getty, 1 ' t 1 aru oper of Blew & oO Se Lame ADE Pe arc HOOVER REPORTING Oficial Report Washinet g 3° 4G Newer i 6-6666 30 a £Ts toa, D.C. pena err eines sea ALES COMPANY, IN sortie BORE RB Se IYER SR SORE nA A aE BEE ME MEIN OE Taal ERNE 2 °c DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE MEETING CF AD HOC CONSULTANTS REVIEWING REGIONAL MEDICAL PROGRAM APPLICATIONS Conference Room H Parklewn Bullding 5600 Fishers Lane ; Rockville, Maryland 20852 Wednesday, May 22, 1974 Panel B convened at 11:00 o'clock, a.m., Mr. Peterson, Chairmen, oresiding. | PANEL B: Mr. Kenneth Barrovs, West Des Moines, Iowa Dr, Joseph Hess, Detroit, Michigan Dr, Albert Heustis, Three Rivers, Michigan Dr. John Hirschboeck, Milwaukee, Wisconsin Mr. Joseon de LaPuente Dr, Charles McCall, Dallas, Texas Dr, William Thurman, New Orleans, Louisiana Dr, Paul Teschan, Nashville, Tennessee Sister Ann Josephine, Notre Dame, Indiana PO CONTENTS Were tee meer [Regions: Page Maine 15 Motion 28 Vote BY Motion 4O Vote 4O Motion YL Vote 42 Albany 49 Motion 57 Vote 60 Northern New England 62 Motion 75 Vote 19 Connecticut 82 Motion 100 Vote LOL Central New York 103 Motion L15 Vote L16 Hawali 118 Motion 131 Substitute motion 132 Vote 133 Arizone 135 ' Motion 152 Vete 153 Motion 153 Motion amended 160 Vote 164 Regions (continued ): Greater Delaware Valley Motion Vote PROCEEDINGS MR, PETERSON: We might as well get started. (Discussion off the record. ) | MR. PETERSON: Before we do get down to individual regions, I would Like to mention some things going back to what Herb took off on, not trying to repeat, on the other hand, but get down to some of wnat I see as the more nitty-gritty details, You heve already heard from Herb and the review guide that I hope all of you got, the kind of things that seems to me is elmost imoerative that we individually and collective- Ly sort of try and keep in mind, the necessity for trying to keep ovr focus on the overall region and its proposal, need to try and couch our review in terms of the criteria and Factors which we specified as being the basis for our judgment. i Clearly if we try to look at very many projects, we are in trouble I think I calculated we would have two minutes per project if we operated on a project basis. On the other hand, there certainly are going to be { some instances where the reviewers end staff will want to Single out some projects. I guess primarily because they may raise policy issues or they have attracted strong negative CHP comments. So those are exceptions. On the other hand, as Herb indicated to the total group this morning, I think we are going to be confronted y | in a number of instances with projects which staff has already. identified and pernaps others which you and in the applications you have Looked at, there are some policy issues about which we may not be eble to resolve in our best tact at this juncture, 4 ' maybe simply to flag those. | And certainly the time that Herb dwelt I think on the. last table, he passed out to everyone, I guess the column C we spent more time talking about than anytning else. That target amount, while it is not a formula, while it is not an assurance that the region will receive that much» I tnink yet in meny ways it is going to have to serve as the orincipel benchmark or backdrop against which we Look at these applications, rather then necessarily the much larger amount in some instances that is being requested. | But in terms of the review procedure itself, we mve | tried to assign each application to two people. We haven't designated them as primary or secondary reviewer, and the fact there is one column and another doesn't really have any great significance. I may deviate from that certainly. There are a few instances, I know you have one or two, Mr. Barrows, where due to last minute cancellations Dr. James I think just called the other day and I had someone call me wno had their third numeral thorax within the past day who isn't here, so there will be a few applications where we only have a single reviewer because of last-minute cancellationes i 5 In a few instances we have tried to get to someone else. I knoy Bill apparently there was a contact with you on Northern New England since you had visited that region and possibly Bill will be able to pinch hitter as another reviewer on Northern New England. Generally I would propose to not have the staff comments -- you do have prief summary sheets in your books, not to have staff comments precede the reviewers, but rather to follow as appropriate efter the two reviewers have’ addressed themselves to the epplications. I think in sitting down with Dick Russell -- where ts Dick? -- who is chief of the Western Operations Desk and with Frank Nesh who is chief of the Eastern Operations Desk, yesterday afternoon, we have singled out a couple of applica- tions where we will deviate from that rule where I think in the case of Hawaii, for example, there is some significant background we think we probably would Like to present initially, perhaps also a Metro New York where we have got a different kind | of application. But generally we will look to the reviewers initially end any staff comment subsequent to that if appropriate. Certainly apart from the two reviewers that will pe called on, on the other hand, I think we do need to permit ourselves some time for a brief: discussion fromthe others, questions and answers, hopefully aimed at either bringing spe- cific information or general impressions to bear, other people o on the panel have where they may have them, or to get some issues crystalized. We will ask the two reviewers, in those singular instances where there is only one, the reviewer, the two or single reviewer to prepare the rating sheet which, again, I believe was sent out to everyone along with the review guide and it is my understanding that each of you in the folders that | you hed in front of you have about five or six bianks there. Je have got additional ones if anyone runs out. But subse- Guent to each review, where Dr. Hess or Dr. Teschan is me of the reviewers, I would like to ask each of you to, as we go along, | to the best of your ability, to try and complete a rating sheet for each of the regions where you have been asked to review it.) And to either let myself or Shirley Simons have those. Because We are going to try, as we get back on Friday, that will be one - basis upon which we will try and give the total group again an impression of how the two groups have looked at their respec- tive regions. We also will need to get from you, from the group, some kind of recommendation, as toyour recommended level of funding with respect to each region based upon their current application, recognizing that in the overwhelming number cf instances, regions will also be submitting applications in July. But we do need that. | I think we have heard enough about the kinds of t constraints that we are operating under. Not the least of which ere lack of really good current information in many instances. Time is obviously something we are going to be wrestling with I think for the next 2-1/2 days. There are, for those of you who may not have brought all of your applications with or misplaced one in the cafe- teria, or indeed if there is a region you weren't asked to re-. view you might be interested in taking a look at, we do have a small supply of applications for all of the regions this panel is concerned with back on that table behind Tom Simonds, | | So feel free to pick up an application if you have ! any desire to do so. | As far as conflict of interest is concerned, we nave | tried to arrenge these two panels so that at Least in the gross gseozraphic institutional sense, people from Great Midwest are Looking at the eastern and western parts of the country than vice versé. In other words, Joe and Al are from Michigan, we are not going to be dealing with Michigan and hopefully at Least | you won't be dealing with Michigan in this context. : DR, HEUSTIS: We couldn't really help you on that. MR, PETERSON: On the other hand, there may be in- stances, I can't think of any, but where based on your own | | knowledge, where you feel there is some potential conflict of DR, TESCHAN: Early. MR. DE LA PUENTE: I have only one commitment this afternoon that I could not avoid. MR. PETERSON: So as far as you are concerned, Joe, we need to avoid looking at the regions, Northern New Eng land and a few others you are going to be the reviewer on, we have to defer those until tomorrow. MR. DE LA PUENTE: Yes. MR. PETERSON: Okay. MR. BARROIS: I heve a 4:30 flight on Friday. MR. PETERSON: No, I think we calculated~- MR. NASH: We would Like to get to Northern New Englend sometime today if wecan, because Spencer won't be here tomorrow, if we can work that out. MR. PETERSON: What time is your engagement this afternoon? MR. DE LA PUENTE: Three o'clock, MR, PETERSON: Okay, we Will do that this afternoon. It may not be a good decision, but that is what is important in Washington -~ don't worry about the judgment, do it on time. In addition, because some of the staff -- Spence Colburn is a prime example, but not the only one -~- some of the staff that have departed MRP but heave been brought back for this also have some crunches and commitments. We are going to LO have to do some adjustment there ang I think I have identifies | ‘most of that in my discussions with Dick and Frank yesterday, but we are going to try to handle all of the applications Spence has the backgrounds on, because he is going to be out of town beginning tomorrow in connection with his new job in the Bureau of Quality Assurance. | WeLL, with that brief introduction, before we get started, I wonder iff there vere any additional questions in terms of details, procedures, or quite apart from deteils and procedures, profound philosophical issues, some of which L vould be willing to take up at Lunch. MR, BARROYS: I believe some of us are better pre- pared on some than others. I went down mine alphabetically. MR, PETERSON: You are better prepared on Albany? MR, BARROWS: Than I am on the last two. I hope to do that tomorrow, I think Paul is in the same boat. TI don't mow abous the rest of us. MR. PETERSON: Well, again, if I should call for an application where you or someone else would Like a little more time, if you would let me know that, I will, on sort of an ad hoc spontaneous basis, ab least in the beginning we have all kinds of flexibility. When we get down to the last two agpli- cations, our flexibility is considerably reduced as to the num per of adjustments we can make. 11 MR, DE LA PUENTE: One issue we could discuss very briefly, it has to do with vacancies that many of the applicants have made in view of the fact we are dealing with just one year and that has a conflict, you know, as to-- we let them fill all the vacancies because as far as the money is concerned, they are within range. I have a problem. Does anybody else have it? MR. BARROWS: Yes, we have that, we have it from another direction. Assuming they get the budget, will they be able to fill the vacancies and do the job within the time spen available? MR, DE LA PUENTE: Precisely. MR, BARROWS: I would guess we had better take a look at those on an individual basis. They tend to vary, criti- cal shortage of staff or-- DR, TESCHAN: One philosophic comment, I think you put your finger on as usual, mainly the Local decision may be the ultimate reality. RMP's tnink affirmatively in the most distressing circumstances and I think risnt now the stance in many of the RMPitL is to think affirmatively about the transi- tion in the future, I think quality of the professionalism even in the short range -- talents, if anybody has any -- is going to pick up the staff in whatever mode it will be, Whatever is recruited for next year is available for follow-on. I am not nearly es much worried. MR, PETERSON: There