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3 1-89
&

HEALTH RESOURCES ADMINISTRATION

PUBLIC HEALTH SERVICE

THIRTY-FIFTH MEETING OF THE
NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS
Conference Room G/H
Parklawn Building

Rockville, Maryland
CLOSED SESSION

Thursday,
June 12, 1975
The meeting of the Council was convened, pursuant
to adjournment of the Open Session, at 11:35 a.m, o'clock,
DR. HAROLD MARGULIES, DEPUTY ADMINISTRATOR, HRA, CHAIRMAN,
Presiding,
COUNCIL MEMBERS:
DR, HAROLD MARGULIES, CHAIRMAN
DR. COLIN RORRIE
| MR EUGENE--RUBEE-
MR. JERRY GARDELL
| MR. KEN BAUM, EXECUTIVE SECRETARY _
<——
MRS. EDITH M. KLEIN
DE, HOKE WAMMOCK
MRS, MARIA E. FLOOD |

MISS ESTHER M, MARTINEZ

 

 

Me

 

 

 
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COUNCIL MEMBERS (continued)

DR. JOHN GRAMLICH

“MRS. AUDREY M, MARS

DR. RICHARD JANEWAY

MRS. WYNONA R. GORDON
DR. ANTHONY L. KOMAROFF
DR. BENJAMIN W. WATKINS

DR. PAUL A. HABER

—_— ee se cee ee ee ems enemies tee

 

INDEX
STATE: DISCUSSION BEGAN:
Alabama 118)
Arizona 119
Arkansas 135
Bi-State 136
California 145
Central New York 147
Connecticut 147
Colorado-wyoming 151
Intermountain 154
Mountain States 158
(Arthritis) . 161

Florida 167

DISCUSSION ENDED:
118
134
136
143, 145
146
151
149
157
158
161
166

— *168

 
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INDE X (Continued)

STATE:

Georgia

Greater Delaware
Hawaii

Illinois

Indiana

Towa

Kansas

Lakes Area
Louisiana

Maine

Maryland
Metropolitan D.C.
Michigan
Mississippi
Nassau/Suffolk
Nebraska

New Jersey

New Mexico

North Carolina

Item:

 

CHP Review and Comment

Resolution adopted

DISCUSSION BEGAN:

169
169
171
172
175
176
178
179
180
_ 180
180
181
186
189
196
197
199
199

204

ENDED:
169
171
172
175
176
178
178
180
180
180
181
186
189
196
197
198
199
203

205

 

 
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.to discuss now before we decide how we want to go about it

 

 

PROCEEDINGS hs

|
CHAIRMAN MARGULIES: May we reconvene? We have some

broad choices on the method of review, which I think we need

and how much we need to get into the activities.

You have been asked, as you know, to look at the
applications and to look for problems. We, in turn, have
relatively little flexibility in what we do with the applica-
tions and how we fund them.

As you have already heard, and I assume have agreed,
we will review these applications on the basis of their con-
tent and quality. What we will have to do, as a Regional
Medical Program, planning activity, HEW function, is to pro-
vide funding to the RMPs on a basis consistent with transition
activities, which means essentially they will end up with
kind of a formula based on their previous level of funding.

The variance to that could be based on problems
which we find in the individual applications. To make it
extreme, if an application before you consists of nothing
but new projects and a discontinuation of everything old,
you would have to say, "This clearly does not become eligi-

ble for continuation".

And you would have to decide whether the core staff

should be continued.

MRS, GORDON: We seem, to have a difference of

j

 
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opinion as to what is a new activity, or at least in one of
my applications, They do not consider as a new activity one
that they have not done before,

To me that's a new activity. To them, if it has
been approved but not funded, then it is not a new activity.

CHAIRMAN MARGULIES: Approved but not funded is not
a new activity.

MRS. GORDEN: It's not?

MR. GARDELL: It is not,

CHAIRMAN MARGULIES: But it also gets you into the
question of how you want to express your judgment on the
suitability of that.

DR, JANEWAY: It has been my interpretation that a
new activity, related to transition, is, however, an allow-
able new activity; or is that not correct?

< CHAIRMAN MARGULIES: I think we would have to look
at the nature of it. It can certainly come into the discus-
sion. For example, if it is a method of producing a transition
which is clearly established, and which is going someplace
and which may involve something relatively small in nature,
fine,

But a number of things could be hidden under that,

and you would have to look at it and exercise some discretion

 

on.it. I think we are going to have to go at this by judgments

made as we go along, whether that would, in fact, be something

 
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we could fund.

We would have to look and see and get some good ex-

amples and go back to the continuing resolution language and

decide for ourselves what is best.

MR. BAUM: Most of the funding included for trans-
ition, Gary and I did a quick and dirty run through a print-
out one day, is predominantly in the core staff and core pro-

gram staff project type activities as opposed to being in

projects.
There were, I think, only three or four regions that

had any projects labeled “Assistance in Establishing HSA"

that were projects outside the core.

DR. JANEWAY: That's why it makes it extraordinarily
difficult to make that determination. I am not sure even

with the Form 15s -- you can't do it.

CHAIRMAN MARGULIES: I think if what you are talk-
ing about is a new project, then it would be clearly out of
line. If it is an activity which expands but moves in the
direction of transition, then you have something to talk
about. |

That doesn't make it automatically eligible, but --

MR, GARDELL: If it is not designated with a non
then it is clearly a project.

CHAIRMAN MARGULIES: What we can do, because we are

going to have to provide funding against a limited budget

 
tr

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and a large request, and because we are going to do it on
the basis of prior levels of funding, we can take a series

‘of| bloc actions, which could reduce the amount of time which
{

-we have to spend on this and some other kinds of issues.

For example, the question of arthritis activities
is one that we will have to look at and consider for bloc
action. ‘The question of the CHP comments, most of which came
in very late, but — all recall one of the requirements
under our legislation is that there be comments by CHP agen-
cies on the proposals.

Since this was done very late and very fast, it gave
the CHPs, which are also in the process of transition, rela-~
tively little opportunity to react. We may want to take bloc
action on that, which we will suggest to you after the lunch
period.

Then there are the issues which Ken Baum listed for
you, On the EMS,PSRO and on the kidney activities, where we
need to take into account the comments made by the agencies
in government which are concerned with those specific activi-
ties. .

These could also be done en bloc, depending on how
youfeel about it. What I would like to have the Council con-
sider is whether they see before them, among their applica-

tions, several where they feel there is little enough basis

for discussion so that they would be willing to identify those

ood

 
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to be taken en bloc action for approval, with the under-
standing that the funding would be a continuation on the
basis of funding that they are on at the present time.

The only way I can get an answer to that is to find
out from you whether you find in your applications several
where you think there is no special problem and no cause for
comment.

Before I ask you to react to that, I will allow time
between now and lunchtime for members of the staff who have
reviewed these, and who may have later information than you
have, to talk with you about any of the applications that they
have reviewed that you have. i

We will allow a little time between now and when you

want to break for lunch for an informal discussion to bring
in any issues raised by further review, further information,
CHP comment or whatever it might be.

And I will ask you after lunch how you want to act
on this particular basis. Are there other questions to be
raised at the present time?

DR. JANEWAY: Just to help formulate some thinking
processes, what is the total volume, dollar volume of the
requests in this cycle?

MR, BAUM: A hundred and four million.

CHAIRMAN MARGULIES: A hundred and four million is

the total volume requested. The amount available is $50

 
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million minus if we have the earmarks, one percent which is
standard for evaluation, about $3.5 million -- $4.5 million

for arthritis and half million for public accountability

- study.

So you end up with $44.5,

DR. GRAMLICH: Was the arthritis earmark existing
at the last ‘time anybody knew about the wording of the legis-
lation?

CHAIRMAN MARGULIES: Yes, I suspect it will remain.
But the question always is, what is the language that emer-
ges. Sometimes they will say $4.5 million shall be sent,
if practical it should, no more than _- you need to cover
the issue two ways after lunch. |

One is on the assumption that you have to spend °°:

that amount of money, and therefore bloc action. The other,

that it is not required of you, but then you decide how you

will do it anyway.

DR, KOMAROFF: Currently the regions are acting at
what dollar level?

MR. GARDELL: The dollar level total is somewhere
a little bit over $90 million. That is the annualized level.
They got almost $112 million in the June and August awards
last year.

CHAIRMAN MARGULIES: That's a little artificial.

DR. WAMMOCK: We hit that a little much on the head.

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“Administration asked for this total amount and Congress passed

 

 

ae

CHAIRMAN MARGULIES: Yes, there is a little late
release of impounded funds which inflated the balloon con-

siderably. At the same time, what we had in mind when the

it, they were thinking $12.5 million to carry them through
December 3lst,

That was clearly in everybody's mind and was the
purpose of the transition function. But you have already
discussed the difficulty faced in hitting that and you have
to consider some alternatives.

| DR. GRAMLICH: It was left flexible at the Council
meeting that if additional funds were available, projects
which deserved this would be stepped up and increased and we
would sort of cut down a little bit.

CHAIRMAN MARGULIES: I think you should also realize
when you get into review that the method of practice in the |
RMPs has been for the individual RMP to have a high level of”
freedom in reprogramming within the RMP, so that they can do
some things in accordance with the kinds of things we want to
work out.

I felt very strongly about what I said and what
Paul Ward was saying, concerning the huge advantages to be
gained in working openly and constantly with the RMPs to
carry out a transition.

It is their intent, and I think Paul Ward spoke

 
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1-98

accurately and for everyone, it is their intent to assist
with this transition process as much as possible. They are
an excellent group of people and represent a strong back-
“ground and a lot of experience and we plan to use them,

MR. GARDELL: One thing that should be remembered
is that when we went back to the days when we considered meri -
torious for increased funds, we talked in those days about the
discretionary funding, which we did.

And in those days we also had triennial experience.
We no longer have. We have been on a continuing extension
basis now for quite some time, and we are no longer talking
about that.

You also remember in those days anyone who had tri-.
ennial authority for a program also had authority for rebud-
geting to extend those on an annual basis.

Now everyone has the same authority for rebudgeting,
and I think this has to be taken into consideration as well.

CHAIRMAN MARGULIES: But they also need considerable
help from us in doing rebudgeting effectively, and getting

done what they need to get done. If it's all right with you,

‘I will ask that you remain available for members of the staff

who would like to talk with you before lunch, and then as long
as that takes for you te fall into consultation with one

another, fine.

We can reconvene, then, at 1:00 o'clock.

 
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- Sef

i;
(Whereupon, at 11:50 a.m., the meeting of the
Council was recessed,to reconvene at 1:00 p.m. o'clock this

same day, Thursday, June 12, 1975).

 
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1-100
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AFTERNOON SESSION

 

1:00 p.m.
CHAIRMAN MARGULIES: | I believe we can call the meet-
-ing to order again. I will be readily available during the

remainder of the period of review. When we adjourned at the

end of the public meeting, we raised some questions about the

review process, which included some opportunity for you to
meet with members of the staff to consider bloc actions, and
to take a look at some of the associated things, like CHP
reviews and comments.

In the interim, you had an opportunity to talk with
one another, and you may have some thoughts that you have de-
veloped during the lunch hour.

DR. KOMAROFF: One question that we raised amongst
ourselves is that apparently unexpended funds for this year
will be available to the region next year.

So if it looks like, on the basis of the progress
report, that there might be a lot of unexpended funds, that
is something to take into consideration in recommending an
additional fund level for this year.

CHAIRMAN MARGULIES: That's a difficult problem for
us this year. In the past, what we have done is make any
additional grant awards on the basis of unexpended funds, so
that we did not allow RMPs to accumulate large reserves, add

to those and end up disproportionately.

 

 
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_existence, and if we had pursued too vigorously the question

In earlier years that was not done, and it was a
mess. Now we are caught in a troubled situation, where the

RMPs are entering what appears to be the last months of their

of unexpended balances out there, those unexpended balances
would have disappeared very rapidly.

So we are not in much of a position to do anything
other than assume that they are not disproportfonately high.
I have talked with Mr. Gardell and other members of the staff
about this question.

I think it is true that some of them have funds
which are more than others. We need, if we can, to take
this into consideration when we make the actual gfant awards.

But under the conditions of the previous court re-
quirements of distribution of funds and grant awards that we
are now coming into, I suspect we would raise more shectres
than anything else, if we tried to do anything about it.

To be specific, the court determined that we would
make grant awards in accordance with our prior practices.
This covered some of the money which is now out there. It
would be very difficult to recall that, or, in effect, to
recall it by reducing the grant award against what has already
been put out.

And I think we might be inviting more trouble. As

a consequence on this issue, we really don't have any

 
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alternative. We will have to accept the fact that there are

funds out there.

MR, GARDELL: Particularly if we merely extend the

. existing budget period. That extends the period as far as

they are concerned. If we extend it to 12-31, with the ad-
vice that that is the way to go, then we will extend them
beyond that, until an agency is designated and funded.

Then, I think, as Dr. Margulies said, if we took it

back now we may be in trouble as far as the court is concern-

‘ed. They are running on an 18-month budget, now, and you

will just add six months more to it at the moment ,
DR, WAMMOCK: I think that has some leqitimacy to it

because you do have fallback on some projects which you have

- '
mes

not been able to carry forward.

MR. GARDELL: Also, we thought among ourselves, that
if we do extend beyond, and we don't have anymore money spe- -
cifically earmarked for RMP, and they have funds of their

own, with the authority to rebudget as they have, this might.

_be less of a drag than on some of the new funds which should

be used for 641, rather than the categorical grant,

| CHAIRMAN MARGULIES: On the bright side, there is
always the possibility that funds out there can be utilized
in accordance with our present legislation to support the

transition process for HSAs as well.

It is not totally bound into one particular pattern.

|

 
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-subject to Council approval without discussion on the partic-

_ it would be. It would be approval of what is requested, with

 

: L-LuSs

fr
You can always come back on that basis. Do you find, in

looking ever the applications at hand, that there are some
which you feel under the circumstances can be treated as

|
ular problems?

DR. JANEWAY: I would like to ask one question. Does|-
the Chair want to make a ruling or have some discussion from
the Council as to whether recommendation would be at the re-
quested level of maximum funding, and then the staff would
make the decision for allocation of funds based on the total

availability of dollars?

CHAIRMAN MARGULIES: Essentially, that is the way

the understanding that the amount obligated would be in ac-
cordance with the pro rated extension of the present level

of funding, based upon the funds available in this fiscal

year,

The concept of some bloc actions, then, is all right.
At least some of you have some applications you could treat

that way.

There is also the issue of the CHP review and comment.
Ken, would you like to comment for us on where that stands.

at the present time?

MR. BAUM: Where is the red book?

MR. GARDELL: Right here.

 
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MR. BAUM: The best way to start a discussion of
the CHP review and comments is to hold it up for all to see.
That is the book of CHP reviews and comments.

