you know the Conference of Governors held a committee -- he testified in that capacity before the Senate on the lealta Resources Planning leaislation. 1 Those are just facts -- but you know the pressure Iam sure for getting as many Federal dollars to fill that Navy vacuum in Rhode Island, you know the political and other pressures, I suspect, have been very fierce. DR. TESCHAN: Well, I sort of read the question i | If Ae 91 wt 276 as: How would you spend a quarter of a million dollars in a year, and get something out that is worth a quarter of a million? And studies in qeneral, tend to he published and never read. MP. BARRONS: Mo, this is the type of thine -- I don't know, we can't resolve it -- but I don't know hov Congress can intellicently evaluate anything when they cet this “Mickey Mouse stuff. Here we are, dealing with this disaster oroslen with a recional medical vrocran mechanism -- using this to treat that -- DR, PESCHAN: No, this is merely putting a Band-Aid on it. DP. McCALL: Exactly. mm, BARROWS: And a quarter of a million bucks is just oone. MR. STOLOV: I Giscussed this with (Mr. “Malker] who is the new Coordinator of “hode Island, or will be the new Coordinator, and I mentioned Murphy's studv of the $1.40 per capita going into Rhode Island, as opposed to 45¢ in Mass, and 75¢ in New Hampshire -- and although this is an economic disaster area, when you look at the whole state of Rhode Island, it is a large project -- and Lawton wt 92 et? said: We will be looking at it, not only from the two counties, but possibly utilizing it for the State ~~ But this is sort of off the record, but the question has been raised, at least to me. MP. BARROWS: To me it looks like two professional staff aoodies. PHT CUAIPMAN: But to get back -- sorry -~ DR. HEUSTIS: Can I refresh my memory, can I nave my memory refreshed? THR CHALIPMAN: Co ahead, Al. DR. UEUSTIS: Is the -- is this the same project as has the health vlan education project that already has $490,909.99? mum CHAIPMAT: Yes, that's their [AMECK]-Like activity, where there is aonarently a carryover anoroachine $499,009.99 from prior awards -- so we are talking about rouchly $690,999.99 for two vears for that activity. DR. HEUSTIS: This is leaqal -- just yes, or no. MP, STOLOV: Yes. The money is oblicatea. DR. HESS: Could we aqet a description a little bit more? I think it's very, very difficult to make any kind of essential judgment on a one line statement of a title of a project and I think it would be helpful, to me at least, to know where to fit in this thing -- if we could hear a little wt 93 278 more description as to what these two projects are -~ the science and (Science Council) and the health services in time of economic transition. tue takes in -- the membership includes all educational health services institutions through the State -- public and private consortium molded into a data base which coupled with the sophisticated determination of their needs and DR. McCALL: The Health Science Educational Council | result of manpower supply and distribution changes -- maximun henefit. Specifically, this provosal is asking for a fourta vear. DP. HESS: ‘What is the monev used for? DR. McCALL: I don't knovv. DR. HESS: I know these one-nage summaries are very explicit about these. Well, for example, is this to -- some of it T am sure, is for administrative purposes, or -- is it to vay for faculty, or for conferences, or vartlyvy sunportive -- DR. MCCALL: Of the $209,000 reauest, 123,990 is salaries and wages, In that request is 5,000 consultants, $13,009 rent $5,900 communications not, 279 wt 94 $7,590 computer data processing. and of course I have nothing at all concerning the $499,999.00 carryover. and maybe -- I have not bean to the Pegion at all so L< really can't -~ DR. HSS: Mow many schools are involved in this The numbers aren't in the summary list at all. “un, STOLOY: All the institutions in Rhode Island -- OUR CHAIPMAM: Well how many are there? That's Brown, Pembroxe, and -- “MP, oFOLOV: And there are community colleces as well, in Rhode Island, and lLawton's letter may be more specific -- it does snell out some thines. ns to the $409,000 fiaure that was as of a fev months ago -~ so the spvendina rate at the end of this fiscal year probably would be reduced --~ mh ae ey do vlan to do a lot cf suocontractina locally and if vou wanted to comment on that, Dr. McCall, as to whether -- DR. McCALL: This letter is dated May 10th, from Bob Lawton to Jerrv -- says that -- iT . . « interests of “thode Tsland in terms of 260 wt 95 regionalizing its health manpower and the continuing education of health professionals, lies in a fourth year of support for RINSEC" (Or whatever it is) "In its developmental period. This is the product in vart of a slow start, which is perhans not so unusual considering the difficulty of establishing a viable and coordinated consortium of many forces. "Pirst I would sav, and my mresence here is the proof of this, that the concept behind RINSE and the commitment of the public and private partners to its success is still excellent. The elecance of RIMS desion will he complimented by the procuctive results of its nrocram. "Some of the immediate and spnecific objectives, newly crystallized, are the followinc: "The develonment of criteria for need in the major health professions. This is essential to determinince the gaps after the completion of a current inventory of active professionals, nov in process. I consider this. a difficult and pioneering, but necessary effort. i "9.. A major exvloration and development of a positicn { t on physician extenders of all kinds and their certification or licensure. his will include an inventory of the } 1 1 : - a: . . ! authorized and informal extenders, plus a determination | | t wt 96 of the needs for them, by type. "3. he application of a successful design of core curriculum and career ladder, already develoned exnerimentally for inhalation therapists, to other professions. "4 KW coordinated program for continuing education of physicians similar to the 'compact' successfully develoved in Florida. "SA major effort for the continuing education of physicians, pharmacists, and nurses on the problems of Gruca interaction." DP. HESS: Mov, can vou tell from the budoet sheet or anywhere, how much the collaborating institutions are contributine to this overall project? | DR. McCALL: No, this is not shown -- DR. HESS: No money is shown -- DR. McCALL: No money is shown as coming from other sources, on the record that I have. DR. HESS: In some of this there is a legitimate concern of the educational institutions, and I can see where RMP can form a linkino, a coordinatina function. But you now, you know the hard work of doing this is hasicallv an institutional resnonsibilitv. DR. TOSCHAN: You don't have to provide them with a link -- wt 97 282 THE CHAIPMAN: In response to your other question, the $250,000.00 study health services in a time of economic transition -- skipping through here, this is in the Office of the Governor of Rhode Island ~-- but some of the specific activities -- and I am reading: "anticipate that during the funding veriod, include an assessment of the impact of base closings on the 3 delivery and financing of health care in the affected community. "” forecasging of sunply~-demand relationshinvs for health services resulting from information obtained in the assessment, formation of policy options and the coordination of various planning efforts with State plans anc resources .. - -- and then they co on to talk about economic ana other matters -- I sunpose -- I suspect that there's an avfull lot of economic as well as health in that -- but again, I can't -- that's a backdroo. DR. TESCHAN: Do you have to get down to brass tacks? We don't have enough information here to get anold of this one in the kind of detail that would justify putting a half million into something we don't know wnat. It looks like a vig in a noke situation. A site visit would be in order, and seems to me wt 98 since we are now site visiting 56 programs, or 53, we midqht as well site visit this one. SISTER ANN: At this time, at this point in time, we have a demonstration project that can't be comoleted in the demonstration time -- so their whole project system needs to be looked at in the way they feve desianed these. And then there's one here “for regionalization and maternity for newborn care in Massachusetts" And this hasn't been broucht uo with people who are coing to be the providers and the consumers -— and there will »e some emotional issues, we could stir uo a hornet's nest if they are not ready to use this. so I would concur that this ~-- this seems to m2 a program that needs to be looked at, at this point in time if we are going to give funds. MIE CHAIRMAN: Who is the quy with the action in this dqroup? DR TESCUAN: Thurman. [Laughter.] THE CHAIRMAI: Seems to me that more than almost any region we have looked at, I have heard a lot of concern xpressed about individual projects which by an large, in terms of dollars, are significant. ™7o studies, each a quarter of a million, the continuation of Rhode Island [AHACK] waicn, if you will look at the carryover funds, is at least a half a million. wt 99 INDEX MOTION 284 So those are certainly -~- and between the three or among the three is getting -- and I don't mean to be because I think the neonatal one is around $80,000.00 about $600,000 out of an application at this point of $1.9 or roughly one third of the project -- the group has some serious concern with and I think we need to flag that for the Council. DR. HEUSTIS: I move we approve it at a million dollars. | DP, THURMAN: Second MPESCHAN: Second -- I don't mean to compete with vou but -- TIR CHAIRMAN: We have a motion and a second, to aporove at a million. Chuck, I think I saw a little strain -- DR. McCALL: Excuse me, I think we haven't heard from Sister Ann on this Ws | SISTER ANN: No, I'm -- DR. HEUSTIS: If my motion is premature -- I'm willin DR. McCALL: I assume that with the time restraints it may not be practical, at least in numbers, to have a Site visit. I'm not sure. T£ it were, I would sunport that. But if ve are not going to be able in these unusual circumstances, to have one and we've got to come un with a fiqure -- and it's certain Me wt 100 that whatever we recommend -- zeroing in on all these concerns -- specifically -- so that if we took the $600,000 back that would leave almost $1.3 million and surely it's not that | i simple in my mind -- Iwas thinking about $1.4 million as a recommendation MR. BARROWS: I think that is reflecting the wlole | pattern of their approach. If vou were to descrihe this as you do meat, this has more fat in it than any cut we have seen to date, and probably ever will -- DR. THURMAN: Can we speak to the issues raised? Now June and July are not bad months to cet tne citations raised if there are available personnel. Can we advise Council that this orogram, because of all the things that have been discussed nere this morning, badly needs quick site visit. -- THE CHUAIPMA: Mini-site visit -- , There may even be the possibility, although I can't vouch for this, that one could mount a mini-site visit between nm now and the Council “eeting, which one of the Council “ember might -- a one-day sort of thing. DR. MCCALL: I think that's highly desirable, ' R. TESCHAN: Because I certainly couldn't supoort uo this figure -- I'm having difficulty supporting a million. DR. HEUSTIS: I agree. wt Lol 286 MR. BARROWS : I agree, yes, I'm with you. DR. HEUSTIS: I'd like to get this in as soon as possible, I guess -~ DR. HESS: I think you have to recognize that currently funded at an annual rate of about $2.7 million -- DR. THURMAN: Joe, you well know that we have never discussed this program -- but everybody has said that it has been overfunded. mpm CHATPMAN: Well, is the suagestion onc of really trying to mount a mini-site visit, either before the Council convenes or certainly immediately after -- hefore a funding decision is made to really shane the recommendation as to the funding level? Or do you want to put a base funding recommendation in and -- DR. McCALL: I wousi like to see us go that route of the mini-site visit before, preferrably hefore the Council -- DR. THURMAN: Could I make an alternate, suostitute motion suggestion? Or whatever we really want? If you read Stan's first page here, they are asking for 1886 -- two continuation projects, and eleven new projects --~ that gives them a program before the $671,900. and if you add $324,090 to continue the two projects for a eo. wt 102 TI y neleasen MOTION 287 period of time, you do come up with a base of a million, really. And 50 I think, why not let's -- this 671 ficure they don't currently have those people now ~~ why not let's arrive at eicht, or a million, with an understanding that the site visit would either add to or subtract from ~~ but no funding is possible without ~- Mp, NASH: And no continuation funding ~- I just want to make sure I understand vou now ~~ no continuation funding next vear -- the $290,990. for the [AHNACK] until DP, THURIMI: Thev have $490,900 nov, so it vont hurt them at all. TIE CHAIMMAN: Would you accent that as a surstitute motion? DR, HRUSTIS: I didn’ 7 uncerstand that you've cia anced it any -- excent to add the site vis Lt -- DR. THURMAN: Well not really. I said, aoine hack to the fact that we don't ove them anything, in that sense of the word, for nealth science council because they are carrying this money forvard. I was shooting for £899,000, which really wouldn't hurt them by the time we ran the site visit here. DR. HEUSTIS: Would you change a million to S290 ,000% DR. THURMAN: Yes. wt 193 THDEA MOTION 288 DR. HEUSTIS: Well, I would support that. DR. TESCHAMT: And I second that also. mun CUAIRMAI: O.K. what I have heard -~ what we have then, if I understand it, is a minimal, interim -- or not "minimal" necessarily but interim funding level recom~ mendation of $309,909.90 with a strong recommendation that some kind of a mini-site visit be made to Tristate, looking at some of these new activities, and also the [xhack] to Getermine whether that figure should be upped, and if so how much -- or indeed, that it micht even be lowered. Is that rouchly the sense of the motion, Pill? DP. HEUSTIS: Does that include the $200,090 for monitoring activites? DR. THURMMI: No that wipes tnat out. DR. HEUSTIS: You are eliminating that. O.n. DR. TESCHURMI: And we would love to know what the RAG has been thinhina. MR. NASH: No, the RAG didn't really approve this, I don't believe. TUR CHAIRMAN: Herb is here, let's try this idea out: on him, to see if this is reasonable the Regional -- MR. NASH: He'll be sorry he walked in on this at this time. THE CHAIR: Herb, we have spent a good deal of time with Tristate, recently. We are concluding now, and wt 104 289 perhaps more than any cther region, serious questions nave been raised about a small number of projects -- several new ones that total half a million -- continuation of that Rhoée Island ANACK for which an additional $200,000.00 is being asked, but for which there is some $400,009.00, or mavbe $300,009.99, in carryover funds. And the aroun's recommendation, which hasn't been voted on, but which is on the table now, is to recommend an interim fundine level of simply $800,009.00 in the place of a rouchly $1.8 million request -- with a strong recommendation that somo kind of mini- one-dav site visit he made to myristate to look at several of these large, new study-like activities that are beinad vroposed, as well as the progress and neecs -- future needs -~- for the Rhode Island [AHAC:.] -~- eitner before Council “Meeting, which is a short time avay, or about three weeks or less than three veeks; or before the final funding decision is made. “Yow this is the first time we have come to any kind of a recommendation. I think there are enough serious concerns about specific activities, and questions -- MP. PAHL: Well we, of course, have not been site visiting other regions, but I think it's an unusual set of circumstances, in something like this, there is no reason that we couldn't accommodate that recommendation. wt 195 290 But I wovld much prefer to have the site visit prior to Council Meetina than after Council -- THE CHAIPMAN: And presumably, includina somebody from Council -- MR, PAHL: Somebody from Council and liaison. I think the Tristate one, particularly, has given us some questions, internally also, and this certainly reflects, perhaps a little bit more emphatically the issucs that have come to my attention. We can accommodate that recommendation, and will act on it. We can't accommodate many site visits because of the time involved, but certainly in unusual circumstances we can, MP, BARROWS: Well this need is dramatic, too. mup CHAIRMAN: We do have a motion to that effect, then -- let's call for the question if there's no furtner discussion. All those in favor -- [The motion was properly out to vote and carried unanimously. ] wt LOG ey. MEW JERSEY: THE CHATIPMAN: O.K. Paul. DR. TESCHAN: Well, the New Jersey application is a little longer than West Virginia, but has about the same general qualities in being able to describe simply and in relationship to the region's needed goals and their shorter term objectives which have been arrived at by explicit process, so that you can follow it. There are corporate crantees -- the program serves 7.2 million veople. They have established sixteen profession- als and some eight clerical people approximately, and they are asking a program staff support to the tune of $825,000.00. | They have eight projects, as far as I see it, and this snans, really, the entire set of goals relating to access, suvvort of categorical -~- sunport of quality assurance activities and some efforts in the area now of cost contain- ment, and a beginning exnloration as to how the CHP and the RMD mav be getting ready for the next development in the leaqislative activities. They also function on the contractual system. They have a larce contractual budget -- that's essentially how they are functioning. ™hey have an interesting staff organization so that in addition to the usual essential manacers, that is the fiscal, development and evaluation type thing, they also have 107 292 a program development who has a named, on-line, full time manacer that has to do with the subject matter -- so that there is somebody free -- and so vou get the sense that tnere is a very discrete proaram assigned responsibility for the conduct of these affairs throughout the region -~ and sort of a tight, exolicit wav. If you read a cnart vou can understand exactly how tney are proceeding. Our past experience is coherent with the idea that the PAG annears'to be extremely explicit and active, and has some of the most effective peonle -- including one of the Members of this Council in the other vanel -- this committee -- on the panel -- who has been not only extremely knowledce- able, but very articulate about the program in presenting how the PMP should be working in developing not only CHP capabilities, but the projects in virtually all the areas. I am interested that there are twenty orantees amon the thirty some nrojects. They had 36 onerational vrojects hut not all of them are current, I might add -~- and 7 developmental ones. So that anong that entire croup there are quite a number of arantees which annarently are the recinients of the contractual funds -- orimarily operating out of Progran Staff. So that it's not either centrally managed or qrantee managed, or anvthing of the sort -~ you aet the feeling there that there's a good dissemination of resvonsi- bility in the overation of the procran. g wt 198 293 One of the fascinating things about New Jersey has been the way they have been on top of so many of the new issues in terms of better access ~- emergency medical services -~ quality care insurance includina assistance in PSRO develooment -- but also, more explicitly than almost any other program I know about, though the Staff may know hatter than I, of course, for qood reasons. But the most expelicit exnerience I have had in setting scandards for auality for certificate of need tyne activities -- i.e. the technical review grouos, or the conmittees, have put together standarcs of excellence, or standards of quality care, in a whole variety of specialized and spvecialty services And one gathers from the narrative, that these have, in fact, n certificate of need and that the BMP Committees fHe been used uh have been used by CIP certificate of need type activities for advice on the basis of standards -~ but not only the standards have been adented by CHP but the staff has narticipated in the review of certificate of need ana given the orofessional and technical advice to CIP deliber- ations. Mow that's really, one of the first explicit examples in my experience that in fact, CIP has used FP in an anoropriate wav. I think it's a real credit to the history of that develonment. wt 109 29h Now the final thing that I wanted to go into -~ there's a fair amount of detail -- But the other thing I wanted to mention was --~ a good deal of back and forth discussion, especially in one set of correspondence which Frank has got a nice covering letter on -- from apparently the "Nortnern New Jersey Conference of Clinical Council" I can't tell whether it's an Nor Bowe mim CHATRUIAM: It's B -- area-wise. DP, PRSCHAT: And the discussion of the letter of the Txecutive Director of the B Agency, is sort of a cantank arr: ee eee buckshot tyne of vituneration, wto which, there is one of the ” mot beautiful resvonses that I have ever had the pleasvre of reading. Al {[Plorin] has gone, in five paqes, to cevelop the history of how CHP existence in New Jersey, is larascly 9 K esult of RMP effort, through three cenerations of executive directors -- and he takes each of the issues relative to each of the projects, and beautifully ¢cevelops then in some verv simple, clear lanauage, in a highly professional and hichly unvituperative and unomotional way giving the facts of the case. You know, this little corresvondence file, to me, is one of the most beautiful pieces of exchange that I've had the pleasure of reading. I'm just delighted that we = wt 119 295 had this for supplementary material -~ it's the basis of really a more general recommendation that I vou like to leave with you all, and that is that -- not in my own feeling -- is that recognizing the legislative mandate of CHP -- recognizing the relations the regulations of NMP for interaction -- I feel that we should recommend to Council, for Council policy, that says that: We urge that Council bring to ar. [Pavell?] and other appropriate people's attention, that interaction is a reciprocal process and tnat we should have mandated hy reculation -- quite aside from leqdislation -- reciprocal interaction and resvonsibility, mutual responsibility, explicitly directed from the head of the CHP Agency here, to all 5 Agencies particularly, wnat they do with the As is a different sory, of course, and it's up to then. Secondly, that so far as our deliberations in this Committee and in Council, that we should ignore the negative C@P comments, except as ee (a) number one, the B Aqency informs the local RHP of their criteria and review in common process ~~ precisely as our PMP informs the B Agency of the RMP's review of common vrojects -- total reciprocity. (b) number two, that the B Agency shall furnish to the @™P aaency, explicit statements of the objectives and priorities and as need statements, against which Rip 296 targets their development. wt lil . So my feeling is, yes, we recognize and feel entirely appropriate the RUMP should respond to CHP -- just exactly as said -- no argument. but that it needs to be done at the same professional level to which RMP is TNDESS RECOMMEND being called. That needs to be established as a simple issue of basic intecrity between the tyvo programs -- particularly if they are going to he legislated into some kind of relationshin. Mow that's a formal recommendation I woulda like to have this croun discuss and consicer at some point. Tt's a dicression from the current thinking and = --~ Ana now my final, to sum it un, I think this is a beautiful program, , a ton level overation. Our feeling is that we would vrobably recommend the fundina approximately 15 to 29 vercent above the current tarcet -- but minus about on $609,909 which is due about Julw lst -- and that comes out to be about $2.9, million. And that the Recion essentially should be congrat- ulated for the wavy they have proceeded. DR. HEUSTIS: What was vour figure again, please? DR. TESCHAN: $2.9 . DR. HEUSTIS: And then. you're going to knock them down by a million? MP. NASH: This application is 3.9. wt 112 MR. million bucks. DR. . 