is only one thing I would have tec cay, the issue Joe has raised, we did see the RMP's with the announced phase out in January of 1973 go down in the agsregate and there are obviously considerable variations here from roughly L4OO full-time staff to about 700. In other words, lest fall, September, when we got to -- well, it was the November application, but it sort of reflected the situation es of Last September, the RMP ts were down in terms of program staff about half of what they hed been prior to the phaseoul. By January of this year they had picked up about 306 additionel people. That was during the period when neither they nor we knew what the court was going to order, and, in other words, it was at a time when I think the imponderables were even worse than they are now, At least now I can see down the tunnel for 15 months, maybe less. It is only 13 months now. It is almost the ena of May. In December and January, I really couldn't see down the tunnel for more than eat the best six months. So I don't think that answers your concerns, Jce, put I think it is not irrelevant. DR, HESS: I think i11 founded though it mey be, we must have some confidence between the Congress and Administre- tion that the intents that are now being expressed will find 13 expression in some legislation that will allow this type of activity to continue in some form or another. I think that is what you are seying. I think that has sort of been a backdrop and if they fail to come through, you know, I guess that is not our respon- sibility. But at the same time, Looking at the public's need, and the fect that this type of activity has proven itself to be effective for doing e job that needs to be done, that somewhere or other there is enough broad support that somewhere, ! or other the political element of this system will find a way to continue it. DR, TESCHAN: I think the corollary for me from all that is we should meke some effort, I hope we get some agree- ment to that, make some effort to make sure that as well as { possible, each of the regions is ready for the transition for the follow-on, I think this is the time to get ready. DR, HESS: Yes, DR. TESCHAN: Even though the imponderables shut off the enthusiasm for that in the region, I think perhaps we éould; help stimulate wnat changes need to be made to get regions in line. SISTER JOSEPHINE: You know, in going over some of these applications, I have noticed in many cases where they were i looking for staff they cicked uo staff from CHP programs, which 14 to me is the direction toward the change in total administra~ tion, and this should be commented wherever they do this, be- cause I think this is addressing itself to the transition you are talking about. MR, PETERSON: Well, I am sure there are going to be. all kinds of issues of both a generic and specific nature sure facing during the next two deys. We might kick off and I thouzht my sense of geography, what it is we might kick off : with Maine, since it is in the upper right-hand corner of the mep of the United States, itmviously is not at the head or end of the alphabet, neither the larger or smaller states, but that is my rationale. Besides, Spence Colburn, thst is one of the states we are looking to Spence for some additional comments, since we do have two reviewers there. | ! I wonder, do you want to lead off on that, Charlie? DR. MeCALL: Be glad to. MR. PETERSON: Okay. Il scp sears Pi dias L5 DR, McCALL: I wish I had had an opportunity to re- view this program back when I found a direct line, I found opportunity to look at a quality program, and it obviously has) t ry | strong Leadership at the staff and advisory group level. It comes through loud and clear this program makes 1 | t ! preat plans not only in transitioning what is coming, but in | \ | continuing and financial support from other sources. Ang I | really don't think there is any-~- there is no question raised | in my mind in terms of their conflict, in terms of their stated objectives end their program, the lements to achieve those | objectives. | The only Question I had in my review was since their. funding seemed to be a Little Low currently, and I assume that was because of all of the vagaries of the past years that we have been going over and the excellence with which the progrem hes been based, other sources of funds not only planned but in hand and being utilized et the current time. So that that needs to be looked at when we come up with a figure or recom- mendatlon. DR. TESCHAN: Who is the grantee? DR, McCALL: Medicai-- | MR. PETERSON: Medical Care Foundation, Incorporated. It is a private nonprofit corporation and has been since dey one. | | a DR. McCALL: I will confess when I received these tw | | 16 voLumes <-- this is only half of it, oh, gracious (indicating) -- materiel, just padded in here, and I since learned they were | asked to come in with a complete application but I enjoyed going through this application. It is clear, it is informa- tive, end I really found this operation useful certainly. MR, PETERSON: Al, you also Looked at Maine. DR. HEUSTIS: ALL I can say is I had two impressions. I received these two beautifully bound books and thought who are they trying to convince? , | I received this other one from Caiifornia with the other materiel, end I didn't really think they were trying to convince anybody. Beautifully done -= grapns, different styles in the typewriter, different colored paper and so forth. And I Looked at it with a negative prejudice. . | DR, McCALL: TI agree. | DR, HEUSTIS: And I read it. Everything you said is true. DR. McCALL: Unbelievable. DR, HEUSTIS: This is the only one I reviewed that hed any need or basic population data. DR. MeCALL: A1Ll there. DR. HEUSTIS: This is the only one I reviewed that | indicated the other than the RMP support that was going into the current programs, 17 ! This had a pretty definite and clear-cut attention | to process as far as priority ranking in how you got that way. ALL of the questions I had were answered and a few of the questions I didn't have also were answered. I thought it was well organized, that certainly their record right down the overall list we had, all of the different criteria. , I took this document which you have in the review sheet and broke down each paragrapn into the number of things | that you mentioned, plus a few of my own. And on Maine, I rated everything that wes rateable in the good column except for the reffection of needs identified by comprehensive planning, whieh I put down as insufficient data. Tnis may well be about as comprehensive planning has not identified any : needs and not been doing the overall job. - I would support any extra money that anybody has in going to the Maine program as being capable of being extremely well spent, with sreat results as far as continuation pro- jects at cost levels. I was particularly imoressed that they were able to get some help from the state government. Not only in picking up some of the projects that RMP had started, but help from state government aes I understood it, at Least to go into the reguler day-to-day operation of the program for the next Piss cal year. 16 I feel very strongly and very positively about this program. It was a refreshing one to read and made reading some of the others -~ well, it even compensated. It was a very refreshing one. DR. McCALL: No collaboration, but T obviously had the same impression. My recommendation was funding maximum eligible. MR, PETERSON: What about the other reviewers who may nave questions or comments about Maine? DR, HIRSCHBORCK: I don'& have eny comments about the application. I haven't seen it. But I have always been curious sbout the interface with neighboring states in Northern New England, whether this is well taken cere of. DR.McCALL: If it is not spoken to one way or the other, I have no knowledge other than the application, DR, HEUSTIS: Any more then Michigan's at least as it used to be a number of years ago doesn't say anything about Ohio or Minnesota or Wisconsin; maybe it should have. DR. HIRSCHBOHCK: How they relate. MR, PETERSON: Maybe Spence or Frank have something to say on that? MR, COLBURN: They have been very close working staff, three prosrams , tri-state who has New Hampshire and Maine and Vermont, all of New fngland, The New England progrem, an epidemiologist used 19 to go to Maine quite frequently and he has helped the Maine program, has capitalized on what was done in Vermont with re-~ gard to coronary care networks, safeby program, Now they are moving into the area of establishing guidelines and standards within the coronary care network for treatment. And I think this is cepitelizing on the success of thet tymof activity in Vex | mont just as an example of the exchange thet takes place be- tween those three programs in the upper part of New England. MR. BARROWS: If the titles of the project are at all valid, the direction of the program seems to be excellent, very much on target. DR, HEUSTIS: There isn't any Question in this par- ticular program where there has been great leadership, at leest material aveilable to me, by the program staff. They haven't tried to sit back and say, ‘What would you fellows Like to do and we will fit it into an overall pattern.’ They have come out end said: This is What we want te do; would you be willing to work along that? That is the kind of regional program that I think is carrying out the reel mission. | DR, MceCALL: They List their new projects, continuing projects, List those they are requesting no further RMP funds for, exceeds-- either they have finished their mission or have other source of funding. | { DR. TESCHAN: I want to ask about the CHP relationshic. | | | i 20 I am not quite clear, there are no functional (b)'s, Chattergy has not done anything witn the (b)'s to try to get them going or he has and they aren't functioning, or-- T an not quite sure, or can you tell? DR. HEUSTIS: I cannot answer. MR. PETERSON: There are four or five. MR. COLBURN: Five. MR, PETERSON: Functioning, there are five funded, be (a). (db), (c). DR. TESCHAN: He is getting no statement of priorities objectives? | DR, HEUSTIS: None from (b)'s, ALL I could say was there was really insufficient data presented on what the (o)'s vere contributing to come to any value judgments,at least on my part how the cooperation was. MR. PETERSON: Again, I think Spence or Frank will have to help me with this. Ido not recall that Maine is a region where the CHP comments either were negative or pointed a direction, but perhaps I am WronBe MR. NASH: Spencer, didn't he invite the (b)'s in and have them sit around during the discussion of these applica- tions? DR, HEUSTIS: Excuse me, may I -- I misspoke a moment I Looked in the wrong column, HOOVER REPORTING CO. IKC. 320 Massachusetts Avenue, NE. Washington. 0.0. 