Most of these have come in since the staff review.
They were still coming in. As I said yesterday, I really
wasn't kidding. As soon as they cleared the "In" box out,
most --more of them came down the hall, mostly from Colin's
office, where they had been deposited.

We made up folders for those that came in up to
about a day and a half ago, when we just could not handle
the volume of material physically anymore.

The CHP review and comment is required by law. It
is only a review and comment procedure, and the requirement
is that the Regional Advisory Group, before acting ona partic
ular project or activity, has to solicit the comments of the
appropriate B agency serving the area.

And it has to take their comments officially into
account. Tf they go against the comments they are supposed
to have a reason therefor.

Some of the comments we got initially that were nega-
tive have since had letters back from the RMP saying, "You are
all wrong about this". And there have been one or two instan-
ces where this has gone back and forth several times.

Because the volume of the material here is so much,

and because we have no way of knowing the merits of some of

 
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1-105
the cases, it will be very difficult -- it would be impossi-
ble te try to go through the applications one by one and
through all of the comments.

Let me say, in general, the comments fall into
several classes. One, "We love you. We think everything
you are doing is fine and we endorse what you are doing."

This usually came from B agencies which are current-
ly receiving some funding from Regional Medical Programs,
not surprisingly.

There are others that say, quote, "Darn it, don't
you know you guys are supposed to drop dead, and us B agen-
ches are supposed to become the HSAs? So what are you doing
saying you are going to do anything about transition?".

There is another class that a to say, "You did
not give us enough time to comment, so we are not going to
comment, and we are mad at you."

Then, there are those that raised particular points,
either about the application in general, or more specifically
about particular proposed activities.

| I think what we are proposing to you today is that
we recognize what the situation is with these, and in some
cases there are comments that the staff has worked on, or
that raise real problems that have to be discussed and the
staff around the room can bring these into discussion at

I

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But by and large the correspondence is too volum-
inous to handle on an individual basis here, and it is really
for the individual regions to handle. So we are proposing
a resolution, which you will find in your folders that in
a nutshell says, "Where there have been comments received
by the Regional Medical Program, before you go and fund some-
thing at the local level, the RAG has to take these comments

‘e:
into consideration at an official meeting."

Secondly, that the comments and the RAG's actions
and reasons therefor have to be fully and completely record-
ed in the minutes of the RAG meeting.

Third, that the minutes of the RAG meeting that
relates to a particular set of comments or the portions
thereof that do have to be furnished to the commenting CHP
agency. .

And, finally, that those -- that all the RAG's
actions on all comments they receive from any CHP B agency
must be filed with the Director of the Bureau, here in Rock-
ville, so we have a record and can answer all the Congres-
sional mail.

It says it in a much more complicated fashion.

CHAIRMAN MARGULIES: The simplified version is the
resolution which you can read, and which is, in fact, avail-

able to you,

I think you ought to take a couple of minutes to

 
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what has been proposed, and when they have said, “Don't do

it", it has been because there was a duplication or something

 

 

read that. I would like to raise one other question before
you get to that, because I have to slip out.

The other action of a broad nature that we would
suggest that you ‘consider taking, because it will not really
add to the deliberative processes to go through it individ-
ually, would be to accept the recommendations on EMS, PSRO
and the kidney activities which have been made from the
associated agencies, |

As you know, in each instance there is an ongoing
activity, and this agency or another agency, which we had
asked to review and give us -- from which we wish to get
recommendations.

For the most part these have been in accord with

of that kind.

We are really not in a position to go back and see
whether what they say is duplicatory is, indeed, duplicatory,
It might be well for you to consider bloc acceptance of
those.

Before you get to it, you might want a few examples
of what we are talking to.

MRS, MARS: Would arthritis go into that bloc, too?

‘ CHAIRMAN MARGULIES: We have to have special action

on arthritis, because there it is a matter of deciding on

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aww

whether there will be the amount of money identified for
the arthritis action, and how it will be worked out.

We have a suggested action on that, as well. But
before I go away, I would rather wait for a moment to see
if there are any questions to be raised about this.

We are not trying to cut down access £0 these. If,
at any time, you feel that you would like to move into a
more detailed analysis, please do so.

The fact is that we can't do anything very deliber-
ate about the funding process, so that we don't have a lot
except on a very broad basis that will guide us into a differ
ent kind of action that we are going to take.

DR. GRAMLICH: Should we divert most of our atten-
tion to Plan 4 in the guidelines, which looks to cuontinua-
tion to June 30, 1976 and pay less attention to the other
three groupings on the assumption that if the program is
good the funding will be allocated administratively, depend-
ing on the monies available?

CHAIRMAN MARGULIES: I think it would be inappro-
priate for you to -- unless you wish to, for gone reason -~
to restrict the funding around an arbitrary date.

| | I think it should be on the assumptios that what is
being proposed can be carried out over the period of the next
fiscal year, with the understanding that we are going to
try very hard to bring about a transition by December 3lst,

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application may be approved only if recommended by the RMP's

 

 

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and, therefore} we will be guided in our own administration.

But by that.

DR. GRAMLICH: And that if the total approved by
the Council of all our RMPs dollarwise is greater than our
allocable funds, there will be a pro rated reduction across
the board?

CHAIRMAN MARGULIES: It will be pro rated, and it
will be on the basis of the previous funding of RMPs, unless
you make some specific designation to the contrary.

DR, KOMAROFF: What if total approved funds are

less than the available funds? Will that require an addi-

Fo t
.

tional Council meeting?

CHAIRMAN MARGULIES: In those circumstances we
would obligate lesser funds, and return the rest to the
Treasury. And you would get another bonus next year in your
taxes,

MR, GARDELL: In your document you have the proposed
resolution for comments on the CHP action. Would you like
me to read it for you? Let me read it into the record.
This is the proposed resolution concerning CHP comments on
RMP applications, June 12, 1975.

“Whereas, Public Law 91-515 provides that an RMP

Regional Advisory Group, and only ‘if opportunity has been

provided, prior to such recommendation, for consideration

 
 

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Medical Program for which the application is made will be

of the application by each public or nonprofit private agen-
ey or organization which has developed a comprehensive re-
gional, metropolitan area or other local area plan referred

to in Section 314(b) covering any area in which the Regional

located'.,

"And whereas, in accordance with the above require-
ment, it has been policy to solicit comments from, one,
areawide Comprehensive Health Planning Agencies receiving
federal assistance under Section 314(b) of the Public Health
Service Act, as amended, "b" agencies.

"Two, other organizations meeting the requirements
of Section 314(b) and designated as areawide Comprehensive
Health Planning Agencies by the appropriate state Comprehen-
sive Health Planning Agency, "a" agency, therefore:

"Be it resolved that: The National Advisory Council
on Regional Medical Programs recommends that each Regional Me
ical Program be advised of the following in writing:

"One, that, prior to funding of activities by the
RMP, the Regional Advisory Group is required to consider
formally, and act upon all comments and recommendations pro-
vided by the above CHP agencies with respect to the activi-
ties to be funded. |

“Two, that particular attention should be given to

comments which raise questions, suggest priorities or

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recommend specific revisions or disapproval.

"Three, that all action with respect to CHP com-
ments and the reasons therefor be fully and duly recorded
in the minutes of the RAG.

"Four, that the portions of the minutes dealing
with CHP comments be sent to each commenting agency with
respect to its own comments.

"“Pive, that all portions of the minutes dealing
with RAG action on CHP agency comments be furnished to the
Director, Bureau of Health Planning and Resources Develop-
ment."

I think you should know, and I think it has been
said, and it is alluded to in here that in some instances
some of these comments did not go to the Regional Medical

Program, but came in directly to us.

And, therefore, we have to make very sure that they
have an opportunity to see them and consider them before we
can, ourselves,make any decision.

Also, we have the Regional Directors’ comments in
some instances, or the Regional Health Administrators from
our' regional offices, and those we will consider, also.

Are there any suggestions or comments to this
resolution?

lures. FLOOD: I would move that the National Advisory

i

Council accept this resolution.

 
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DR. WAMMOCK: Seconded.

MR, GARDELL: It has been moved and seconded that

this resolution be adopted. All in favor? |
DR. GRAMLICH: May we have some discussion?

MR, GARDELL: Yes, sir.

DR. GRAMLICH: Under the "Be it resolved" section,
Number 1, isn't that now being done? ae

MR, GARDELL: It is, in some instances, and not in
others. But one of the things you have to remember is~
the amount of money we give for Regional Medical Programs
will be different from what they have budgeted.

So they will have another meeting of the RAG or
Executive Committee or whatever committee has the responsi-
bility for deciding on the budget in line with the amount

of money that is funded them.

They will meet again, and at that point in time

they will have to consider what comments have been made
from the B agencies.

DR. GRAMLICH: Under the same "Be it resolved":
paragraph, does this imply that the RAG must accept the
CHP?

MR. GARDELL: It does not have to, but it must.
justify why it didn't, if it doesn't. It is not required
to accept and live by then.

It is a comment and a suggestion from the B agency.

 
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But it is not directive in nature.

DR. GRAMLICH: The real need for this proposal is
for documentation then only?

MR. BAUM: The language in quotes in the first
"whereas" is a direct quotation from the RMP statute. Or-
dinarily these comments are made prior to the application
coming in here for approval.

Since the current round of applications was pre-
pared on less than one month's notice, it just was not possi-
ble to do that, and an emergency procedure was established.

And we told the B agencies that we would receive
their comments here by June 30th -- May 30th -- and they
could also simultaneously send copies of them to the RMP.

However, the RAG had already acted on the applica-
tion that was in here. We told them, in the instructions,
that the RMPs were to get B agency comments by any formal
or informal process that they could, prior to sending in the
applications.

And that the comments could be formalized in writing
later, which is largely what these letters are. This is
simply to make sure that this section of the Act is complied
with fully. |

And that any comments that may not have been made

because of the time, slippage are taken into account prior
| ‘
to funding.

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_tonight. That was the latest word.

gory, basically, the comments we are getting. We have a

 

 

tof a7 ht

DR, GRAMLICH: So it is an after-the-fact resolu-
tion.

MR, GARDELL: Moved and seconded. All in favor?

(Chorus of ayes) | |

MR, GARDELL: No?

(No response)

MR, GARDELL: Then it has been adopted. Thank you.
We have no suggested language for the consideration that
we must give to the comments regarding the programs furnished
to us on EMS, PSRO and kidney.

What we would like to hear from you is whether, if
you give us the authority to react properly to those commentg,
see that they are included in the conditions of the award,
where app.opriate, and we will do so.

I checked on PSRO at lunchtime, and we do not have
their comments as yet, but we are requesting them again.

MR, BAUM: They said we would be getting them by

DR, JANEWAY: Is it the Chair's intent to handle
these as a group or seriatim by category? .

MR, BAUM: It could be as a group.

MR, GARDELL: You mean these three?

DR. JANEWAY: Yes.

MR, GARDELL: Yes, they all fall in the same cate-

 
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few disapprovals which Ken commented to you this morning.
We will take that into consideration, and if appropriate,
we will not fund them, regardless of what might happen here.

DR. JANEWAY: That would be an appropriate part
of the discussion, however, for the record, prior to voting
upon the resolution? |

MR. GARDELL: Yes,

DR. RORRIE: Very definitely so. Would you be more
inclined to take them as a separate -- each individual --
talk about EMS, if there are any comments about EMS and then
move on that -- take a vote on that, and move to PSRO and
the kidney? a

DR. JANEWAY: I thought that might be easier to do,

+
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especially since we don't have the PSRO comments. You may
know what they are going to be, but we don't have them,

MR. GARDELL: In general, we do. And there are about

three different categories, but we don't know what falls into
what categories.
Then you want to proceed and consider them with
application, oe just separately -- I am not sure I understandy-
DR. JANEWAY: I am perfectly happy at having them --
taking them in the way you have them. But one bloc at a time,
even though they fall in the same category.
MR. BAUM: What you have in your folder is a complete

list. In the write-ups you have some comments as to which

|

 
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ones have some conditions on them,

MR, GARDELL: But you won't have them all,

MR. BAUM: Essentially, what we are asking for is
‘a motion to accept the recommendations of End Stage Renal
Disease Program, the Emergency Medical Program and the PSRO
program, subsequent to their review of these particular pro-

jects.

MR. GARDELL: Which is basically what we did last
year.

DR. KOMAROFF: To accept them as binding, or to
convey the message to the region for it to do what it will
i} with that message? |

MR. GARDELL: It is a combination, Tony. Some of them
have asked -- where they said "Make sure it is coordinated
with state Health Department", that, I think, is one of the
more frequent comments that we received on EMS.

MR. BAUM: But there are several disapprovals, and
jj we cannot fund those under the law.

DR. KOMAROFF: I see,

MR. BAUM: The EMS law specifically states that you
cannot use other funds to fund a complete EMS system, excent
those appropriated under that ACt. So we have to clear with
them, to make sure that it is taken care of,

/ You can fund partial systems, but not a complete

'

system, among other things. There are legal requirements in

 

 

 
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that case,

DR. KOMAROFF: If PSRO and kidney were to disapprove

an action, the Council could override that action, and move

MR. BAUM: Yes,

DR. KOMAROFF: Why not take that kind of judgment
in sequential fashion rather than en bloc?

MR. BAUM: I think it's better to take it up after
we go through the applications.

MR, GARDELL: It might be, to see how they come out.
Are there any that we should consider early in the game?
Is there anyone who is not staying through here, and should
be considered earlier than others?

Otherwise, we can just go through as they are listed,

What is your preference?

ek de

DR, WAMMOCK: Alphabetically. : wt

MR, GARDELL: Fine.

‘MISS MARTINEZ: Mr. Chairman, the only variance from ,
the schedule, it might be wise to consider Colorado-Wyoming |
together with Intermountain, because some members of the
Committee have reservations about cross-jurisdictional coop- |
eration.

MR. GARDELL: Does anyone have any objections to

that?

MRS. FLOOD: Intermountain states -~

 
bo

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DR. WAMMOCK: Those areas, I would think, could
go together. There was a lot of discussion last year about
that. |

MR, GARDELL: When we get to Colorado-Wycoming, why
don't we consider all three at that time? Then we could go
alphabetical at that time.

' The first one is Alabama.

MRS. GORDON: Do you want us to indicate if we
think one of these is similar to bloc approval?

MR. GARDELL: Yes, ma'am, that would be appropriate.

MRS. GORDON: I submit Alabama is suitable for bloc
approval. |

MR. GARDELL: Are you suggesting that the application
as submitted is acceptable, and you have no question about
the amount of money, and you are assuming we will make that
appropriate distribution of funds? |

MRS. GORDON: Yes.

DR, WAMMOCK: Why don't you state what it is?