297 BARROWS: Yes, we are knocking them down by a TESCUAN: I thought that the recommended funding | relates to the tardet, about 15 to 20 percent above the tarcet --~ minus about $609,900.00 in Julv. They are over target by some -- I fordet what -- HESS: They are currently funded at 1.6. TRSCHAN: And I thought that from 1.6 to 2.9 it's a substantial rise and it allows a little money for the July 1 Council situation, and it brinas it a little closer for the procram. Wow I would have no objection if semebody anted to ' fund them fully or in some larger amount, you know. mT baits was the other the matter of observations MR. of just what CHAIPMAN: Maybe we ought to, since Mr. Barrows n this, hear from him before re carry 0 reviewer funding level, or other comments or further. BARROWS: My review is pretty much a reflection Paul has said. In short, the program leadership 3 in line with what the figures appear to be, which are availapl. i ranks, participation, I thought, was superb. In fact, overall I came out with the impression that this was particularly in deptn, the the type of program I would recommend. Period. relevance of their past activities and the wt 113 298 proposed activities in the broad, RMP mission, was just top notch, and more than that, they are relevant to the needs of their area -- particularly the underserved, seemed to he just riaht on taradet. I was deeply imoressed. They hed another attribute which vas outstanding and this to me, and really this is maybe a philosophical matter with which you may not all agree; We need the ideas, the exnertise of academia and we need the sunvort of the Government if ve are really cqoinag to cet anythina really done in the mainstream of imnrovine. It's got to come from tne oracticine, professional level, and thev have done more than any program I have seen, to cet the practicing vrofession involved, With ‘that, I came out vith just this very ton ratine and I disrissed the CHP thing as a ventilation of nersonal pique which had no merit. TIE CHAIPMMI: Mavbe I ought to ask Frank. IT think we have an issue that is resolved here, Frank on the =- MR, NASI: You mean on the CEP? THE CHAIRMAN: Yes, riaht. MR, NASH: Ves. Well, of course Dr. Thurman is certainly accurate in his description of the letter -- Dr. [Ford?]’s affair -- it was beautiful. and I have since neard from the region, that the wt 114 3B Agency Board approved, I mean, recommended approval of tnis application -- so I think that this bit of "spleen venting" by the CHP Director wno has only »een on the board about five months in that varticular agency anyway , is ~~ OR CHAIRMAN: Have vou got any more insights on the warfare in “Mew Jersey, Northern New Jersey, Tom? PROM THE FLOOR: That's not my bailiwick. THe CHAIPMAN: Oh, oh, that's right. New Jersey ~~ that's a conout. [Laughter. ] 4 DD, TRSCHAIT: I'm dust callina for fairness an a SNe be r « ecuality eum CHALRMAY: Well that is a -- the letter was a Director's letter, but the Board -- under what duress or erommted by what reason, did take action cuito onpesite to that, avprovina the Now Jersey aoplication. I realize vou're just asking for fairness and ecuality MR. NASI: o repeat, we may have a policy question tJ in this particular reqion. One of their pronosals is to establish 3 PS?"Os and I don't know whether we can use our money for the actual establishment of PSPOs or not “Pp. BARROWS: Is that to be established, or just to provide the preparation activities? MP. eAHL: I'm not sure, it’s backuy support. wt 115 support -- but it's a B aqency. 300 COMMENT: It isn't actual support here, though. TIE CHAIRMAN: It may be an issue that we want to flaq, though, and get into some consultation, if we haven't, with the appropriate PSPO staff here, and depencing uvon the outcome of that, we may, or may not, want to highlight somethina for Council. T have the same question in my mind. It certainly is, in one sense I think, very consistent with the kind of cualitv assurance activities and standards setting -- or standards develooment, that has characterized one major thrust of the Jersey PHP. On the other hand, bureaucrats have a wav of -- MR. BARROS: Pete, I read that as simply a resvons¢ to helping the medical community get ready for this procram and -- 5 GHD CHAIPMAT: We mav want to cneck up that PSM staff, I think, in any case -- just so that veople don't have their noses out of joint around here. DR. TESCHALI: The basic funding of the PSRO comes from the processing of the business -- so you know, it isn't going to take -- the actual financing of the PSO is not a problem. MR. PAIL: They want to provide the same tyne of MIN CHAIRMAN: Now are there any other matters or 201 or comments or questions of the two reviewers, or of the staff, for that matter, that relate to Jew Jersey PMP? DR. ERUSTIS: Do you think Barrows will agree with the money figure? . MR. BAPRONS: Well I was a little more generous. I'm not as good at nicking figures out of the air as vou fellows are -- but I would sav that when we wind un, this should be in the premium category -~ very clearly in the premiun catecory. Now, where that ficure is, I don't nov. matin TT TIRANA Cr 1! sue AL wy ae Nell, they are asking, as Paul has indicated, they are reauesting in this application almost $4 million -- 93.979. @aey have indicated, and that does not include any nev activities in one sense, althouch there is some nev program staff activity, T oather, and some expansion -- and they will te in, with a duly application that txcy estimata at $699,909. DR. TLOSCHNI: Well like I sav, I have no objection to upp that ante, but I just didn't know how to do it. 3 Q DR. HESS: Let me ask you a couple of questions: Humber one What's the population of the recion? DR. TESCIAN: Seven and a half, MP. MASE : 7.2, really. DR. EESS: And is this just the state of “Nev Jersey wt 117 302 THE CHAIRMAN: Right, it follows the state line. There is some overlap with Greater Delaware Valley in the Southern and less populated -- Philadelphia and Camden area, and the Cranberry Bogs and the resorts ~- But I think certainly New Jersey RMP has defined itself as the entire state and, indeed, have conducted activities throughout the state. MR, NASH: They sent a staff nerson down to Southern Mew Jersey, and paid the salary and all exnenses for a year in establishina the South Jersey CAP acency. They consider tnemselves a state-wide program. Rod "Murphy? THE CHAIRMAN: Oh, ves, Rod literally is hack today from a management assessment visit to Yew Jersey earlier this | week. MR. MERCKER: I spent Tuecsdav and “ednesday with the Procram Staff of the New Jersey Reaional “ledical Procran and their manacement is excellent, The procram manacement 4 in warticular -- they are in the vorocess of taking on full cornorate resvonsibility from the University -- the University | Nedical School -- and they rave develoned the additional polic™ basis for this, but they still have some administrative nanagement nolicies to develon. m But their procram management was superb. They nave a wav of operating by health specialty areas, where their staf. wt 118 303 members interact extensively and effectively with the projects. It was very, very impressive. THR CHAIPMAN: I don't think we have ~- unless the Chairman missed it -- a formal recommendation on the floor to ~- of course a fioure was mentioned, but I didn't ask for it, nor did I hear a second. Hm, BARROWS: I'11 second that. DP. TESCHAN: I'm beginning to hear a concensus because if we have a 7.2 -- and it's ona per capita basis we'll be talkina about 3.6. THE CHAIRMAN: Are you revising your motion? DR. PESCUAN: I'm raising the cuestion. BARRONS: I would be more comfortable witn ID Ll © something like 3,or 4, or 5. mun CHAIRMAN: 2.9, 3.4, 3.6, 3.5 ~~ what do ft hear next? [Lauchter.] mp, de La PUENTE: Well, in view of wnat I have neard, and in view of the budact that I have seen, and in view of whatever I know of the New Jersey program, and in view of the other suacestions that have been made during this session, I think that $1 million down from the ficure he they have requested is too much. So I would qo along with jix . Barrows. THR CHAIPMAN: Sister, you have better connections than we do -- what do you savy? (Laughter. ] at 119 304 STSTER ANN: Mr. Barrows, there is one thing I haven't worked out, and that is the process of discernment. [Laughter. ] DR. THURMAN: After what Joe just said, I acree- with this, and I am certain that all of us who have seen ‘lew Jersey, are very, very pleased with the vey it runs. But we are talking about a recion right now that is getting 91.4 million -~ and then we are talking about suddenly leaping to $3.4 million. COMMENT: Ho, £3.6. On the other sheet. Dn. THURMAN: Then I go back to my criticism of the sheet. But on the other hand, I think that's an unreal leap into -- mp, BARROWS: Well, would you buy $3.2? DR. THIRMAN: I would go back to 2. SISTER AUN: And I go back to $2.9 too -- that's -- DR. TESCIAN: Why not move for $2.9? Now that's with the point that this is the superlat story, and if the Council felt disposed to increase still further, that the Review Committee would take no umorace of that. DR. HESS: I would like to just make a point here: : a0 wt 120 IMDEZ 305 I hate to see us unduly influenced by a reaion that comes in with a huge recuest and grant a lot of funds, just because they ask for a lot of money. In other words, we look at Puerto Rico -- a top notch program, that comes in with a modest request -- and vou know, pretty close to what we think they can use; and we cive them that. Noy this is a first rate program, but they come in way, way over -- vou know -- what they have previously been getting in the last year of funding. And somehow, that just doesn't sit richt. DR. THURMAN: Could I add something again? THE CHAIRMAN: Certainly, Bill. DR. THURMAN: Bo you see any need for an extra slug of money for them to carry out their cornorate thinc? IR. MERCKEN: A modest sum of money. They Aave requested an added accountant to tne staff. DR. THURMAM: O.K. I second the motion for $2.°. THE CHAIRMAN: O.K., we have a motion to recommend funding New Tersey on this application of $2.9, with the sense, I believe, of the groun that certainly it reflects a favorable task toward the region and presumably (but again, one nas to see the proposal, their supplemental proposal should be looked at in Julv by this group) in a quite favorabic wt 121 light. 306 That should be around $690,000.00 Ts that essentially the sense of the motion? MR. BARROWS: Yes. MIE CHAIRMAN: Is there any more comment on this? If not -- all those in favor -~ [The motion was regularly put to vote and passed favorably by 8 and unfavorably by 1 vote.] wt 122 THE CHAIRMAN: O.K, it's (as they say in Hollywood) "High Noon" and I think with the concurrence of the group, this is about the busiest time in the Cafeteria and I think we do have time for DR. TESCI THE CHAIRMAN: AN: Two more. Two more? Well then, you will have to help me identify the easy ones. Pochester has been suggested -- is that one on which you are not the reviewer, Joe? DR. HESS: I weren't -- [Lau DR. THURMAN: THE CHAIRMAN: I think we are going to have to ¢2 Well, qnter. ] I couldn't make the judament if THE CHAIDMAM: Oh, I don't know. The humor is getting strona. cr in about half an hour, thinas are getting out of hand. Well, whv don't we just lead off with Rochester and ask doce to lead DR. HESS: DR. HESS: off. Hess Well, volunteers. ROCHESTUR this is the third application which) we have discussed this morning in which there is an inverse relationshio between the size of the -- the amount of paner -- and the guality of what's on it, at least in my estimation. 123 308 In terms of the overall orqanization of the RMP they seem to be well organized in terms of their overall goals and objectives, and they are consistent with the national goals and objectives. Their review process is clear and well defined. As near as I can tell from the application, the leadership on the part of the program staff, seens to he high quality. They have identified within their reqion -- the areas of need -- they have apparently done some cood backoround vor in terms of the identification, and they've got a Recional lan worked out which displavs it clearly and simply on aman -- particularly in terms of their undersurvevys and the need of orimary care, and that tyne of thing. One of the thines which I enjoved about this application -- they have their coals, and then at the bach thev have their objectives of the nrojects relatec to the goals -- and the fundina is disvlaved rieht along with it. [Displays a Gocument.] Shoir overall qoal here, and listed in priority order the wav they priorize the vrojects -- the monev that goes vith it.’ ?né then the cumulative total that will he spent on that particular goal. Now this particular application is only for a continuation of a core staff, with a small increment -- plus wt 124 309 tuo small increment -- two small projects -- and the rest of what we see listed here under "goals" will be coming in in the form of projects in July. .§0 that basically, all we are asked to do here, is to proof the cumulaticn of a relatively small corps staff and two small projects, and this is communicated in such a well organizec fashion. that it just seems to me they got their heads tocether in that reqion pretty well -- and I was favorably impressed and I see no reason why we shouldn't give them what they want. we Sak DR, PESCUMI: Is there more coming in July? DP, HPSS: Yes, thev are coming in -- there's a big increment cominc in in July -- the projects. You can already see clearly wnat those projects are coing to be and how they will relate to the qoal. So I have rated them on either "Satisfactory" or “Excellent” in every cateoory. Mere were just tro that I vut "Satisfactory" on however, with more information perhaps at staff level, they might well be categories of excellence -- and overall, based on what I see here, I have rated it as a “Suverior" region. MP. PAHL: What's the CHP? DR, THURMAN: Ed Lane -- he sent in a nice letter saying he supported the whole thing. wt 125 310 THE CILAIRMAN: You have a region here, an PMP, which aeoqraphically is defined in exactly the same a? ~! a y = conficuration as the single area-wide B Agency Genesee -- they have, I think, good relationships, and I think we may even have an incestuous relationship developing in the sense that I believe Peter Mark's brother may become the B Agency Director, with Walter's retirement this summer. Now this may not help -- having known other brothers, but -- DR. THURMAN: No sisters? - MIR CHAIPMAT: Bill, you were the other reviever on this application -- it is a very modest one in -- both in amount and in what it is thev are proposing now. But we tn Q 0 fete o3 2 know vretty well what their $1.4 million application i to loox like in terms of specific activities. DR. THURMAN: Joe said evervthing that. I vould Aave said about those priorities -- well organized, strona CAC, qrantee situation is a separate from the standnoirt of never having had a real evaluation group; and the CNP voted unanimously to recormend approval of the anplication and sent a very dood letter. Al So that I would suovort everyvthina he said, and recommend the absolute figure of $361,437.00. They also bring up tne auzstion in their anolicatson though, that they have put out an RFP of September 1, '74 - + . oor , : ; June 39th, '76, in the *FP that they have distributec all wt 126 311 the way down -- this is the health care delivery program and always has been -- $1,300,000 -- THE CHAIPMAN: What you are saying, I think, is that we may see a number of activities proposed in the duly application, which vould run beyond the end of next fiscal year -- which we have said is at least permissible to be looked at. Again, I don't knov whether we will see what we are tryine to look at in Metro ‘ew York later this afternoon where almost everything will be orovosed for to years. Well Bill, vou wanted to sav sonethinc? DR, THUPMAM: Io would second. WUP CUAIMIAT: You would second o.k. Rn. HESS: I so move. {[Lauchter. ] Myo motion was recularly put to vote and carried unanimously in favor.] TYE CHAIRMAN: O.K., I think we have it. I think that is a record -- we even beat Puerto Rico on tnat, Joe. 312 WASETMUGTON & ALASKA wet 127 THE CHAIPMN?: I think we could, again, provably take up one more region. Dick cave me a nod from his end -- he has been in contact with “Washington a lot this morning, because he did have some questions we thought migat have some partial ansvers to as it relates to CAP here. t don't know whether we vant to nroceed with Nashindton and Alaska, or another region, mis tyvo reviewers on Washinaton and Alaska are “ur, Barrows and de La Puente. Do you want to take it un? MR, BARROWS: Yes, I think we can. This, in my judoment turned out to Se another fine program. tT rate them vretty hichly in almost every catecory. The coordinator, Donald [Clarkman] I understand, has a very fine revutation. PAG Chairman, is a Dean of the University Medical Scnool. Four members of the University of Washinaton are on the Executive Committee, which concerned us a little bit -- and that's out of seven. They did suffer quite a depletion of staff during the phaseout vroblem. They dropped from 52 down to 35. They planned to rebuild, and the re-beefing up may constitute wt 128 313 something of a problem for them. MR. de La PUENTE: Yes. MR. BARROWS: Their staff organization looxed to me, logical and simple. They've got a regional advisory group of 42 -- and six or seven of them are from the University -~ the rest from the standpoint of interest the representation is pretty well balanced. RAG seems to be forcefil and active, and is still presticeous enouch to attract a cood auality of neople to replace those wnose terms have expired during all of the surveillance of that. They've dot sonethina like fourteen ‘committees and subcommittees -- they are oretty snecialized, but they seem to be functionallv effective. Past nerformance -- continuation after DMP 'S -- in the top drawer. ™heir direction has heen riant on target, whereas both the mission and their special area needs -- And I might voint out in that connection that they are dealing with three catecories of problems: They are a tertiary center for a large ceocranhic area. There are metropolitan areas which are fairly classic. And then they have tremendous remote area problems -- Alaska ty and Washington both -- and they seem to Geal with all of tnem 129 314 well. They have been responsive to other federal initiatives. Their Regional iledical Agencies and network all the way up the line, is good. They assist the CHP -- the ad hoc studies -- close collaboration. Their objectives are, again, on target. They are specific and relative to the needs. The proposals seem to be, to ne, consistent with the exoressed objectives and oriorities and they have placed the right kind of emphasis on it. “here has been abundant exnosure to CHP feedhacs on everything - and they have gotten some feedback and that not being studied. . Q Feasibility, based on a track record -- the nature of the program and svecial conditions, Looked vretty cood to me, Their CHP relationshivs -- I miqht mention a little bit about that: Thev have tyvo CHPs and seven Full time stafi. functionine Bs, plus some others in various stages of development. They maintain a reaqular communications contact with the Bs and they provide them with ‘technical support and sone modest funds on their enterprises. Both A directors are on the PAG and there is other t I ' | i \ ! i 130 cross-membership. And one of their projects, Project Number 88 for $75,999.00, is to develop a test idea for combining of CUP, RMP, and to prevare for the uncoming legislation -- and I think that they will do a good job. I had, to start with, one reservation, whicn sort of vanished as I went through it -- this was a program which was sufficiently highly dominated by the University of Washington -- hut it didn't seen to com? out in the product that came out. ~ could find no evidence of that dominance. Mow whether I am wrong or not, I don't knovw but ZI couldn't supnort the conclusion that there was tnat dominance, In summary, I rated them as a "Superior" carous substantially better than the average PMP -- looked to me relevance to mission, needs, involvement -~ both vrofessionall: and public communities and their efforts rate -- there is aggressive preparation for the upcoming transition in planning and they seemed to be very well orcanized. And so I vould recommend them, again being one of our better orocrams, if there is a premium treatment available. that they would qualify for it. THE CHAIPMAN: Thank you. Vy sn + Joe, vou vere the other reviever on this. ™ ~ a 131 you have on this to add, suotract, or emphasize? MP. de La PURHTI: Vell f want to emphasize that they are areas of program enonasis on target with the needs from what I see. They have very good relationshin with the CUP -- and that in that state C'P Director proposed Washington and Alaska mombers of the Regional Advisory Board ana that the staff particivates and is assicned specifically to work with the development of the CHP Agency. I think this is immortant. Mhey have created many things which are outside of t v the university enclave. They worked with the General “fason Pesearch Center, the Scattle Reaional Healtn Board, tha Seattle's School Tistricts, The University of the State Mosnital Association, the Washineton State nurses Association, the Washington State “edical Association, the Batter Administration of Nos vitals in Seattle ~- ana, last but not least, the Viortinrcst Chicano Yask Force, from wien these people I have heard very favorasle comments in terns of Washington Latin Ancrican people. So Tam with vou. I am imoressed with Vashineton, what they have been doinc. That's about all I have. DR. TESCIAY: Somebody was saving that they we: anead in the quality of assurance -~ and this was well befor the quality of assurance -~ wt 132 317 At the conference they had motion pictures showing the currents of standard setting and studies of patient management -- and in comparison with what happened to vatients: , and what standards of staff were put together -- ana showed the feedback by which changes in management were ; effected by the output of that exercise. Mow that's a corwlete renal circle done on 16 mm color motion victures while the rest of us were still learning how to spell “suality assurance. And I just folt that this should be -- uP, BAPPOVS: I felt the same thing come through their deronstration of foresicht and orderly plannine for anticipated events. Dick, because while relationshivs with CHP have heen described. as dood, I think it was also clear from this anplication trict havpened to be one that I looked at, mvself, by accident wnen they first were coming in. I was just trying to cet a sample of what the annlications looked like. And certainly, their anplications drew some fire from some of the Ci? agencies, as you note -~ indicating their Executive Committee was meeting yesterday and Dick had been in contact by phone with Washington and Alasxa this morning, to ast some feedback on that situation. Ind that's one of the reasons we held over on this one. 3 vt 318 Dick, what do you have for us? mp, RUSSELL: IT chink the concern that I nad with the application was that they did not spell out how they were going to respond to CHP comments. That was one concern T nad. I was amused when I read the one from Svokane, the CHP B Agency, to see this type of comment coming from an acency which RMPs in phaseout devoted 59 percent of their ficld manual to this narticular agency. IT thought that was interesting. Well, anvhow, the Txecutive Committee is going to resnond, in writinc, to enon of the necative comments, and we will have conies of those. I falt it vas imnortant for them to have a formal resnonse -- for their own record. mum CHAIRMAN: Rouncil will nave the benefit of this letter. mm. BAPPOWS: I didn't gloss over tnrat, put they met mv criterion. They are in cood communication to ~~ thev get feedhack and they have a legitimate and fair nrocess for dealing with that. Now i think that's all we can ask for. ie can't ask for everybody to look un -- MR. RUSSELL: Wo, I agree. But I just felt that for their protection, they should respond. DP. TMSCHAN: I wonder, to see if vou can ~~ 319 if your current reading agrees that Donald Sparkman came out wt 134 with probably one of the first carefully drafted revisions of bylaws to accommodate the August 1972 EPNPF policy for the change around ~- and has, therefore, a free standing self-pernetuating PAG. I would infer fron what you said, then, that | members are not appointed. ‘There is no special right of 2 appointment, as I gathered there ~- and if there are happenines before 7 REG Exec pneonle -- that that happened in the : fair play of standard