20002 [} et DR. McCALU: He really met with them aheed of time, the (b) agencies even came into the R&D review I think. DR. HEUSTIS: I have down “Extended cooperation and coordination with the CHP is good. Highest possible effective relationships are good. Joint activities are satisfactory." I misspoke; I was looking at the next column. Sorry. I misled you. DR. TESCHAN: Trying to get a feel. DR. McCALL: It seems they did. MR, BARROWS: It would be awfully difficult for us | to pull doller figures out of the air for recommendation, but would it be feasible for us to say break these down into groups of fives and the preferences we think they should snare in the budget? It sounds, for instance, this should be one of the top ones. MR. PETERSON: I em not sure when you say preak then down into groups of fives, what-- MR. BARROWS: Top -- DR. HEUSTIS: Aren't you thinking of this overall | assessment activity? MR, BARROWS: If that ls what it is to be, then, then fine. I thought we had to come up with some financial recom- ! |: mendations. | MR, PETERSON: We do need to come up with some | HOOVER REPORTING CO, INC. : | 320 Massachusetts Avenuz, NE. ‘| . Wachinatan TC NAN? i . { 2e recommendations. It is obvious if the recommendation exceeds the totai supply of money, there is going to have to be some adjustment. But pernaps I can answer your Question in pert. At least it was our hope that as a result of the review dis- cussion and the rating sheets that nad been able at the time we get the two groups beck together, be able to sort of disple literally wheat tne two groups hed come up with separately and probebly falling out intc not unlike a bell-shaped curve, | there were some at one extreme considered among the better, some at another extreme thet were considered poorer, with oarenthetically the emounts recommended for them, and I think | pernaps triparte -~ again I don't-- but this we had hoped to be eble to do. Becsuse I think it is difficult, because some of this indeed is comoarative. DR. McCALL: And we are going to come back and Look at what we have recommended here, MR, PETERSON: That is our intent. DR. MeCALL: Set maximum reting, I would Like $2 million requested. | DR. HIRSCHBOECK: How do they deal with their fund- ing? They don't get as much es they have? DR, MeCALL: Yes, It has been in use all along, one has been in use and is effective. | DR, TESCHAN: Do you recommend two? MR. NASH; It is target figure, bear that in mind. 4 | HOOVER REPORTING CO, INC. 320 Massachusetts Avenuc, NE. ' Washinetan. D.C. 20007 23 DR, McCALL: I didn't when I put my $2 million down, I didn't see the target figure, and it exeeds it by over half a million dollars. DR. HESS: I would like to introduce another element in this discussion. What is the population served by that RMP? MR, PETERSON: Slightly under one million if my-- DR, McCALL: About a million. MR, PETERSON: The State of Maine has a little less then a million people, DR. HESS: I think that factor has to modify, put into considerations. Now, another factor is whet, within that document-- apparently they have done a better job than most in terms of outlining the health needs of the population. In my own mind I don't think of Meine as a-- well, it is a rural, but com- prised of at least my image is of pretty hardy self-sufficient people who, you know, can take care of themselves pretty well. And that may be a reflection why they have got such a gocd application, I don't know, leadership there. It boils down ultimately to a handful of people. But be that as it may, I think we have to modify our| thinking about how the needs of the people in Maine compare with the needs of people in Mississippi or. Alabama, or, you know, other sreas of the country. And look at tne HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 24 relationship between funding recommendations, the size of the population, and what we know about the hea Lth needs of that particular region. If they have got a million people, just to give us & rougher index, and $2 million application, roughly $2 per capita, RMP funding for that; atthe other end of the scale th are RMP's that come out with something Like 25 cents per capit And I em not suggesting a capita thing except I think we do have to keep in mind the needs of the population, how large the population and the amount of money that is going in. There ought to be some kind of rational way to rationalize thet at that level as well as just how good the program is. DR, McCALL: I totally agree with you, having come from a region that nad 12 million people. And under my great leadership was reduced to $1.2 million funds. So that is a very important point that I am very sensitive to, and my only reason for taking this high level at this point is to say we don't know where these others are going to shake out. If you are going to come back when these things are finally looked at in terms of the total dollar available for quality, need, population served, it would be final figure, this program comes through at such high quality to me I would Like to see us not start Low and not be able to give them the meximum they should get when you look at the overall. @ G ZzD DR, HESS: These folks sound to me like people who can moke efficient effective a of money. DR. HEUSTIS: hie is really what came througn to me. DR. McCALL: They are going to function if we don't give theme dime. I think you shouldn't penalize them for thet, MR, BARROWS: Thet is importants as a taxpayer I hate to see these bucks soent on the basis of need without produc- tive use ol them. DR, HEUSTIS: I recognize need, but in these troubles times it seems to me efficient productive use of money might be things that would impress the Congress rather more then teking enother progrem that I reviewed that has a large need and a large problem end not as good 4&@ programm. DR. HESS: Iam not recommending putting a Lot of money into a poorly managed program, but to carry this arsu- IMent to a ridiculous Level, if they could use $5 million, would you give Maine $5 million just because they are a top-notch progréem you see? DR, HEUSTIS: I think you have to balance relative-- DR, McCALL: Fine thing, I am not sure I would even recommend $2 million. MR. BARROWS: I wanted to bring this down, bring another factor into the decision, | DR. McCALL: It might make it easier for you to try HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 o Zo to make some better judgment of all these things at this points, MR. PETERSON: I think, you know, our judgmental process which is collective and right now pifarcated, I am not going to intrude too much on that. Let me only mention one thing, Maine is requesting slightly over 32 million. It ts one of the few regions which has indicated to us tnis is their total package, so their 32 million is not going to be a supplemental or additional, or further request in July. Their tarset figure, column C, was rovgh Ly SLY million. I think that again looking at it in terms of some rough per capita, Maine indeed exceeded the national norm at an earlier point in time by virtue of the fact that it had been considered @ good program at the time we were steering towerds selective funding. I think what I have heard is a range from $2 million, and somebody said they are going to continue whether we give them @ dime or not, so we have got between @ dime aud $2 million Would somebody like to put somewhere between those two points, perhaps lay 4 recommendation as to an amount on the floor? - MR, BARRG/S: That is the thing that bothers tne. We do not have a target budget for our whole business, If we had something Like this and then could say classify them, and then cut the melon when we get them all through on- the amount HOOVER REPORTING CO, INC. 320 Massachusetts Averiuc, NE. ' Washington, D.C. 26002 of money to be spent, it would be a lot eesier. Just picking figures oub of the alr, I am afraid our results will be very fortuitous. . MR, PETERSON: I didn't mean to. DR. HEUSTIS: It seems to me you have on overall assessment five categories. MR, PETERSON: Right. DR. HEUSTIS: In ell good conscious, more data is availeble in Maine about previous funding than any of the | others I reviewed and there was just insufficient data about | background and use of money and about progress to really make a valid funding judgment on the basis of the written material that they gathered together with ell of the constreints. I feel very strongly the same as you do, perhaps the best we can do is to say that this is an interior program ard it is entitled to maybe better treatment if the need Is there and-- of course, if there are two superior programs and both nave needs, I would agree with you. Some of these things on the basis of more information we could come up with dollars. MR. BARROJS: Even divide them into groups, the plus group, average group and minus group, and cut it like that. MR. PETERSON: Let me see if I can help us out of this. Since we will in one sense be operating against a 28 1 ‘ benchmark of a target figure, whet I hear the group saying is that it would like to make a recommendation vis-a-vis Maine -- correct me if I am wrong -- that says here is 4 x | | region that, in our judgment, without giving a specific amount it should perhaps be above the tarset figure, whatever that | increment is. I think we, again, as staff, Dr. Pahl is the Director, in the final analysis, wno is going to have to divide $109 million or $114 million up, certainly is going to be influenced I think by virtue of the fact that this whole re- view process is overeating with a great deal of lack of informa tion and the like. Ari thet the pluses or minuses will be ine cremental rather than order of magnitude. | It is more defensible to say let's give this region ! 20 percent or 10 percent more, as opposed to LOO percent more or less. Because I don't think any of us feel comfortable with that process. I wonder if in those terms somebody would -- DR. McCALL: Maybe to help you have th figures, the | sense is there in whet you are saying, I think we all recognize it, with all the constraints and time, we have to come into focus. We really can't go back end write all the imbalances and inequities that may exist. Maybe3l.5 million recomuendation does that, it is ea Little above requested, it reflects its superior rating. If there are others, that is the cense, And 29 it would take into consideration per capita needs and other things as well as their quality. DR. THURMAN: Second. MR. BARROWS: Their request is $2 million. DR. McCALL: Yes. MR, PETERSON: You are saying recommendation of $1.5 million? MR, COLBURN: I was going to say in the past, the | previous procedure was to make a recommendation regardless of the availebLLlity of funds. Then you know the distribution of | funds would be based on total recommendations. MR. NASH: I think Dr. Pehl wanted some sort of recommendation. te DR, HESS: I think it would be helpful if we go throush end we come to grips with a specific figure on each i the enc t 0 eT project, and then come back if we want to adjust it of time. DR. McCALL: This is what I am integrating into the $1.5 million. MR, NASH: I think that gives us a benchmark to work: with as we move alongs. “DR, HEUSTIS: I would have great difficulty on anything except political grounds of recommending that you - approve anything except the request. I can-- if you asked me to make a technical decision, the program is worthy of support. ; t HOOVER REPORTING C9, INC. : 320 Massachusetts Avenue, NE. Washington, D.C. 20002 ' / 30 If you ask me to make a po Li tical decision, there is not enough money, then tt seems to me the political decision, at least as I see it, ought to be made et a higher level than which I have said at the present time. SISTER JOSEPHINE: I would like to say I made a site visit to Maine with Dr. Brandon and Dr. Vaun, who is in She other group, end I guess in 1969 or 1970. It was at the time | when theywre first beginning to get thelr resources together. And I had an opportunity to stay several days and so a couols : of us went around and we visited in different places in the state, nd in response, Dr. Hess, to the number of people, you know, I am so impressed with the distance, the distances, — the scattered population -- really, the total lack | almost of services, you know, that were available. | | | Iwas also impressed as we sat and talked with the t people, with the fact that, you know, they had already been in- volved in the process, the people were Listening to what they _ need, And the program thet has veen developed, you Know, ! I would be reasonably sure has been developed in response to needs that were really identified, and I don't feel that is true of all programs. DR. HESS: No, I am not questioning the needs were identified. I think that has been well done. i MR. BARROTS: Introducing the equity. If we adopt this thing, what we are saying then is HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | i Washington, D.C. 20002 [; 31 we have coneluded our formulas as an outstanding program, and get 75 percent of what they asked for. DR. THURMAN: No. Not at all. I think what we are saying is can any group operating at $1.5 million Leap to $2 million? Now, .in seconding the motion, I am not proposing we give 75> percent, I think this is @ region that gets results, I rather doubt if it would be able to leap to $2 million. MR. BARROWS: You are bringing up a very valid con- sideration, do they have the capacity to do this job; in effect, they are esking for two times present budget. DR. THURMAN: The other thing we have to consider is: there hes never been @ human being who wrote a grant who didn't add something to it. DR, HEUSPIS: I disagree, but go ahead and make your | point. | DR. THURMAN: That is my only point. They knew they | might as well ask for everything they could get. But I don't believe it is possible for them to spend $2 million in a reesonable way. DR. HESS: That is a LOO percent increase. DR, HEUSTIS: Mr. Chairman, the thing that bothered me was the feet the oniy figure we have on this sheet is this HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.E. Washington, 0.0. 