MR, GARDELL: I don't think she needs to.

DR. WAMMOCK: Just state what the annualized level
is. |

MRS, GORDON: It's here, and I thought you want to
avoid all that, if possible. | |

MR. GARDELL: The one we are really using -- I will

send it around, if you like. The one we thought you, might

 
wy

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- and 25 cents.

best consider is an annualized figure, based on the awards
made, which we mentioned this morning, of the June and Aug-
ust awards for the 12-month period.

And it excludes arthritis, which was an earmark.
That's the annualized level, and if you like, we can pass
those around.

MRS. GORDON: Do you want to go through this?

DR. WAMMOCK: No, I just want to know the figure.

MRS. GORDON: They are requesting $1 million $535,864

DR. WAMMOCK: And the annualized was --

MRS. GORDON: Two million forty-five thousand. Some
of them are not being -- |

MR. GARDELL: We have that down for bloc. Albany.

DR. WATKINS: Albany, a bloc. Are you going to in-
Clude arthritis, $57,000?

MR. BAUM: Arthritis will be taken up separately.

DR, WATKINS: Then that can be bloc. |

MRS, FLOOD: Mr. Chairman, if I might express a con-
cern on Albany. There was an item that had a question raised
by staff review, regarding an HMO development ~-

DR. WATKINS: That's $15,000 and it’s cleared up.

MR, BAUM: It's my understanding that was deleted.

MR. GARDELI Arizona,

DR. GRAMLICH: If we keep going at the rate we are

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going now, we will be done in 15 minutes. That would never

do.

I have a couple of generic questions that relate

- to Arizona. I think it's a good program, and they are ob-

viously cooperative for CHP and they are thinking in terms
of transition,

One of the question relates about a nurse practition
er education program, for $101,552, which was approved but
unfunded. I believe, and I think this will come up again,

I believe you will find this in other programs, that this
is a new program.

It has been approved in the past, but not funded.
Therefore, they are requesting funds for it this time. As I
interpreted our earlier discussion this morning, that was
all right.

MR, GARDELL: That's correct.

DR. GRAMLICH: The second question I have, in addi-
tion to the core budget, there are other programs which
seem to be staff functions in Arizona, and I think we will
see this again, also.

Arizona has one called"Program Direction and Admin-
istrations! which is a transition budget item, They also
have one called "Other Professional and Technical Assistance"
which is designed to assist CHP and BHP in their transition,

.-

also staff functions.

 
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hemLétd

And these are added on to the core staff. I think
it's all right, because I think these are probably other
duties over and above what the staff has to do.

But I raised the question because it seems like
an effort to pick up a little more money for the same staff.
Are we in favor of that?

And is it includable in the transition process?

MR, GARDELL: And provided they will get enough
funds to be able to do it. The program staff, actually a
good part of the unexpended balances, if there will be any
out there, a be used more profitably, and probably I should
say more justifiably with program staff than it could for
new activities, and that is one of our areas of concern,

I think this is the area in which they can be more
helpful towards the formation of the new agencies than they .
could through projects, and that is where the thrust is.
| DR. GRAMLICH: The thrust is there, there is no
additional personnel requests.

DR. JANEWAY: It is my recollection that last year
we cut their request very severely twice with the proviso
that we would anticipate, if there were additional funds,
they would come back in for more money, based on their pro-
gress in the interim.

You remember that part of the leadership of the

RMP had been otherwise occupied in the District of Columbia

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“that they had $306,00 that was not spent or not obligated.

 

 

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for two years prior to that. |My memory may not serve me
correctly --

MR. GARDELL: It is serving you very well. Asa

. matter of fact, it is in the amount of $306,029, That was
an administrative error made by the grantee, as I recall it,
and not by the RMP,

But we did have an expenditure report in, and we
said that if we ever got any supplemental funds made availabla
to us, other than our annual funding, that we would consider
making it available to them at that time.

We have given them the opportunity to amend their
application -- where are we, Dick?

MR. RUSSELL: The one that Dr. Janeway refers to is
there was some question about the leadership of the RMP and
other organizational problems,

Those were resolved. However, the RMP did take a_
cut in recommended funds available. They turned the program
around. However, the funding issue is further complicated
by the fact --~ I will use hypothetical figures,

Let's assume that they were recommended for approval
of $1 million $300,000, The expenditure report, which we |

got in from the University of Arizona, the grantee, showed

tn fact, that money was obligated. The RMP had com-

!

mitted the $306,000 out this way, past the end of the budget

 
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* been spent, then they still had it.

was nothing we could do about it,

period.
However, the University of Arizona's policy would

not count that as an obligated amount. If the cash had not

The expenditure report which showed -- we went back
to the expenditure report, which showed they still had the
$306,000. So instead of giving them the $1 million $300,000
they got a million dollars.

This was clearly an error on the part of the grantee;
and at the time the error was discovered in the current ap-
propriation, not the one we are considering now, they were
informed that if we have the money we would recognize the
error, and would reinstate that money.

But we couldn't, because all the money was gone,
During the staff review this issue came up, and it was de-
cided, administratively, that it was alaead issue and there

It is very difficult to convince Arizona that some-
thing is a dead issue. So they came back again and we de-
cided to reopen the issue for Council consideration.

You dia not get this in your first packet of mater-
ial because we just got it ourselves, the day before yester-
day. Arizona is now asking that Council consider reinstating
$306,029, the deficit in their current budget period,

This is a separate request from the transitional

 
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application, which is for $1 million $356,000 plus dollars.

So I think these two issues should be handled as separate
actions.

DR. GRAMLICH: Bearing also in mind that if the
pattern continues in the Council session, we are going to
wind up with some$100-plus million dollars in approvals,
for which there will be $45 million or less available.

There will obviously be across-the-board cuts over
and above the figures we are talking about. Under those
circumstances, I think it appropriate to approve Arizona's
grant request at $1 million $300,000, $1 million $356,950.

‘MR. GARDELL: Ignoring the additional request on
the way.

DR, GRAMLICH: Unless the Council wishes to take
different action. This is a separate action relative to
this request only.

MR. GARDELL: As Dick said, we considered this a
dead issue, because it was an administrative error on the
part of the grantee. The fiscal year had gone, the funds
had been provided for, and we had no way to go back and
recover.

If we do it at this point in time it means that
much money will be taken away from the 52 remaining RMPs
in order to accommodate their administrative error.

If you want to be very cold and calculating about

 
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* an unexpended balance of $306,000, that is why we bought

“we are talking about?

- and whether you want to give it.

additional $300,000 increment, would we want to talk about

bw LED

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it, the grantee is the individual which ultimately submits
the report of expenditures in the application.

If they sent one in initially which said there was

it.

MR. RUSSELL: There may be a question of propriety
here, too, of taking money from the supplemental eppropria-
tion which as best I Zan tell is for transitional purposes,
and taking funds from there and reinstating --

MR, GARDELL: Funding a deficit,

MR. RUSSELL: Yes.

MRS, MARS: Did the grantee ever receive the $300,000.

MR, GARDELL: No, they did not. We reduced the
new cash by that amount.
* DR. KOMAROFF: Actually, Council has approved, in
a sense, that money in terms of its past actions. It is

really a staff decision whether you could find that money
Only if Council wanted to specifically prohibit that

it, as I understand it? You allocated less total new dollars
last year on the basis of this misunderstanding.
But it was not a Council-imposed restriction.

MR, GARDELL: No, it was not,

 
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rot 1-126

DR, KOMAROFF: Okay.

DR, GRAMLICH: I didn't hear any cries of anguish
from the Council about the new project.

MRS, FLOOD: I have to concur with Doctor's concern
about the new project for the nurse practitioner program.
Although approved and unfunded, staff review also comments
on the questionable practice of beginning this: massive pro-
ject that really demands continuation funding, with no real
documentation of what might be the maintenance source for
this nurse practitioner program.

Although Dr. Gramlich has recommended funding at
$1,356,957 I woulg prefer to take request Number 2, deleting
that fund, and bringing them to a level of $l, 039 -- some-
thing<-- $1, 038 something. |

MR. BAUM: We have a calculator, if you need it.

MRS. FLOOD: It's $1, 141, 390 minus $101,552, It .
is $1,441,390, minus $101,552. I am taking Item 2 level,
not putting the constraint of December 31st on them, but
deleting that item from Item 2 is my recommendation for Ari-
zona.

DR. KOMAROFF: Are you taking Level 2 rather than
Level 3 and then subtracting $201? |

MRS. FLOOD: Based on their current annualized
situation, plus some of the comments raised among other issues

for Arizona, I feel this should be sufficient funding for

 
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1-127

the transition.
It comes out to $1,039,848.

DR, GRAMLICH: I an not sure I understand your jus-

i
tification. Are you saying funds under request number guide-

line two, rather than Guideline 3? .

MR. GARDELL: You know what two is, don't you?

MRS, FLOOD: It is what they anticipate their costs
would be to terminate on December 3ist.
MRS. MARS: You are saying to spread it out through

the additional six months to June 30th next year?

MRS, FLOOD: That's right.
MRS. MARS: Taking that figure, but. spreading it
out.

MR, GARDELL: You are taking Number 3 and spreading

Number 2 funds over it?

MRS. FLOOD: That's correct, I feel the staff ex-
penditure for the development of the nurse practitioner pro-~
gram would also disappear, the staff effort and time, which
has raised their program activity funding and their adminis-—
trative staff, in the third column.

DR. GRAMLICH: If I object to that, it is simply
that by this action we are taking a specific program, which
was approved a year ago, which is a good program and has
been brought up this time for funding and saying, well, it

is not a good program, and that is not correct.

 
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: L-128

It is a good program, and it is one that is needed
and it is one that can be carried on. As a transition I

would hope it would be carried on by the HSA continuously

- because it is much-needed.

But by this action we are saying, "No, it is not
a good program", which is not true.

DR. KOMAROFF: Would the HSA be able to continue
support for that? I gather from what Mr. Ward said this
morning that is exactly the kind of thing the HSA would not
be able to continue support for.

Even if it is a fine program, the fear is you will
train a bunch of psople and the program will collapse out
from under them and you will have a bunch of disillusioned
trainees,

DR. GRAMLICH: Arizona has been very good in finding

continuation funding, with something like $2 and a half mil-

- lion dollars, over the last year.

DR. KOMAROFF: If you are confident it would be
continued by some source or another -- /
DR. GRAMLICH: I have no proof,

MR. GARDELL: Is there any indication of what the

source of support might be?

MR. RUSSELL: I do think we have to be cognizant
of the comments from the Arizona Department of Health Ser-

vice, the CHP A agency, as well as those from the CHP Council J

 
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Both of these agencies question the relationship
of the family nurse practitioner education program to the

emergency nurse practitioner program currently funded under

- Section 776, P.L. 93-154.

I don't know what that is, but obviously there is
another federal program which has some relation to this
type of activity.

This is sponsored by the College of Nursing of the
state university. This they will have to take into consider-
ation, should they choose to fund.

MRS, FLOOD: The only other consideration that I
might make, in that case, Dr. Gramlich, is your -- would be
a chastisement or inference that they were not a good pro-
gram, would be to delete the nurse practitioner funding of
$101,952 from Item 3. o
But in no way would I give an approval to go with

this nurse practitioner program at this time.

MRS. GORDON: They are not going to get this amount

_ OF money anyway.

MRS. FLOOD: But if you don't delete this project,
they have the prerogative of reapportioning funds to support
it. |

MRS. GORDON: That's true, but they would have to
cut out the ones already going to start the new ones, The

reason I bring that up, there is somewhat the same situation

 
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in Alabama.

They have five approved but unfunded projects that

- |
I, personally, would, hate to see started. However, they

\

‘are not going to get the money that they want to need to

do it.

DR, WAMMOCK: That's the reason I said you can't
ae

vote en bloc. |

- | a e
MRS, GORDON: They have a very low priority on
|

these items,

MR. GARDELL: You can vote en bloc if you are of
the feeling that there is nothing objectionable in the appli-
cation. fhen, certainly, they will have to establish their
priorities with their RAG after they get the amount of money
we can make available to them.

We can go out with a condition based open your
recommendation that such and such an activity not be funded,
regardless of how much money we give them.

I think that is the issue we are facing right now.

DR. WAMMOCK: That's one reason we need to take a
good look at the situation. |

MRS. GORDON: I felt somewhat secure in that they

were not going to fund these, because they have very low

priority.

DR, GRAMLICH: The process is such that when a

request for $1 million $300,000 is granted and only $600,000

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. Washington, the nurse practitioner program happens to be

\
is forthcoming, at the local level the RAG will have to re-
prioritize. If, in the RAG's opinion, in Arizona, which is

probably more rational than ours sitting around here in

Number 1, it will be funded.

But if it happens to be Number 20 out of 21 it won't]
be funded. We would probably be wiser to send the burden .
of responsibility back to the region which knows what it is
talking about in relation to this particular program, rather
than pick out this program and say, "No, it's no good",

DR, WAMMOCK: You want to send it back and let them
shake it out?

DR. GRAMLICH: Right, which is where it should be
shaken out,

MR. GARDELL: Right. I might be incorrect in this
feeling I have, but when; they get the amount of money we are
able to give them, I have a hunch that some of the new activi+.
ties, new but unfunded _- approved, but unfunded, they may
fall by the wayside in preference to funding continuation
activities, which are probably more difficult to turn off.

They will have to turn off a number of them anyway
when they get the amount of money.

MRS, FLOOD: In light of the CHP comments that would

require them to face the issue of an existing similar program ,

I would then relinquish --

 
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DR. cramuron They will have to make that decision
at their level, But the process is there, and the mechanics
are there for them to equitably do this.

DR. WAMMOCK: They have indicated what they would
‘like to do. ,

DR, GRAMLICH: Maximal.

DR. KOMAROFF: What is the dollar level we are rec-
ommending, “:hen?

i “MRS, FLOOD: One three five six nine five seven.

DR. KOMAROFF: Not minus the $101. Would you want
to convey the advice that they be careful about assuring con-
tinued funding? Just send that message?

* DR. GRAMLICH: Good,

MRS, GORDON: I think that would be appropriate for

nearly all of them,

 

 

MRS, MARS: Is there a motion on the floor?

 

| DR. GRAMLICH: I initially moved its acceptance for

bloc action.

é

MRS, MARS: Has it been seconded?

DR. KOMAROFF: Second.

MR, GARDELL:. This is $1 million --

DR. GRAMLICH: It is $1 million $356,957.

MR. GARDELL: May we also indicate that the Council
did consider the reimbursement of the administrative error

in the past, and elected to have the Arizona RMP utilize its

 

 

 
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. motion, it's all right. It might be cleaner to separate

funds to the best of its ability and we were not going to
provide additional funds for that purpose.