nominating process. Is that correct? MP. BARROUS: I don't recall seeina their noninatine process, but the end result of whatever their process, looks like cood balance except for this one thinad I mentioned, And I could find no evidence of the University, or pro- university bias in what they were doing. MR. RUSSELL: The voice in Alaska, was probably the first program that came up and drew up a very clear letter of understanding between the University and the RP. I know there has not been that dominance. Now there was one occasion where the university - has, as qrantee, come into the programatic concern, but as grantee -- thev couldn't exercise the procramatic aspect -- so that it hasn't been a problem, let's say. THE CHALRUAN: I don't know why people snould be 320 wt 135 surprised by the phenomenon of "biting the hand that feeds you." It seems to me that much of the post-World War If economic assistance would sucaest that as a natural and, perhaps, not even unhealthy phenomenon. Once you help a guy qet on his feet, he will take a whack at you as cuick as he will the next cuy. mo, BAPROWS: Well, there is a certain amount of feelinad your oats in that kind of thing ~~ DR. TESCHAM: How many peonle are involved in this at. thing? THE CUATDMAY: To am not sure -~ it's about tvo and a half or three million nconle. tH : ae 2 ) IT know Alaska: Ouarter of a million. When there it was less than Pairfan Countv, ten vears ago. But they are scattered out all over. DR, HESS: Seattle is less than a million. Snokane -- Qu “MP, BARRONS: Snokane, their snace problems an culturan problems are horrendous. THE CHAIRMAN: I think it's probablv a little over a million, Joe. MR, RUSSELL: But I don't have that -- I've got the figures in my briefcase, but not here. But for the record, the applications you reviewed did not have the salaries of the proara m staff. They were wt 136 321 submitted in the regional application, and we do have those -- put they are not out of line. DR. THURMAN: I just want to ask you one question: You are satisfied that they are able to utilize the additional half million dollars that vou're going to recommend? MR, BUPROWS: I would have only one reservation as was said on these veople ~-- thev have suffered a fairly supstantial staff depletion. tT would think, thoudqn, based on he comnetence of the Coordinator, and their relationship with both academic and vroviGer centers -~ tev could mount a qood tean. | t has good manacement. I'm not too worried about that. ct And I think that they are beine fairly modest. They are jumping from, now, a funding sevel of about 1.5 to 2 million -- and I think they can -- Subject to this staffing problem, I think they can DR. HESS: All right, if you have this viev, their current fundine level of 1.8 -- so that if. MR, BARROWS: I have 1.4 or 1.47. DR. HESS: Well, there has been a discrepancy between that sheet and this one. t 33 a “a “a i ct tt The latest figure we have, is 1.4 -- DR. HFSS: Where do the figures come to on this sheet? The first six months? SUT TYTN ONDAN loTLO:1 322 DR, HEUSTIS; Are these fiqures not six months old? The only date I can find on this document is January, 1974, and IT was led to believe this was prepared as of January 1974. MP, PUSSELL: No -- DPR, ESS: This would be the funding level for the six months -- one through six. DR. THURMR1: I based this on the other one, which is 1.5 to 2 million -- can thev handle the extra half million Beak collars? “Ip, BARROWS: -- total planning -~ talking about July of another half million -- I Gon't think they will be cetting everythinda they ask for. DR, THURUIAT: Eut are vou satisfiec he can reasonably use this? MR, RUSSELL: Yos., But let me answer, “Ir. 2arro: “hen this nhase came out, this cave them an onpor- unity to revarmm their staff so that it wasn't all loss. ves, I think they can manace the money. DR. THURMAN: I would move we aoprove the recuested level. [The motion was properly seconded. ] “THE CHAI PRMAL : That's 2.77 -- as requested. Is there any further cuestion, additional comments Or corrections? wt 138 AL1L those in favor -- 323 [The motion vas put to vote and carried, unanimously. ]} mim CUALPI: It is 12:20 and this may be a good time to break. We have completed nine regions and we have eight left to do. COMMmMNT: Do vou think we can wrap this up? THE CHUALRMAI: I think that is still -- and that's why I need to consult with my colleacues -- but if we do have it within our wherevithall to complete them all today, put tT don't think, on the other hand, that I have the ability and the other staff, to vrap some of these things un and ‘ L. f Gisplay them for you. ty Q i 4 T think we vould have to ask you to sit around ic an hour after that. So I think, realizing thet some of you are coinc to have to leave todav anyvav -- Charlie, vou are going to have to leave todav fairly early anvway -~ that we probabiv - 4 still are faced with a brief session tomorror. Dut tH don't knoy what my colleaques are doinad. I think we can vrobablv, cet throuch with tue applications today. MP, BAPPROWS: Could we shoot for that, and then whatever time we have tomorrow, we could just look baci: and see what we have done? THE CHAIRMAN: Yes. We can't do this instantly [Indicating blackboard] not that this has anything to recommend for it, but I think wt 149 we can shake s waiat your acti and the others 325 ome thinas out and give you some idea of ons were, wnat they look like, collectively, may want to look at ita little, too, and see maybe adjust something up, or down, something here or there where But I don't think we can give you that immediately. DP. DR. we could knock something seems to be inconsistent. PESCUAN: That is a very helpful chart. MIVRMAN: Are we required to keep these? CHAIRMAN: Mo. THUR 3 Do we have any other easv recions oft? CHAIPMAN: Well, you neoole are the reviewers. I would think maybe tlestern Pennsylvania is an easy region -- continuation o on that... reviewers -- that we micht DR. Until after lu THURMAN: I'm trying to see if the group -- CHAIRMAN: Mo, Western Pennaivania -~ MASI: Wo, -- West Virginia is primarily a f Uestern -- vou may get a lot of questions CHAIPMAI: John, vou and Mr. Barrows were tne do you recall any difficulties -- is that one polish off in a brief neriod? HIPSCIBORCK: Well I think we had better wait neh anywav. 326 wt 141 THE CHALRMAT: O.K. I think we're going to come to having lunch nov. So it is 12:25. Could we try to be back by 1:10 oF r:1i5 at the latest? you see, we have four hours and eight reqions, and if we can do that -- [The proceedings were recessed for luncheon at 12:25.] HEW Ns-l 1 fls arc hws-1 9 Boi ad re ~~? 10 11 12 13 i4 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, fC. Washington, D.C. 20002 LON GARRABR 327 AFTERNOON SESSION 1:15 p.m. MR. PETERSON: I guess we are ready to commence. Joe is not back, but before we do, I did huddle briefly with Bob next door. They broke a little later than we did. We are just about neck and neck now. They have six left to finish. We have eight, but I think our view was, and I wanted to check it with the group, that we are going to be able to finish the applications today, but there seems to be some need for a meeting, however, of a very brief duration, an hour or so, perhaps two hours tomorrow morning to sort of take a step back and look at each of what the panels has done and ratify it as a whole group, that is the actions of the respective panels, so that just Bob and I made that decision. I see all kinds of problems that we try at the end of a long hard day for both groups to try and come to~ gether briefly. It is going to be late. How do you people feel about it? DR. HIRSCHBOECK: I agree with you. MR. PETERSON: I know you are going to have to go, Charlie. You know, if there is someone else who feels as Bill or others may, that in one sense the plowing of the field has been done, and I think you know one would be able to take off at the end of the day. hws-2 ~ 10 ii 12 13 14 16 V7 18 19 20 21 24 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. | Washington, 0.C. 20002 JAA BAB ERER oo i | DR. HESS: If we can, aS a group, look at the ones | we have reviewed, and satisfy ourselves within that review that we have been fairly equitable based on the factors that we : identify, and then the basic work is done, and it is a matter’ of seeing if the two groups can function. ! DR. HEUSTIS: To do that don't we have to have | something up on the board? | / MR. PETERSON: I don't think the board is large | | enougn. I started doing somethings with respect to the morning applications. This is something that I think the two groups are debating a little bit. This percent of target figure column I don't think - that important. What I was doing was to show a figure if there was any for a July application so that I was keeping the first three columns, or that is, the first four columns, but then indicating the estimated July application, again trying to group them so that, you know, looking at this mornings, I find New Jersey and Rochester and several programs sort of up in that first group, and Joe did ask, and I will try to get this data so we can incorporate it for all of them, a rough | population figure like 3.2 million, or 2.1 million. I think if you can settle for a legible Xerox copy of a legible longhand sheet. we can have that for you first thing in the morning, and we would, on Panel B, take a look hws-3 I 3} ~~ 10 11 12 13 14 16 Vi 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. + Washington, D,C. 20002 f (2029-546-6666 IED for 30 minutes at what we have done before we reassemble, and if that means we get together at 8:30 instead of nine, that I again leave up to you, but again I sense it, and it i seems to make sense to me if you look at some of these things) -- well, we won't have that job done, obviously, at five o'clock. DR. HESS: Can we find out, or do we know which of these two figures are the most correct on this previous, or let us say, the six-month current funding level? DR. THURMAN: I think Al is correct when you look back on the applications. I think this really goes back to : January, and I think this sheet, although I don't particularly like it, is the sheet. DR. HESS: This one? "MR. PETERSON: I am embarrassed by numbers that I don't agree with, thus I tried to either only have one set of figures in front of people, or if one is going to put two sets of figures to see if they don't agree before you place them. | | The first column in this figure I believe is correct in this sense. It is the current six-month award times two. MR. NASH: No. It is the annualized level, on the third level. i MR. PETERSON: Yes, that is the way it was explained } i t i. i tc me. hws-4 Nw = 10 11 12 13 i4 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320. Massachusetts Avenue, N.C. Washington, D.C. 20002 (ONIN SAR RBER 330 New Jersey currently, for the current six-month period has a grant of X number of dollars. The figure that is shown now in this column is X times two. That is one of the always surprising things. DR. HESS: I wonder if there is some staff person we can call on, whoever put that together. MR. ARNOLD: I don't know where that came from. MR. PETERSON: Let's not introduce another set of figures. DR. HESS: I think somebody on the staff level ought to be checking these out. MR. BARROWS: Let us have someone look into it. DR. THURMAN: I think your point earlier that Dick | i E t White's sheet is a sheet that was put together months ago, and I think this sheet is fairly close to up to date. MR. SIMONS: This one is correct, but it will take Larry to explain it. MR. PETERSON: It is always a puzzle as to why we pass out three of them. MR. SIMONS: This first column does not have such things in it. MR. NASH: It may not have the Region's portion of the 6.9 that was held and later released. It may not reflect 1972 dollars for EMS and HSEA's, | There are a lot of basic possibilities, and maybe hws-5 =} 10 11 12 13 14 16 17 18 19 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. | Washington, D.C. 20002 Grant can explain it. DR. THURMAN: It does not reflect carryovers? MR. NASH: It is taken off the last award notice. It doesn't tell you the real fund B picture in the Region. ‘MR. PETERSON: Can we sort of make this our prime reference? We will entertain an explanation from staff as to what the disparities are. DR. HEUSTIS: After we get through with all of the material? MR. PETERSON: I am always reluctant. I know I should be saying yes, but I don't differ myself, and I am looking around and saying who is going to deliver. DR. HEUSTIS: No earlier than before we get through with all of this. MR. PETERSON: Mr. Pullett, Review Panel B and | its Chairman, humble Chairman, sort of wanted a brief explan-' i + ation as to spare sets of figures, column one of a printout. . I just tended to ignore it. JI was lucky. I thought one was more credible than the other. What was the recent point in that case that gave us a problem? In New Jersey we show a current and annual annualiz at roughly $1,458,000. That I understood, and correct me if I am wrong, was literally New Jersey's current six-month ed (3 wa 10 il 12 13 i4 16 li 18 19 20 OS HOOVER KEPGRTING CO, INC. 320 Massachusetts Avenue, NE. * i Washington, B.C. 20002 i i | | fa) eo Mm avard times two. MR. PULLETT: What you do is, you double what you had in the 1974 funds that they received, plus the carry~ over. MR. MR. MR. DR. of the dollars PETERSON: That includes the carryover? PULLETT: Yes. PETERSON: Their share of the six? THURMAN: That truly represents a total figure they had to spend in the six-month period multiplied by two. MR. MR . DR. MR. DR. PULLETT: If it is carried out. NASH: If they contracted it out. THURMAN: That is obligated funds. NASH: It would not even show here, you sec. THURMAN: As we look at it, we are not con- cerned about obligated funds. We are talking about an operating figure, and this is the total actual operating figure on this printout. MR. of 1974 funds, DR. MR. two, and it is DR. DR. PULLETT: No, it is what they received out plus their authorized carryover. THURMAN: That is what I thought I said. PULLETT: You said their operating level times not. THURMAN: I see. I stand corrected, HESS: The total amount of money that they hws~-7 ~ 10 11 12 13 18 19 20 to we bo Lo = 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. | Washington, D.C. 20002 (7075 546-6666 333 ! . . have to work with during those six months. | MR. PULLETT: We made a distribution of 1974 funds. which was approximately $24 million, and that went into the | awards beginning in Award 1. To get their annualized level we doubled that, and: i added their authorized carryover, so when you say an annual- ized level in a 12-month period it is not doubled what they have been operating on in the six month period. DR. HESS: Are you familiar with this sheet? MR. PULLETT: Yes. DR. HESS: These figures are generally higher if you double the six month present funding? MR. PULLETT: They would be higher than the annualized level in a lot of cases. When we made the initial awards they were for a six month period, so we gave their distribution of the $24 million for six month period, and authorized any carryover from the previous period, but to get the annualized level we doubled the 1974 funds and then added in the authorized carry- i f over, because that was only for a six month period. DR. HESS: So this would be plus the carryover figure. MR. PULLETT: The six month period would at least equal the annualized level, and in most cases exceed it. MR. BARROWS: The working capital that they had to 0 334 hws-8 1 work with last year. It was this figure, was it? I mean 2 up until now. 3 ll MR. PULLETT: That is another projected 12 month |; 4 figure. 5 MR. BARROWS: So in terms of real money this is 6 what the program was operating with. q MR. PULLETT: That would be projected over a 12 8 month period. 9 MR. BARROWS: That is the base that we wanted. 10 DR. HEUSTIS: On this document the only date that li I see is funding award January 1, 1974. 12 Am I to assume that this was as of January, that i3|| everything on this hseet is January 1, 1974? | i4 MR. PULLETT: If you look on the face page of 1b that, there was a face page. 1é DR. HEUSTIS: Never mind. Tell me what is on the u face page. I don't think I ever saw one. i MR. PETERSON: I certainly never saw a face page. . 19 DR. THURMAN: Is this the face page? | 20 MR. PULLETT: That is the summary page. | 91 DR. TESCHAN: Region 17. ! MR. PULLETT: The six-month level was actually what ; they are operating on, on a six-month period. They are the , funds we have authorized. That includes the carryover plus ° fiscal 1974 money. ! 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, MLE. Washington, D.C. 20002 Ann hws-9 ~) 10 11 12 13 id 16 li 18 19 20 i] NO 24 25 HOOVER REPORTING CO, INC. 320 Massachuseits Avenue, N.C. Washington, D.C. 20002 335 Now, to project the 12-month budget period we doubled what we gave them out of our 1974 money, which was approximately $24 million, and that added on to that any authorized carryover which was based on two things, their distribution of the 6.9 plus any unexpended balance they had under the previous budget period. DR. THURMAN: He has answered my question. I know what it is. MR. PETERSON: Okay, we want to get back to our business here on the review of applications. I think we have already highlighted both Western Pennsylvania and Virginia as regions we did not feel too prepared to deal with before. Having had lunch we might start off with Western Pennsylvania. hws-10 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. Ulanbinntan AM INNA? 17 an “1 10 11 12 13 14 16 18 19 20 21 | 336 REGIONAL MEDICAL PLAN FOR WESTERN PENNSYLVANIA REVIEW BY DR. HIRSCHBOECK DR. HIRSCHBOECK: The application is essentially for continuation of funding, except for the addition of one project, which is the Health, Education Network. As stated here, this constitutes $170,825 of our total request, which I understand will not be counted against the total amount appropriated with PRFP. MR, PETERSON: I will explain that. Because of the court order which reads these funds are to be made available to the plaintiff, that is to mean the RFP's, and we had funded this particular project under 910, and thus in order to give it a legitimate umbrella we asked that it be submitted as part of the Western Pennsylvania RMP application, but what you people really need to do is vote a recommendation for Western Pennsylvania, and then take an auxiliary, or adjusting the one in effect. It is a matter of administrative convenience in the event the court order would not be modified, which it probably will not. MR. NASH: Really two applications. MR. PETERSON: It is really two applications, but in order to be able to continue to fund that AHEC it had to come under the aegis of an RMP at this time. DR. HIRSCHBOECK: Another factor that is confusing — 337 1 is that funding for many projects terminated on April 1. hws-1l 2 There is a gap of two months, or three months 3;, xeally, between the end of the project and what appears to 4 be a start up again of some of these same projects, with a 5 gap of no funding. 6 Now, I am getting this information principally from the Forms 15, and I think we ought to have that explained ~~ 8 by staff a little later on. 9 As far as the Region itself is concerned, at the 10 time of phaseout they were grappling with the possibility 1 of becoming an independent, free-standing corporation, and 12 they are now the grantee, that is the grantee is the University : 13 of Pittsburgh, and apparently the cost figure was very high, | | 4 almost $500,000, and the question was raised, I suppose, by | - | 15 central staff here that maybe they should look into a re- | arrangement. 16 7 At least it sounds that way in the way the text \ 18 reads. They set up a task force, and the task force decided | 1 to stay as they are, and that is an independent, free-standing corporation. 20 *P The University of Pittsburgh Health Center is the 21 grantee. The bylaws, of course, do not even mention it, but 22 that is okay. 23 The bylaws are arranged such that they function 24 ‘ very independently. i HOOVER REPORTING CO., INC. , 370 Massachusetts Aven, N.C. i hws~-12 1 =~ 10 ll 12 13 i4 16 17 18 19 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. RN Anan many pies. 338 However, the Regional Advisory Group, the Coordin- ator, Dr. Kiefer, who is the Coordinator of the program is also a member of the Regional Advisory Group, and is in various positions along the line, and still the coordinator, and yet, what I am trying to say is that he has fingers in The relationship with CHP is difficult to assess because there is only one communication which says that they will apply in the near future regarding the comments. I would like to find out a little more about the CHP relationship here. Well, they distributed quite a bit of project support for the insurance development as a one shot venture. The statement is made by the Joint Commission on Creditation on Hospitals, which is found in quite a few hospitals, and this area has not had the working expertise to! deal with the medical audit situation and other similarly newly acquired activities by the Joint Commission. The Western Pennsylvania RMP provided funds for some six or seven hospitals or related agencies in the Region to get quality assurance and medical audit, and so on. As I interpret this, this was a single one shot deal that was given to these institutions. In general, I would say that this is an average program all the way down the line. hws-13 1 =I 10 11 12 13 14 16 VW 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. 