20002 I | 32 currently annualized level of what they ore getting. Tris doesn't take us back to what they did before they were cul, and not having that information and not having the informe- tion on how well they had spent their money before they were eut, L am just wondering -- MR, NASH: That figure, Doctor, does not include a large supplemental award for EPS or HSA activity out of 1972. Actually they have been operating at a level over $1 million. Spence, do you have -- MR, COLBURN: I am trying to recall -- DR. HEUSTIS: I am just saying on the basis of one year of restricted allocation -- MR. NASH: You ere talking about ability to handle a large group ofmmney and this actually isn't that. MR. PETERSON: There are, as Frank points out, in e number of regions, Maine isn't the only one, where the current annualized level which is really the present six-month award times two, it is that simple, is perhaps misleading -- not in all instances. In some ways the column © figure, which reflects a percentage of the immediate pre-phaseout level {s more indicé- tive of the kind of annualized level, approximating the kind of annualized level that Maine and nearly all the other progress were operating on prior to January 1973. But again, in.the interest of moving the discussion HOOVER REPORTING CO,INC. | 320 Macsachusetts Avenue, NE. ' Washington, 0.0. 20002 (202) 546-6668 wa along, we have got a situation here now where two reviewers, one in effect has laid a recommendation on the table for $1.5 million, I heard Al indicate thet he would have problems with anything less than the full amount requested. I think simply in terms of the order in which those two figures were mentioned, I would ask if Charlie regards his $1.5 million as a recommendation to that effect? If so, if there is a second ? DR. THURMAN: I seconded it. MR. BARROJS: Did you say a real index of their pre-crisis funging was this targetted available thing. wR. PETERSON: That target figure is an extrapo la- tion from that and it more clearly approximates the level of activity in the region than necessarily the first column which doesn't reflect in some instance rather significant supplement funds. Maine, for example, had a good deal of activity fund for ae couple of years which now does turn up again in some of these projects. MR. NASH: Actually at one time they were managing $2,872,000 in one year. DR, TESCHAN: I would like to make the point, Frank, if we would be able to have that kind of figure, at least ready during these discussions, that would answer that kind of question. MR, PETERSON: I think we do. Pr Se 44 MR, STOLOV: For every region we have computer funding printout. MR, PETERSON: Is there any other discussion? . Again, I think I have heard a motion, a second, for $1.5 million, and I think if there ls, I would put the guesticn to the group. | Those in favor of the motion? MR, BARROS: Is the $1.5 million based on what you just said is not a significant increase in the level of activity they have been carrying? MR, NASH: No. In fact, it is a decrease from one prior year. DR. HESS: But they have also cut back in staff probably. MR. NASH: No, they maintained basically pretty well staff even througn the phaseocut. They lost ea few, but basically it is pretty mucn the same staff. | MR. PETERSON: I wonder if I could ask the question. Those in favor of $1.5 million? : (Show of nands) i MR, PETERSON: Oh, we are going to have one of these. No, Givided -- all right. | | No, it isn't divided. I am sorry, Sister, and we have got nine people; I was Looking at the eight, four for ena ’ oc © HOOVER REPORTING CO, INC. usetts Avenue, NE. 320 Massach _ mm ANAAD five against. MR, BARRGIS: Could we put the $1.5 million on the hook end come beck to it? DR. HEUSTIS: I think we should do this. Is this motion lost then? MR. PETERSON: Yes, it has. DR. HEUSTIS: Is not column C the amoutn of money availeble for funding this fiscal 1975? MR. PETERSON: That was our estimate at a time when we weren't even as sure @S we are now. DR, HEUSTIS: So it may or may not have any rele- vance to the previous funding levels of the programs? MR, PETERSON: Oh, I see. The column C does have relevamre to the previous funding Levels, Al. We took pre-phaseout Levels, annualized levels, and calculated a percentage thereof, At the time-- it still does, it adds up to 5114 million. At the time we did thet, that was our best guestimate of roughly what we were going to have, and we were trying to give regions a target. It so happened that we are going to, in all likeli- hood, end up with either $109 million or $114 million. DR, HEUSTIS: Mey I suggest if we have to make what I call a political decision, could we lay the funding amounts for each of these programs on the teble until after we nave had a chence to Look at them all, and then we can look.at the i { ' i \ j 35 request, we can Look at what you have got down here and then ye can go through and decide whet can we do to come out some~ where within the available money and be fair. : DR, TESCHAN: I think we could easily indicate that Maine is in the top, divide the regions into approximately three big groups and with the details of the population, and the kind of other comments wehave had. Amd then begin to edjust after we see the total group. MR, PETERSON: Is that the sense of the group that we lay recommendations as to funding emounts aside until Thursdey afternoon, Friday morning? MR, BARRGIS: No, we could strike a tentative figure but L personally don't feel that we are doing justice to these by just picking a figure out of thin air. I have no way of knowing whether $1.5 million is petter then $1,450,000 or SL,750, 000, To me it is just picking a figure out of the air. DR, HIRSCHBOECK: We have to deal with this problem, those who are not applying for July Ist money. | This is exactly the significance here. If we do not take that into consideration, we might be ghort changing them considerably. MR. PETERSON: Charlie. DR, McCALL: I am concerned, as we had reviewed, on the whole, the gaps, the changing situation, and We are 320 Massachusetts Avenue, N.E. | Wiachinatan AE PAG? i { HOOVER REPORTING CO, INC. | t i (eT E ' wi 1 coming here in the last chapter of this program, the structure having.been designated, very fine people still here, but small in numbers, overworked, mechanism torn asunder. And even wher it-was there, we knew there were some inequities and some things that needed correcting, we were working on. It seems we are really taking on something that really doesn't make sense, To think with all those Limitations we are not-- as last gasp, use some sort of judgment, start @ new bench- mark, write all of this in terms of population and everything else, . Not thet I am not for doing those things; it seems to me this is not the coint in time at which we are armed with. end able to do tnet any better than taking all of the prob lems. and our disagreements about them, the former benchmark, and using it es where we start, and then modify up and down in light of what comes in here rather than trying to go back and eo through ell of these and now come uo with some sort of neWwe-- MR. BARROWS: I wrestled with that in my own mind ana ceme up with this general feeling, whether right or wrong, any~ body can say, but I felt we had a responsibility to pr-serve reasonable stability of the program. But we should take away from programs that didn't appear to be able to use this one-time money effectively within reason and give tnat extra money to HOOVER REPORTING CO, INC. 390 Massachusetts Avenue, N.E. ¢ Hiashington, D.C. 20002 i (a3 QO) a9 the programs that are doing the top-notch job. DR, HEUSTIS: Great. MR, BARROS: Whether that is good policy or not, that is the way I came out with it, DR, HESS: And you do that purely on the quality of the job and setting aside any other factors about the region? MR. BARROWS: Well, one factor, the population inequities being on historically, and I don't think we can dramatically change that now in this snort time. DR. HESS: It is not a matter of changing it. But t my mind it is not a matter of carrying that to excess. MR. BARRGIS: I would keep a reasonable stability sa ing treat the average in one way, cut down a Little bit on he programs that are not too effective andgive that money to the programs that are. But not make violence with 30 percent to 190 vcercent. THURMAN: DR, I hope we won't have this emotional king of discussion with each application, A lot of us would like to have more information than we nave to make a decision, yet we have never had enough information at any time in the past to make any better decision than what we have been asked to make right now. I don't see any difference as we sit here, except the unéerstanding the programs as they exist have gone throush living hell as far as from an organizational standpoint. But JF either they have had the relationsnip and capability of doing it, they have known their state, they have known their capsbility -- but the only rationale -- I don't mean that in e derogatory concept. The only rational comment was Sister's because she was there. | To me I am not the Least bit concerned about reach- ing into mideir pulling out a figure in May of 1974 and 1 was concerned in June of 1972 doing the same thing, with the same kind of progran, So that I think we are trying to find an excuse for our inebility to approach something in an irrational fashion when we neve alvays approached it in an irrational fashion. So that I just-- this sheet doesn't mean a damn thing -- pardon me, ledies -~ doesn't mean a damn thing to me, beceuse here is @ program, the people have come in, excellent grant writers; two reviewers have been snowed -- again, I don't meen that derogatorily -- been snowed by this preparation. Sister has said that the people in Meine are interested in it. These peoole have asked for $2 million. They have got one yeer of self-sufficiency for & small population. And then they have got to carry these programs without us. What more do we need to make a rational decision then those facts? MR, BARROWS: I don't say this is going to be HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Washington, D.C. 20002 (ON0\ BAR-ABAA | - without us, the succeeding programs contemplated by Congress will absorb at least some of this? DR, THURMAN: Let's see, if you and I knew the answer to that, we would be the world's greatest -- DR, TESCHAN: What is the punch Line? MR, PETERSON: What is the figure? DR, HEUSTIS: Mr. Chairman, I would offer a motion. MR, PETERSON: Fine. DR, HEUSTIS: To bring this to a head. Motion was for $1.5 million, request is $2 million; T'll be rational