DR. GRAMLICH: If you prefer to make that all one

them, :
MR, GARDELL: If you wish, Handle it ‘separately
if you like. I just wanted to be sure you didn't forget it,
because we do need your guidance.

DR. GRAMLICH: I would make a clean motion,

MR. GARDELL: For the record, would you make a mo-
tion, please?

DR. GRAMLICH: I move we adopt the figure of $1 mil-/
lion $356,957 for appropriation to Arizona. |

MR, GARDELL: Is that motion seconded? “*

DR. KOMAROFF: Second. |

MR, GARDELL: Discussion?

DR. RORRIE: This is a bloc action,

MR. GARDELL: But you are coming up to the other
part, the $306,000.

DR. RORRIE: That's separated.

MR. GARDELL: All right.

DR. RORRIE: Why don't you make a motion on the
$300,000 part?

DR. GRAMLICH: Have we acted on the first one?

-MR,. GARDELL: It's going to go bloc action, Doctor,

|

 
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1-134

in
so we don't need to. What we need to do is face up to the

administrative error,
DR. GRAMLICH: To get the discussion going, I would
- Move that the $306,000 request from Arizona, supplemental
request or replacement request, be unfavorably considered
by the Council, for administrative reasons.
MRS. MARS: Second.
MR. GARDELL: All in favor?
(A chorus of ayes)
MR, GARDELL: No?
(No response)
MR. GARDELL: Very yood.
The next one, Arkansas.
DR. KOMAROFF: Arkansas, currently funded at $1.6

million, request for $900,000 to $2.7 at its highest level.

No new projects involved. I recommend approval, at a maximum

level of $1.3 million, which would allow for a major expansion
of the core staff -- it would allow for a moderate expansion
but not the major expansion requested in core staff for the
purpose of transitional activities,

I would like the staff to pursue the question of

ee

purchase of equipment with the neonatal care projects. It

 

seemed to me the purchase of equipment was mentioned in the

application, and if we are going to be consistent on that

policy, we should prohibit it.

 
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approved but unfunded.

ured they couldn't,

will have to do it, because when that policy went out, the

MR. GARDELL: Our concern on equipment was at the

time we were considering no new activities, and that included

The last discussion I had, and Colin can straighten

me out if I am incorrect in recalling it, was that equipment
\

would be an allowable item, provided it wasn't office-type equi

ment, but was necessary to the project and the conduct of the

project or activity.
DR. KOMAROFF: So, X-ray machines and whirlpool

baths and things could be purchased? .
MR, GARDELL: If they are going to fund the activity,
DR. KOMAROFF: That might be wise, in a given situa-

tion. What bothers me is that if the message went out to

all applicants that no equipment could be purchased,’*and we

now shift gears, it may be unfair to those people who would

have liked to have applied for equipment purchase, but fig-

MR, GARDELL: They can rebudget, and we can also

make it known to them that this is what they can do. We

situation was different from what it is today.
| DR. JANEWAY: | Tony, can you describe the spinal
cord injury project? |
DR. KOMAROFF: No. And since I couldn't, that is

why I recommended a very cut back level.

 
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that an honest RMP will be penalized at the expense of the
guy who pads his budget.

The fellow who pads his budget will proportionately
get as much as the honest fellow who will be cut proportion-
ately just as much as the budget requires,

MRS, MARS: I think staff is capable of realizing

oN

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that and analyzing that,

DR. HABER: I don't think the staff will cut twice.

If we cut it I don't think the staff will cut that one pro-
|
portionately, as much as it will cut another one.

DR. GRAMLICH: If we are leaving that decision to
staff, why are we here?

MR. GARDELL: By law.

MRS. FLOOD: I have to concur with Dr. Gramlich's
concern, And with all due respect to the remaining staff,
you are limited in staff. Your operations officer, your
project officer contact, your desk operations are limited.

The realization of what is occurring in an RMP to-
day are not as favored to staff here as they were. at one
time, and I have serious concerns about some of the areas.

I do, perhaps, more what Tony is doing, but you
may have to be faced with the dilemma of some sort of percent-
age statements based on last year's annualized, etcetera.

Dr. Gramlich is quite correct, If they have sub-

mitted something, and not taking into consideration unexpended

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. 1-139

cut in an RMP, it may happen that way. But if you don't
make too drastic a cut, I have a feeling that with the
distribution of the funds we have available, it probably
won't make that much difference.

The main difference we mentioned this morning is
identifying the significant areas. We have no objection
to your setting a ceiling of funding. |

We are probably not going to reach that, in any
event, in almost all instances. So asking for $106 million
and getting $44.5, that tells you something.

Even if they are under the annualized level, we
are not going to be meeting that annualized level, because
that's about $93 million, not $44.5. _ |

However, don't feel that it is an effort in futil-
ity, because it will be guidance to us.

DR. GRAMLICH: We ought to approve all of them at
the maximum rate. :

MR, GARDELL: Unless you have significant problems
that need to be discussed, I think that is shy we are con-
sidering the bloc action.

DR. GRAMLICH: I don't have a solution to it, I
just don't like it. | .

MRS. MARS: There is nothing we can do about it,
the money isn't there.

DR. GRAMLICH: The inequity that worries me is

 
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They are as conscientious as they can be in both

and they are intertwined, so we understand. That is not a
good answer, but that is what we are having to face,

DR, WAMMOCK: What did you set end budget at?

DR. KOMAROFF: At the total.

MRS, GORDON: Program staff, they are going from
full-time to half-time, but the salaries are increasing by
quite a bit. | | | |

DR, WAMMOCK: ‘Twice as much.

MRS. GORDON: For the same number of people, the
same full-time equivalents.

DR, KCMAROFF: It seams to me there is a funda-
mental issue we are talking about here. We know if we
approve en bloc $1.2 million they won't get it, they will
get some part of it.

The question is, what role does the Council wish
to play in setting those ceilings, and what role do we
want to leave to staff?

I will be aggressive and set ceilings on each of
my regions, and other people look like they say, * I will
approve the whole thing, and whatever part of it staff
delegates or allocates, so be it",

That may create an inequity in the way funds are
finally disseminated.

MR. GARDELL: Where you have made a very drastic

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DR. WAMMOCK: Yes.

DR. JANEWAY: They have a new coordinator. He
has more energy, to light all of the lights in this room.

MRS. FLOOD: Dr. Janeway, do you feel an increase
in funding at this point in time does not present any prob-
lems due to lack of leadership with the current program co-
ordinator and the deputy coordinator being only half-time
involved in the bi-state transitional year?

MR, GARDELL: That's a good point. We have talked
about it,and I think that one thing you have to consider
is this. As we head toward that coffin that everybody men-
tioned this morning, we will see more and more of this occur
ring.

We have long since thrown in the towel on requiring
coordinators to be one hundred percent of their time on our
projects or our programs, simply because they have an oppor-
tunity to do something else, get their feet in somewhere
else. | |

And if they can still provide direction with a
deputy and administrative officer, this we have gone along
with to the extent possible. | |

As you know -- you know what is happening to
Dr. Felix. He will be half-time on STs and they are in the
same building and they work together. Also, wé had no

alternative but to buy it.

 
he

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1-136

DR. WAMMOCK: I would like to ask a question on

head and neck college education program,

DR. KOMAROFF: I thought neither of those was des-

- cribed in sufficient detail to know what they were going to

do.

DR, WAMMOCK: I don't see any reason for it being

in there.
DR, KOMAROFF: I agree.

DR. WAMMOCK: You just can't pick out the left ear

and forget about the right ear.

DR. KOMAROFF: I move approval, at the level of

$1.3.
MRS. MARS: I second it.

MR, GARDELL: It has been moved and seconded, that

Arkansas be funded at $1.3. Do we have any discussion?

All in favor? |
(Chorus of ayes)
MR, GARDELL: Noes?
. (No response) .
MR, GARDELL: Bi-state.
DR. WATKINS: I move a bloc on bi-state. The HMO
mentioned is used for a study group, and there is no infringe

ment on HMO legislation. j

MRS, GORDON: They are requesting more money this
!
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dollars that they have, will staff address unexpended funds
available to them?

| MR. GARDELL: Let me tell you again what I alluded
to this morning, and I think [pr. Margulies did, too, in his
address.

We mentioned that our normal procedure is to go
out and get an estimated unexpended balance, and add that
to the new funds and distribute accordingly.

We felt this time that, first of all, if we ask
them for that because of the court order that is existing
and probably will extend into the additional extension period,
we might run into that two ways,

One, by violating the court order in the eyes of
the attorney, or, secondly, that they might rush to obligate
their funds and say they have no unexpended balances,

And, therefore, it will again be an effort in fu-
tility. We felt rather than do that it would be more relaxed
if we just gave them their proporticnate share of the funds
that will be available to us now.

And leave the unexpended balances that may be there
out there at this time. So, if come Decenber 3lst, the
appropriate agencies have not been designated and funded,
they may well have some funds available at that time to carry

themselves on, and not require new funds to keep going until

the agencies are designated and funded,

 
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~~ nae
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\ a
\ That's about the only way we can do it. It's an
awful way to run a railroad, which has been attached to our
bill in the past, but nevertheless I think it gives them
greater flexibility.

And if they can't face that flexibility, they can
always close their doors, and that's their option. In the
interim, we will be trying to find homes for the various
activities that are worthy of transition, as we say these
days.

DR. GRAMLICH: What we are suffering from is the
crisis orientation.

MR. GARDFLL: Yes, sir,

DR. WAMMOCK: We have a lot of other things that.
we are suffering from, .
| DR. GRAMLICH: But they are all crisis oriented,

MR. GARDELL: There was a period of time here when

it was pretty well known or discussed that in addition to

‘the supplemental, the continuing resolution of $75 million

might also be available, so that we would have about $175
million -- $125 million to distribute.

That could have had some effect on the applications
that have come in also.

MR, BAUM: We have had some information here about
the wording of the appropriation. It came from the budget

People. The question we asked, is arthritis earmarked? And

 
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hw kh tS

the answer came back, "Yes, at $4 and a half million",
The conference committee did not change this.
Public accountability reporting is in for $500,000. We

asked was there any specificity as to what the funds can be

spent for under Title 9?
\

\

And the answer is "No", But I am not sure that we
can rely on that,

MR. GARDELL: So we know as much as we knew before,

MR. BAUM: We know there is an arthritis earmark
now. |

MR. GARDELL: There is a motion on the floor for
bi-state, and that is for $1,223,134, “fs that seconded?

MRS, MARS: Yes,

MR, GARDELL: Havé “we finished with our discussion?

All in favor?
(Chorus of ayes)
MR, GARDELL: No?
(Chorus of no)
MR. GARDELL: We'll take a count. All in favor?
(A show of hands) |
MR, GARDELL: Five. Noes?
(A show of hands)
MR. GARDELL: Five,

DR. GRAMLICH: ‘The Chairman will have to break the

 
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MR. BAUM: Dr. Haber will be back tomorrow morning.

MR. GARDELL: Shall we wait for Dr. Haber to come
back rather than breaking the tie?

DR, KOMAROFF: What about the chance of a new mo-
tion at slightly less money that everyone might be happy
with? |

DR. JANEWAY: Go ahead.

DR, KOMAROFF: I move approval of $1 million, which
looks like it might not involve much expending --

DR. WATKINS: I will accept that.

DR. KOMAROFF: This effectively keeps them at the
level they are at this year,

DR. WAMMOCK: I second that motion,

MR, GARDELL: - It's moved and seconded.

MR. ROBBINS: May I introduce one thought? In
considering this particular RMP, there seems to be a feeling
of great confidence in the fact that the annualized figure
of $922,944 represents current annual funding, and it isn't
true,

It should be multiplied by a factor of about 1.2.
There is a mechanical calculation that was in error in my
judgment and I think that is agreed. This appears to be
pretty much what they are currently funded at,

MR. GARDELL: You're right. It's a little short of:

what the annualized level is,

 
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MRS, FLOOD: This gives them by million $112,289,

MR. GARDELL: Right. Again, you see this annual-
ized figure runs up to almost $112, and we have $44.5.

DR. KOMAROFF: Let me withdraw my last motion and
move approval at the current level, which I understand to
be $1 million $112, 289,

DR. WATKINS: Second.

MR. GARDELL: We have to rescind the previous mo-
tion which was moved and seconded.

DR. WAMMOCK: He withdrew his motion, he voluntarily
withdrew.

MR. GARDELL: This one is at $1, 112, 289 and that
was seconded, Discussion? All in favor?

(Chorus of ayes)

MR. GARDELL: No?

(No response)

  
 

California is/ the next,

  

DR. JANEWAY: California, which currently is funded
at the rate of $10.million $741,004 has an alternate Number
3 request of $7 million $523 --~ $523,407, and I recommend
funding at the level of $7 million $219,866.

My reason for that, and the deletion is, although
it cannot have any effect on the way they allocate the money
is the glowing report they give to their regional emergency

medical services program, which has a funding level currently

 
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of $303,571, andj it occurs to me that it is time the state

took it over.

MR. GARDELL: Is there any indication that the
state will, that you saw in the application?

DR. JANEWAY: In talking with staff, it is my under-~
standing that the state in all likelihood will take it over.
Is that right, Dick?

MR. RUSSELL: Yes, this is what they are pushing
for. A large part of this request, I think it is $123,000,
is with the State Health Department, and that will work on
state legislation to get it all in one big ball of wax.

The other, as I understand now, is to keep the
segments going until there is a state appropriation that

can handle this.

DR, JANEWAY: I rather think that a deletion of
that magnitude will not hurt the program, There is a well-
designed phase-out plan, and they have no intention of being
HSA.

I am at peace with that recommendation,

MR. GARDELL: Then the figure that you recomended
is $7 million $219,866?

DR. JANEWAY: Correct.

MR. GARDELL: Is that motion seconded?

DR. WAMMOCK: Seconded.

MR, GARDELL: Discussion? All in favor?

 
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(Chorus of ayes)

MR. GARDELL: No?

 

(No response) _

—_—_"

MR. GARDELL: Our next one is Central New York.

_ Our primary is on *he phone. Let's move to Connecticut.

DR, GRAMLICH: Connecticut is an interesting region
If grant allocations were made by the number of words in-
cluded in the descriptions, Connecticut would absorb the
$44 million $500,000.

It is a very difficult grant request to read, and I
apologize for net knowing much about it. But that has no
correlation with the amount of time I spent trying to know
something about it.

It was very difficult to read. The other thing
that characterizes Connecticut is that there is a constant
battle apparently with the CHP outfit. |

' The CHP comments mailed to us last week were, in
general, quite unfavorable. They even went so far as to
say that all you are doing by requesting this particular
project funding is trying to buy an HSA, which is stated
flat out in one of the CHP letters.

| How you assess something like that is a little
difficult, and I apologize for it. More specifically, be-
cause the program request for new funding under the title,

"Transition Activities and Program Development" was really
i

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-— mse

‘something that should be supported.