339 I do not see anything outstanding about it, nor is there anything that would seriously criticize,other than possibly a relationship with CHP, which is not well expressed here. Also, I should say a word about the staff. The staff seems to be quite complete. There are hardly any vacancies, so there should be the capability of carrying on with the additional funds which they intend to ask for in July. MR. PETERSON: Thank you, John. Ken? MR. BARROWS: My observations were very parallel to the doctor's. To show you my skills as a planner, I approached my five projects alphabetically, and I have considerably run out of gas on Western Pennsylvania, as it is the end of the line. Generally, I came up with the same conclusion that this was a pretty good average type of program. The management and administration of the thing looked a little bit cumbersome to me. They have a number of regional advisory groups, area advisory groups. This did not look like a very skillful thing from the management point of view, but now I will have to eat my words and come back with this. They have done an excellent hws~14 we ~ 10 11 12 13 i4 1b 17 18 i9 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Vinnbineban TP INA? 340 job of community interest and participation in this thing. I might say they are really one of the better in that respect, and there is commendable honesty in this report, They talk about a lot of programs that are terminated, and, in fact, come out and said the program laid an egg because the people found out it was too much work. I think it is an application you can take at face value, but I came out with a good average type program. MR. PETERSON: Norm, I don't know if you want to come up to the table. It seems to me that there were at least three areas that questions were raised about. One is what appeared to be a gap in funding. The other is CHP relationships, and the third may be the ubiqui- tousness of Dr. Cleary, but that is something we have lived with. MR. ANDERSON: I imagine the survey was made a year or so ago, and we have determined that Dr. Kiefer was not in line with the grant relationship. The recommendation was made at that time to rectify this, but during the same week, at the time of the survey, also a notice came out from RMP that we were to be phased out. We sort of let it slide at that time, and Dr. Kiefe as I understand, is to retire sometime this summer, and as you have very adequately observed, Dr. Kiefer is a member of the Executive Committee, and also plays a very active role ry hws-15 BO he =~ 10 11 12 13 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Ml. hinedan NE ANNND 341 in determining program policy. I won't try to minimize this, as that is a fact. On the other hand, I think Dr. Reed has pretty much determined what their program priorities are, and has tried to allow to promote these through Dr. Kiefer. The second point was there has been some animosity. I am not sure what precipitated this, but nevertheless it has existed, and I think over the past two years my experience with the Region is that they have made every effort on both parts to try to rectify the problem, and here again, I would be the last to try to identify what the problem really is. Now, in terms of the third area -~ what was that? MR. PETERSON: The gap. DR. HIRSCHBOECK: Some of these projects ended in April, and they were asking for funding beginning July 1. MR. ANDERSON: Part is due to the phaseout and terms of priorities to try to complete certain activities within a timeframe, and they do have a very good selective procedure to determine their own priorities. I think in all due fairness to them, they felt this was some of the things they ought to complete within a certain time period. There has been a certain amount of lag time, but that doesn't mean the activity has completely stopped. DR. HIRSCHBOECK: It is, as you read these Form 15, . hws~16 os she = 10 i1 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Wht dan AP IAN 34e I got the impression that there is going to be a gap in fund- ing between, or beginning July 1, 1974 and what apparently was a termination on April 30, 1974. -It has either been improperly placed there, or I i don't understand what it is all about. MR. ANDERSON: I am not quite sure I understand your question. MR. PETERSON: I think if I understand John, he sees some projects which presumably are going to stop at the end of April and renewed funding beginning July 1, which is being requested. That does seem a little unreal, and it may be. MR. BARROWS: I got the impression these were en programs they would like to have carried on, but they ran out: of money, and they have some programs they want to revise. MR. ANDERSON: Local support may come to their aid for a temporary time period. DR. HIRSCHBOECK : Here is one discreet activity summary -- Laurel Mountain Quality Assurance Program, Mercy Hospital, Johnstown, and the progress period, in the progress | section which is from July or from January ist, 1974 to April, 1974, and then the period of the project is July, 1974 | through June, 1975. In other words, there is a period of April, May and June. hws~-17 ~] 10 11 12 13 14 16 17 18 19 20 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. Wiebe nda AK INNNYD 343 | MR. NASH: What is he doing there? This is some- | $ thing they initiated in January, and he is giving you progres on the four months up until the time they formulated their application? MR. PETERSON: I was just comparing notes with Tom, and he said he really didn't have anything of substance or concreteness. I think both he and I can speculate about some of the reasons for the less than cordial relationships between the major fee agency, and I am not sure it is called Allegheny County, but anyone, the one that encompasses Pittsburgh and : the surrounding area, and I know something I observed, I : think I observed out there two years in the review process, and it was out on the table and Bob Carpenter was in the next! room and it caused him a great deal of travail as long as he was in that post. MR. BARROWS: You think they feel competitive? You see, this has an apparatus of local advisory groups that RMP might treat as a threat or something. MR. PETERSON: Some of it may have been, and con- tinues to be personalities. | I don't know if the same gentleman who was there | when I was out there two years ago, and would come down from Buffalo, where Jack Angle had encountered him, but is he ] | still the same person out there -- Mitch Roth? |. hws-18 1 2 we ~ 10 11 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320. Massachusetts Avenue, N.C. Washington, D.C. 20002 (202) 545-6666 344. MR. ANDERSON: On the positive side they do share the same types of review committees at the local level which the CHP's participate with RMP. DR. TESCHAN: I don't think we can resolve the question here, and if it is an important question in an out- going way we have to cite it to them. MR. NASH: The question came up about Dr. Kiefer. I don't think he is in the budget for next year. MR. PETERSON: He is retiring this summer, and it was always a kind of strange relationship. He was the name coordinator, but in recent years he never drew any salary rom the RMP budget. | MR. ANDERSON: He was never on salary. MR. PETERSON: I knew in recent years he never had. When Bob Carpenter was the Director, the full time sort of direct management program has always been in someone elses hands, but Kiefer was not to say adamant, but he didn't want to step out of that symbolic spot. Maybe our problem is being solved by retirement. DR. THURMAN: Looking at the staff document for a minute on the projects, the first five really are all pro- gram staff, is that correct, as I read this, $731,000? MR. ANDERSON: The first four, yes. DR. THURMAN: So we are talking about a corps hws-19 1 oe =~ 10 1 12 13 i4 16 17 18 19 20 21 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 345 figure of $731,000, and the request is for $1.9 million when we really get right down to it. MR. ANDERSON: I accept your figures. DR. THURMAN: Obviously they are correct. Then I have just two other questions. Are we conflicting with ourselves in the Regional program because it is carrying over for two years, and the statements in it show no reference to reality about what is going to happen over the next two years, and they have not fulfilled the primary criteria initially that was to limit transplantation to one area, and instead we are supporting two hospitals that are doing it in the same county. They did it themselves. MR. ANDERSON: I didn't read that. DR. THURMAN: Regional renal project, to ration- alize transportation resources within the Health Center and program due to inadequate numbers, and they said they still have not solidified the four Allegheny hospitals to bring together for one transplant thing. I am not so much concerned about that, or are we really, for over a two year period here, looking at the Regional renal transplant in the way that it should be done. That is a staff question. I don't know. MR. ANDERSON: The limitation of my knowledge here is that the University of Pittsburgh is doing transplants. hws-20 (2) at ~ 10 ll 12 13 14 16 17 18 19 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. ; mA nanan 346 only within its particular Region, and they have attempted to set up some satellite facilities in community hospitals that can participate with the so-called network. DR. THURMAN: Everybody does that for bringing in cadaver kidneys, but the way this reads, they are doing the transplants in other hospitals. DR. HESS: Read that again. DR. THURMAN: "Rationalize transplant resources within the Health Center and the limitations imposed on transplants from cadavers." This is a major question of the Kidney Panel about whether or not they were doing it, and for hospitals. DR. HESS: You didn't read the sentence you did before, but it sounds to me as though they were coordinating four hospitals, not transplanting in hospitals. DR. THURMAN: You have to read the whole thing, and I may have misled you. MR. PETERSON: This is an issue we need to get some specific concrete information of how many hospitals in the Pittsburgh area are actually doing transplants. I think the Council ought to be aware of it, be- cause we had the same sort of situation in Philadelphia. MR. ANDERSON: If you are right, we will have to put a stop to it. | DR. THURMAN: One last question. hy 5-21 1 =~ 10 11 12 13 i4 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 347 On Project 225 we are talking about $239,000. MR. ANDERSON: Project 225? You are getting ahead of me. DR. THURMAN: $293,000, and we are going to educate less than 40 nurses. DR. HEUSTIS: That is $490,000. DR. THURMAN: It is going to cost us $10,000 a nurse, and it is a two year project, but if you are going to put it on a one year basis it is still $10,000 a nurse, so that is an awfully high figure. MR. ANDERSON: We have flagged this, as you have to. This is a policy decision that has to be deter- mined. DR. THURMAN: I don't argue with the need for these people, but I have never seen a budget quite that high for this kind of a program, and I just wonder about it. DR. HEUSTIS: How much of the $1.9 million is for projects that will be carried out in the second year? MR. ANDERSON: There are only two projects identi- fied, 25 and 26, and the one Dr. Thurman has identified, and the renal project goes into 1976. MR. PETERSON: Those two projects all add up to roughly $725,000 out of $1.9 million budget if you assume, which I don't think we can necessarily can have in one year and hws~-22 qn =~] 10 11 12 13 14 16 17 18 19 20 21 2A 25 HOOVER REPORTING CG, INC. 320 Massachusetts Avenue, MLE. ¢ Washinaton. D.C. 20002 i [' j . 348 a half, and in another year it is saying about $350,000 plus would dangle over into FY 1976. Those are the two other than program staff, the two larger projects, renal and adult nurse practitioner education program are the two in that carryover. DR. HEUSTIS: They would probably get around the : one year grant by making a contract for some people to provide services and the GAO will allow this kind of thing for ser- vices to be provided in the future. MR. PETERSON: I cannot answer that. We have said as a matter of policy that we would permit it, and I think it also includes grants management, which was in on the discussion, and if the obligation was a valid one entered: into prior to June 30, 1975 that the basis for taking an i audit exception by GAO-HEW would not be there. It would be : a valid expenditure of the funds. | DR. HEUSTIS: Is this any different than entering . into a contract for someone to maintain your typewriters for two years? In that case I think there would be a valid GAO : objection. This is something that was brought up earlier, and I didn't follow it at that stage, and this is something that I think ought to be referred to staff for clarification of policy. hws-23 1 wie, ~) 10 11 12 13 18 19 20 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | 349 MR. NASH: Is your question whether to contract this for two years or one year? DR. HEUSTIS: My question is is it possible for someone to use fiscal 1975 funds to provide services that obviously will be provided in 1976, that is fiscal 1976, and the only reason for entering into a contract is to subvert -- well, that is pretty strong. In my opinion the reason for entering into the contract is to get around the one year limitation. We can't answer it, but it should be resolved. MR. PETERSON: It does seem to me it may not be good procedure, and indeed might be illegal. I don't know about the latter, but this is not all that unusual in terms of either Federal granting operations, forward funding, and indeed in many situations, and I can remember AHEC activities, many of the RMP's I believe in effect are contracted for a period well beyond one year in the early fiscal year. That doesn't make it right, but there is a great deal of practice and precedent there. DR. HEUSTIS: It seems to me the funds for 1976 ought to come out of the next year's budget rather than here. | MR. de la PUENTE: A person in good faith makes an application in a certain year. This application is supposed to do a certain amount of work, and supposed to take one year, hws-24 1 we 10 ll 12 13 14 16 17 18 19 20 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. i 350 two years, three years, and when this period or this applica- tion, if it is awarded that year, he is entitled to do his work regardless of how long it takes. DR. THURMAN: What is your recommendation? MOTION FOR RECOMMENDATION DR. HIRSCHBOECK: I was waiting for the Chairman, but I move that we approve this application for the continu- ation phase, and this amounts to $1,814,588, and we will have to take up the others separately. MR. PETERSON: Your recommendation, John, if I heard you correctly, is for the continuation of Western Pennsylvania, and the amount requested Norm tells me ought to deal with the total figure. We will put them together. MR. ANDERSON: Okay. MR. PETERSON: We havea motion for Western Pennsylvania, and that is the amount requested for the RMP separate from this one AHEC which is an appendage to their application. Do I hear a second on that? DR. THURMAN: Before we offer another motion, can we go off the record? .MR, PETERSON: Off the record. (Discussion off the record.) MR. PETERSON: Back on the record. hws-25 1 we 6 ~l 10 11 12 13 14 16 17 18 19 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. : 351 Parliamentarily we have a motion with no second. MR. BARROWS: Does it die? Informally then I didn't share the doctor's enthusiasm. They are now at a level of $1.2 million, and they are talking in terms of this and their upcoming applica- tion is going to amount to about $2.6 million. That is well over a 100 percent increase in activ- ity, and I don't think based on what they have done to date they have the horses to take up that additional work. I would be much happier, let us Say, they should talk in terms of $1.4 million, or something like that. MR. PETERSON: We have in what effect is a sub- stitute motion of $1.4 million in terms of the $1.8 million. Is there a second to that motion? DR. TESCHAN: I will second it. MR. PETERSON: Any more discussion or corrections? DR. HEUSTIS: May I say the current level of funding according to this summary sheet I have is $1,193,000, is that right? MR. BARROWS: I said $1.2 million. DR. HEUSTIS: Okay, and you are saying $300,000 more? You are saying $1.4 million is what you said. MR. BARROWS: Yes. | DR. HEUSTIS: I think it deserves more than $1.2 million. h 8-26 ~~ 10 11 12 13 i4 16 7 18 19 20 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 352 MR. BARROWS: I refuse to answer it on the grourds it might incriminate me. I was trying to come to a figure that would be appropriate for an average program. DR. HEUSTIS: This is an average program. MR. BARROWS: But apparently some more new vital direction. DR. HEUSTIS: If you were increasing it you would be treating it the way we were treating some of the better than average programs. MR, PETERSON: I don't think we really have those programs at hand. | DR. HEUSTIS: In my opinion you would be treating that way. I call for the question. MR. PETERSON: Well, $1.4 million had been recom- mended for Western Pennsylvania. All those in favor signify by raising your hands. (Showing of hands.) MR. PETERSON: Those opposed? (Showing of hands.) MR. PETERSON: The motion fails for lack of a majority. MR. BARROWS: We are ready for a new one. DR. THURMAN: I make a new motion to present hws<-27 1 wo sl 10 11 12 13 i4 16 17 18 49 20 21 24 25 - HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, NC. ' 353 operating levels, and let's make them $1.2 million with a provision that staff try to clarify, number one, the legit- imacy of the renal regional program as we now know it, and much better clarification of the nurse practitioner program, 025. MR. PETERSON: It is still a motion of $1.2 million and those two clarifications I think are inherent. DR. HEUSTIS: Can I ask a question? MR. PETERSON: Surely. DR. HEUSTIS: In that $1.2 million which is the current operating level, is there not included $170,000 in this extra separate project? MR. PETERSON: No. MR. NASH: That is funded by a 910 grant currently. DR. HEUSTIS: So that does not include the $170,000 MR. PETERSON: No. DR. HEUSTIS: It would limit their current level exclusive of this added net worth. MR. PETERSON : This is just coming into the same package. It really is not reflected in their base. DR. HEUSTIS: I think we are giving them $200,000 too. much. | MR. BARROWS: I will second that. MR. PETERSON: Any further comment? The motion is for $1.2 million. hws-28 1 HOOVER REPORTING CO, INC. : husetts Avenue NLL. A 320 Massac Vain wR ~} 10 Il 12 13 18 19 20 2. A AnAAS 354 Those in favor show your hands. (Showing of hands.) MR. PETERSON: Unanimity, and this does include the clarification by staff both on the renal project and apparently cost per capita of educating our training nurse practitioners. MR, ANDERSON: Can we ask Dr. Thurman to state his concerns about that project? DR. THURMAN: Before we do I move that we approve Project 0044 in the amount shown. DR. TESCHAN: I second. MR. PETERSON: Any discussion? Those in favor show your hands. (Showing of hands.) DR. THURMAN: With the Chairman's permission we can do that without holding up the progress here. MR. PETERSON: Certainly. MR. ANDERSON: May I be excused? MR. PETERSON: We have disposed of Western Pennsylvania. I 1 hws~29 tae an 4 10 11 12 13 14 16 17 18 19 20 24 25 HOOVER REPORTING CG,, INC. 320 Massach usetts Avenue, NL. ne aannns 355 VIRGINIA REGIONAL MEDICAL PROGRAM REVIEWED BY SISTER ANN JOSEPHINE MR. PETERSON: I think again one of the Regions we sort of hesitated in getting involved with before lunch was Virginia, and if it is okay with you, John, I am going to put you on two in a row, but I am going to ask Sister Ann to initiate the review on this one. SISTER JOSEPHINE: Virginia is a program that for a long period of time kept a categorical orientation, and once they changed from their categorical orientation to projec and subsequently a program, total program orientation, I think that Dr. Perez has to take care of needs in the whole State of Virginia by meeting with all of the different agencie in the State and parceling out the funds to meet these needs in rather small increments in the total State. The first time I went there on a site visit, which was around 1970, the first place he took me was to the State Capital, and the first thing that happened to me, I was the only one who was searched, to be sure I had no bomb, so the next day we went along with the sightseeing. The soldier said to me when I said it is inter- esting that I am the only one you searched, well, he said the Berrigan brothers made you suspect. The whole climate in Virginia -- and I assume there will be someone going to help with the staff review -- 356 hws- 30 l there is something very different about the climate in 2 Virginia. 3 i! There is something different about this Regional 4 Medical Program. 5 Once they get the direction of what it is the 6 Federal Government wants, it appears almost verbatim in their 7 objectives, in their thrust and everything, and this type, but 8 it is a little difficult to evaluate if it represents a con~ 9 viction, represents a way to go, or represents a way of con- forming so they can move on with their business. 10 1 I think possibly this is not too far from wrong. 12 At the present time I have conflicting figures on the number 3 of staff. 7 On hand there are 14 members, and as I see it there 6 are 20 budgeted positions that are vacant, I believe this is 1“ right, and this has been, as I remember it, an ongoing problem. u They have always overbudgeted the number of people 8 that they would like on board from one time to the next. They i» never come on board, but the figure keeps staying high. . MR. NASH: This is a convenient way of perhaps 91 having some additional funds to take advantage of an opportunity that might arise. 22 DR. TESCHAN: We have also seen some diagrams and 2: . charts relative to capital expenditures, so that on any 24 correlation plot, Virginia seems to be out of line on the low HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. nA Annan hws-31 fel “1 10 11 12 13 14 16 V7 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. -f--. MA AANNY SISTER JOSEPHINE: Presently the program staff, o plus the program of $368,000 they are budgeting for $559,900, : but that includes over $200,000 for these 20 vacancies that : I doubt they will be able to get. On July 1 they are planning on coming in with another proposal that will cost $1.3 million, making a total of $2.8 million for this program. As of this time I reviewed the projects that are listed, of the 19 projects listed on the yellow sheet, you will notice that seven of these relate to hypertension. My question would be could these probably somehow or other be coordinated a little differently. JI don't know. You may want to comment on this, or this may be a way of just involving different agencies in this whole project of hyper- tension, or maybe they are doing some research that is going to generate statistics or some paper, I just don't know. MR. NASH: This is an ongoing project, and I cannot really answer your question. SISTER JOSEPHINE: There are seven hypertension projects. MR. NASH: Gene, do you have anything on this? MR. NELSON: No. | SISTER JOSEPHINE: This program has generated a lot of community activity. .I would say the leadership is satisfactory, and probably the leadership, Dr. Perez, is a hws-32 1 +m 1 10 11 12 13 i4 16 17 18 19 20 24 25 HOOVER REPORTING CO, "NC. 320 Massachusetts Avenue, NL. ¢ 358 very sensitive to the different groups he has to work with in Virginia, and probably one has to work with many for some period of time to appreciate this fact. The Regional Advisory Group, I think, it seems to me is doing a good job. I notice that Dr. Neuno is Chairman of the Group at the present time, and Dr. Neuno is a young Spaniard from Malesia, and I have seen him stand up on several occasions to Dr. Perez, which is interesting, in making the decision. They have indicated when this program is phased into the new program that is going to be developed by the Federal Government there will be no difficulty in phasing these projects out. | They have also phased out a certain number of projects. I can't remember now how many, but they have phased out without any difficulty in getting additional funding. . I Their objectives and priorities follow the national | t guidelines specifically, and they have listed their projects under the objectives of improved availability, continuity, improved quality, efficiency and economy, and improved health data base. | | The health data base is one of the projects that 2 is just beginning to be developed in the State. | | The CHP relationships are good. In fact, I got the) impression on two site visits that the Regional Medical Program | ' t { } hws-33 1 ~~} 10 li 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, IRC. 320 Massachusetts Avenue, N.C. | 359 funds a number of projects through and in conjunction with the CHP. Dr. Hirschboeck, any comment? DR. HIRSCHBOECK: I have nothing to add, partic- ularly. I am not very familiar with this Region. I had never visited nor had much to do with it. On the other hand, it may be a judgment just on the application, and data presented. I would rate this as an overall average type pro- gram, nothing unusual about it, struggling to meet the changin times, and that sort of thing. MR. PETERSON: Okay, we may or may not have a CHP problem here, and perhaps Tom Smith, who is from the Philadelphia Regional Office, and Virginia is serviced out of that Regional Office, has something to say in this regard. Tom? MR. SMITH: We have had a special concern, one in particular. MR. PETERSON: Which one is that? MR. SMITH: Is that necessary? MR. NASH: Probably Tidewater, isn‘t it? MR. SMITH: Tidewater, correct. Everybody knows that. This may be another sort of Western Pennsylvania g situation, I don't know, but the specifics had to do with hws-34 1 ao -~] 10 ll j2 13 4i4 16 17 18 19 20 25 HOOVER REPORTING CO, ‘NC. 320 Massachusetts Aventis, NLL. | 360 project review by the RMP, particularly regarding the BMS project which apparently was not considered for review, and CHP thought it should be. Apparently the agency was not advised of this fact, and interestingly, on paper it seems the relations are excel- lent, because the agency director is a member of RMP, and I am quite surprised the project was being considered. I guess I can't say much more than that. At least one agency is very unhappy, whether that has to do with personalities or not, I den't know. MR. PETERSON: Is Tidewater Norfolk? MR. NASH: That is right. Pete, the gentleman which you are speaking about is a member of the Regional Advisory Group, and the Regional Advisory Group in Virginia is likely to include no new activities in this particular application. This is a request for continuation of staff and ongoing projects. They have sent out, or solicited new project pro- posals for the July 1 application, and our last communication with Region 5 of the 18 agencies have submitted a total of 12 proposals which in Virginia RMP's review process at this time. | I think what we have here is a personality conflict DR. TESCHAN: When you get this kind of news what hws-35 He ~? 10 li 12 13 i4 16 1? 