and split the difference. MR, PETERSON: Is that a motion for $1.75 million? DR, HEUSTIS: $1.75 million. MR, PETERSON: Do I hear a second? DR, TESCHAN: I will second it. MR, PETERSON: Second to get a vote. Any other comment? Question: How many would recommend -- and IT thiric we do have the sense that all of these are tentative plus, minus king of motions, it is again ea rough motion, it is again-- how many would concur at $1.75 mi LLLon for the Maine RMP? ALL those that do, show their nands. (Show of hands) MR. PETERSON: That motion is voted down also I think, four tofive again. | I don't know whether we are moving in the right direction. Do we have another motion? * DR, TESCHAN: Let me fly this ones 10 percent or more of recommendation to Dr, Pani that he consider Maine in the top group; secondly, that he consider funding at more than the eoproximate ratio that he hes dealt with before, on which these figures were completed, say something like 10 percent or so more than that, on up to the totaLlamount of the application, depending on availability of funds. DR, HEUSTIS: I will support that. MR, BARROS: That sounds good to me. i an) DR. HESS: Cop out, DR, TESCHAN: Sure, it is a cop out. DR, HEUSTIS: As I understand your motion, you are leeding us to put these into ranking things, so that some will be financed more than before, some at about the same level and some at less than figure to be decided after we have all of the evidence, I think this gets me off the hook from making 2 political decision for which I do not feel qualified. I am perfectly willing to make a political decision, DR, HESS: I think that Dr. Pahl wants from us 4 } ‘ i figure and that for us to avoid the need for making that recori- mendation, difficult thousn it may be, even though it feels like we are rolling dice, as we Iike to pride ourselves in, you being very logical, rational people, but when it comes right down to it, you have to take a leap and make some judg~ A i ments, I would say I think we ought to not avoid the re- sponsibility that we have been asked to assume and do it even though we are uncomfortable about it. With that preface, I would like to offer a motion for 31.6 million. MR, PETERSON: We have a motion of $1.6 million. Do we have a second? DR.McCALL: Second. MR. PETERSON: Question. DR, THURMAN: Call for the question. MR. PETERSON: Call the question. DR. HESS: Are you asking for? MR, PETERSON: Yes, for those in favor, $1.6 ini LLion, five for and four presumably against. Okay, the recommendation of this group, by oainful i | process and high degree of tentativeness, is $1.6 million. DR, THURMAN: Fully with the understanding we may come back. DR. HESS: We may come back and revise this. This is kind of a breaking~-in process. | MR. BARROWS: We ere cutting the melon without HGOVER REPORTING CO, INC. ; ! 3270 Hassachusetts Avenue, NE. Washington, D.C. 20002 | . TAN ERO ELLE HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. : Washington, 0.0, 20002 knowing how meny shells we want to cut. DR, TESCHAN: Right. | MR, PETERSON: Dick, you had wanted to say something. MR, RUSSELL: Yes, I was a Little bit disturbed ana concerned during this discussion. It seems to me we are gete- ting two issues mixed up. One is the role @ this group in { t terms of making recommendations for funding levels; the other, as Dr, Heustis talked ebout, was the political part of the decision Dr. Pehl and the Administration will have to make in making the funds actually available. What I heard in this discussion ~~ I have no vested tnberest in Maine whatsoever -- here we have an apolication thet eoparently is well put together, the projects do fit the goals and objectives; historically this program has been very i strong. ALL the pleces fit together. | I think it is that type of information on which thie group should make its decision. | Now, in terms of the target figure where we have programs that don't come across as strong, I think that is soins to be important to look at that, so you do have to take that into consideration. But I really don't think it should be whether or not the actual funding made available will come out as your recommendation. You do have a cnance-- DR, TESCHAN: But, Dick, you are not helping, you 44 ere at variance with the imperatives to come up With a number. Lam comforteble with that kind of ambiguity, say 'nooreh for Maine’ and leave it at that. But if we are under an imperative, maybe we should settle the question, ere we or eren't we. If we are, we heve to go beyond where We ere, MR, PETERSON: Herb Panl's decision in terms of de- ciding signing a grent awerd, statement for Maine with ea figure. thet is going to take place after the Council meets. - I think with a Council that insisted upon a review comnittee, kind of restructured review process, 13 new members thet while it is true that the Council is in a sense the formel recommender, I think they are going to have more aiffi- culty coming up with numbers if we don't provide some bench- mark for them. I think, Dick, et least in our skull sessions, in phe preceding deys, you know, I think we can belebor and overdo the numbers game. And I am speaking personally, not as your chairman. I think we as staff, and Herb -- you know if there ers no numbers, we eren't all that helpful. MR, RUSSELL: I am not saying-- I think you need numbers ultimately. MR, PETERSON: Right. MR. RUSSELL: But the viewers have a chance to rate HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Washington, D.C. 26002 (202) 546-6666 the RMP's. DR, McCALL: I think there may be some abstaining. MR, PETERSON: I am sorry. . DR. HEUSTIS: Mr. Chairman, I object to this. We spent already too much time on this. DR. MeCALL: I don't mean -- I am talking about the future. I am not talking about calling for Maine. In the future. I don't want to go back and do that on this one. DR, HEUSTIS: I have the very strong -~ I like what you said and-I Like what you said and it seems to me even though we heave done it before, and I wasn't a party to it, I may have gone along the same aes you did. But it seems as though if we give him the ammunitia, if we have extra money, this is what you do with it, this is who you give more and thi wa is wno you take away, that is our primary function. DR, TESCHAN: I feel better about that. DR. HESS: He is not bound to use these figures. ee DR. HEUSTIS: Not bound but as he makes the politica decisions, I don't know the gentleman, but being a politician probably to better or lesser degree, and somebody questions iti, he seys, "But, haha, the Ad Hoc Committee, Advisory Council, this 1s what they recommended.” And he justifies in some instances where it is convenient, he justifies it. And he is no different from any governor or any legislature that tries to HOOVER REPORTING CO. INC. 390 Massachusetts Avenue, NE. |. Washington, D.C. 20002 POND BAG BRER ' to make-the political decision. we get a program person to eutb his budget so that he doesn't have DR, HESS: Al, just let me comment on that. ° If I understand the purpose of this ad hoc review, it is to bring some edditional perspectives to bear on these very complex issues and so to ask this group to weigh in our minds es best we can all the various dimensions that should go into decision making about, you know, this national program on a region by region basis And that the most precise re- flection of the summation of those judgments is in dollars 1 at this stage of the game. And that the role that the Director and Covneil are not bound in any way, shape or form by those | recommendations, but nevertheless that 1s the most concrete | translation of judgment that we make. | MR. BARROIS: Pete, let me make a proposal that may simplify tnis whole problem. We clearly have two distinct philosophies on this thing and we are going to be talking about that all night. Could we do this, could we let these numbers come out of the air from the frequent revelation from the record or | wherever, get them altogether, take a look at them when we are all done and go over them and do-- “MR. PETERSON: We propose to do that. MR, BARROWS: Do our equity on it. MR, PETERSON: I feel less concerned about spending 47 | a Little time with the first few applications, because L think this is where we are going to have to wrestle with some issues: and set some guidance to ourselves as to how ve operate. It seems to me there are at least three things thet will go to the Council and Herb Pahl, at least there are three inputs from this group. There is a number that may be tne i ' softest end least offensive. There may also be in most instances some kind of helf quantitetive rating besed on several oeople; and thiraly, there will be the general sense which I hope staff will be able to reflect accurately and which in the case of Maine, quite apart from more or less, thet there was e general, general sense consensus that this wes, all things considered, a com- peretively sood strong program that had Maine stability during the period of the lest 18 months, And I think, you know, it is not as if the number is the only thing we are go ing to Teea him. I think we need to keep that in mind. So we ere triangu- lating. Sister Ann. SISTER JOSEPHINE: Yes. May I say one other thing. I think the 53, out of 53 programs there are only 6 thet are complete, as we are going to review them, that aren't gol: to have enything for the Mey Ist review, or the July ist reviel. I think that thet is a consideration also, we have | to keep in mind, and this is ons of them and I th ink this is HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, 0.C. 20002 (202) 546-6666 very important. MR. PETERSON: Well, I would Like to esk the group at this juncture, it is ten after twelve, our cafeteria is probab Ly most crowded now; on the other hand, by the time you get to certainly 12:45, the fare starts becoming severely : diminished. Not that it is all that great to start with. It seems to me we have got to make a decision either. to go to Lunch now or try to wrap up and let our pellies push us in terms of one more before we go to Lunch. DR. THURMAN: Move for one more. Nobody here needs the fare that badly. DR. HEUSTIS: Who do we give these things to we gon't need any more? (Indicating) MR. PETERSON: You can put them under the table. Hend them behind you and somebody will put them back farther. MR. RUSSSLL: 4s usual, we will pass them on down. (laughter) MR, PETERSON: I wonder if we could taxe Albany. This is an instance where, by virtue of the fact of a recent lest-minute cancellation, we only have one reviewer, Mr. Barrows, and move on with Albany then, since you said you were best prepared for Albany. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, D.C. 20002 ALBANY 49 MR, PARROWS: Thet is a smali tribute to my prepara- tion, I assure you. I think most of us on this committee can make extended and culeatory statements of the same kind that were meade on behalf of steff. I quite honestly had difficulty in doing justice to five spplications. I say that in advance, because if I didn't say it, you would detect it es I went along. In any event-- DR, THURMAN: We won't be critical. MR. BARRGIS: No, but you would cut hell out of the budget. To end the suspense, I have a pretty good impres- sion of the Albany program. It is a @H4-county progrem. The grentee is the Albany Medical College. These were all the figures, but I had to go by them. Budget request was for 31,056,000, Their present funding for half a year was $556,000 so about the same level of funding they ere seeking. The director, Dr. Kraft, nas been with the program since its inception except he has be director since January 1973. The chairman is a retired physician hospital adminis trator. Executive committee represents a wide variety of DY interests and remarkable -- includes education, labor, com- munity egencies, business, and so on. Staff of 7O full time, two part-time professionals. They plan to add two more. Their survivel, staff survival through the phaseout looked to me good, Variance ranges from two to eight years. Regional Advisory Group 43 of them. I noted the director is an ex-officio member of RAG, This is a philosophical tning. I think that puts him in 4 peculiar position to influence the whole process. And fron the looks of the steff, I think this is kind of a one-man type of progran, but that is just a guess. The executive committee exercises planning. Basically the committee structure looks pretty good. | Logical structure, I can't say who dominates from whet is reported. Past performance, the direction has been I think quite acceptable. They made a promet effective response to the '71 change. Their track record is zocd; of 27 active projects since '7l, L2 ere continuing with RMP support, but LO they are flying under other support. Only two have termin- ated. “Their goals and objectives are very well articulated ang very congruent, as the record shows the RMP mission. | The proposal situation to me better than average 5L compliance with thelr own stated objectives. I had more trouble with that factor. nyerybody states the same objec~ tives in glowing terms, then they go off and do something else: put I think they stayed pretty close to their opjec- tives. There is no CHP agency in their area except in Western Massachusetts. They are working with that one. Thet seems to be harmonious. And they are trying to get another one off the ground. So I think thelr CHP agency relationships o ny @ zood. I think they have got a reasonable chance of suc- | cess. Much, of course, is going to depend especially on these prosrems designed to serve the underserved areas. Much will depend on future funding from a variety of sources. Icame up with a good to excellent rating for the total program, I summarize it this way: ARMP has retained ssential strengths. Well managed and well oriented. Proposals consistent with basic RMD mission. Recommend funding proportionate share of what is available, at least equal to past level. MR. PETERSON: You have heard Mr. Barrows’ review. This is one we don't nave two reviewers. Check with Frank, I don't think any people around the table in their prior in- carnations had at least site visited Albany, but I am sure HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Washington, D.C. 20002 t IANAN CAL COCE HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. ° Washington, 0.C. 20002 | i 52 there ere some of you who have some impressions, perheos have ned some specific information ebout the Albany RMP. So before I check witn staff, I was wondering if there is any-- froin the rest of the reviewers, whether there is anything specific or general they want to add to what Mr. Barrows had to sey? DR, TESCHAN: What is the population? I missed it. MR, BARROWS: 24 counties, Metropolitan area -- Albany, Schenectady -~- DR. TESCHAN: I just meant millions. MR, PETERSON: We don't have a fact book, do we? MR. NASH: No, =I don't know. MR. PETERSON: I will have some population figures after Lunch. My guesstimate in the Albany area is probably approecning or over a million certainly. It may be a couple of million. You have Schenectady, Rensselaer, Troy -- you also have a Lot of . Adirondack, without too much population exceot up around the Plattsburgh area. MR. BARROWS: Pushing over a million and a-half. I have one question. Let me just throw out, obvious+ ly, on the basis of my information, it is terribly difficult for me to say what is the proper problems for relating to "other federal initiatives," that is particularly true in the , \ | i DO case of emergencies here. The activities for which there has been $136,000 Looked to me to be fairly consistent in that they were more preparing to get ready for entering the emergency systems program then they were in doing the same things that the emergency systems program I understand is doing. Iam just mentioning that as something that ran through my mind, MR, PETERSON: Franx, do you or Norm have anything--~ there vere 2 number of projects Listed inthe summer here that relete to HMO's, EMSt, et cetera, Are there any significant problems or policy issues that you see posed by these? MR, NASH: I think the HNO, I believe, is @ reasible studye MR. PETERSON: Within our guidelines, earlier policy guidelines. MR,NASH: Yes. Yes, I'd say EM activity is continuing. MR, PETERSON: Something started by the EM legisla~ tion. / MR. NASH: Yes. MR. ANDERSON: Also program activity supports previous approved policy we had; it complements. MR. PETERSON: And I know Albany is one of those places that are few in number now where there is no major 54 (o) agency in the Albany area. There is one they overlap with in the Berkshires, northern Massachusetts. Albany said, "Throw this sheet away!) == not-- ~ figuratively. Albany is a region which, again, we had indicated target figure of about 1.5 million. We have an application here which is entirely continuation, program staff and some projects continuations. They have indicated that they will be coming in with an additional epplication on July 1 for new sterts totaling about half a miLlion dollars, This one, this request totels just slightly over a million. Thus our estimate et this juncture is that Albany will be requesting-- haopens to be e couple of thousand less. dust about thet ~ target figure. But the present application is for 31,056,000. DR, TESCHAN: I wonder, management assessment, re- view verification, if there is any indication whether, in essence, the grantce is behaving according to policy? Any evidence on that? MR, PETERSON: Norm, we did have some problems I know some years ego, but both with respect to review and management, review process has been verified and found in compliance. MR. ANDERSON: -Yes. Right. MR.NASH: Right. MR, PETERSON: Are there any recent management assessment figures? 5D MR, SIMONDS: That is one of the very eariy cones. © That hes been several years ago, would have no relevance to MR, ANDERSON: We here, program staff, support what Mr. Barrovs said. MR, PETERSON: Can you Lift that up four decibels? MR, ANDERSON: During the pheseout period, they were able to maintein pretty much the program staff, Keot Lt | pretty much intect. The RAG did continue to meet on an every- two-month basis. They continued to maintain a stable level of opera- tion throughout this time period, DR. TESCHAN: Would you identify the progrem as being in the big middle group? MR, BARROWS: The big-- DR. TESCHAN: Middle grovp? Woulg you put it at the top of everything you have seen or bottom? oO MR. BARROWS: I would say probably top of the midd Group. I was impressed with something eocerning which f. have mixed feelings, pernaps more then any other program that Ilooked at. They heve addressed themselves to the probd- lems of the underserved. That is a high risk type of activity So prospects of success ere Low. Brownie points for trying to do ea good job are high. I come oit with a sband-off on e.. vw I don't Know how the rest of you feel about this. MR, PETERSON: Are there any more Questions, com- | ments, observations from the review panel members? Staff? Norm? Frank? MR. NASH: WNo. DR, TESCHAN:. Do you want a motion? MR, PETERSON: Yes. Iwas go ing to say it looks Like -- much as I regret it -- now this is e request only for 31 million. DR, TESCHAN: Yes. MR, PETERSON: So I don't think we are-~- DR, TESCHAN: I em sensitive to Sister Ann's point here, thet we have to consider the later -- perhaps after considering the leter-- MR. NASH: Even if you consider what they propose to) come in with July ist, they would still be a little less than the targeted figure if you give the targeted figure any force | MR, PETERSON: Yes. I think here we clearly have to. | i be guided, Paul, by the fact while in Albany and in many, many, others of these,we will be seeing a second request which will total X or Y amount that really our recommendation at this session, certainly tne other inputs Will have a bearing on the second set of recommendations, hopefully many of the same people will be involved, that we have got to Look at this re- guest and make our recommendation in those terms. So that I guess I am saying -- DR. TESCHAN: Motion for $1,066,000 then, approxi-~ : mately. : MR, PETERSON: That is the maximum, Yes, John. DR, HIRSCHBOECK: These request figures include the | indirect costs as well? MR, PETERSON: These are total costs I believe, that i I is a battle I think I have finally wn. We used to show you people direct costs whichwas very deceptive. These ere botel costs, direct end indirect. And that is what it costs to run the Albany program. ! DR, THESCHAN: Do you heve the indirect cost rate? | MR, BARROWS: Yes. Somewhere. MR, PETERSON: Medical College, it is probably in the neighborhood of 40 or 50 percent of salaries and wages. DR, THURHAN: 50 percent on salaries. MR, PETERSON: That is roughly what you are running Ofle MR, ANDERSON: 60 percent. MR, PETERSON: Probably the best guess I will make in three days. DR. TESCHAN: The record ought to snow that is one of the things that kills a program in Congress, And we ought tc raise the question as to whether this isn't -the time for the ve Albany group to recognize that fact, and see whether or not they can begin the staff processes necessary to get them reedy for corporate grantee. MR, PETERSON: This I don't think has ever been actively considered in Albany, has it? MR. NASH: I don't think so. MR, PETERSON: I know what you ere saying. I don't know whether it is even in our jurisdiction to recommend it or to move it, or whether that is our duty; but it seems to me if we have responsibility for the program, for the public accountability of funds, that this is one critical issue. | MR, BARROWS: They will be doing that under any pend - ing new legislation, won't they? ! DR. HEUSTIS: Mr, Chairman. MR, PETERSON: Yes, Al. MR, HEUSTIS: Out of the projects I reviewed, it seemed to me California and I think Maine made no provision that I could see for any indirect costs whatsoever. | MR, PETERSON: Thoe are private nonprofit corpora- tions esteblished essentially for that purpose, so those be- came direct costs. DR, HEUSTIS: This is even for-- MR. SIMONDS: Both of those programs right now are in process of negotlating indirect costs, because they are managing funds other than RMP funds, so if they don't, RMP money is going to be spent on the management of these out side. DR, TESCHAN: They generally pay indirect costs to universities, but the direct administrative costscoordinators put together varies with the years, @S you may remember, and 10 percent being a pretty good figure to put on it, DR, HEUSTIS: I think Meine had a policy, if I re- call correctly, of not peing indirect cost to anybody. I don't know whether it is carried out and I may be in. error. MR, PETERSON: Paul, I think many of the things you say ere true, but I wonder whether the issue of direct cost or indirect cost is something which this review group ~-- it maymore appropriately be a matter of Council. I happened to a number of years ago once sat and tried to take on indirect costs eat National Foundation on the : Arts end Humanities and I nad three university presidents sitting on that Councils Princeton, fellow just left the University of Washington, end Brown. I didn't realize what kind of tiger I had walked inte. I at least at that juncture -- I acknowledge everything you say, but I, one, question whether the review group is really the forum in which to deal with it, and two, at least in the next L4 months, I can see, of some stability, whether it is a policy we are probably going to accept as regions teke it on themselves and many have, but Albany is not one that hes made any move to disessociate itself from @ medical college and sets up a nonprofit corporation. It is a cost of doing business. It may indeed have done the program harm Again, @ personal view. DR. HESS: Maybe the best thing can be done, note in the comment, the question was raised and would be worked out administratively. MR, PETERSON: Right, and I have done that. Did I hear a motion recommending the amounts reques- ted for this application, 31,066,000? DR. HEUSTIS: Somebody made it and I support it. MR, PETERSON: Okay, you seconded it. Are there any other comments? If not, those in favor of that recommended amount raise their hand. (Shar of nands) MR, PATERSON: &veryone. Anyone egainst or abstaining? I think I saw nine hands up. ALL right, we have in an hour and ten minutes -- which comes out to 38 minutes per application -- disposed of two easy applications, ‘So while I am encouraged, I don't think any of us ougnt to set overly encouraged. I think it probably would be a good time to break for Lunch, as I say. DR, THURMAN: Will we finish Soday? MR, PETERSON: If we take some class action. What would be a reasonable time to ask the group bo. reassemble? 