But in the amount of $252,440. But because it

7
was disapproved by the CHP, because it looked like a form

of, quote, "Supplemental funds", unquote, I think I would
recommend that that particular aspect of the program not
be funded.

There are parts of the Connecticut program that are
superb, and it should be maintained. But I would recommend
deletion, of the request for transition activities and pro-
gram development, in the amount of $252,440. |

And deletion of the health resource and development
service, because staff points out this should be picked
up by another federal agency. .

Leaving a total recommended of $747,390. I take
the time to bring this issue up because here I am saying
transition funds which really ought to be supported, Iam |
recommending denial for.

If Council feels strongly, I would be happy to
retract.
~~" MR, BAUM; How much are you deleting for the health
resource development service?

DR. GRAMLICH: One hundred thousand dollars, which
is the total amount requested.

MR. GARDELL: Jerry, do you have anything to add

to this? . ‘y

 
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virus disease, and fr must say ~- coordinated to the RMP, the

1-149

MR. STOLOV: The coordinator has addressed the con-
ments raised by the CHP, and I wonder if, rather than re-. |
spond to how he responded, if we can ask how these ba enter-
ed into -- and let pr. Gramlich see them,

I think he has attempted in as many words as he
Put in the application to address the concerns of the CHP,

And I would like you to have access. to this, prior to going

further,
It just came in,

MR. GARDELL: Why don't we hold up on this one until

are -- shall we Say they border on conflict of interest, and
I think it is Partly because they don't understand the law.

This is| the role, It has been coming out all morn-

 

Permitted by law.
I think we may need to pursue it a little further.
DR. WAMMOCK: fr want to sustain pr, Gramlich in
his remarks about this gant. It was rather voluminous, and
I got rather discouraged about it,

DR. GRAMLICH: Connecticut must have a peculiar

 
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CHP comments were twice as worthy as the RMP coordinators
were,

(Laughter)

MR, GARDELL: We can take Central New York now.

MISS MARTINEZ: I was a little bit concerned at a
number of projects, kidney, tissue typing, burn center,
model hypertension,

“ The funding they are asking is not too far above

that of last year's program. Only $10,000 as far as I can
tell are related to transition projects, which is another

concern.

I would move that Central New York be funded at

* $910,000.

MR, GARDELL: You see on the new list that we have
that their annualized level, which we are suggesting, is
$1 million $120,000. |

MISS MARTINEZ: Oh, I see. I'm sorry. Rather than
Alternative Number 4?

“MR, GARDELL: No, this is just their annualized
level. You do what you please with it. But r want to show
you that it is different from the one on this face sheet.

MISS MARTINEZ: I withdraw my original motion, then
And I move that they be funded at $1 million $120,000.

MR, GARDELL: So that's a bloc action. It's moved

that it be funded in a bloc action. Is it seconded?

 
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DR. GRAMLICH: Seconded,

MR, GARDELL: All in favor?

(Chorus of ayes)

MR. GARDELL: Noes?

(No response)

MR, GARDELL: Our next one is Colorado-tyoming.

MISS MARTINEZ: I had no particular concerns with
this, but I found the discussion®=- in the discussion that
a few of the other members did have some eoneerna, |

I would like to defer to Mrs. Flood first.

MRS, FLOOD: Regarding the Colcrado-Wycoming RMP, I
think it needs to be brought to Council's attenticn that
the application submitted for our consideration made no
mention of the planned leave from the program of the coor-
dinator.

Subsequent to receiving the application, staff be-
came aware that there might be this potential, and has
several times inquired and been given what appears to be
some relatively vague answers as to when Dr. Nicholas might
be leaving the Colorado-Wyoming program.

I am aware, and have documentation, that Dr. Nichola
has been appointed to the faculty of a medical school, part-
time appointment, beginning January lst.

A larger percentage of his time, effective April

lst, with a potential full-time appointment to take place on

 

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August list,

I feel strongly that this Council needs to instruct
staff and other divisions of staff as necessary to get the
documentation of the salary levels that have been provided

to the coodinator of this program since January 1, 1975,

I also expressed scme conern as to their reticence

\

—— e \
to inform the RMP of the planned change of leadership ef
|

,
{

this program --

MRS. GORDON: You say he will be leaving, or he has

MRS. FLOOD: He began ten percent of his time fac-
ulty appointment with pay on January Ist, '75, 50 percent
of his time effective April 1st, and it is anticipated at
this medical schcol that he will be available 100 percent
of his time beginning August lst.

The leadership, then, is left in doubt for the
funding levels that they have requested.

MR, GARDELL: Mary, can you add something to that?

MS, MURPHY: Nothing more than I talked to Mr ,Bran~
don. pr. Nicholas can seldom be reached. According to
Brandon he said that Dr. Morse would be Dr. Nicholas' choice
of successor.

MR. GARDELL: But he has not requested it.

MS, MURPHY: No. 7

MR, GARDELL: What is the pleasure of the Council?

 
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——_

MS, MURPHY: I might add that Dr. Morse is a Ph.D.

MRS, FLOOD: The other concern is, do we have infor-
mation as yet as to whether any programs, even though they
are continuing programs, have been reviewed and commented
on, and the transition projects reviewed and commented on.
by the Inter-regional Council? |

Of course, we will have to face this issue with
Intermountain and Mountain States.

MR, RUSSELL: We have built in, you will notice,
in the staff recommendations that any of these funds be
considered, when appropriate, by the Inter-Regional Council.
We feel very strongly about that.

To my knowledge very similar to the CHP review and
comment, there just was not time for the INter-Regional
Council to meet on these applications. Mary may have some

additional information.

MRS. MARS: May I say that they have continued
to have quarterly meetings, and consider these problems?
MRS. FLOOD: So they are still an active Inter-
Regional Council?
MRS. MARS: Yes, they are still active,
MR, RUSSELL: To my knowledge we have had no indi-
cations of any serious conflicts since quite some time ago.
MRS. MARS: I think they realize that it is more

important than ever to maintain a really close coordination

 
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with the other RMPs, because the HSAs are apparently going
to ignore state lines again. At least that is the present-
ation that they make.

MR. GARDELL: What type of guidance would you sug-
gest that we pursue with respect to this region?

MRS, FLOOD: I would like the Council to address
Colorado-Wyoming and request immediate clarification of the
Status of the coordinator, and the wians of their Regional
Advisory Group to replace the coordinator, with clarificatiol
of their budgeting for the percentage of time that the pre-
sent coordinator has actually been spending since January
lst.

MR. GARDELL: That we will do. And also his re-
Placement, what they Plan to do. Does that take care of
the guidance at the moment -- did you want to take up all
three at the same time?

I thought that is why we -- do you want to go, then
to Intermountain?

MRS. MARS: Well, we have a problem with the coor-
dinator there, inasmuch as Dr. Stewart has been on leave
for six months. He is in Ghana, and he was loaned to the
Kaiser Foundation to work on educational planning programs
there. |

He is supposed to return in July. However, Mr.

Collard, who has been his second in command, has been

 
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administering the program, and inasmuch as I made several

site visits to the Intermountain Program, I met Mr. Collard

and had a great deal of considerable amount of contact with

him.

In my estimation Mr. Collard is a more capable ad-

ministrator, actually, than Dr. Stewart, so I would have no

reservation on Mr. Collard's carrying on the program, in

the event Dr. Stewart did not return.

Also, they have an exceptional RAG chairman, and

as far as I can gather, he has continued +o remain active.

The chairman of RAG meets every two months with the IRMP

staff, which I think is exceptional. ;

And the Executive Council has remained active. It,

too, meets every two months, so there is certainly no prob-

lem with administration, despite the fact that Dr. Stewart

is not present.

They are presenting six new projects. Certainly

the projects will potentially affect the planning areas.

However, they are certainly not essential to transition.

However, they have also been thoroughly recommended by

the CHP agency, and reveiw.
MR. GARDELL: Let the record show that Dr. Gram-

lich and Mrs. Klein are absent from the room, because of

the regions we are discussing.

MRS. MARS: The RMP has participated in the area

 
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designation process in all of the States that it services.
And it has really Played a leading role in the statewide
health service area, in Utah, particularly.

There has been a question concerning an agency
set-up called The Health Systems Research Institute, which
was formerly known as the Health Development Services Cor~
poration.

This was partially financed by the, .RMP, but it is
now a free-standing, non-profit corporation, and it is staf-
fed by former IRMP staff,

The corporation has made a great deal of headway
in addressing the health problems of the area, They did
submit some projects, but these were withdrawn, I believe,

The other project that came under question was one
that the University of Nevada was involved in, which was
a rural nurse practitioner preject. ‘This was turned down,
was not approved.

Apart from that, they do not intend to try to be-
come a health service area or system,. They de have a good
arthritis activity, which does not really concern us, but
they have done a very good job on that,

So I would recommend On the whole that we honor

 

their Number 3, which is $1 million $301, 364. thie
is below their current funding, their annualized funding,

which is now $2 million $638,970,

 
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MRS. FLOOD: I second Mrs. Mars' motion,

MR. GARDELL: Did you have any recommendation on
the funding, Miss Martinez, or just as was requested?
|
MISS MARTINEZ: Yes. That would be one seven
three three two six -- three six five.
MR. GARDELL: Colorado-Wyoming is not a bloc a
MRS, FLOOD? That's their current, annualized

figure, the one seven three ‘three.

MR. GARDELL: Yes,

MRS, FLOOD: Miss Martinez is presenting that as
a motion. I would like to ask if she would consider their
Item 4 budget line request of $1 million $301,384, which
is below their actual annualized figure listed on the addi-
tional page we have received. .

MR. GARDELL: Do you want to withdraw your first
motion and move that the amount requested, Alternative Num-
ber 4?

MISS MARTINEZ: Yes,

DR, KOMAROFF: Second,

MR. BAUM: It is $1 million $301,384,
MISS MARTINEZ: That's right.

MR. GARDELL: All in favor?
(Chorus of ayes)
MR. GARDELL: No?

(No response)

 
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MR. GARDELL: Intermountain. Mrs. Mars, did we

move on that one?
MRS. MARS: |We did not move on it.

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MR, GARDELL: I'm sorry. It reminded me we had

not gotten --
MRS, MARS: One million $560,000, Number 3.
MR. BAUM: What's the figure on that again ?
MR, GARDELL: One million $560,805. |

The third one is Mountain States,

MRS. FLOOD: We have a motion for the $1 million
$560,805, but did we have a vote on it?

MR. GARDELL: Did we have one -- $1 million
$560,805, was. it seconded?

DR, KOMAROFF: Yes, sir,

MR. GARDELL: Discussion. All in favor?

(Chorus of ayes)

MR, GARDELL: Noes?

(No response)

MRS. FLOOD: If Dr. Gramlich thought Connecticut
was wordy, he should have faced Intermountain, The first
item of interest, Intermountain has received negative re-
views from the Comprehensive Health Planning -- I'm sorry,

I mean Mountain States.

I apologize, Mountain States has received some

negative statements from the CHP in the state of Montana.

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- gram staff activities.

ros
There has been response to that by the coordinator and the
negative statements were that they thought that the state
of Montana would adequately provide them with the transition
al support that they would need to develop their HSA,

And they would not require the Mountain States
RMP function; They requested a large amount of funding
for technical assistance and development of HSA services

to the states they serve,

There is also an area of concern in that the fund-
ing that they request for many of the projects that they
had delineated as continuing for the next coming year are
broken into two segments, between June lst and December 3lst

And a second segment from the first of the year
through June 29th of '76. Interestingly enough, the last
six months are usually at a higher level of funding than
the first six months. |

Therefore, it presents some difficult problems to
set an exact level of maximum for Mountain States. Their
current annualized level is at $2 million $348,425, as per

the new listing received today.

Their request is for $2 million $840,968. I would
like to recommend to the Council that they accept Alterna-
tive Number 2, which is in the amount of $2 million

$236,249 and which reduces approximately in half the pro-

 
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MRS. MARS: You mean to cut them off then --

MISS MARTINEZ: No, not with a cutoff date of De-
cember 3lst. It reduces them from their current annualized
approximately $112,000.

But leaves them sufficient funds to participate
in the transition activities that need addressing in this:
area, again urging that all overlapping activities be re-
viewed by Inter-Regional Council.

Number 2 is my recommendation to this Council.

DR. WAMMOCK: That cuts them off December, '75.

DR. JANEWAY: No, she is making Number 2-Number 3.

DR, WAMMOCK: Okay.

MR, BAUM: Was that a recommendation for a condi-
tion that all Inter-Regional things be reviewed, or just
advice?

MRS, FLOOD: No _-

MR. GARDELL: Do you want that to be in all three
letters of advice going out to these regions?

MRS. FLOOD: We have been assured that the Inter-
Regional Council is function and that there have been no
serious problems with overlapping the terrain. . Rather than
a condition it would be the continuing advice to reinforce
our previous action to this Council on this matter.

MR, BAUM: But that's to all three regions? p

MRS, FLOOD: All three regions, yes, sir.

 
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MR, GARDELL: That they be fully aware of all ac-
tions that might be duplicative in transitional activities.

MRS. MARS: Cooperation.

MR. GARDELL: That's probably better. Very good.
Is there a second to that motion?

DR. WAMMOCK: Second. |

MR, GARDELL: Discussion? All in favor?

(Chorus of ayes)

MR. GARDELL: Noes?

(No response)

MR. GARDELL: Let's take a coffee break,

(Whereupon, a short recess was taken).

MR. GARDELL: If we can resume. We are gcing to
handle arthritis in one package, Do you want to do it now
or do you want to wait until the end of the review of the
applications and then handle arthritis?

MRS, MARS: I don't think it will affect the
applications. Why don't we do it now?

MRS. FLOOD: May I clarify in my own mind Items
4 or three or whichever happens to be the one we finally
approved in each instance, includes the dollars for arthri-
tis programs within that RMP,

So we say we have approved them at such and such,

Will the Arthritis Division delete that, come down to a

level, etcetera?

 
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git as an Observer for this body at the original technical

uy

MR. GARDELL: These do not, as I undérstand; do
they? These applications do include the arthritis on all
of them?

MR. SPEAR: Yes.

MR. NASH: All except Albany. Albany came in too
late to be on the print-out.

MR. GARDELL: To the annualized level of distribu-
tion of funds that we will make, we will add to that their
share of the earmark for arthritis.

MRS, FLOOD: What I wanted you to tell me was delete
the arthritis dollar first, and annualize or appropriate or
share it and come back with a sharing of arthritis,

| MR. GARDELL: Yes, in other words, you are consider-
ing $44.5 million at the moment, with no arthritis in it,
and the arthritis will be an add-on, if you will.

MRS, FLOOD: All right.

MRS. MARS: Do you want a resolution on arthritis?