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. Wfeabinetan AP OAAND 361 happens? MR. SMITH: Can he stop punching that thing over there? MR. PETERSON: Let's go off the record. (Discussion off the record.) MR. PETERSON: Back on the record. SISTER JOSEPHINE: All RMP planning has been closely coordinated with the Governor's Committee. “this is a program that has stayed very closely to the Governor's Advisory Committee, and originally then I think the Chairman was the head of Public Health, and then finally we got someone else as Chairman of the RAG. Then this close association with the Governor's Advisory Committee may well be the thing that will make it possible for this program to phase into a State program, and there are a lot of different projects. MR. NASH: This particular project you are speaking of, if I am not mistaken, has been submitted by Tidewater CHP to the Regional Office in Philadelphia for consideration of funding by John Reardon's shop also. It is also considered for the July application. Now, whether the RAG will approve it or not, no one knows as of this time. MR. PETERSON: I wonder if any of the other reviewer have any observations or comments they care to offer, or po ce hws-36 2 ~] 10 11 12 13 i4 16 li 18 19 20 HOGVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, 0.0. 20002 [ 362 | perhaps have some comments? MR. BARROWS: Just from the caption and titles of these proposed activities it would appear that they have pretty good program direction. That is they are working on the right theme. Is that a reasonable observation? SISTER JOSEPHINE: Yes, I think that my impression that the Virginia Regional Medical Program is that Dr. Perez keeps very close tab on what everyone is doing, and then also/ keeps tab on the agencies with whom they are working. | I don't think he is the greatest developer of personnel, you know. MR. BARROWS: I wasn't talking in terms of manage- | ment, but talking in terms of purposes and objectives. SISTER JOSEPHINE: These are the needs identified by the people, apparently. These are really in response to needs, and they don't look spectacular, or anything of this type, but I think | they are in response to the needs that can be identified. ! DR. TESCHAN: It is undertargeted. MR. PETERSON: Dr. Thurman, as a displaced Virginian, do you want to speak? DR. THURMAN: I think it would be inappropriate, having really left the State. Nothing hurts me more than to be constrained to hws-37 1 ~~] 10 11 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO- INC. 320 Massachusetts Avenue, N.C. Washington, D.C:20002 FFNTN BAR ERAS aw 363 science. MR. PETERSON: Do any of the other reviewers have any questions? DR. HEUSTIS: I understood, Sister, you said the beginning they parroted what came out of the Regional Medical Program. SISTER JOSEPHINE: I think the objectives and the guidelines they line up for themselves are just as close as they can make them to what it is that the Federal Government dictates, and then I think they try to fit into this program. MR. NASH: They suffer from being too close to Washington. DR. HEUSTIS: I would have problems under similar circumstances. DR. TESCHAN: We have agonized with Gene for years in the Southeastern Group with these things, and I get the sense from what I am hearing, you know, coming in with that background, I am hearing a much more positive type of situ- ation there now, and the thing I don't think is that we could accuse Gene of, as it were, conformity as a subterfuge. I think that Gene is conforming on two grounds. One is that he is lost, you know, he realizes that you really do have to play ball with the front office, and the other feature about it is that the front office is asking is not so different from what the situation is in Virginia as in hws-38 ~) 10 11 12 13 i4 16 17 18 19 20 oO nN 24 25 HOOVER REPORTING CO, INC. 320 Massach usetts Avenue, MLE. Rn Annas most other States, if not at all. The main national priorities of health we are sup. posed to be recognizing are really what the problems are. I don't find that an artificial situation at all. MR. ANDERSON: May I say something? I am not responsible for the program in Virginia, but I did have the distinct honor of being on the site with the Sister and two or three others two or three years ago. At that time I was very impressed with the fact that they laid the program out in a very honest and straight forward manner, not trying to please Washington, or the rest of us, but they laid the problems out in terms of this is our problem, and this is the way we are trying to deal with it. | In my limited experience with the State of Virginia and the RMP's throughout this has been their approach to trying to resolve the problems. SISTER JOSEPHINE: You know, I have no reason to question the way they have gone. In fact, after the first visit, when I went on the first visit, I came with some preconceived notions, but after the first visit I realized that there their response was a very sincere response. I realized also that they were making an. attempt to identify the problem, and they were making an attempt to hws-39 1 ay ~) 10 11 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. ; 365 listen, and then to design projects that were in response to the problems and, you know, whether they were reading it correctly or not, that is another ball game, but they did | seem to be responding. But then it has been several years since I have been there. MR. NASH: I think the hypertension activity is an example. If you will recall, on our site visit they were just proposing that at that time. They had some representa- tives from two or three communities that were present at the site visit, and explained the need for this sort of thing. Sister, I certainly agree with what you say. MR. PETERSON: We have a request here for roughly $1.3 million with an indication that Virginia, and it is essentially a continuation, that Virginia will begin all of its new activities in July with an estimate that this will be a little larger than the $3 million plus. I don't know whether you, Sister, and/or Dr. Hirschboeck have a figure in mind with respect to the current application. SISTER JOSEPHINE: I would like to ask a question. Do you feel those 20 vacancies, that it is realistic to assume these 20 vacancies are going to be filled? MR. NASH: You put me on a spot there. My personal! opinion is they probably will not, if we consider the length hws-40 (3) ~~ 10 il 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, 1.0.) Unehinatan AWE ONAN? 266 of time remaining for RMP. You see, this is an award that will not be made until July. MR. PETERSON: Late June, for a period of July l. MR. NASH: This gives them one year, and their ability to recruit that number of people for one year's employment I think would be questionable. Dr. Teschan doesn't agree with that. DR. TESCHAN : Yes, but coming down to the question of employment of the people under those circumstances, I would go right along with the conclusions you would draw that in terms of hiring and firing, there is no question about it, because the people hired and fired would not have the exper- ience, the background in the context in which to make those judgments. We cannot expect them to go out on a limb. DR. HEUSTIS: I note in a program that has been described as average, if I understood correctly, they have proposed overall to increase their total request about 100 or some 100 to 150 percent. Is the program much more than maintaining it at the current level the way we have done at the other average things? SISTER JOSEPHINE: Yes, it is my question also. It is one of the reasons I asked about the 367 hws~41 1 possibilities of bringing in people who they will have to 2g have to maintain or develop the kind of program to carry on zi, the kind of program they have indicated, and I would think 4 they could not. 5 I would think that in the July review all the 6 projects are going to be there, and I think one is going to ~T have to take a hard look at this. 8 This present May 1 request I would recommend that 9 they are at the same level that they presently are, with the indication that there is concern about the number of projects 10 YW that will be coming in in July with the 20 vacancies on the 7 program, and it may be that can give some indication where 13 they plan to get these people, whether they plan to bring 4 them in from CHP staff, I don't know. They may know where 5 they are available. i” MR. PETERSON: When you say at the present level, u you were thinking then, Sister, in terms of that $971,000? 18 SISTER JOSEPHINE: $1 million. om DR. HIRSCHBOECK : I second it. . MR. PETERSON: Any additional questions or comments? 7 MR. de la PUENTE: I call the question. 93 MR. PETERSON: Those in favor of $1 million with : concerns being expressed, and hopefully some of this can get 9! ” in with the larger projects coming in the first of July, and 24 ‘ their real ability to filling some of the vacancies. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. 1. AP ANNAN hws-42 1 qn ~] 10 iW 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. * ata. AL ARNAD 368 All those in favor raise your hands. (Showing of hands.) MR. PETERSON: It is unanimous. I think we are now at 225, and I would like to have one of the staff people we asked to come down specificall for our next project, the Metropolitan New York and Lakes Area, which is Bert Kline, who previously handled those Regions when he was with RMP. Bert is now in Planning and Legislation, and if there is no objection I would like to move on to that Region, because this is a very unusual application in one sense. I don't know whether, Bert, you or Frank, or I should set the stage, by the nature of this next request. Suppose you come to the table, Bert, and het us have a brief comment or two so that everyone will have the backdrop for the reviewer comment in the nature of this next application. y hws~43 1 ~ 10 il 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. 369 HEW RECOMMENDED MEDICAL PLAN FOR THE METROPOLITAN NEW YORK AND THE LAKES AREA DISCUSSION BY BERT KLINE MR. KLINE: Well, Mr. Chairman, what kind of back-~ ground would you like, a little on the program, and how it got where it is right here now? MR. PETERSON: I was thinking of everything for two years. MR. NASH: If you gave a little rundown on what has happened to the organization down there, because we used to have real problems in that region. MR. KLINE: If will take a couple of minutes for those not familiar with some of the history of New York Metropolitan Area, which in approximately 1971, I think New York Metro had some severe communication problems between the then Coordinator and the grantee. At that time I was associated with the Metro Board of New York and the staff, and also the Regional Advisors, and it just seemed it was sort of a shell game. The grantee could not very well keep track of what was going on at the program level. The staff was kept fairly well shielded from what was going on, and likewise the RAG. As a result of all this the situation with everyone was sort of reaching in to see what they could pull out of hws-44 1 ce we “7 10 11 12 13 i4 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 200) Maceachusetts Avenue. NO. ! 370 the program in terms of support for their particular efforts, a little lobbying going on within the RAG, lobbying going on within the grantee, a little bit of lobbying going on with the Coordinator. Staff morale was some kind of shot. Well, any way, some dynamics began, and we started off with the management assessment visit, and started into getting into some of these problems, documenting some of the problems. This went on with some recommendations. Some funds were cut back, some were reprogrammed. All during this time the staff turnover was tremendous, and through the course of eight or nine months with some pressures perhaps from here in the ways of money being held back, and so on, things began to happen by November of 1972, that the Coordinator had resigned, and by December | of 1972, if my memory serves me correctly, Dr. Thurman, the grantee, resigned, and we had more or less during the course of the year of 1972 sort of cleared the deck, which was kind of interesting, because at that point there had been a residual staff which was waiting and somewhat eager to get on with the job they could see very clearly, but could not get to. Dr. Harrington, who had been the Deputy Director | at the time, was named as the Acting Director. 371 hws-45 1 ; Jack Eller, who had been the Evaluator at the time 2 was named as the Acting Deputy Director of the Program, and eee ee cere nine Mil ee ent aceeme 3), they began to make some changes which had long been recom- 4 mended, and to do it rather effectively, and it was about that 5 time that RMP's became the phaseout victim of the budget. 6 This, then, threw everything into sort of chaotic ~ situation, but I think in terms of looking at this particular 8 application, in terms of talking to some of the people up 9 there, I tend to suspect now that their staff is getting just. 10 a little better. il In any event, their application has been certainly 12 stronger than it had been in the past. Their organizational 13 structure is a little better. 14 What they did do in this particular application 15 was to, I think, they read the directions rather carefully 16 as a matter of fact, and what I can gather they assured | 17 within this application the grantee would assume responsibility 18 for all activities which extended beyond the period of June yo {| 39, 1975, so they asked for monies for two years, by and 20 large. I have broken it out in the little yellow sheet 21 7 there about $3.0 some million for the second year of activ- 7 ities, and a total of about $4 million for the first year's 7 activities, which include staff and other activities, with 7 the grantee saying, and being recorded herein, that if RMP HOOVER REPORTING CO, INC. 320 Massachusetts Avenc:, N.C. hws-46 ee an =) 10 11 12 13 14 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO., INC. 320 Massachusetts Avenue, N.C. | UWI. L te tan ne onan 372 is phased out at June 30, 1975, they, themselves, will take responsibility for monitoring and surveiling that money. I think in the instructions that went out, I think | this was deemed as somewhat illegal, so they took the legal approach and requested almost $7.5 million, and that is kind of where it's at. I don't know if there are any further questions on this. MR, PETERSON: There may be after the reviwers. We have Dr. Bill Thurman on this one. Dr. Thurman, you want to lead off there? DR. THURMAN: I think Bert has filled us all in quite completely, and excuse the term, Sister and other ladies present, but I have never been more bastard on a site reunion than we have been there. We had to meet with all the medical school deans who wanted to quit because we were there. We had real concerns, as Bert indicated, right then about Arronson's ability to take over a bad situation. He had nothing but fighting going on in his staff, and there was absolutely no question that the staff was totally blocked | off from participation in this program. It is just unreal, and yet, there was a talented staff there. I think the present application reflects the fact hws-47 ~ 10 11 12 13 44 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320: Massachusetts Avenue, N.C. ' Washinatan AP INNA? 373 that Arronson has taken over very well. He has pulled to-~ gether a staff that is adequate. They have also put together an application that if it was inconceivable they could have put together before. Our real concern is that he looked at that moment like a terribly weak sister -- and that is not a pun, Sister Ann -- we didn't think he had it. I think our other major concern that is still reflected in this application, and that is one that I have, is that this, in essence, was then, and is now, a one-man RAG in the presence of Mr. Popper, in a way, and I think if there is anybody who did read every fine line and figure out how they would do it, and swear he could monitor it for the coming two years is the RAG Chairman, who is a very unusual indi- vidual. This RAG Chairman is very much dollar-oriented, and he orients the dollars to the RAG, and that does show through in here occasionally. There is no question in my mind that the staff is far superior to what it was, and there is no question also that in the preparation they have much better morale than they had before. I think that the weakness of the RAG is not because of lack of interest in that some of them really took us over the coals, but they also were not informed, and I think that hws-48 1 oo ~ 10 11 12 13 i4 16 17 18 19 20 21 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NLC. 374 again I would question whether or not they ave truly informed now about what is going on. They were not informed then about the difficulties with the schools, which I think was unfortunate, and made it very unfortunate for us. I think the school situation now. is well handled, I mean because they got out of it. You will notice from the list of projects in here that there is still an attempt to carry forward to each . school some RMP money, or we have used the term the day of political payoff to keep things running smoothly. On the other hand, some of those projects are quite good and strong. In reference to the projects there are some very strong ideas, but most are carbon copies of other programs within the Region itself. My question was whether or not all the projects, that the same thing could be strengthened by corps staff leadership with multiple outreach indications. “the examples are kidney, manpower and hypertension problems, and so on. I feel the money here is going to be wasted, but I have been wrong before. We have spoken of the problem of the continuation of the money past June l. 375. hws-49 1! . The CHP has never worked out of New York. Their 2 relationship is good only because CHP does not have the strength 3 to react yet, so it has given it a cursory review. 4 The CHP is becoming much stronger, and if this 5 program goes on, the CHP will get into it. 6 All in all, I feei this program has significantly ~l changed since the days of our last visit there, and it is well 8 reflected in this document; the changes that have occurred 9 and have taken place. 10 |! - For that reason I support the program, and would 11 call it now a slightly above average program. 12 I think it is clearly better than some of the other 13 programs we have classed as average in the past two days in 14 leadership and direction and everything else. 15 I will come back to the figure after Al has had 16 his say. 1 DR. HEUSTIS: Al worked under the constraints of 18 what he had available to him, which was the written document, | 7 and I take respectful exception to the staff saying that they 7 followed the direction that at least in my copy they did not 91 number the pages, and I never had so much trouble to find 99 anything in trying to relate back and forth, to try to get things going. 23 I did not have the appreciation, not having done 24 this before, when I took a crack at the first because it was 25 HOOVER REPORTING CO. inC. . 290 Maccarhusetts Avene, NO. | : hws-50 i fo er ~ 10 11 12 QO 13 14 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue. NL. | 376. the thinnest, which was Connecticut's, and the one I took a crack at second was Metro New York. MR. PETERSON: Is that when you called and said you weren't going to be able to make it? DR. HEUSTIS: Just from the document I am not privy to this other information, but just from the document I was not too impressed, and as you have said, I certainly wasn't impressed with what they have done in the past, and it scemed as though they had great difficulty in sorting things out, for example, and it was very confusing. For example, there is an item that has a different project number that is in twice for $947,632. MR. KLINE: Project Numbers 50 and 62. MR. PETERSON: This is the EMS? MR. KLINE: Number 50 was their pilot of last year which was not supposed to have the money attached to it this year. DR. HEUSTIS: My problem was this was widely separated in the organization and getting discouraged, I wondered if somebody said let's just duplicate this without too much thought. I guess you folks have so much more valid inform- ation than I have that my very discolraging report, and my rating as far as this goes was below average, and as far as the other kinds of things, it looks as though the program hws-51 Re aon 10 ll 12 oO » 14 16 17 18 19 20 21 95 HOOVER REPORTING CO, INC. 3éU Massachusetts Avenue, ME. ' oa =i ~] leadership was satisfactory; the program staff didn't impress me too much. The RAG which was satisfactory in the past in performance got a low rating. The objectives and priorities again were satis- factory. The proposal is satisfactory, and one feasibility I just didn't really think it was very hot, and CHP relation- ships again, you tell me there is no CHP, and I rated the thing as pretty good. MR. PETERSON: There isn't any, in one sense, There is a funded areawide CHP, and in so many major metro-~ politan areas, Washington, D. C., still doesn't have one. It was very slow in getting organized, in getting funded, and even now I suspect that Bill suggested it is not really functioning, and it is difficult not to have at lease adequate relationships with someone who is not functioning. MR. NASH: Pete, I was up there in February and March to take a look at their review process, and we had a representative from the CHP Agency also visiting with us, and I don't know how far along they had gotten with their mission of developing a plan, but certainly from what he told us the relationships between the two organizations couldn't be better. MR. KLINE: This was interesting too, because all hws~-52 cP sm ~? 10 li 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. meton, D.C. 20002 P82 y EAR LEGH 320 Massachusetts Avenue, NE. § 3fY the way back to, I guess about 1971 or early 1972, I am losing track of time now, they did have good relationships with whatever existed in the way of CHP. THE CHP was coming into existence at the time, but there was a good working relationship right from the outset with the CHP. DR. THURMAN: I didn't mean to imply it was bad. It just didn't exist. The problem is there was nobody there to argue . with. MR. KLINE: I think the CHP, although I am not sure if it advanced along the same kind of slope and graduated advancement that was going some time back, it should be functioning reasonably well now. DR. TESCHAN: There is a $1 million project on this, Health Care Services. That is a pretty big figure, and it is a one year -- well, I guess two years. MR. PETERSON: All of those projects which have a C are essentially two year activities so the annual cost again is roughly, I guess, about half of that. That is still a $550,000 activity. DR. THURMAN: That in actuality, the design of this program is superior probably to most other programs we run across of this nature. DT. TESCHAN: To what? 37 \O hws-53 1 DR. THURMAN: They are trying to make all of the hospital rooms and clinics operated by the City of New York, NB i and also by private hospitals much more in touch with each other ww 4 and much more of a regional type of referral, so that the 5 lady in Queens who decides she needs a ceasarian operation G can go to a hospital there rather than come to a hospital in downtown New York. 8 — That is what the impact and the plan was, and 9 their ability to get the great majority of the hospitals in 10 ||. the area to at least consider this. 7 It was easy to get the City of New York, the city 12 hospitals, but they brought in a lot of the private hospitals: 13 There is a lot of fighting going on in Westchester County, 4 and certain parts of Queens, which have never gotten any 7 money at all, and metro New York City. 16 It is overly priced here just like the EMS programs u are overly priced, but it is a great idea as far as trying to 18 deliver health services to an amorphos population that cannot | 1» be reached well at this moment. It is overpriced. »0 "DR. HIRSCHBOECK: Are we going to judge these 1 projects on the basis of one year funds, or two year funding, or what? 22 | : How do we handle the desire on their part to circun- 23 | vent these? | MR. BARROWS: Let me get some preliminaries here. | HOOVER REPORTING CO, INC. : 320 Massachusetts Avenue. NT. | : i hws-54 ~l 10 il 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. Qf Macearhucntte Auvanna NT - of New York hospitals if it goes into a second year. 380 Is the nature of these projects such that they could have been presented as one year, or will it take two years to get the job done? DR. THURMAN: Of all the C project in here, prob- ably about 40 to 50 percent of them, that is a rough guess now, need two years to really come to fruition. Take the program we are referring to, the $1 million program, on the other hand is going to be financed either by the City of New York hospitals, or the consortium MR. PETERSON: I guess John's question, I wouldn't want to provide an official RMP response, this is almost a case of one, the extent to which Metro New York has asked for two years support, and my own personal view, and underscoring the word personal, is that I think we need to look at this in terms that say to Metro New York, or any other Region that really has done this, here is an amount of money if you want to do some activities over two years you are going to perhaps feel the pinch in other areas, because most Regions, you know, if we were to consider most regions, I suspect there are some activities which they could have looked forward to. multiple funding on a grander scale. I think it disposes of a difficult question. I don't have a real answer to it. Maybe Bill Thurman's recommendation will help come hws~-55 ~! 