21:15? 1:30? DR, HESS: I:15. MR, PETERSON: Can we try and be back by 1:15. We will start with Northern New England by virtue of the fect Joe has e three o'clock deadline. Thank you all so much, (Whereupon, at 12:30 o'clock, p.m, the meeting wes recessed, to reconvene et 1:15 o'clock, p.m., the same day.) NORTH EN TUOW DING uA Seep t ber ne APTEROON SESSTON (LIL7 pem.) MR, PETERSON: We were going to pick up with Northers New England, but I did want to mention 2 couple of things. : Again, on the rating sheets, I am not going to, at least to the best of my ability, let you get out of this room | tonight where you have reviewed a region without letting me have | i ' i those rating sheets. Secondly, to the extent that any of you have, as I think perneps Mr. Berrows did, had some notes from whence you spoke, even if they are in Longhand, I would also appreciate your leaving those with us, although I won't insist upon that. Because there has been a great deal, as you know, of titigation ebout correspondence and notes in Washington of late, and I don't want to get into that. ji MR. BARROWS: What wes that you were referring to? (Laughter) MR, PETERSON: I should also have mentioned this morning that if any of you need any assistance with travel snd the like, I think we can handle that and maybe I can ask Shirley or someone, but to the extent you have got those kinds of prob~ ‘lems, let us have them and we will take care of that. Finelly, and this is really directed to staff, I would appreciate it, for the benefit of Mrs. Chiang, that when steff does speak up for the first time, if you would identify yourself -- not for my benefit, not for most other people, but for her benefit. With that brie, if not lucid, introduction, could we push on for Northern New England, sometimes known as Ver- mont. Joe de LaPuente. MR, DE LA PUENTE: This is an application for the 0 support of program steff ny 1d selected continuation of on-going, projects. They will present some new projects that have a high priority in their July Lst aoplication. The progrem is committed to addressing community | problems and the development of their solutions. By now they | have Geveloced a cardiac care management system, 2 respiratory disease communications netvork, a high risk infant care and transportation system, and a strategy for addressing emergency medicel services issues. Their present thrust will be that of encouraging and. developing community involvement in program development, in progrem planning, and in program evaluation. The region is particularly involved in the continued evaluation’ and improvement of the medical care system, and they are doing it by developing specific guidelines and delivery of selected services. They are doing it through the support of | "Disease management committees” towards the assessment and the) maintenance of established guidelines. And also they are Going | | it through the support of providers engaged in improving their progrems towerds the maintenarce of established guidelines. They have Linkages with the Department of Medicine al ‘the University of Vermont, the State Health Department, the Medical Society, voluntary agencies, and most hospitals in the state, Community support seems to be demonstrated by the continued involvement of their Regional Advisory Group during this period of indecision. Their Regional Advisory Group continues to be intimately involved not only in the managemen of the program, but also in the development and support of sub- stantiel orogram priorities. The Regional Heart Management Connittee, for examole, includes 29 standing members, and they have continued their activities during the Last 1é@ montne. The present core staff includes eight persons, four of whom have edvanced degrees. Their staffing pattern appesre to be very similer to that existing prior to the pnese-out order. The present vacancy pattern may represent an oppor-~- tunity for the director to develop a staffing pattern more consistent with his future progrem plans. : Their present request is for a core budget of $432,800, including $292,800 for salaries and wages. ‘heir request for the seven projects envisaged amounts to $687,000, for a total request of 31,039,670. This represents approximac& 1 | } a 4O percent core staff activities. The core staff, however, is continually involved in the support of disease management committees. ra Their present application is for $1,039,670, It i estimated that their July 1 request may amount to $1,839,670 compared with a projected availability of $1,199,300. I will not go into the cluster of projects. L wes very much impressed witn the type of projects that they have: a regional end-stage kidney treatment program, a project to increase the capability of rurel ambulance and emergency roon | personnel, @ regional progran for high-risk infents and mothers, @ regional respiratory disease program, an ambulatory pediatric care project, a voluntary problem-oriented healtn care information system, and a progrem addressing the sources of communication among school children. Ht _ sesses @ good track recora U if ih summary, this region pos in obteining community support for its activities. They wane to shift their program empnasis to improve primary care and strengthen community level organization. Presently they are involved in providing an environ- ment where quality assurance can become e Living reality. Their present request alone exceeds that of previous funding. But special consideration should be given to determine whether or not the staffing level presently proposed is consistent, both with the activities proposed for the coming year end the level of support that they will probably receive. This is not to detract from haw much I was impressed by this region in terms of hor precisely they develop their priorities, how the project they have forthcoming agree with those priorities. So I have a recommendation, MR, PETERSON: Maybe we should hold that, Joe. MR. DE LA PUENTI: Yes. j ee MR, PETERSON: This is an instance where Dr, James was the other reviewer, but I wondered, Bill, since you had been up there either in a structured or kind of offhand fashic. if you might want to briefly address Northern New Englend and then Ll will ask staff if they have any comment before we open | it up to the whole groug,. DR. THURMAN: I hed your enphasis--- first of all, since ovr site visit, there has been @ change of directorsntp.i The new person seems to be @ relatively strong leader. There hes been stability of a corporation now where there wesnit before, which wes one of the recommendations that was made . at the time of the site visit. | One of the strong continuing strengths as Joe inate | cated was the RAG chairmen who was the strongest person at our meeting, much stronger than the director at that point in time is still there and still actively involved. I think that some of the things that was suggested et the site visit have not truly been carried out and many Of people here know that Vermont or Northern New England had more deta than enybody in the country, including Census Bureau, nm & re And the feeling wes that RMP money did not support that significant way. They have cut it back, but it is still there, sig- nificant amounts in the project they are bringing forth right NOW. | I would second what Joe said from the standpoint community programs are certainly strong as are the disease committees and those have continued to develop. One of the most significant things to me in reviewing this now is that when we were up there before, the state Lialsorcs vere not well worked out as far as continued support for many of these programs, This is now very clearly defined and work- ing Quite well. Steff is quite small. Staff goal, 10 percent of the total money releted to the project, but that doesn't come out in their prooosel. It is written, but that is not the way the figures come out. I th ink the projects in essence show good cause. Kidney project is needed in their state. EMS, despite data base, does not expect, what you expect to show in the application we have in front of us, they. have one of the best high risk infant programs in the country. I think they have certainly met the goals and 63 priorities with this application and TL think that they will with the others. I heave just two concerns. The first is each of the projects is overbudgeted for what they expect to accomplish in a period of time; and tne second is they clearly state in | the application that core staff should be 10 percent of the project and yet it is almost 50 percent of the project. ‘So 2 that I think subsedauent to the time that expense and our group were uo there, this program has made a lot of changes in rete erence to the advice letter that went forward from staff after review committee and Council, And I think that the director is an unknown factor because he is totally new. He was not in the program tnen. I would support everything Joe said. | | | | MR. BARROIS: Could you identify on this List of t i items the ones that you say are-- DR, THURMAN: OO7 has a very strong -- ER, emergency services program has data base information, The respiratory disease is very much that way. And, of course, O37 is pré ? mary data program, And 0306 is again data base program related. to the school system, but was already avaitable to then, So those ere the ones that still have a heavy -~ that is nothing -- when were we up there, '72 August, you should have seen it then, It was nothing but one floating base of deta. So I think this program hs come a long way and certainly ry deserves~-- MR, BARROWS: You say these items are too fat in thes date budget? | , DR, THURMAN: Yes, sir. MR, PETERSON: Let me ask staff, before we fully open this up, as to whether there are any particular concerns or policy issues that we see posed by this application, which I would hesten to point out is essentially a continuation of program steff and some ongoing, previously ongoing projects. It totels ea little over a million dollars. We have an indication from Northern New England that they will be in for elmost-- for roughly ¢800,CO00 worth of activities, all new, with their July submission. So that it is a little difficult, I suppose, to deal witn wnat is no more than 60 percent of what we anticipate, although this is sert of core and on-going ectivity. Spence or Frank, do we have eny particular informa- tion concerning the policy issues? MR, COLBURN: I have no kidney, PSRO, HMO, I don't think we have any conflict with policy. MR, PETERSON: Okey. Frank. MR, NASH: No, I don't have anything to add. MR. BARROWS: Let me ask a question. MR. PETERSON: Okay. (Vv MR. BARROIS: The continuation request is based on some things that have been suggested, are really not ail that productive. | Does staff have any idea what is going to come in or Will they