MR, GARDELL: He is going to make a very slight
presentation, and then we have a resolution,

DR. GRAMLICH: There are two brief historical points,
The reason I got involved in the arthritis, not because I

am an arthrologist. I am not at all. But I was asked to

review, which was held about a year ago.

}

At that time the technical review worked on the

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legislature, the National Institutes of Health, which will

 

1-163

principle that it was a one-year project. That there would
be no future funding, or there might be a separate bill
which, incidentally, legislation is in the House that will
ultimately take over all the arthritis.

Then, it is my mission to report to the Council
and serve as a bridge between the Technical Review Committee
on Arthritis and the Council. |

That was the basis on which we made the necessary
allocations last year. The second historical point is that
the Technical Review Committee set up some guidelines on
which they recommended approval of certain programs.

The major principle of the guidelines that they
established were it was to be essentially an Outreach
Program. In other words, getting the information and patient
care out of the institutions, rather than an In-reach, or
research program primarily. .

There would be a lot of decisions and backing and

filling between the American Rheumatism Association, the

ultimately take over responsibility for running the program.
But that is not our baby. The other things that
the Technical Review Committee recommended and our Council
adopted, a lot of money should not be spent for data collect+
ion and computerized registry and data banks,

But software purchases were all right. But hardware

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purchases, television, complexes and that sort of thing
were not to be encouraged,

That public education was important, as long as it
was not twisted into a fund-raising adventure for the Ameri-
can Rheumatism Association or Arthritis Foundation.

That large expenditures for equipment were not appro
priate, and that residencies and fellowships, in terms of
educational components, were not recommended, Essentially,
it was set up as an Outreach Program, it was funded at the
level of $4 and a half million.

And from what information I have been able to glean,
largely through the kind services of Matt Spear, it has been
a highly successful program, |

Everybody seems to be grateful that it has done what
it was supposed to do, _ Everyone has been serprised that
they were able to move as fast as they have and get accomp-
lished the things that they have.

That's the background, The foregound is that you
have in front of you a summary sheet, which is very lovely,
and it will make it very easy for us. .

In brief, very briefly, there is according to our
best information a $4 and a half million earmark, out of
which has to come one percent, or some small administrative

amount,

MR, BAUM: The one percent will come off the top.

 
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It won't bother the earmark. |

DR. GRAMLICH: I+t comes out something near it.

The nice thing about this happenstance is that the requests
for arthritis funding, with a couple of significant dele- |
tions, come out to be just about the amount allocable.

So it is a situation where staff, Council, PRMP
can say, "Sure, we can grant you what you asked for", so
there is not a lot of controversy involved. There are a
couple of deleticns,

And the most significant one, you will netice, is
under Tri-State, for -- the request $599,082 and the sug-
gested allocation was $145,260, the reason baing quite simple.
In the 1974 review cycle -~ the $453,000 which has been sug-
gested for disallcwable is on the following basis: |

In 1974 a very large program was requested by

‘Tri-State, and the review committee turned down as inapplic-

{
able the same program that they are now resubmitting word

 

 

for word for 1975.

| In other words, the amount of $453,822 was for
projects disallowed on technical grounds in 1974 and Tri-
State said, “Okay, we will just fire them through again",
i On that basis, and because of the fact that they
were disallowed and, therefore, are probably illegal, if we

were to allow them today they would be illegal, but on that

 

 

}
basis they are not recommended for funding again this year,

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In essence, what we are suggesting is that the
funding review ~- the funding recommended by staff be ap-
proved, I should add, also, that two of the existing -- of
the 1975 request, are for programs that were approved in
1974 but not funded.

‘Interestingly, Iowa, which was approved and funded
in 1974,>~has found continuation funding and is not request-
ing any additional funds. All this adds up to a figure of
$4 million $254,561, which is in the allocable funds limit.

And therefore I suggested approval as recommended.

DR. WAMMOCK: I second the motion.

MR, GARDELL: The recommendation is made and second-
ed that the funding recommendation of $4 millicn $254,561
be the amount for the arthritis applications. Is there
discussion with the Council?

Matt, would you like to add something to this?

MR, SPEAR: Nothing. |

MR. GARDELL: All in favor?

(Chorus of ayes)

MR. GARDELL: No?

(No response)

DR. JANEWAY : Could the record show that each of
us abstained on a vote relating to that person's own state?

MR, BAUM: It's not necessary on bloc actions.

DR. GRAMLICH: May I make a closing comment on the

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Subject? I think if Ken Baum would switch us into the ~
masstro singer -- the award woulda go to Matt Spear, He
has done a superb job of collating and getting accurate
data and putting all of this together in understandable and

usable form,

MR. GARDELL: His back is black and blue from our._|

having paddled it so often. Thank you, Doctor, |

    

& is Florida,

  

DR. KOMAROFF: ‘The region currently funded at $3.2
million requests anywhere from $385 up to a maximum of $2.6
million. It is a reasonably well-written application, with
more detail in their discreet activity summaries than I
have found in other applications,

I recommend approval at the level of $2.1 million,
which would allow for continuation of some operational
activities, and the kind of transitional Planning activities
that we support,

MRS, FLOOD: I second the motion,

DR. JANEWAY: That's actually $100,000 less than
they request under Alternative Number 3,

DR. KOMAROFF: Correct,

MR. GARDELL: The motion is for -- again, please?

DR. KOMAROFF: Two point one million,

MR. GARDELL: Discussion?

 

MRS. MARS: Why did you choose $2.1 against $2,202?
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DR. KOMAROFF: What I did with each of these is
try to estimate on the basis cf past accomplishments of
individual project activities, or the current filled posi-
tions on the core staff, what would seem to be a reasonable
expenditure in the next year.

I simply made arbitrary judgments to pare down
those projects that looked like they did not need a big
extra bolus of money or a proposed large expansion in the
core staff that didn't seem reasonable or practical this
last year of the program.

MR, GARDELL: Particularly there was not a large
movement in program staff for. transitional activities.

DR. KOMAROFF: Right.
DR. WAMMOCK: They have a continuing education pro-

gram which is very good, but only two areas participated,

and that is Jacksonville and Tampa. That is outside of |

Gainesville -- it does not include Gainesville, nor does it
include Miami.

DR. KOMAROFF: They are also doing some very good
things in screening. ,

DR. WAMMOCK: Yes.

MR. GARDELL: All in favor?

(Chorus of ayes)

MR. GARDELL: No?

MRS, KLEIN: No.

 
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MR, GARDELL: | One no.

DR. WATKINS: The great state of Georgia shows a
current level of $3 million $524,000. They are requesting
$3 million $500,000. They are involved in HSA applicants
and plan to help them after they have gotten started.

Georgia is a good region, as you know, and I am
asking that we have a bloc.

MR. GARDELL: The motion is to hold it for bloc
action. All right. Greater Delaware.

Jerry, I think on Connecticut we will hold until |
tomorrow, if you don't mind.

DR. WATKINS: Greater Delaware has a current fund-
ing of $2 million $702,512. I am recommending that it be
funded at the same rate, .

MR. GARDELL: At their annualized level?

DR. WATKINS: Right.

MR. GARDELL: It has been reccommended that Greater
Delaware be funded at $2 million $702,512. That is bloc
action? ~ |

DR. KOMAROFF: No.

DR. WATKINS: No, it's not bloc,

MR, GARDELL: That's right. They requested $3
million $399,000.

| DR. KOMAROFF: Seconded.

po

MR, GARDELL: Discussion? Frank?

 
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MR. NASH: I wonder if we could have something
in the motion here about earmarking the money for Theraplex,
the project in Delaware.

MR. BAUM: Do you want to talk to that, Frank?

MR. NASH: This is a project in Delaware being

funded for the last two years with the Greater Delaware

Manpower RMP. They do this as a convenience for us because

there is no RMP in Delaware.

So we assured GDV that the consideration of this
project would be separated from the rest of their applica-
tions, and the money would be earmarked for the activity.

MR, GARDELL: How much is that for, Frank?

MRS. FLOOD: Ninety-seven thousand three hundred
and seventy-five is what is listed.

MR, GARDELL: Does the level of $2 million seven,
Dr. Watkins, dces that take it into account?

DR. WATKINS: Yes.

MR. GARDELL: Of that $2 million $702,000 we would
say that $97,375 is for Theraplex; is that appropriate? |
DR. WATKINS: Yes. .

MR. ROBBINS: There are two projects proposed by
Greater Delaware Valley, which are approved but unfunded
projects, and therefore we moved for this -- that CHP agency
recommended that they not be funded. I

The total amount of money is only about $50,000.

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MR, GARDELL: Are you ready for the vote?
All in favor? |

(Chorus of \ayes)

MR, GARDELL: Noes?

(No response)

MR. GARDELL: Hawaii.

MRS, KLEIN: I had~some questions about the figures
on Hawaii, and apparently there are bone discrepancies on
the report. First of all, the current level is -- does not
include arthritis, which is about $200,000.

Since they made the original application they have
deleted these two programs, the note is made at the bottom
of the page, $114,000. So they request under Number 3, as
I understand it, is one -~ $200,000 be Low their existing
funding.

For that reason I think it should be subject to
bloc approval, at the figure they have requested, under
Number 3, |

MR, RUSSELL: I wonder if the Council would consid-
er as part of this recommendation earmarking for a specific |
program, as we have done in the past. |

MR. BAUM: Why don't you explain it a little further

MR, RUSSELL: In terms of the Hawaii Regional Medi-

cal Program it also encompasses the Trust Territories of the

Pacific Islands, American Samoa. For all practical purposes

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that is a separate program, and functions as a separate

program,
7 |
It is only ‘through this earmarking process are
we able to get the regional group in Hawaii to put some mon~

ey out there, and it has been very effective. They are

used to it, and we don't want them to change their ways
: |

at the last minute. |

MRS. KLEIN: Maybe I'd better change and make it a
motion to approve this at the following figures: The total
for Hawaii would be $1 million $190,159. Then for the basin
projects, the total weuld be $163,896.

I so move.

MR, GARDELL: Is that included in the $1 million
$190,000 or in addition to it?

MRS. KLEIN: It is in addition to.

DR. KOMAROFF: Second. |

MR, GARDELL: It has been moved and seconded.

DR. JANEWAY: That's a bloc?

MRS. KLEIN: No, this is a specific motion.

MR, GARDELL: Actually, it is a motion only that
you are earmarking the Pacific Basin; right?

MRS. KLEIN: Yes.

MR, GARDELL: Discussion? All in favor?

(Chorus of ayes)

MR. GARDELL: Noes? re

 
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1f3?. .

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= ST
fr . :
MR. GARDE! Illinois

DR. JANEWAY: Illinois is currently funded at

$3 million $500,000 or thereabouts. I am going to move

that it be funded at the level of Alternative 3, J2 mittion )

ee | i
$222,186, | pe _

I have some comments -- I will move and then -~-

 

 

MRS, FLOOD: I will second Dr. Janeway's motion.

MR, GARDELL: Discussion?

DR. JANEWAY: I think that certain of their pro-
jects are excessive in cost. Including the promulgation of
problem-oriented medical records and problem-oriented medi -
cal record and medical care evaluation, both of which take
Place at one hospital, very research-oriented.

A very good hospital. The CHP comments on the
Peoria Frozen Blood Program and on the dialysis consumer
workshops indicate that there is not a need for these speci-
fic activities, as requested in the RMP application.

MR. BAUM: Which two were those?

DR. JANEWAY : The Peoria Frozen Blood Program and
the Dialysis Consumer Workshops.

MR. GARDELL: You are going along with the proposal?

DR. JANEWAY: I am making comments to indicate why

 

I chose Alternate 3 rather than Alternate 4,

MR. GARDELL: Do you want us to specifically to

 
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that it is particularly transitional towards HSA.

exclude those?

DR, JANEWAY: No, sir. I think it could be from
the staff, if some consideration was given to it, but! be-
lieve that is their operational responsibility. I have a
little bit of difficulty, and I guess it is philosophical,
with modeling family practice outpatient care in Southern
Illinois, and in developing a discharge data system for r11i-
nois hospitals, which is a new project.

It seems to me a discharge data system is a Joint
Commission requirement, and I see no reason why RMP ought
to be funding that. Although they want to amalgamate all of
these into a state data system, which I think is an admir-
able thing. |

That is either a per diem administrative charge
or the hospital is involved and not a government responsibil-
ity which would reimburse for anyway, under Title 18 or Titlel
19 for those activities. | |

| Those are my reasons for choosing Alternate 3.

MR, GARDELL: What is the number of that project,
Doctor?

DR. JANEWAY: I don't remember.

MR, BAUM: I have the names --

DR, JANEWAY: Sixty-four. That is a new project,

and, although it does relate to a data system, I cannot see

 

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ae

\ wr. GARDELL: It is new, in the sense that it was
not funded before, but it was approved previously. On the
list they have no activities previously requested. I think
you said -- it has a C so it is program staff, |

MR.GARDELL: So the motion is for Alternative 3?
Are we ready for the vote? All in favor?

(Chorus of ayes)

_ MR, GARDELL: No?-

(No response)

MR, GARDELL: The next one is Indiana. Mrs. Klein?

MRS. KLEIN: I don't think there are any problems
in Indiana at all, and I would recommend it for bloc action
at Level 3.

MR, BAUM: Let me interject here, We got a phoned
recommendation for Indiana from the Chicago regional office
the other day that thought very highly of it.

MR. GARDELL: The motion has been made that the
Indiana level be $753,500; is that seconded?

DR. KOMAROFF: Second. -

DR. GRAMLICH: Why did they not request a level
Number 4? i

MR, BAUM: If they had no new activities, they

only had three.

MR, GARDELL: But it is a good question, because

there are some things that are changing in this.

 
a)

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DR. JANEWAY: That's why I assumed the $204,000
item was a new thing under Illinois, because it does not

show up until Column 4,

MRS, MARS: Some of them are requesting four and
still have no new activities listed.

MR, GARDELL: They might be under program Staff,
that is the only thing I can think of.

MRS. MARS: That's Number 3, too, For instance,

On my Oklahoma one,

MR. BAUM: Some might have put identical things on
both three and four. |

MR. GARDELL: In cther words, they were telling us
yes they would go -- Number 4 was Supposed to have some new
but some just didn't do it. Some gave us One column and we
had four to fill out so it went the other way, too.

All in favor? * |

(Chorus of ayes)

MR. GARDELL: Noes?

   

(No response)

“MR, GARDELL:

DR. WAMMOCK: We have two applications. One from

July lst to June 30, 1976. Then ~- that is dated May, '75, ane

the second is dated May 13, 1975, Their annualized support,

$1 million $057,877.