10 11 12 13 14 16 17 18 19 20 21. 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. | Wachinetan. 0.0. 20002 381 up with an answer. MR. KLINE: I would like to comment on that one point really, the $2 million project in particular. That project has a series of discreet activities. Were they to receive reduced funding on that particular thing, they would fund particular activities on a priority basis within that $1.2 million. DR. TESCHAN: Was there evidence of some priority setting? DR. THURMAN: It is not in order, on that list. Bert's point is a good one. It was asked for undex RMP from the standpoint they could involve everybody with RMP dollars, whereas otherwise the City of New York is going to fund it for all the City of New York hospitals. They believe they will combine with some of the others, and the County Medical Society is going to fund it with Queens. Its availability as a plan will become somewhat more difficult. DR. HEUSTIS: That makes very good sense, I think, that is that approach. MR. BARROWS: Looking at the thing in a very. broad sense, and taking into account the population we serve, which is what, seven million or eight million? DR. THURMAN: They say 14 million. MR. PETERSON: That is probably a little too high. 502 hws-56 1 MR. BARROWS: We are talking about, let us say, 2 ten million people. We all go by the extraordinary expenses 3 in New York, the extraordinary amount of time it takes, the ’ extraordinary difficulty in getting things together, as witness. 6 trying to get a CHP. They have been working on that for 6 eight years now. a When you look at all those together, and you con- 8 sider there what they are asking, it is really kind of modest, 9 it seems to me.. 10 || - MR. PETERSON: Bill, you said something which 11 suggested to me at least that you might have a motion in your 12 hip pocket, or recommended funding level. 13 MOTION FOR RECOMMENDATION 14 DR. THURMAN: I move we approve it as a slightly 15 above average program, and we throw out for discussion here, 16 discussion of $2.2 million. 17 I think if we do that, my own opinion is, and that 18 is all it is, is an opinion, they will look hard at some of 19 these projects. 20 | I am afraid some of the buroughs of New York will 21 go out. But there are some very significant steps they can 99 make in developing health services in Metro New York with that 93 kind of money. oA MR. BARROWS: It is about 30 percent lower than 95 last year. HOOVER REPORTING CO. INC 320 Massachusetts Avenue, NE. hws-57 1 ~] 10 11 (4) 12 13 14 16 17 18 19 20 21 24 25 HOGYER REPORTING CO, ENC. 320 Massachusetts Avenue, N.C. 383° DR. THURMAN: No, they are operating on $1,142,060 now. My figure is in the range of $2.2 million to $2.5 million. I have read Bert's recommendation, and I can't «argue with it too much, but I have ended up with $2.2 million. MR. PETERSON: Did you say $2.5 million? I was thinking $2.2 million. They have indicated to us Metro New York, that they will be in with an application in July of around $2 million in addition. MR. NASH: That brings it to a level of $441,000, five percent above the target figure, assuming both applica- tions are approved in the amount requested. DR. THURMAN: They requested $7.7 million. DR. HEUSTIS: My problem, I go along with the $2.5 million, and my problem is really this. I wasn't anywhere nearly impressed with the written document, but I sure am impressed with some of the things that they were trying to do together involving Metro New York hospitals, and certainly am impressed with the problems of doing things such as an area of New York City, and this two year business, I just am not particularly impressed with that. What I was really trying to do is wrestle with the 384 hws-58 1\| fact that really on the past record they didn't deserve very 2 much, but it looks as though maybe they have a new lease on | 3 life, and that they could do something, and if you could a 4 up with some kind of a figure that would give them a little 5 help, but certainly not everything that they wanted. 6 DR. THURMAN: That is why I gave them $1.3 million. ~~ That is not an insignificant amount of money, except when you 8 look at 8.5 million, nine million, or ten million people. 9 DR. HEUSTIS: I look up there at the greater 10||. Delaware Valley. Is that Philadelphia? 1 That is really the only problem I have in this. 12 DR. THURMAN: Well, if somebody wants to go higher 13 and -- 14 DR. HESS: I wonder about going up to $3 million 1b or something. 16 New York is a health care jungle, and my guess is 17 that New York probably has had it. 18 This is a small staff, seven full time professionals, no planned incremental, so that was one of my concerns, can 19 a staff that small handle it. 20 21 Do they have the administrative mechanisms to 99 handle this much money? Mr. Kline? 23 oA MR. KLINE: I had the same kind of concern, and I cannot answer it, because I have almost an all new staff. 25 | HOOVER REPORTING CO, INC. 320 Massachuselts Avenue, N.C. hws-59 1 ~T 10 11 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CQ, 'NC. 320 Massachusetts Avera, NLL. - are people with excellent reputations in New York City, and uy OQ Cal The only new people being carried over are the Deputy Director and Director. MR. PETERSON: How long ago was it? MR. SIMONS: Bert was up there in 1972. MR. PETERSON: Really, that information on the staff is completely new. It always has been a small staff, as you know. MR. NASH: Pete and I were up there, at least on a part time basis, some 60 percent, four physicians, and these it was their proposal then to hire a full time nonmedical staff to assist these four people in various program areas in which they are working, so this would add tremendously. DR. TESCHAN: How about the financing? MR. PETERSON: Maybe Tom, who has been part of the management assessment effort has some insight. MR. SIMONS: The grantee does all of the accounting for then. I don't think there is any of that going on, on the staff level itself. DR. HESS: So we don't have to worry about that. MR. SIMONS: One other thing, as far as staff. Jack Eller was with me on a management assessment to another place. They have hired on a part time basis a physician to work with them. These are physicians who have hws-69 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 4 I Washington. D.C. 26002 pes nh wl 10 jl 12 13 i4 16 17 18 19 20 386 reached a stage that they don't want a full time activity, but they still want to get involved. MR, KLINE: I talked to Jack Eller on the phone the other day, and he has extremely high praise for the part time people. I queried him about the size of the staff once again, because that has been a chronic problem with him, and I said I noticed you have some part time people, and he said they are very helpful. MR. PETERSON: I think that is a case where the proposed additional positions would come in, would it not? MR. NASH: Yes. MR. PETERSON: We have not been consistent. DR. HESS: Does that mean seven additional pro- posed full time professional clinical people? MR. KLINE: Yes. DR. THURMAN: To get back to the staff sheet one more time, the $88,000 is in overhead and is what pays for all the accounting and financing mechanisms, and at the New York Academy of Medicine in the program staff figure there is a $88,000 overhead, but that pays for their accounting to the New York Academy. DR. HEUSTIS: I would like to support the motion as made with the proviso that when this comes to the Council, and should there be extra money, that the Council look upon hws-61 1 a ~) 10 Bi 32 13 18 19 20 21 25 HOOVER REPORTING CO, iC. 320 Massachusetts Avenue. NC. | 387 the needs of New York in a favorable fashicn and that my thought about increasing, is what I think about the needs of New York City more than anything else. MR. PETERSON: You have any problem with that? DR. THURMAN: No. MR. PETERSON: We have a motion for $2.5 million for this May 1 application for Metro New York. Any additional discussion? DR. HESS: I may just ask what will that do now? Let's say that they come in with a batch of new applications in July, and a certain number of those are again passed. They still have the freedom to reallocate within the two decision making periods, so if they want to boost, for example, this Medical and Health Care Services, they can out of that total package that we are not bypassing a lower figure now, we are not necessarily restricting their ability to increase funding in that particular project. MR. NASH: No. As a matter of fact, about a month ago Dr. Arranson and the RAG Chairman came in and met with Dr. Paul, and they explained at that time that their applica- tion is going to be roughly $7 million. That is the first application, and the fact that they would be asking for support for many of their activities over a period of two years. Obviously, Dr. Paul told them that seems like a little high figure, but go ahead and send it in. hws-62 1 ~~] 10 11 12 18 14 16 17 18 19 20 21 24 25 HOOVER REPORTING CO, IKC. 320 Massachusetts Avenue, NE. i _ other Region, would have the kind of discretion and lattitude | 388 There is very little else you can tell them, becaus they can request anything they want. They did say that they would take whatever was recommended in this award, and would have their RAG meeting, and they would look at their total pYogram. They would prioritize the activity and select those that they wished to fund. MR. PETERSON: I think in response to what I heard is your policy kind of question, that New York Metro, or any within the two awards which becomes a single pot of money again within the Council's policy regarding discretionary funding to move things around. The problem that they would have in the short run, of course, is that they are not sure of how much they will get out of a July application. There may be some things that they have got in this application that they would want to defer starting until they see that, or some things that they might start at, start at a minimal level, and depending upon the outcome of July, extend it. But the general answer to your question is yes, they would have that kind of discretion. DR. HESS: Then these projects will not be in the next package. hws-63 1 ~] 10 11 12 13 44 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, IC. 320 Massachusetts Aventie, N.C. | thing as far as this working relationship, the city emergency 389 MR. PETERSON: No. DR. HEUSTIS: But there is nothing to prevent them) for funding these projects after they get their July money. | MR. PETERSON: No. There are a few caveats, but I didn't see any projects that involve construction of some kind. DR. HEUSTIS: I look at this arrangement as perhaps simulating the use of non-RMP money that I feel confident is there, and whereby perhaps instead of paying for the whole rooms, that they might pay for part of it, and the city might pay for part of it. MR. PETERSON: We do have a motion on the table for $2.5 million providing for the Council looking at your recommendation given the needs of New York City, that there is some leeway, and that we look upon it favorably. Any additional comment or questions? If not, all those in favor signify by showing your hands. "(Showing of hands.) MR. PETERSON: Okay. We had one member absent. We did what I was trying to avoid doing, if that clock is correct, and the cafeteria is now closed, but I was wondering, we have five applications left, and I think we can get them under our belts if we probably work until 5:30 ‘nws-64 1 ~~ 10 Ail 12 13 14 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. AOA AnAAnA 390 Would you people like, despite the fact that ‘he cafeteria is closed, to take a stretch at this point? (Short recess.) MR. PETERSON: Well, let us proceed now with the Lakes area. ‘ Mr. Barrows: MR. BARROWS: I will try to be brief. The Lakes area is a nine county area in Western _New York and Northwestern Pennsylvania. I think they are asking $2,072,000. I do not have the last year figures here. Last year they were running about $1.4 million. Their Executive Director is Dr. John R. Angle. He has been in the program since its inception. He spends 80 to 90 percent of his time with it. “ The RAG Chairman is Father Garrard, an educator. The Executive Committee is composed of four officers. The professional staff has 19 full complement. They have 13 on board of the complement, and need six. I might add that by my guess they are well supplied with chiefs, but they are short of the important Indians. In the Regional Advisory Group they have 43 people, two from each of the nine counties. The rest are fairly diversified by interest and background. hws-65 1 “1 10 Ul 12 13 i4 16 17 18 19 20 21 22 23 24 20 HOOVER REPORTING.CO, INC. t 391 There is a substantial non-provider representation} In fact, it is alsoct iike a CHP Advisory Group, usually routine about theis puucesses. They have a very elaborate structure. They have 25 committees, and it looks to me as if there are a certain amount of overlap, and what have you. It appeared to me that their processes were demo- cratic, but awfully complex. Their major thrust normally has been along three lines. The main one seems to be education. I, too, think we are giving more lip service to the current RMP mission than they were actually. For example, these are things that I am not that particularly acquainted with. They are asking for $154,000 for the telephonic electronic program, $200,000 for a tumor registry, which I understood was pretty well half full. Area prospects for success undertaken seemed to be fair, reasonable. Their objectives and priorities are adequately stated -- transmission of new knowledge, regionalization, and improvement of delivery, but they seem to treat contin- uing education as the way to achieve all of the goals. The proposal looked to me like something of a residual rural mission. The feasibility is good and bad. They have a fair hws-66 ~ 10 il 12 13 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. Wie bin dtan AO IAANY i! 392 showing of State and local cost sharing on some of their pro- grams which woulc suggest some commitment back of them. They hres two CHP B's that they have in Western New York and Northwestern Pennsylvania. Each has a repre- sentative on the RAG. Five of their county committees are joint. They share in their development review with CHP. When New York expressed its concern whether the large majority of these proposals relate to the major goals of LARNP, of 21 proposals they disapproved eight, because they were not related to the goals, where they had weak planni and they approved two with major conditions. Now, I would say that ordinarily I can understand the sibling rivalry between CHP and RMP, and there is a lot of ego trips and petty bickering, but this letter from the Western New York B Agency struck me as being a pretty darn rational critique under a proposal that had been submitted to them. That was my impression, in any event. Generally, I would say that this is a weak average program, slow in responding to the 1971 mission. They have a staff shortage of what I think are fairly key people in any implementation activity, and that will limit their capacity. I have some question whether the staff and RAG structure are functioning effectively. ng, hws-67 es ore) ~] 10 11 12 13 14 16 17 18 19 20 21 22 23 2A 25 HOOVER REPORTING CO. INC. 320 Massach usetts Avenue, N.C. dan AM OAAAD As I say, I wind up with a no better than average | rating, a kind of weak average. I would be glad to hear somebody else's view that micht be more cheerful. MR. PETERSON: I am not sure I can satisfy you on that score. Dr. Heustis is the next reviewer, and I can say that he is charitable, but I cannot say he is going to be charitable about the Lakes Area, and perhaps the best way is to ask him. DR. HEUSTIS: In general you almost read my notes. This was one of the ones that I think that I made the remark that the first time I went through this I got a pretty decent impression when I went through it fast. Then when I went back and read it more carefully and tried to put things together, I had great difficulty trying to pinpoint the reported specifics, for example, short term goals and priorities may well in fact exist, but they were not emphatically stated, and not with sufficient speci- ficity at least to satisfy me. I found it interesting in the classification of the projects that some, if you classified them by the so-calle major thrust, there were three of them on the use of knowledge one on Regional linkages, and nine had to do with personal health in one way, and they also classified them another way, hws~-68 ~ 10 | 12 13 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. tat 320 Massachusetts Avenue, N.C. taaban AP OND 39h three for health screening or assessment, three having to do with patient care, one coordination, and six Os manpower development and education. That, you can see, is where the emphasis is. I couldn't find any information that was very helpful on how the staff planned to implement the major thrust, and I could not find any information on how the relative priority of the various components was assessed, although they do say the priority was assessed. My comments as far as the CHP, I have the same reaction to the letter from Western New York, in which they very specifically commented on the new projects. Of the five new projects, two were not approved, and three were approved. Of the two that were not approved, they had to do with regional hpertension and the preparation of nurse. faculty. The three that were approved had to do with ambu- latory health planning, somebody in the household. = think with the extent and capabilities and the program staff, I just can't help but wonder why they couldn't provide sufficient information in health planning to put some of these things together to stimulate those asking for grants to get something done. Apparently they didn't, because as I analyzed hws-69 ~ 10 11 12 13 i4 16 17 18 19 20 21 22 23 2A 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. | Washington, 0.C. 20002 ann Ren hee the money figure here, somewhere that out of the total request of $2.072,000, almost $800,000 or slightly less than one-thira was listed for the proyam svaff. | In addition, aimost $1.1 million was listed for activities for program staff activities, leaving sponsored projects only some $215,000 as far as others were concerned. It would seem to me that in one way it could be a little onesided. DR. TESCHAN: You are saying the staffing isn't . adequate enough to handle that amount of business? MR. HEUSTIS: No, the staff ought to be concerned, to be responsible, and to get others to try to handle the projects, rather than running it themselves. It looks to me if you have a difficult Region and a capable staff, the easiest way, at least to my thinking, is to distend it and carry it out with your own group, probably a very limited usefulness in the long run, because it goes when you go. | The harder way in the long run is to get somebody else interested in carrying out the good idea so that it has a greater chance of staying. | _ I guess my general belief is that those projects that are carried out by others probably have got, on the whole a greater probability of being funded into projects. DR. TESCHAN: Continuation funding? hws~70 =~] 10 il 12 13 14 - 16 Vi 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue. nC. || Washington, D.C. 20002 _ and I had to break those down as poor, the proposal I wante 396 © DR..HEUSTIS: Yes, yet dealing with strong medical schools, and with a strong situation we know the difficulty at least in getting started. In the overall specific assessment I thought the program leadership was good to excellent. I thought the same about the program staff, the Regional Advisory Group, a little lower, satisfactory; per- formance and accomplishments, satisfactory. I have trouble with the objectives and priorities, originally was higher, but again it is on the poor side. The feasibility again is on the poor side, and CHP working relationships, in spite of the disagreements, it looked as though there was the opportunity to communicate, and on that my judgment is good, even though there was differ- ences of opinion expressed. I weighted the whole program the same as my colleague did, on the low, average side. MR. PETERSON: Well, I think there have been a couple of concerns expressed that have been shared by staff, and I will call on Frank, and also ask Bert two or three things that we had some questions about. MR. NASH: I will make a comment about the CHP. What Dr. Angles did, was as soon as he got a pro- ject in and before it had gone through his own review process, hws-71 = 10 il 12 13 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. | 397 he sent it to CHP agency for review. As it ended up he sent in 21 projects. The com- ments were received by CHP. The Regional Advisory Group approved themselves only five of the 21 projects. They did approve one that the CHP recommended disapproval for. This was the one submitted by Niagra University for training nurse practitioners, and the Region explains to me that the CHP agency there does not have a nurse on their staff. The Regional Advisory Group thought from a tech- nical standpoint the CHP's comments in this particular case were not really accurate. MR. PETERSON: There were a couple of projects or activity concerns that you at least noticed or mentioned to me. MR. NASH: You will notice Project 1, the Tele- phone Network, that activity they have been supporting now for about seven years, and they propose to continue this in the coming year, and even a year after that. “DR. HEUSTIS: There were some two year requests I failed to mention. MR. NASH: That is right. This for me is a staff person. I think in the past if they didn't have a policy we practiced it at least that RMP would usually fund an hws~72 ~ 10 il 12 13 14 16 17 18 19 20 21 22 23 2A 25 HOOVER REPORTING CO., INC. 320 Massachusetts Avenue, N.C. Washineton, D.C. 20002 398 | activity for three years, and then on rare occasions, perhaps for another 12 to 18 months, at the most. Staff would wonder if this concerns the Committee any that they would continue to fund this thing into the 1970's. MR. PETERSON: Let me mention one thing in that regard. My office, a couple of years ago, we contracted for a study of these types of networks. I don't recall that the New York one was one of the subjects of it. The contract was an abysmal delivery product by Systems Development Corporation, but one of the things that we pretty well knew beforehand, and they did manage to docu- ment the ability to find continuation funding for these kinds of telephone radio networks was fairly low. Now, I think in Wisconsin there was about as much success as anybody had, and that was in percentage terms of what, 50, 30, 20? DR. HIRSCHBOECK: The University extension ccn- tinues to support it. MR. PETERSON: I know in Wisconsin it really was the University Extension Service, and you were looking at nurses, as well. DR. HIRSCHBOECK: We were just augmenting their program. hws-73 1 =I 10 il 12 13 i4 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avent, N.C. 399 MR. PETERSON: But there had not been a very good track record on the whole. Wisconsin is the exception. Anybody seeming to get much money to cost share or to continue funding these activities, once they are empty, to pull its dollars out. “I think that may be a reflection of what is happening in Western New York. I don't know, but this is the staff's concern. This seems to have been part of the Western New York - Lakes area package of projects since the year one. MR. BARROWS: It has never been my impression that RMP was designed to provide continued operation of service. Here, you are asking for about one-third of a million dollars for this network that is seven years old, and their tumor registry, that alone they are asking $200,000. I would think once you establish whether it is going to fly or not fly on its own, that is the time for RMP to get out. MR. NASH: I asked them for the tumor registry, and they said they had funded it for three years, but you need at least five year support to gather enough data to make these things useful in feeding back information to physicians. MR. KLINE: Can I comment on that? hws-74 ~ 10 11 12 13 14 16 17 18 19 20 2l 22 23 24 25 HOOVER PEPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washineton. D.C. 20002 4 LOO MR. PETERSON: Surely. MR. KLINE: In 1971, December, a site visit strongly suggested that the program get out of that tumor service registry because it was not felt at that time that it represented a very strong project. At the time the indication was that it had been contracted or planned for a five year effort. This plan as it now shows carries it into the fifth year and on into the sixth year. I tend to have a little bit of concern about that. The other concern that I have about this program is that it doesn't look very, very much different than it looked three years ago, which is kind of amazing. This is sort of like a static program. The rural program has been going on for three or four years. The tele- phone collection network, from the day the program opened. The tumor service registry almost from the day the program opened. The two activities essentially are there, emer- gency medical service and their area health education center, and the other activities they have are relatively small and new. I guess my primary concern is I looked at this with a tremendously huge staff, and they do have a very large staff, and they do have some very excellent people on that hws-75 ~) 10 11 12 13 14 16 17 18 19 20 " 91 22 HOOVER REPORTING CO, INC. 320 Massachusetts Avenua, NE. Washington. D.C. 20002 404 staff. The problem is they essentially haven't come Up with a program. MR. BARROWS: They don't have the leadership. I have concluded that the program that wasn't doing much probably wouldn't change, and the upper limits of my responsibility would certainly not warrant coming forward with a proposal that does much more than continue their present funding level, which would be about $1.4 million. MR. PETERSON : Let me add one thing regarding a specific activity which Bert singled out as being one of the few newer things, and that was the Lakes Area Health Education Center. Now, my information is roughly 18 months old, but we did staff visit a large number of the health services educational activities back in May, June and July of 1973. The ola one that I went. on happened to be the Lakes Area one, so I don't have any personal comparisons to be able to make, but I do know in talking to people who were on that site visit, and more importantly, the others who would have been on a far broader range of site visits, that was one at that point, one of the weakest ones. They had real problems with getting any kind of commitment. This wasn't a matter of domination. They had what was admittedly an extremely difficult, nasty situation in hws-76 (5) to 10 11 12 13 14 16 17 18 19 20 ‘ 21 HOOVER REPORTING CO, (NC. 320 Massachusetts Avenue, f+.C. Washington, 0.0. 