They are requesting Number 3 at $922,750, The only

 
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bone of contention here is the question of travel for

$85,950. Most of this money, this is about ten percent of

the budget. ,

Most of the funds here are for the establishment
of a health systems agency. Sixty-thousand dollars of this
travel is for a health systems agency, and $15,000 for
overall direction and coordination of the IRMP, ~~

Iowa had a good program last year and they are re-
questing Number 3, and they are going to phase out some
projects as they go along. I don't know about the $85,000

for travel.

I am sure they will have a one-state HSA system.

I am inclined to suggest that the $922,000, Number 3, stand

as is, instead of quibbling about the $85,000 for travel,

because they do have a good program going and they seem.to

| be well organized and coordinated.

MR. GARDELL: They were in and we had quite a dis-
cussion with them at one point. I feel like you, that they
will make good use of their funds. |

DR. WAMMOCK: I have every reason to believe they
will make good use of their funds, because they will have
a one-state system. They have it all laid out, and I think
they laid it out before January 4th.

MR. GARDELL: That figure might go down, too, when

they get the money they are going to get, or they may need

 
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more when they find out what we are giving them.

DR. WAMMOCK: ‘They are way under their annualized
funding, so I don't see any point in quibbling about it.
I so move that Number 3 be approved.

MR. GARDELL: That becomes a bloc.

DR. WAMMOCK: There is one item here that was not
clear in my mind. The Sioux Land Health Planning Council,
they raised some question about some of the funds in the
total budget were directed toward funding existing service
projects,

And they felt there was no justification for this.
But the central office replied to that, and indicated that
there were no -- these funds were not directed toward fund- |
ing existing service projects. |

So I think they got that clarified,

MR. GARDELL: Okay. Kansas.

Let's show, for the record, that urs, Gordon has
left the room. One thing I must tell you, before we go
any further. We did get a letter today, and it is important
The Greater Delaware Valley's budgets all ran through Decem-
ber, and Dr. Wolf said that was a typo.

| He meant to have them run through June 20th, 1976.
He said he was thinking of 12-31-75 when he put the '76 in
there, but the money is not to change. There was just a

typo, in case anyone thought they were requesting beyond

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that point,

Kansas, We can't take Kansas, that's Dr. Haber.
Lakes Area is the next one. |

DR. KOMAROFF: Lakes Area is up in Buffalo, It is
currently funded ata level of $1.5 million. They request
ranging from $440,000 up te $2.6 million. That $2.6 mil-
lion would approximately double the core staff in this last
year, and add six new projects. 7

The application is quite well written. B agency
involvement is good. The RMP is viable, and three of the
six new projects, which I believe are not c type projects,
are in fact planning activities that could be said to relate
to transitional needs.

I recommend a level of $1.6 million, which is slight
ly more than their current level, less than they optimally
request, which would allow for some expanded effort of this
good RMP to transition, |

MRS. MARS: You don't think you could stretch your
conscience and make it Number three one six seven two one oh?

DR, KOMAROFF: So stretched, $3 million $167,210.

MR. GARDELL: That becomes another bloc; doesn't it?

DR. KOMAROFF: Not quite. The highest level was
what the bloc was.

MRS, MARS: They do have an exceptionally fine co~

ordinator. He is really outstanding.

 
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MR, GARDELL: Is it seconded?

DR, WAMMOCK: Seconded.

MR, GARDELL: Discussion?! All in favor?

(Chorus of ayes)

MR. GARDELL: No?

(No response)

MR. GARDELL: Louisiana. Why don't we hold this
until tomorrow? |

DR. JANEWAY: All right.

|

MR. GARDELL: Maine. We have to pass that.
Maryland, !

DR. WAMMOCK: Maryland, level of funding is $664,323
There was a lot of discussion last year about Maryland, I
believe, at this Council. The project itself was not func-
tioning very well in short terms.

So we decided to give them a little injection of
a little money, a little infusion or perfusion, So the
present request is for $820,179. The program staff is one
half of these.

_ The continuing activities, there are no°new activi-
ties. There are no approved, unfunded activities. ‘I read
the staff review of this and there is one project here, a
kidney project, Number 47, it costs $43,449, |

Somebody might want to comment on that. The presen

application provides for eight continuation projects, severa

he

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' past year, perhaps we ought to continue to give them support

|
of which will be of interest to emerging HSAs including pro-
jects devoted to rural, primary care and ambulatory care
in medically underserved areas of Baltimore. I think that

inasmuch as they showed improvement in their program the

and encourage them at the level which they have requested,
which is Number 3, unless somebody wishes to challenge me
on that.

MR. GARDELL: This is a bloc action, in other words}

DR. WAMMOCK: Yes.

VOICE: That's over the previous Council level.

MR, GARDELL: But it is less than their annualized-;
no, it's not... It's over their annualized level.

DR, WAMMOCK: A hundred and sixty-five. But last
year they had a very good program, and it appears that they
have -- they are able to be up and walk around a little bit,

4
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like a newborn calf.

MR, GARDELL: It has been recommended that Number
3, $820,179 be approved for the Maryland application,

MRS. MRS: Second, |

MR. GARDELL: Discussion? All in favor?

(Chorus of ayes)

MR. GARDELL: Noes?

(No response)

MR, GARDELL:\ Metro D.C. 8. Klein?

we

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| MRS. KLEIN: There are some problems presented in

connection with this application, Maybe we should have some
staff explanation of them. One of their projects was to
hire three people apparently two for transitional purposes

to assign to the HSA.

‘They have also applied for some section which I am
not familiar to place all planning activities in the D.C.
government instead of HSA, and there is a question as to
whether a staff of three people --

DR. GRAMLICH: Mr. Chairman, what are we talking
about? |

" MR, GARDELL: Metro D.C. br. Haber is not here--

DR, GRAMLICH: Thank you.
MR, GARDELL: I'm sorry. - Were you all reading the
wrong one? |

DR. JANEWAY: That's the first time Memphis ever
wanted to put anything in D.C. |

MRS. KLEIN: There is a question as to whether this
is proper to use $40,000 of funding to hire three people
and have a non-private corporation administer the program.

Personally, I would like to have some staff comment
on that. There are some other problems in here, too.

MR. STOLOV: There were two questions, One relates
to the new law, which may or may not, we are still unable

to tell, what has been decided in terms of how the District

 
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. oe
and Montgomery County and Prince George's county, this
area of metropolitan Washington, is going to be a health
service area.
If it was decided that a certain section of the
law called 1536, this means that the District of Columbia

can be unto itself, similar to other states, an entire plan-

ning area.

If they decide to go that route, then the metro
Washington's RMP putting aside Title 9 funds for $40,000

for personnel appeared questionable.

We felt that our Act is Title 15 of the new law,

and we were concerned about putting Title 9 monies into

Title 15, as pues? as the District of Columbia's Medical

Society is the grantee for the metropolitan Washington
RMP.

And the-law calls for a non-profit-making estab-
lishment to be the HSA or the city government. If it was
the city government, under 1536 this would cause problems.

MR, BAUM: Let me see if I can clarify that. Under
Section 1536, which was put into the law by Senator Pell :
largely for the benefit of Rhode Island, this is a position
that says, "States which meet certain qualifications do
not have to have a non-profit HSA and would not be divided

into health service areas",

Planning would take place for the state, and the

 
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state government would perform both the state agency
function and the HSA government.

In short, the government becomes the HSA for the
state, and the District has applied under that option, along
with Rhode Island and several other states, Has it been
settled whether that would be approved or not?

So there is at least a strong possibility that
the government of the District of Columbia will, under this
provision, also function as the HSA, and you will, therefore
have planning on a governmental basis, as opposed to through
private groups.

The question is, if this is going to be a govern-
ment function , probably if it is not going to be a govern-
ment function is it proper for the RMP in essence to hire
a shadow staff for an HSA which may be a governmental unit
or in some other agency?

MR, STOLOV: The reason we put it in is to feed
back advice to the RMP that when they do rebudget their
money, to be cognizant of this section of the law, and the
possibility of using RMP monies for a new title.

So we did have to pull this out of the application
as a highlight. It is only a more factual statement. I
don't think we meant to delete the $40,000 as much as to
call it to their attention.

MR, GARDELL: By the time we write the letter we

 
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write the letter we may have better guidance for them.

MRS. KLEIN: Mr. Chairman, what would be our op-
tions? If the staff feels that the $40,000 is justified |
one way or the other, would we wish to authorize it and then .

give them advice as to what, legally, they should do to make

that function legal?

MR, GARDELL: Yes, I think we have to go out with
advice to them at the time. If they can't fund it, they |
will have the opportunity to rebudget, But even at that
they will get less, probably, than they have budgeted for
anyway.

But they will be guided accordingly.

MRS. KLEIN: There was some question, too, about
EMS projects, which I would like some clarification on.
This is educational for me.

MR. STOLOV: On the last sheet of the staff panel
review summary, we received comments about the EMS, the
federal EMS program, It is on the last page, and it amounts
to similar recommendations.

They wanted RMP activities to be coordinated with
the local government. The last one, Number B., I would
ask Mr. Baum to clarify. Most people think that they would

like to use our funds first,

i : .
But they are saying, /"Use our funds first, and any

left-over RMP funds should go back to the RAG to be used"

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at the bottom or the top. No new activities are requested,

and I think that's pretty generous of them.

MR. GARDELL: What is the advice, Gerry, that you
are suggesting on EMS?

MR. STOLOV: To follow bloc action and observe the
comments from the EMS.

MR. GARDELL: All right.

MRS, KLEIN: I think, then, that it is proper to
move that Item No. 3 be approved. That would be $1 million
$101,389, with the instructions as to these conditions, with
reference to these two matters.

MR. GARDELL: All right, is there a second to that
motion?

DR. WAMMOCK: Second .

MR, GARDELL: Discussion? All in favor?

(Chorus of ayes)

MR. GARDELL: No?

va

 

(No response) _

MR, GARDELL: Michigan is our next one. Dr. Wammock
DR. WAMMOCK: The level of funding is $2 million
$938,534, They are requesting funds for $4 million $079,194,
There is a lengthy discussion here about the overall program
report.

I don't know what end to start out, whether to start

They have established a statewide hypertension task force

 
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introduction of a state hypertension plan,

Statewide Health Manpower Council ~~ consortium
arrangement at the regional level for implementation and
continuation, Establishment of a state-wide kidney task
force. |

Transitional changes, activities being directed.
best at the part of the program -- staff activity includes
continuation relative to planning function, sutcessor agen-
cles which I assume are HSA, and so on, |

Then there are several items over activities requir-
ing special attention. EMS planning, coordination, $134,000,
24 areawide emergency drug analysis program. I don't see ,
what that has to contribute, |

Education, detection and prevention Cz. bone disease
in patients with chronic renal failure. Implementation of
Michigan Plan for Kidney Disease, $56,000. Renal disease,
radio and television spot announcements, I think that could
go out.

Patient self-instruction on dialisis and transplant-
ation. Central repository, histocompatibility service, It
takes a pre-sensitized transplant recipients and poligeriatric
arthritis program, $398,000.

Evaluation of poligeriatric arthritis program,
$49,000 and that gets it up to almost half a million dollars.

Pharmacy peer review of drug abuse review of $50,000, Then

|

 
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the Michigan RMP has requested $150,000 as far as the pro-
gram staff component for transition activities. This in-
cludes $100,000 for non-specified contract, for funds to
provide direct lassistance grant for the organization of
health system agencies and constitutional groups as the
needs emerge or are approved by the Michigan RMP Regional
Advisory Board.
| The point I am raising here, their level of annwel-

ized funding is $298,000. They have requested $4 million
and I think this ought tobe cut almost in half.

MR, GARDELL: Are you suggesting the annualized
level of $2.9? That's the one we gave you this afternoon.

DR. WAMMOCK: I would be inclined to leave them
where they are. There are some things in here -- renal
disease, radio and television spot announcements. I would
like to talk about education of children, but I will not do
that now, or anybody else.

MR. BAUM: We got a comment from the regional office
that they felt it was rather heavily weighted on education,
continuing education type activities, They felt it was |

heavily weighted in one particular area, and I think it was

that.

DR. WAMMOCK: Anyway, I would go with $2.9.

MR. GARDELL: You are not recommending any projects
be deleted?

 
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DR. WAMMOCK: I think they will have to find what
programs they want to delete themselves. The projects
are too numerous for anyone to say that you should delete
this.

The Drug Abuse review, I don't know what that --

MR. GARDELL: Some have been referred to other pro-
grams, too, obviously.

DR. WAMMOCK: Yes, the Arthritis Program -- 140,
549, poligeriatric arthritis program is covered in the other
section. So I would so move. |

MRS. MARS: Second,

MR, GARDELL: Discussion? All in favor?

(Chorus of ayes) |

MR. GARDELL: Noes? |

(No response) —

MR, canortie( tsstesteps.
MRS, FLOOD: Mississippi is currently funded at an

annualized level of $4 million $180,184, I must begin my
presentation with a harsh criticism, even at this late stage
of the game, of the Regional Medical Programs of this country

that this particular region fails to have any minorities on

the staff,

I am aware that the staff of DRMP has repeatedly

brought to the attention of the leadership of this particular

RMP that in this geographic area of the country there is
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no longer any reason for this to persist,
But nevertheless it does persist. In project
staff, out of 144 there are nine minority people working.

But in the core staff there Still remains to be any minor-

ities involved.
| There is a large request for equipment in this
application, and although that Subject has come up for dis-
cussion during the Council Session today, there is a mention
by staff that the program will make the change on the equip-

ment request,

Deleting the equipment request in an unauthorized

Or non-approved $58,000 for arthritis, I wish to also delete
,

approximately $40,000 of what is termed to be HSA planning,
but which has come under. criticism by the Regional Office
of HEW,

And perhaps this falls into the same category as
Connecticut, where criticism is launched at federal funding
to strengthen capability to become the HSA for the area,
when there are other agencies without this funding to support
them,

I would recommend that the Council approve Missis-
sippi at the level of $3 million $626, 686. This is still
a strong budget, and does allow them to continue their pro-
gram staff activities and their continuation funding, with

only deletions of the amounts listed for equipment and

 
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arthritis.

And the $40,000 that was to be spent directly to
support Mississippi RMP's efforts to become the HSA.
MR. GARDELL: Is that motion seconded? .
DR. WAMMOCK: I will second that motion,
MR. GARDELL: Discussion? I think I remember some-
thing about the minority situation.
| MRS. FLOOD: It is shining in its absence.
MR. GARDELL: I remember some reason why, I just
want to see if Joe can back - up,
MR, JEWEL: I can't. - a
MR. GARDELL: I think I spoke to Dr. Lampton about
it once, and it seems to me they were having problems get-
ting people to get on the staff,
MRS. FLOOD: It could be that the grantee presents
some problems, but I don't believe it's any longer excusable.
MR. GARDELL: It certainly can be raised again.
MRS, FLOOD: They are also planning to increase the
staff, so this might be an appropriate time,
MR. GARDELL: Wasn't there something with respect
to the HSA?
‘MR. JEWEL: I just had a nasty letter on that, and
I think the ruling was that this was actually outlined in one

of the transitional type activities.