20002 [ 402 Erie, Pennsylvania where you have two hospitals jockeying for some sort of number one position, the medical staffs, the physicians in the community being staffed sort of, you know, their appointments with one or the other, and at that point was one of the weaker looking ones, and I don't know whether we have any later information, and it wasn't in the prog- nosis for good progress, and was not all that good in the health educational center. MR. NASH: ‘They still have the same Project Direc-~ tor for this. MR. KLINE: Pete is commenting on the Erie, Pennsylvania Health Education Center. I visited five emergency health service projects last year. | Of the five we visited, I tended to suspect that it probably ranked at the top so probably offsetting the possible deficiency in the health activity, their medical service activities were performing very highly. DR. HEUSTIS: I wanted to ask Mr. Barrows if he would accept a slight amendment to his thought of financing at the current level -- that is financing it at the current level less or a deletion of all of the money for project that have already been financed for three years, less a deletion of one-half of all the money that is requested for the two year projects. 403 hws~-77 i Staff is going to have to help figure that arith- 2/) metic out. 3 || MR. BARROWS: That would be suitable to me, pro- * viding the net answer isn't more than they got last year. 9 DR. HEUSTIS: It would be substantially less than 6 they got last year. We should probably indicate on that, that our ~] 8|| Committee is dissatisfied, or expressed some dissatisfaction 9 with the way the program has developed. 10 DR. HESS: I do not think you can be that strong. 11 . You can give strong advice, but you cannot delete 12 line items, can you? 13 MR. NASH: The only thing we can do is give them 14 X number of dollars and advise that they then rechoose these 15 things in the seventh year. 16 DR. HEUSTIS: I am not deleting the project. I rT am deleting the money for the project. 18 MR. PETERSON: We are not arriving at a figure. 19 DR. TESCHAN: That is your intent, but the net 20 effect is a bundle of money. 21 DR. HESS: Rearrange it any way you want. 99 MR. PETERSON: I think what we have heard reflects, 93 in part, the concern that the staff has whatever the figure, 7 assuming Council goes along. with this, because this is their policy, pointing out and taking nctes of it, and the fact that 25 JOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. * Nashington, D.C. 20002 hws-78 ~ 10 ii 12 13 14 16 1? 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. | Washington, D.C. 20002 i hok several of their activities are well beyond that point and that they ought to be governed, hopefully, accordingly without in effect, saying you can't do it, but they are. Whatever figure, if we are talking at the present level, or something less than that, this request as I look at it totals roughly $2.3 million. If they get a significantly less amount than what they have requested then it seems to me they are going to have to make some hard decisions. MR. BARROWS: Let me see if I understand this. If my arithmetic is right, we would come out not too far apart on this. There is $200,000 for registry, $154 for electra- network. Those would be out, and half of this remaining $150,000, another $75,000, knocking those out would reduce this thing by $225,000. They are asking for $2 million. DR. HEUSTIS: My statement was their present level of funding. MR. BARROWS: Excuse me. DR. HEUSTIS: I propose to knock the $225,000 out from the $1.4 million. "MR. BARROWS: That might be a little severe. DR. HEUSTIS: Do you understand the process? DR. HESS: That takes it down to $1 million. hws-79 10 11 12 13 i4 16 Vv 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 [ HO5 DR. HEUSTIS: The process is we do not provide money for projects we have already financed for at least three years, second, the report shows that they have been advised on at least one of these that they had some advice back in 1972. The other is that we provide only half the money necessary for any -~ that is half of the money requested for anything that they have requested for two years, which really doesn't do a very great disservice to the remainder of the program. DR. TESCHAN: I don't like that. It creates a problem. You are handling it in a way that riles everybody. DR. HEUSTIS: I make a motion to bring this to a head, that we say that staff has to do some arithmetic, because I can't come up with the figure, but $1.4 million less the other two items. MR. BARROWS: Let's round it off to $1 million. MR. NASH: What figure are you using as their current funding level? Apparently we have two different figures here. MR. BARROWS: I was using the one on this sheet, the current and the annualized. DR. HEUSTIS: We rounded it off to $1.4 million, and we started to subtract from $1.4 million. 406 hws~80 1 MR. NASH: The sheet I have shows $1.81 million 2 current, and the annualized level. oo MR. PETERSON: We are really in great shape. We 4 have two sheets that have separate figures. 5 MR. NASH: Mine is dated May 20. 6 MR. PETERSON: What is the correct figure, $1.4 7 million? 8 MRS. WILSON: Yes. 9 MR. PETERSON: It seems to me with having done 10 some hurried arithmetic, if we were singling telephone, 11 tumor registry as having gone beyond the three years, having 12 those three other small projects that were asked for two 13 year support, that rough analysis is about $400,000, and I i4|| think that is what you are talking about. DR. THURMAN: It is $1.370 million minus $354,000 16 minus $65,000, which is $419,000, so $1 million takes care 17 of your recommendation. MR. PETERSON: You would make that as a recommenda- 18 19 tion? 20 DR. HEUSTIS: I accept your arithmetic. 91 MR. PETERSON: I take comfort from the fact that 92 Bill Thurman agrees with me. 93 DR. HEUSTIS: He was agreeing with me. 5A MR. PETERSON: I. was not at odds with someone else's number. HOOVER REPORTING CO, INC. ; 320 Massachusetts Avenue, N.C. § Washington, D.C. 20002 FRAT Pan nan Yh hws-81 ~! 10 ll 12 13 I4 16 1 18 19 20 21 25 lOOVER REPORTING CO, INC. 20 Massachusetts Avenue, NL. ' I dashington, 0.0. 20002 HOT Is there a second? DR. TESCHAN: I second. MR. PETERSON: Any additional discussion? I would just point out that we do have an estimate that roughly a $500,000 plus application would be coming in, in the July cycle. If there is no further discussion or question, those in favor raise your hands. (Showing of hands.) MR. PETERSON: Those opposed raise your hands. (Showing of one hand.) MR. PETERSON: We have a seven to one vote. Before we dip into the next application, could I ask a question of the group, because I have been handed a note asking me what time will be good for us to reconvene with Panel A tomorrow as a single group, and I am assuming that if we are going to allow ourselves a little time to review our own actions, that whatever time I tell them we will need to allow ourselves a half hour in advance. Is the group willing to get together at 8:30 tomorrow? If that is satisfactory I will do that. ‘Now, we have four Regions. I am going to try to get away so some of you who have been reviewing more than other here at this particular point in time I wonder, Sister Ann, would you be ready to takea look at Maryland? hws~82 Ca ~ 10 il 12 13 14 16 17 18 19 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. ! Washington, D.C. 20002 408 HEW REGIONAL MEDICAL PROGRAM FOR THE STATE OF MARYLAND MR. PETERSON: Now, here again I think the staff person involved, Frank and Gene Nelson, need to be prepared to supplement this. We have the free State of Maryland. It was separ~ ately set up from the beginning. ° MR. SIMONS: Hopkins is a grantee. SISTER JOSEPHINE: Johns Hopkins is the grantee agency in Maryland, and one of the criticisms of the ongoing criticisms of the Maryland program has been its very close affiliation with Johns Hopkins University. The program leadership is relatively poor. I get the impression, and these are just impressions at this point, but I do get the impression that the strength of the Maryland medical program has been to kind of maintain a broker image in the area, and to use regional medical program funds to just give to other agencies so they could carry out their work, and I think they describe this type of available money as mini-contracts. When we were there about three or four years ago, I remember there was a question raised by the site visit committee, whether or not this was a good way for them to proceed, and after it was discussed with the group, the con- sensus was that this practice should, if not be eliminated, hhw-8 3 ~) 10 11 12 13 14 16 17 18 19 20 21 24 25 JOOVER REPORTING CO, INC. 120 Massachusetts Avenue, N.C. ¢ Nashington, D.C. 20002 (| “Og be modified. But I notice it is still being carried out. The program staff is satisfactory. However, they draw very heavily on staff from affiliated programs, partic- ularly of the other universities, and that is not always bad. The Regional Advisory Group looked, on paper, to be adequate, but I would have to ask the staff person working with the program whether they are really aware of what is going on in the program, or whether they simply go along with programs that are outlined. Past performance and accomplishments have been satisfactory to poor. It was difficult for me as I looked through this program to identify, to really identify a program that was the program of Maryland rather than the program that is going on in other institutions without close coordination from their Regional Medical Program. | The objectives and priorities are satisfactory as they are stated. The proposal is inadequate in many ways. Feasibility is checked inadequate, and the CHP relationships in the written document appear to be good. The overall assessment I gave the program is below average, but I am simply going on the material that was here in the book. MR. BARROWS: Let me ask a question, as I don't #10 hws-84 know the area that well. In Maryland can you get very far without being pretty closely identified with Johns Hopkins? 4 MR. NASH: Either that or the University of Mary- |) land. 6 SISTER JOSEPHINE: It may be there is no other way ' to go about it. 8 DR. TESCHAN: Where is the element of limitation 9 you are implying? 10 SISTER JOSEPHINE: I think I am probably reading 11|| that into the proposal from the impression I had on the site 12'| visit, where it was very difficult to sit down with the staff 13 and to have them, you know, really identify a program and talk 14 about a program. 15 The ones who could really do it effectively were 16 those who were carrying on the program. It was usually from 17 one of the universities, and it was always someone from Johns 18 Hopkins. 19 I would be interested, and I may be over reacting, 299 || but I would like to have the person who works on the program 91|| reflect on that. 92 MR. NASH: Unfortunately, the person who has worked 93 || On this program for the last three years now has other employ- oA ment. 95 That person is not here, and I think one of the HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. | Washington, D.C. 20002 AAA Pan rene tt Hil hws-85 1 things that has been pretty typical of this program in the 2 past, the observation of site visitors and people who study 3 the Region is that this particular program has never really 4 taken a good look at the needs, and then made an effort to 5 develop a program within the State that would help overcome 6 those needs; that the projects and activities they have engaged in appear to be opportunistic. =~ 8 Somebody comes up with an idea, and they say let 9 us fund it. That has been one of the major complaints about 10 this region in the past, and to a certain extent it may still 11 be true. 12 MR. NELSON: I might say my identification was 13 about two weeks, and I am no authority. 14 Basically, I made some notes saying in reviewing 15 that they were criticized in the past for three major things 1G -~ failure to acquire sufficient staff to do the job, depend- ency to concentrate in Baltimore, and I mean Baltimore City, 17 18 and a tendency to keep the program to themselves. 19 It seems to me we are looking at a different pro- 7 gram this year, and, in fact, whereas they had 22 projects 31 last year, a great number of w lich were in Baltimore and 99 environs, we are now talking in terms of, let me see -- let a us talk about these three concerns, and first failure to oA provide sufficient staff. They have, in fact, as a result of advice letters, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 SNA car eres hws- 86 i) 10 ll 12 13 14 16 li 18 19 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. / Washington, 0.0. 20002 i i. 412 moved from 4.5 people to nine people in this application. This is something that they have been constantly prodded to do. The second concern is concentration in Baltimore. They have five projects. One provides planning and services in Ocean City. This is planning for health services in the Ocean City area. One is a CHP Planning Seminar for Consumer Orien- tation throughout the State of Maryland. They are requesting $25,000 to, in fact, under- write orientation of consumers to the CHP Plan. DR. TESCHAN: Is that the Health Plan for Maryland? MR. PETERSON: Except for the title. MR. NELSON: I think it is quire indicative of the good relationships between RMP and CHP. I might add that I talked to Eugene Gunthries, who was former Director of Chronic Diseases, Public Health Services. He just left under questionably circumstances two or three weeks ago. Up until that time the limited information I had is that his successor is continuing with his concept, very close cooperation between the two hospitals. A third project, even though it is centered in Hopkins, involves care services for the poor in outpatient departments, correlating with Hopkins in the outpatient hwis~ 87 1 Ow ~) 10 11 12 13 14 16 li 18 19 20 2] HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, 0. (1 ” Washington, D.C. 20002 i E 413 department. DR. THURMAN: That is Number 656. MR. NELSON: The Manpower Planning and Data System, more effective use of manpower and related services in hospital outpatient service department. We have a fourth program involving SAEA concepts, 30 health education agencies. DR. TESCHAN: Which one is that? DR. THURMAN: That is 058. MR. PETERSON: ‘Those are the most undescriptive project types. DR. TESCHAN: Let us come back to that. MR. NELSON: The third concern, the makeup of the RAG now shows involvement of an amount, a large number of consumer groups, and groups representing the poor, and so forth, so I think the program has turned itself around. The percentage of increase in staff would be 39 percent. As to projects they have $760,000, a little less than half of which is for projects, a little more than half of which is for programs. DR. TESCHAN: Another $442,000 due in July. MR. PETERSON: Well, we have requests here, as Sister Ann indicated, for $762,000 or $763,000, if you round it off upwards, which is slightly above what their operating h i-88 ~I 10 11 12 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. Washington, 0.0. 20002 {| 4a level is now. They have indicated they will be coming in in July for about $460,000. DR. THURMAN: Could I ask a question? MR, PETERSON: Surely. DR. THURMAN: On the total program staff they have a figure of $144,000 under “other.” Do we have any idea what that is? Is that beyond salaries and wages? They have a total of the other category. MR. NELSON: $125,000 requested for contracts and studies. DR. THURMAN: Then Maryland has not changed in the $125,000 plus the $57,000 listed under 058 which goes to Johns Hopkins Computer Center, which has always been the biggest argument we have always had about Maryland, so it has not changed. MR. BARROWS: It sounds like a program with a lot of paper shuffling to me. DR. HESS: An indirect measure of RMP impact. Last month I was at Hopkins on a site visit for another program which is supposed to have an outreach compon- ent, and it was evident from the level of thinking on that proposal that for this, this had a lot to do with the school of public health among other things, but RMP's had little or hws-89 “4 10 il 12 13 14 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320: Massa chusetts Avenue, N.C. tee AP ANON 415 no impact on the thinking of those people, and they did not know really how to go about, you know, needs assessment and this whole ball game, and effective RMP would be educating somebody about it. I rather mused to myself that this seemed to be further evidence of a rather weak RMP. DR. TESCHAN: It didn't occur to the Project Director to ask to get the project data. DR. HESS: Neither were RMP's mentioned once, and the people didn't seem to know how to do it. This was really a very self-serving application, as I viewed it, self-serving to Hopkins, but not necessarily to the community and the State at large, which it was supposed to be. SISTER JOSEPHINE: I got the impression the com- munity at large doesn't really know what the RMP is, and the Program Director really has funds that he gives out to other agencies, and the people in the agencies are the receivers of the service, and really aren't aware where the money comes from. DR. TESCHAN: It seems to me we have an inactive RAG in terms of directing it, an inactive coordinator as defined here, and we have a self-serving unconcerned grantee in terms of the principles of the program. If I remember the basic notion of the essential hws-90 /- HOOVER REPORTING CGO, IRC. 320 Massachusetts Avenue, WO, | [' Hashington, D.C. 20002 an =~ 10 11 12 13 14 1¢ 17 18 19 20 21 24 25 416 ingredients of an RMP as defined in the August 1972 policy, those are the three essential ingredients so that if we don't have the essential ingredients it says we don't have an RMP. Why isn't a motion in order to discontinue Mary- land? DR. HEUSTIS: Make a motion, and I will support it. DR. TESCHAN: I so make it. MR. BARROWS: I don't share your abrupt change at this time. In support of what you said, there is a fourth striking deficit in this, and that is the end product is useless. I don't care if they give it to this guy or that guy if they are coming out with something that is beneficial. There are a lot of play things for the computer people, so I would say in addition to these other weaknesses their end product is not impressive. DR. TESCHAN: There are four important reasons not to spend the money. MR. BARROWS: But you get the other point, the reason, and that is for the Council. I don't think it would be appropriate for us to make recommendations, but yesterday we pretty well agreed you are not going to get a leopard to change its spots this late hws-9l ~~ 10 11 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massach usetts Avenue, AC. ‘| i 4.0 AP SAAN ALT in the day, that we are not going to create any great changes in any of these programs in their remaining life scope. I think probably in order to avoid capriciousness we better continue the policy basically of the past without any wild swings up or down. That would be my conclusion. DR. HEUSTIS: We have here, for the first time, that has been spelled out the three things, and the one you added, and it would seem as though quite a part of our func- tion was to make a recommendation to the RAG according to the motion that has been duly made, and supported, and I would like to see those four items put in the motion so we don't lose them somewhere, and let the Council see what we think about this overall situation. MR. BARROWS: I will buy that. DR. HEUSTIS: The motion you say that you would now buy is to give them no money, and that was my intent, and | see what happens, because probably there isn't anything that could have a better influence upon the whole IRD structure for someone to stand up and take the bat and swing it. MR. BARROWS: Let me ask you a question. We have been told by legal, who has wiser and finer minds than ours, that part of our job now is to prepare for this transition to a new type of combined agency, and what the impact of ending one right at this time instead of retaining a leap year fund upon which to build -- hws~-92 1 10 11 12 a, C } 13 i4 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 1 t 418 DR. HEUSTIS: If you will pardon me, the egg that is rocking in the box doesn't do much good to keep it in the refrigerator. DR. TESCHAN: I feel that the new planning corpor- ation is going to need a widely based representative operation with clout, that the worst place to start from would be one of these, and that we do the entire process of representatives of health planning a greater service by getting rid of grantee. MR. BARROWS: Right now you have reason in there that I can buy that this future entity will be a lot better off by starting from scratch than it will be trying to build on some pretty weak foundation. DR. TESCHAN: Especially when you have all the years of badgering. Now, Hopkins and company have to learn, in my own view, it is long since time that somebody got somebody's attention. I know some of the people who are involved in this, and they have been disastrous in other places they have attempted to manage. MR. PETERSON: Let me see if I have a sense of what I hear the Review Panel saying in effect is it would like to propose to the Council in effect that the Council give serious consideration to terminating or phasing out, I think we might, 4 ~ 10 il 12 13 14 16 17 18 19 20 21 23 24 25 HOOVER REPORTING CO, INC. ‘assachusetts Avenue, N.C. | feeatiion, OC. 20062 419 you know, whether it would come to an end June 30, the Council “ @oesn't meet until June 14 and 15, so I think really the termination or phaseout wovld entail some money based upon a conclusion by this group that what we have here is a largely inactive, ineffective RAG. I had written down, and I don't think you had used the word, and I am searching for a word -- a coordinator who is ineffective, a grantee that has been self-serving in the sense that it has managed to use the program for some of its own interests for a long period of time, and this is a situ- ation of longstanding, where there is really little, if any- thing, to show in the way of accomplishments, any output. MR. BARROWS: The end product is the thing that impresses me. You don't have anything coming out with these bucks. MR. PETERSON: Is that the sense? DR. HEUSTIS: If you would not object to the word termination, and we have a full idea that the Council being a reasonable body will probably give them some time to phase out if they accept the sense of the motion. MR. PETERSON: I was trying to summarize what I heard said, not necessarily putting my views on the table, and I certainly would like to hear some response from Sister Josephine, who did review the application, and you conducted hws~-94 Mee =~] 10 jl 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. f Washington. 