They are not going to use the monies themselves,

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They are just contractors. Are you talking about the $40,009

to develop an HSA?

MR, GARDELL: Yes. |

As I recall, and it is very vague, it was assumed
that they would use that money to become the HSA, and I
think they countered by saying no, this is to assist in the
development of an HSA, they are not going_to be one.

That is what I was trying to hear come out. Am I

f
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close, Joe? '
MR. JEWEL: You are close. They are tottering on
who is to become the HSA, I don't know. |

MR. GARDELL: I was of the opinion they weren't.

MR, JEWEL: It is not in the application that they
are or are not. |

MRS. FLOOD: That's correct. The application does
not make that clear. Regional office comment was very
strong. Although the CHP A agency was favorable in its
review and made no explicit mention of the HSA development
component, if there is concern I will give them back the
$40,000. . 4 :

MR, GARDELL: Do you want these specifically
deleted, or just cutting back? |

MRS, FLOOD: I just want to be sure that the
maximum level listed is approved by this Council, reflects

these reductions at a level of $3.million $626,686.

 
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MR. GARDELL: And you want us to mention specific-
ally that the equipment, the HSA and the arthritis are not
part of that figure; is that what you are saying to us?

MRS. FLOOD: I will not explicitly mention the HSA;
how's that?

MR. GARDELL: The only reason I raise it is be-
cause as we said before it has not been settled yet, be-
cause it will have to go back to the RAG, and they will have
to battle it out.

MRS. FLOOD: My only concern would be, you mention-
ed earlier in today's deliberations, that that might be a
direct conflict with the intent of the legislation for us
to make these statements.

MR. GARDELL: There are those who are saying we
are in direct conflict, which we may not be. That's the
point I was trying to say. I am not surg people understand

li

the legislation, and the use of our money to try to help
develop some of these agencies, :
There may be some misunderstanding, and I am sure
it is partly competition. .
DR. RORRIE: I think it is fair to say that any
developmental work that goes on in terms of leadership to
develop an HSA in the state of Mississippi will come from

the RMP,

The A agency in Mississippi is a big disaster,

 
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There are two B agencies, federally funded. There are a
number of other B agencies not federally funded and the
financial support is coming from the RMP,

They have been basically the real initiator of
Planning activities in that state for a number of years. |

DR. WAMMOCK: There is something to be said for
them. They have a strong medical program going on. The
generator there is Jim Hardy ~» Jim is a little bee who
buzzes around all the time.

But he is an excellent teacher, and does a tremen-
dous amount of work. It has made quite a contribution to
the educational level of that state, and also the delivery
of health care, to use that terminology, from the distance
where I see it.

DR. JANEWAY: Does anybody know the population of
Mississippi? .

DR. WAMMOCK: It is almost two million,

DR. KOMAROFF: Between 1.5 and two million.

DR. WAMMOCK: I think I raised the same question
the last time. ,

DR. KOMAROFF: I notice the options to that, Options
2, 3 and 4 anticipate approximately doubling support for
continuing activity. These are not approved and unfunded or

new activities.

This is just double support for things that are

 
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ongoing. What is the justification for that?

MRS. FLOOD: Maybe Mr. Jewel can help us.

MR, JEWEL: It's a double in time I believe. Two
is approved, but three and four I think are just double in
time.

‘MR, GARDELL: One is for six months, and two, three
and four are for 12 months' activities.

DR. KOMAROFF: You think it's a typo under Number
2 that has the doubled amount?

MR, JEWEL: That's right.

MR. GARDELL: No, two is six months for staff and

12 for activities. ,

DR. KOMAROFF: Oh, it's 12 for activities; okay.

MR. BAUM: Two is through December 3lst. You can
see we are getting punchy at 4:20.

MRS. FLOOD: Your point is well taken.

DR. KOMAROFF: Do you know what the current level
of support is for the same activities on an annualized
basis?

MRS. FLOOD: No, we don't.

DR. KOMAROFF: I wonder if we are not going to be
doubling the amount of money going to these things.

MRS. MARS: It's a lot of money to go into that
state with that number population.

MR. GARDELL: Does somebody have the alternatives

 
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in front of them?

MR, GARDELL: One is program staff and related
activities to 12-31. Number 2 is program staff to 12-31,
and continuing projects, or previously approved, unfunded
projects to 6-31-76, or just start doubling on two.

MRS. FLOOD: Completing in December, with the
grantee monitoring the termination of the grants.

| MR. BAUM: My mistake.

DR. KOMAROFF : So the question is, does the million
dollars represent a big jump from the current level?

MRS, FLOOD: the only change I might make in my
recommendation to this Council would be to recommend that
this same level I originally stated $3 million $626,686
specifically excluding from expenditure for equipment and
the disapproved arthritis project. ‘

Thereby deleting the statement that I would iamit
them to spend in the $40,000 bracket.

MR. RUBEL: Is there a second to that motion?

DR. WAMMOCK: I will second it. |

MR. GARDELL: Discussion? All in favor?

(Chorus of ayes) |

MR. GARDELL: Noes?

(Chorus of no)

MR. GARDELL: Two of them; okay, outvoted.

Nassau/Suffolk.

 
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DR. GRAMLICH: This is an interesting unit. It
was recommended by this Council last year for termination.
Apparently Nassau and Suffolk have one foot in the casket
but refuse to lie down.

They were rehabilitated, and if I read their re-

quest appropriately, they apparently have vigorous programs

which suggest that perhaps the action of the Council to

try to kill them last year was all they needed to revitalize
them.

Their philosophy seems to be excellent, in terms
of transition. They have superb CHP rapport. They are
developing an HSA and appear to he well on the way towards
being designated, if the support letters can be interpreted
appropriately. ,

I therefore suggest they be funded at the requested
level for Option 4.

MR. GARDELL: It's a bloc action. All right, we
don't have to vote on that.
| DR. GRAMLICH: Incidentally, it's not an exorbitant
request. It is relatively modest, in terms of some of the
ones we have been talking about.

MR. GARDELL: Our next one is Nebraska.

MRS. KLEIN: Nebraska, under Item 3, are requesting

about $100,000 less than they had previously, They don't

seem to have outlined any transitional programs, although

 
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they mention it.

The only question raised by staff was whether the
funding level indicated the phasing out, and if a phasing
out was indicated, perhaps they should not be funded to this
extent.

But I can't see any reason why they should not be
funded at the amount requested, since they are cutting back
a little bit. The staff will further cut them back, so I
would suggest that this be one of the items for bloc approval

DR. WAMMOCK: They are going to have a comprehensive
nutritional education program. I think this is one big
problem in our present lifestyle,

MR. GARDELL: Are you commending or questioning?

DR, WAMMOCK: I am commending. I was just pointing
it out. It says comprehensive nutritional education program.
Consumer, in general, who feels the lack of adequate nutrition-

|
al knowledge and application involving socio-economic status,

and that's an absolute fact, .
I saw on the TV Hi-C. It costs 89 cents, and the

content of it is only six percent value. It isn't worth a

dern, and that's where we have been taken to the cleaners,

That's why I would vote for this outright, because it would

be devoted -- I have to divert your mind --

i

MR. GARDELL: Not at all. I'm glad to hear you/ like

hoy
{ .
|

something.

 
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(Laughter)

“MR, GARDELL: New Jersey.

MISS MARTINEZ: New Jersey is requesting about
$400,000 less. However, there are two projects in partic-
ular, one is a project that the CHP commented on, and I
agree is very fuzzy, that is 35A and it's for $88,000.

The CHP also commented negatively on 38H, which is
a model ambulatory project, and CHP thought it should be
done by HSA instead of RMP,

Those two add up to $208,000. I would move for
$3 million $591,810.

MR, BAUM: That was $3 million $591,810,

MR. GARDELL: With no specific deletions; okay.
It has been moved that New Jersey be funded at $3 million
$591,810.

DR. KOMAROFF: Seconded.

MR. GARDELL: Discussion? All in favor?

(Chorus of ayes)

MR. GARDELL: Noes?

(No response)

MR, GARDELL: New Mexico.

MRS. GORDON: New Mexico is still dribbling in.

.I really don't know what to do with it at this stage of the

game. Our reviewer has not had New Mexico too long, and

she wasn't all that sure about it either.

 
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But it seems as though I gather that they're fund-
ing CHP, and they are wanting to fund HSA. Am I correct
in this?

MS. HICKS: Right.

MRS. GORDON: They are asking for more than they
had last year, Last year theiz support was $1 million
$596,077, and they are asking for $1 million $799,372,
which includes $414,684 of new activities.

I question that rather strongly. Is there anyone
who is really familiar with New Mexico that could tell us
what their relationship is on the funding for the HSAs and
this sort of thing? ,

MS. HICKS: The only thing we came up with in staff
is that they are basically considered a good region. They

do get the job done, and they have done some magnificent

things.

However, they have a haphazard way of submitting
applications, which is quite confusing.

MRS. GORDON: I found it so.

MRS. FLOOD: I might comment that they did serve
as a resource to the Governor in developing a rather broad
document advisory to the Governor of the state for submis-
sion to the Secretary of HEW on recommendations for the
health service areas of the state of New Mexico, in which

fairly excellent documentation was provided.

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as a resource to the Governor.

I do not know if the Governor followed all of those
recommendations in their submission on the HSAs for that’

state, but they did do some tremendous work in that area,

I would like to comment on the rather large bud-
get item for the cultural awareness efforts undertaken in
New Mexico. Although the state of New Mexico and the New Mex+
ico RMP has always served in the forefront for cultural awarg-
ness emphasis for the 12 western states, especially for the
Hispanc-American problems and Chicano problems.

This seems like an extraordinarily high budget re-/
quest for the end transition year for these efforts. It
has also been pointed out by some of the CHP agencies that
responded to this particular application that they felt that
some of the more recent cultural awareness emphases in New
Mexico have lost their impact, because of addressing the
wrong groups, and that the long-range impact is not valid.

I would question this large expenditure on the
cultural awareness efforts at a time when the state, which
is a rather poor state, and limited in its resources, for
addressing the transition and the need for more immediate
problems facing it, that they should be expended in this
way. |

MRS. GORDON: I was going to recommend funding at

last year's level, which would give them less than what they

 
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'

ask, but which still would allow them some room to play
around.

MR. BAUM: One five nine six seven seven seven?

MRS, GORDON: Yes.

DR. KOMAROFF: That would give them some money
for new projects too, effectively.

DR. GRAMLICH: Any specific exclusions ‘for new
projects? - — |

MRS. GORDON: Not really.

DR, GRAMLICH: If we pass this, we just. approved
$179,000 for nurse practitioner training in New Mexico,
whereas earlier this afternoon we denied $100,000 for Ari-
zona for the same program, except that this one has not
been approved but unfunded.

The other one was approved but unfunded.

MRS, FLOOD: There was some criticism also aimed
at this particular project in the CHP review from the state
of New Mexico.

| MRS, GORDON: This one came-in late, and was not
in the original packages.

MR, GARDELL: We don't have a record of having den-
ied the nurse practitioner program in Arizona this morning.
Maybe we did not record it properly. We did discuss it.

DR. GRAMLICH: We did discuss it, but it was prob-

ably not specifically annotated.

 
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MR, GARDELL: “Remember, there was discussion as
to whether it was new or approved and unfunded.

MRS. MARS: You said to let RAG decide and find
out. You made that statement also.

DR. GRAMLICH: Okay.

MRS. GORDON: I would have great reservation about

$179,000 for that particular project. But if we cut their
recommendation or what they ask, then they would not have
enough money, probably.

MRS, FLOOD: Part of the new monies under the Heal
Planning Council support is direct support to existing B
or areawide planning agencies; is it not, Mrs. Gordon?

MRS. GORDON: As I understood it, it is.

MR, BAUM: Yes, I read that one, too.

MR. GARDELL: We have a motion for $1 million
$596,777 from New Mexico. Is that seconded?

DR. KOMAROFF: Seconded.

MR, GARDELL: Discussion? All in favor?

(Chorus of ayes)

MR. GARDELL: Noes?

(No response)

MR. GARDELL: Can we do New York before a quarter ta

five?
DR. KOMAROFF: May I ask that we take that up in.

the morning? The level of their actual -- their current

th

 
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4

annual level, as I see it now, is one million more than
was printed on the sheet, and that will cause me to re-
think things. |

And I would rather have the evening to do it,

MR. GARDELL: All right.

Then we are with North Carolina. Dr. Janeway, you

get a vacation,

i
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- o
i MRS. compo: North carotina,)thets funds this year
were $2 million $405,881. “ghey are requesting $1 million
$716,833. Of that $68,112 is for equipment, which is being
disallowed for the arthritis,

MR, GARDELL: Are you suggesting that we disallow
it?
MRS. GORDON: No, it was disallowed on this.
MR. GARDELL: Okay.
MRS. GORDON: Yes, I am suggesting we disallow it.
MR. GARDELL: You are concurring; all right.
MRS. GORDON: So they seem to be a good, ongoing

program, I would recommend their request, deleting the

$68,112 which makes $1 million $650,721, if I subtract cor-

rectly.

MR. GARDELL: One six five oh seven two one.

MRS. GORDON: I could have subtracted the equipment
incorrectly.

MRS. FLOOD: Let's review the figures. We are

 
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starting with $1 million $716,833. Subtracting $68,112 --

MRS, GORDON: I think the 68 is wrong.

VOICE: The equipment deleted for North Carolina
is $33,388.

MRS. GORDON: Subtract $33,388 from $1 million
$716,833.

MRS. FLOOD: One million $683,445. That's what I
get.

MR. GARDELL: You are subtracting it from the
$1 million $799, are you not?

MRS, GORDON: No. One seven one six eight thirty-
three.

MR. GARDELL: All right, we are with you. The
motion has been made that North Carolina be funded at
$1 million $716,833 which excludes the equipment --

MRS, GORDON: It does not exclude, It should,
which gives us $1 million $683 —

MR, GARDELL: I'm sorry, $1 million $683,445. Is
that seconded?

MRS. FLOOD: Second the motion.

MR. GARDELL: Discussion? All in favor?

(Chorus of ayes)

MR, GARDELL: Noes?

(No response)

MR, GARDELL: Okay. I will entertain a motion to

adjourn for this evening.

 
Vis pas ’ \

ee

DR. GRAMLICH: So moved.
@ 2 MRS, FLOOD: Second.
7 | (Whereupon, at 4:40 o'clock p.m. the meeting of

4 the Council was adjourned, to reconvene at 9:00 o'clock a.m.

5 tomorrow morning, Friday, June 13, 1975).

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