0.€. 20002 420 the site visit. SISTER JOSEPHINE: I would agree with this. The question I would raise at this point is to phase this program out. How much of this $684,000 do they have? MR. PETERSON: Current? Gentlemen, do we have any idea of what Maryland may have in an unobligated balance come June 30? They have been operating at a fairly modest level. I suspect their balance is not likely to be large, Sister. SISTER JOSEPHINE: You see, that would maintain staff during the phasing out period. DR. HEUSTIS: ‘There is nothing to preclude the Council from putting in whatever money is necessary to do whatever they want. SISTER JOSEPHINE: Yes, and between now and July we might have some communications. DR. HEUSTIS: I hope this is the whole purpose of the arrangement. DR. THURMAN: I move the question. DR. HESS: Just speaking for myself, I am not prepared to vote on that at this point. I would like some time to study this application. This is, I think, the most drastic recommendation that we have considered today. a = es] t \O in fone no e we on ~l 10 11 12 13 f a 14 16 17 18 19 20 21 HOOVER REPORTING CO, IRC. 320 Massachusetts Avenue, N.C. [ Washington, 0.C. 20002 DR. THURMAN: We made this recommendation twice before, though. DR. HESS: Termination? DR. THURMAN: Yes. DR. HESS: I don't remember that we have. SISTER JOSEPHINE: This was considered. I think when this was reviewed these same questions came up. But I think this was reviewed the same way the same questions, that is this morning. DR. THURMAN: The Sister is very charitable. The person who reversed us the last time was the Council. DR. HEUSTIS: It is Council's responsibility to do what they think. MR. BARROWS: I think we ought to do the honest thing and pass the buck. MR. PETERSON: We do have a motion. Rod Merker recently, I understood from Frank, that he recently -- well, I don't know if that is within the past six months or past two weeks, had made a management assessment visit to the Maryland RMP. MR. MERKER: It wasn't recent. It was two years ago, and I think you have a good acceptance of what I found two years ago. I found no overt domination by the medical school, but a lack of leadership on the part of the Advisory Group, hws-96 ~ 10 il 12 13 i4 16 17 18 19 20 21 22 HOOVER REPORTING CO, fNC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 422 which enabled the medical school to get what it needed from the grant, and I think you all know there was a large epidemiological body or school supported in the school for four years. DR. HEUSTIS: Mr. Chairman, the question was callec for, as I recall it. You remind me of an Episcopal Bishop. Pardon the pun, Sister. | MR. PETERSON: The question has been called. I will make a specific point because we will be getting together tomorrow, and you will have a chance to look at an application. Some of these people will have slept upon what I understand to be the motion. There is no reason that we could not, if you and others see fit, make the motion tomorrow that would, in effect, modify or remove this item, but given the motion to recommend to Council the termination of this program within a reasonable period of time with such funds as may be considered, and we don't know the carryover situa- tion for the reasons indicated which I tried to summarize. DR. HEUSTIS: Did you say this has been done twice before? DR. THURMAN: Once before we asked for a site visit, because the point he just made that we were supporting an epidemiological study. 423 hws-97 1 DR. HEUSTIS: Have we ever recommended to Council? 2h DR. THURMAN: It was recommended to Council that 3 consideration be given to terminate the Regional Program. 4 DR. HEUSTIS: Would you object to an editorial 5 change to the motion that we repeat the motion that was made 6 by whatever it was, the previous Review Committee, that this be terminated? ~~ 8 I think this gives further emphasis to it. 9 DR. THURMAN: The only thing I would have to say 10 to it is that it was recommended to Council that it be con- 11 sidered for termination, and Council voted to keep them going. 12 DR. TESCHAN: Put something in there like a comma 13 and then quote in view of the past recommendations * * * i MR. PETERSON: I am not sure I have that. 15 Well, the question has been called for about ten 7 minutes ago. n Those in favor raise your hands. 18 (Showing of hands.) 9 MR. PETERSON: Those opposed raise your hands. 50 (Showing of one hand.) 91 MR. PETERSON: There is just one opposed, and the 99 motion is carried. ; MR. BARROWS: Pete, may I ask one thing? ; MR. PETERSON: Surely. MR. BARROWS: In this message that we transmit to HOOVER REPORTING CO, ikC. 320 Massachusetts Avenue, NC. Washington, 0.C. 20002 | 1 PANO Cee ere hws-93 J ie ~? 18 19 20 21 HOOVER REPORTHIG CO, INC. 320 Massachusetts Avenue, NL.‘ “ashing ton, D.C. 20902 | the Council, do you conterplate including the fact that we faced up to the impact on the upcoming legislation, and came squarely to the conclusion that we would be better off start- ing from scratch? MR. PETERSON: What exists is there is not a re- source for HRP, or anything else that might come down the pike. This is just my praseology of what I heard. MR. BARROWS: I thought we said it would be more harmful to have them around than to start from scratch. MR. NASH: If it is to be a State Health Plan organization, it is highly unlikely to be the agency. DR. TESCHAN: I think it is arrogant. I keep hoping that our encouragement to a transistion stance will allow them to tidy up their relationships so at least they are in the running. The alternative is to lose what is there, and the health field hardly can afford to lose any more than it has ‘already lost. MR. BARROWS: I am not quarreling with you. MR. PETERSON: Okay, we have three Regions left, Metropolitan District of Columbia, Nassau-Suffolk, and Susquehanna Valley. hws-99 1 ~ JO li 12 13 14 16 V7 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue NE. mR OARRAR es HEW REGIONAL MEDICAL PLAN FOR THE DISTRICT OF COLUMBIA MR. PETERSON: I wonder now if we could turn to a sister jurisdiction of Maryland, namely the District of Columbia, or the Metropolitan District of Columbia RMP, and Joe, if you would lead off on that. DR. HESS: The Metropolitan Washington RMP is one that I know from past reviews that has been of some con- cern. It is, however, in a triannium status. The grantee is the Medical Society of the District of Columbia. The Coordinator is new since I remember the last review of this Region. Their broad goals are to provide assistance to CHP's in developing plans, and incidentally, within the last few months the CHP has been organized in Washington. A second goal is to increase availability and access to primary care services, and to improve along with tha possibly the hospital care, and a third one is to regional- ization of experience and secondary and tertiary health care resources. The letter of submission which is signed by the Chairman of the Regional Advisory Committee is quite enthusi- astic, and I would like to read some sections from that. hws-100 a ~~ 10 11 12 13 14 16 17 18 19 20 21 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. ! Doctor, Chairman, Metropolitan Washington Regional Advisory Council. He says, and I quote: 426 This is written by Dr. John A. Kenney, Jr., Medical "Pirst I would like to address the past perform- ance of MWRMP. I have had the privilege of serving on the RAC since the inception of MWRMP. From this vantage point, and from my faculty position at Howard University, I have been greatly impressed by the significant contri- bution MWRMP has made by improving the accessibility and quality of care of the underserved areas and populations in the metropolitan region. "Certainly the activities with which I am most familiar are those at Howard and Freedmen's. However, I will cite several of the most noteworthy projects: “Howard's Cancer Radiotherapy project provides the seed funds that have assisted in developing one of th highest quality cancer treatment centers on the East Coast. "Preedmen's Stroke Praject has demonstrated that the mortality rate and the cost of quality care can be greatly reduced. "The Kidney Project (Howard, Ceorgetown, George Washington, D. C. General and Arlington) has demonstrated that the three medical schools can cooperate and further involve D. C. General and a suburban hospital in the hws-1 ~) 10 11 12 13 14 16 vi 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washineten. 0.C.20602 i} HOT implementation of a coordinated regionwide attack on kidney disease. This project is moving. Already one facility has indicated that they need no additional funds. It appears that all facilities now participating will be self-supporting by July 1, 1975, thereby per- mitting any new funds to be used for expansion or new locations. “Recently initiated activities include the EMS regionwide planning contract, a nurse midwifery project i the inner city, and expansion of hypertension control. | "Several other significant projects include: "Coronary care nursing training - Howard. "Cancer Registry - Department of Human Resources. "Inhalation Therapy - Washington Technical Insti- tute. "Pediatric Pulmonary ~ Georgetown and Children's Hospitals. "Second, I would like to comment on the current viability of the Program. The RAC is enthusiastic and active. Even with the on and off directions of the past 15 months the RAC and its Committees have been active in promoting the principles of RMP's. "In the past three years the RAC has developed into an "action" group. In the first few years of MWRMP the RAC reacted to proposals that were submitted. In n- iws-2 1 ~~] 10 11 12 13 14 16 17 18 | 19 20 21 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. 428 developing the last applications the RAC has appraised the needs and acted to allocate 'blocks' of funds to help meet these needs through requests for proposals and subsequent contracts. The current application has again been developed within this concept." From that, you can get a flavor of the view of the Chairman of the Advisory Committee. Just as one issue in the composition of the RAC, which is comprised of 73 members, 15 of these are minority members. They have a current professional staff of eight, and they want to incvease this. Now, I may have, myself, misinterpreted these white sheets. Apparently they propose to add nine, if that is correct. I thought this was an increase from eight to nine. MR. PETERSON: I am not sure. I would have to ask staff. In most instances I think the proposed was a new total, but in some instances -- well, I think this again is a total. They are simply propcsing to increase the staff from ten to 13. DR. HESS: Well, in terms of the accomplishments they have established several primary care clinics, and have been working on improving specialized services in the area of heart disease, coronary care, hypertension, patient education, 429 hws~3 1 and obstetrical care. 2 In the area of quality of care they have initiated gif projects on review, utilization review, a Regional Cancer 4 Registry, a Stroke Station, Cardiovascular follow up and a 5 bacteriological screening project at Georgetown. 6 Projects which they cite as increasing efficiency and utilization include their cancer, heart disease structure, ~) 8 high blood pressure, and kidney project. 9 They have a fairly good record of joint funding 10 and phasing into other funding. Ten of the 19 projects are jointly funding, and 11 12 seven have been phased out, seven of 19 phased out and con- 13 tinued under RMP funding. i4 In terms of their CHP relationships there was no 1b active B agency in Washington until recently. 6 Their coordination seems to be satisfactory with 7 the B agency in Maryland and Virginia. 18 There is some funding of B agency activities in 1 this proposal, and there is an agreement, a written agree- 20 ment in the application between Metropolitan Washington RMP 1 and the Washington B agency as to how they will work together. 99 It seems to be a fairly clear and well defined : document. 23 In terms of looking at the program priorities, I 24 ° think this is an indirect measure of where the influence, 25 HOOVER REPORTING CO., INC. 320 Massachusetts Avenue, NC. | Washington, D.C. 20002 PAA can ree it hws~4 3 ~ 10 11 12 13 19 20 21 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusettsfivenue, N.C. | Washington, D.C. 20002 [ 430 that is, much of the major influence in the Metro Washington RMP is at the moment. The number one priority is kidney activities. However, the amount of funding is not excessively large. It is about one-tenth of the total. They are proposing $100,000 for kidney activities out of the total program budget of $1.1 million. The second is nurse midwifery, $71,000. Next is primary care activities, $332,000. The next is health care for senior citizens, $150,000. Next, hypertension for $150,000. Next, emergency medical care for $100,000. Next, chronic constrictive pumonary diseases, $165,000. Assistance to CHP's is for $132,000. Now, the largest single proposal is the one relating to primary care of patients, $332,000. I thought it might be worthwhile just to discuss this proposal in a little detail so that you know what is involved in this rather major project. Their objective is to develop facilities at hospitals to provide more high quality primary care to non- urgent patients who appear at hospital emergency rooms. - The approach is to go to hospitals which have hws-5 ~ 10 11 12 13 i4 16 17 18 19 20 21 25 HOOVER REPORTING CO. INC. 320 Massach usetts Avenue, 4.0. “AA nAnnn 431 emergency departments and to work with these hospitals to determine the quality of urgent and non-urgent patients who appear there, and develop a body of information which will then allow these hospitals collectively to plan for better primary care services to help take the load off the hospital emergency rooms. There are also in this budget some funds for some facility reconstruction, as well as some equipment purchase, so that it is more than just planning, but also some reorgan~ jizational facilities, in order to be better prepared to take care of the patients who appear at the emergency rooms for primary care. SISTER JOSEPHINE: How many hospitals do they have? DR. HESS: Three to five. They want the best alternative system. MR. PETERSON: They are D. C. General, Freedmen's, maybe George Washington, Georgetown, and -- well, is that it? DR. HESS: The hospitals are not listed here. MR. PETERSON: They said three to five, so there may be a couple of others, too. DR. HESS: They don't list them in this synopsis of their plan. It was unclear, just to further comment on the project, it was unclear whether the primary care project will ~ 10 11 12 13 14 ib 17 18 19 20 21 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. |} 430 need funding after the first year, or whether it is something that could be accomplished. It looked as though it was a steady reorganization and some revision of facilities, but I am just assuming that although it is not stated, that the hospitals, or some of the sources will pick up the cost after this first year. Looking at the overall project, program proposals, the medical schools are still quite heavily involved. There is a project in here for something like $55,000 for health care for senior citizens, which indicates, in a short synopsis, no provision for continued support. It did appear to me like this was, to a large extent, direct services to senior citizens, showing an area of need, but not reflected in this description. What their thinking was, was about future funding beyond the funding of RMP. This particular one was sponsored by TV&A in Washington. Overall it seemed to me things were a little bit better than the last time I heard this program review, but still overall I could rate it no better than average program. The thing that I found that offered some hope was the fact that they are trying to address, and apparently have addressed in the past primary care in trying to expand these services to the underserved population of Washington, and I hws-7 ~) 10 i 12 13 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, f.0. | | Washineton. D.C. 20002 433 am sure they are considerable. I checked them. I might say there was a farily well developed and outlined review process, the Committee structure, and the staff structure, which appear to me to be satisfactory. MR. PETERSON: Well, thank you, Dr. Hess. Joe, do you want to give your report? MR. de la PUENTE: I found the program, in my opinion, and considering past experience, as better than average at this stage of the game. I mentioned its priorities, you know, not neces~ sarily one, two, three, four, five, and mentioned the reasons for these projects. Let me say that the projects are timely. They are addressed to not only the present but the future needs in an area where there is a great deal of need, in an area where if health insurance comes through we are going to have a lot of expenditures. In the particular areas that they happen to be attending to, ergo, the elderly, and ergo, the needy, I was impressed like you were in terms of the primary activity that because what they are going to do as far as the descrip- tion that I read is going to be an operational research and analysis in which they will consider all the present resources of personnel, equipment, floor space that is being utilized + hws-8 oo ~ 10 11 12 13 i4 16 17 18 19 20 21 24 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. Uanhinatan Al DANN? 43h right now to serve the groups that have to be served. Then they will follow this study in proceeding to alternative programs to these hospitals, and help serve these populations. I agree with you. I think it is a one-shot invest- ment, but it #8 going to be a worthwhile investment and a system in which you get these different hospitals, Georgetown, George Washington, D. C. General, et cetera to decide, you know, what type of priorities they can attend to, or what type of priorities they cannot attend to, and where the patients will go. In addition to that, they are going to be helping and providing monies for working with the planning agencies which relate to this particular project. The other project I was impressed with, and this is Priority Number 4, is the one for senior citizens, because at this point, since the senior citizens are poor, and they happen to have Medicare, they go to either the nursing homes if they are able, or to private facilities, or they are in and out, one admission after the next, and from what I read the visiting nurses would be providing care in the home, and also they will have preventive programs in areas where they are allowing the senior citizens in terms of making sure that emergency episodes do not occur, and if the emergency epi- sodes do occur, that somebody will take care of them. ~~] 10 11 12 13 14 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. ¢ Washineton. D.C. 20002 435 I think this program, in my opinion, will save an awful lot of money for the District of Columbia in the near future. DR. HESS: The thing I was looking for, and may be just an oversight on their part, but I hope they are thinking about it, is that they can demonstrate that for the population that they reduce the hospital costs, that what seems the logical outcome of that is to go to sources of payment and say, look, put some of your money in the home care, and not so much in the hospital. But that was not written in. MR. BARROWS: That is always under consideration, and I am not too optimistic about that. From what you fellows have said, and for what it is worth, it sounds to me as if these people are tackling some monumental, very real problems, and the amount of money they are talking about is relatively small for what they are trying to undertake. I think we ought to resolve any doubt in their favor. MR. PETERSON: How about some of the other reviewers here? DR. HEUSTIS: I have nothing to add. DR. THURMAN: Just two procedural inquiries. The $132,000 is for assisting CHP. Is that proper? MR. PETERSON: It is something which we in our hws~-10 HOOVER REPORTING COLIRC. || . 320 Massachusetts Avenue. NC. RA AAAS WP ke ~ 10 ll 12 13 18 19 20 21 _ instruction guidelines for applications, it was one of several areas that we were asking to assist with CHP planned develop- i { : ment. I cannot be sure from looking at the computer print out that that is what it is. We do have a case here, though. I was unaware, . Joe, and you corrected me properly, that there just has been an areawide B agency organized for the District. They have long been without one, and the one in Northern Virginia, they never could resolve the Virginia~District-Maryland problem. There is probably a lot of catching up to do in one sense, and I think it wouldn't be considered inappropriate’ in a policy sense. Whether the money could be effectively used is another question, which I cannot speak to. If anything, we sort of pushed them in that direc- tion, at least as far as Mr. Bell is goncerned. He is prob- ably looking over our shoulder. DR. THURMAN: I support the need. My question was purely policy, and the other is policy also. There are $80,000 here in kidney projects, all of which on July 1 are going to be funded from other sources. Other than that I support it. That is a policy question. fy b-11 1 np Ge on ~) 10 ll 12 13 14 16 17 18 19 20 nm bo 24 HOOVER REPORTING CO, IHC... 320 Massachusetts Avenue, NE. | 25 | | ‘I 437 MR. de la PUENTE: As far as the kidney project, if I could speak to that, as long as Georgetown is involved, and I feel confident that they are upgrading in the total eastern complex, they have tissue typing, and they have some transplanting, and they are operating in the eastern complex, which is from Atlanta to Boston, and which they interchange patients with the computer, and with tissue typing information on the computer, which in my opinion helps. DR. THURMAN: Don't misunderstand me. All four of those can be paid for as of July 1 out of other funds. I am not sure that it is proper, because mine is a procedure, and I am all for supporting them, but all four of the things that are listed can be supported from other funds as of July 1, this July 1. DR. TESCHAN: Which other funds? DR. THURMAN: Medicare and the Kidney Dialysis. MR. de la PUENTE: They might well go into that type of funding, but if we don't have this complex in which, for instance, they started deciding how mach do we charge for procurement for an organ, cadaver, how much is it going to cost to tissue type every patient on hemodialysis waiting for a transplant; start making all those cost values, and they won't have as good a chance of certifying those costs, and some of the people will have to pay for it. DR. THURMAN: I was asking a policy question. That hws-12 1 NO ~ 10 il 12 id 16 17 18 19 20 25 KOOVER REPORTING CO, INC. Q9T Maccarbicette Avenne NE | | | is all. MR. PETERSON: ‘That sort of thing you might want to note. MR. BARROWS: Might I ask a question? MR. PETERSON: Surely. MR. BARROWS: I know that Medicare and Medicaid will be paying for reimbursement for services delievered. Do they also have funds for development costs? DR. THURMAN: All of us are building in develop- ment costs. We are being reimbursed for Medicare for organ procurement, tissue typing and dialsysis right now, and we have the lousiest system in the country out there. I was under the impression that none of these types of programs were going to be funded, other than that by July 1. DR. TESCHAN: One of the projects is to reimburse the institution for the procurement of unused kidneys. You know, that is not, so far as I know, in the Medicare reimbursement. You get reimbursed for the ones you use and transplant. One of the projects talks about reimbursing for the cost of the harvest of the unused. DR. HEUSTIS: But isn't it built into the cost of the ones you used? hws-13 i ~~