zero in more on immediate needs? MR. COLBURN: I didn't. MR. PETERSON: Spence probably has been away from DRMP, away from us-- MR, NASH: Most of these regions gave us a projected doller figure of what their July application contains. DR, THURMAN: TT think through their application, you feel strongly they are coming in more in the priority line. It never specifically says that as Frank seys. Bub their proposals that they are discussing in the distance in their actual epplication for continuetion indicate that they will pe much more in the Line of priority, rather than tals ELOuUp. MR, BARROWS: I take it you would be ineLined to be more generous with what is coming up than what they are asking fochere. DR, THURMAN: Correct. I eam interested in seeing what Jce's proposal is. I think I would be different. MR, PETERSON: Are there any other of the reviewers who have comments, Questions, observations? DR. HESS: General policy question about renal, in the material we were sent ahead of time it was indicated that | this is an area of at Least decreasing concern as far es RMP, . | because Social Security rules, end so on, permit funding there, Ana yet, on the other hand, wewere told this morning that, you know, their restrictions are essentially lifted, so whatever was being done two years ego could still be done now. In this area of renal disease, what is permissible and what isnot is still a Little fuzzy in my mind. mr. peterson; let me try to clarify that, although I don't think I can stete it very felitiously. There wes, of course, with the enactment of HR-1, the extension of Medicare to really cover most end stage. On the other hand, most of the RMP activities, both prior to thattime and now, are more aimed at resource development, training, end some other aspects. One of the things that we have es a matter of rou- tine, I guess, in the earlier award we made, sort of a formule basis during the past year, have had to do, is, in effect-- here I am groping for words and perhaps some of the other staf? can be @ Little more clear on this. | As you know, under the Social Security, those Social Security amendments, the reimbursement for the actual end stacs treatment, dialysis, transplantation, is restricted to certain approved facilities and if facility is not eoproved, they have. } to request an excepbicn under what are stili interim regulations I believe. In the process we have, in effect, told regions thal before you go shead and fund anything, you need to make sure vis-a-vis that particuler institution sponsor, eb cetera, that this is a facility that either hes or-- you know, the kina of approval for reimbursement under Medicare or is in the process of getting an exception. | I am not sure that really answers your question. | But we certainly -- we have not in our previous aoprovals nor is clearly in this case, we have not said end-stage kidney activities are no Longer eligible for support. | I do think we probably, even if the progrem were to continue, RMP, for two, three, or four year, we would probebly 3 see & Gownswign in that es reimbursements arrangements begi to possibly begin to pick up the other costs, the kind we neve, We, of course, pay for little or nothing in the wey of direct patient services. DR. TESCHAN: Maybe experience would help; that is, as Pete has been pointing out, the HR-L primarily has addresset reimbursement. Indeed, they have tried to get a quality because of the limitation of wnere centers 6re. The instructions we have here I think are very ex-~ plicit in saying we don't fund things that willl result in nev facilities being constructed, or new services made available without prior clearance with SSA, But what all that discus- sion Leaves out is the enormous piece of work that nothing covers, that has to do with building relationships between cen- { | ters and organizing some kind of ratlonal patient flow, so that the right kind ofpatients relative to their stage of renal | | disease reach the rignt kind of talent and facilities. And that whole thing has to do with the community end and educational function which I don't think can be paid for under SSA so far as I can tell, although I notice your comments just at the end there, thet is very-- I mean, if that is substantiated, thet is greet. We were wondering where additional funding of those things is. We were concerned SSA, in dealing with these tnings am in the regulations, totally ignore one of the most impor- tent contributions; namely, the organization of the patient fiov. And we are disturbed about that. It seems to me there | | is a big job for RMP to do in that | | DR.HESS: I wes a Llittke confused about that statement because RMP never was,or supposedly, in business of subsidizing t direct patient services, although in a sense they also were. t | Any time you train people to care for patients to some extent you are subsidizing it, but the bulk of it was in. organizational wor developing a plan, the working oub of-- collaboreting relationships this kind of thing we are talking about. I have, you know, wondered whether if indeed that was being picked uo by some other mechanism. So it is just uncleer,. MR, PETERSON: I think our concern, RMP's concern at this juncture is thet the kind of what you referred to as indirect subsidization sort of activities not continue or be created in an institution or facillty that doesn't have or isn't Likely to have the patient care reimbursement under it. A sidelight, if you will, it is nob relevent to this application, put there is almost a separate quality of care, many PSRO srrengements being established for end stege renal diseese treatment. And thet is what Spence and some of the steff left here are working on specifically in BoA, We find thet in many of the regions, these local re- view bosrds -«- that is I believe what they are called, Lent it, Spence, but they really have a quality essurence function among other things, that local review board at the regional level will be handled ovt of the HEW regionel offices; that in many regions they are turning to existing kinds of Rilp arrangements, resources, people that have been collected to stablisn thet. That is not true across the country, but certainly in some states -- I recently wes in California where there would be @ number of such local revicw boards. And thet pro- cess is being greatly facilitated by the kina of planning resource develogment end people have been pulled together under the aegis of the Celifornia RMP in connection with some aaa of its end stege renal disease activity. We have had reviews by Joe and Bill. Are there any additional questions, comments from the other reviewers or from staff? DR, HEUSTIS: I would like to hear Joe's recommenda-= tions. MR. PETERSON: Yes, I am sorry, Joe. Thank you all. I don't know vhet I would do without yous (Discussion off the record.) MR, DE LA PUENTSS: The cheirman will have to eneck me on this. But it would go something Like this: Thus 3700,000, at thisstage of the game, with strong recomnendetion for maximum funding on the July L application, if they ere the types of request from the size of our expec~ tation. | MR. PETERSON: Let me make sure I heara that; more importontly that all of the othew heard it. $700,000 recommended at this polnt against a slightly over SL million request, but with a strong corollery recommendation that the anticipated $800,000 request that we will see in July and you people will be Looking at then be looue at if the proposels ina very fair light; is that the sense ofr MR, DE LA PUENTE Yes, that is about the size of it. DR, TESCHAN: Second. MR. PETERSON 4 ww cT > CG by oO o 3 6 2 hs aw QO < a ma fee Oo pn) Oo pany cr ty 0 cr caw Yes, Al. DR, HEUSTIS: I was not doing the fire part. Only thing I know about is what I heard you say and what I read in the staff document. But as I looked at the staff document, | at the numbers for the projects tnat were indicated as having pernaps more then their necessary sehre of checks, Lt adds up to @ substantial number, | Then I Like what you seid ebout the program steff perheos thinking twice about filling the vacancies and reacting to the other, and it seemed to me that maybe you were being em | a little senerous recommending $700,000, | The figure I hed tentatively written down was $600,002, Iwas wondering could I have your comment as to why you chose the seven rather than perhaps six? . 2 MR, DE LA PUENTE: In the solrit of having them make their own choice, $100,000 figure I had in mind, to per t them to get staff if they feel it will fit with the new he Ia projects that are going to come out in sucport for them, giving. them sort of the benefit of the doubt. So they can do their own administretion. And not fully eaying go and fill all the vacancies and go full fledged. But that was the only reason, (7 DR. HEUSTIS: You are not bothered by the 25 percent for program or central staff rather than the LO percent which they cay in the document? Or did I misunderstand you? MR, DE LA PUENTE: Tell me that again. DR. HEUSTIS: I thought I understood you to say the written document said for their central staff, they were In- terested in having about 10 percent. Did I misunderstand? DR. THURMAN: That is correct, I said. DR. HEUSTIS: 25 percent according to the document, 50 percent, 430 -~ not quite 50 -- out of a million, 42 percent. Does that not bother you or didn't it bother you whe you msde your recommendation? That is probably where our gif- ference 1s. MR. BARROWS: Discreoancy of that magnitude, I wonder if there could be an error? DR, HESS: In the eccounting. DR, TESCHAN: First of all I think unless you have ét enormous prosrem, primarily contractual work, to run @ progren on LO percent I think would be a little unusual, especially when you see the develoomental ectivity staff should be in. I think 1O percent would be unrealistically low. DR, HEUSTIS: Ien not disagreeing, but this is what they seid in their progrem, This is all I am going by. DR. TESCHAN: I think that would be a mistake. DR, HESS: The total steff is 14 ceople. Bulk hes to be for programmatic activities, not for staff personnel. MR. DE LA PUENTE: This is what happened,the way rT figure before is sctually about 4O percent of the management core staff activities, however the core staff is going to be continually involved with management committees, which is a programmatic issue. ‘So whether you call Lt a@ program or core staff, council -- they support -- it is a group of staff that spends en awful lot of time with these diseased management committees and they give them other support. DR HEUSTIS: Is 40 percent too much? MR. DE LA PUENTE: 40 oercent would be too much definitely, in my opinion, if it was just staff managing the _ projects or being supported by the RMP. tf it is the steff doing what I call intramural support and supoorting some of the activities, then it is not really 4O cercent, probably comes down to 20, And that was the reason I looked at it. DR, HEUSTIS: I don't care to pursue it. MR, PETERSON: We do have a motion, $700,000, which | has been seconded with the caveat that the favorable cast towards the July recuest proposal subsequently warranted. 1 guess there is @ concern of the group that the $400, 000-oLus may be a Little on the large side certainly in terms of the action taken today, but again if one looks at the $600,900 request which may be coming in that that perhaps could be expressed. Are there any other comments? MR. DE LA PUENTE: I would Like to include in there | i | | | | | | | comments of Dr. Heustis, concerning personnel situation in tne ward problen. MR. MR, MR. | know how many projects they will have to manage until their new activity PETERSON: Okay, that concern be expressed. DE LA PUENTE: Right. PETERSON: Particularly until action -- we don't is looked at in July. You know, it is possible the group's action would be Oo much less than what they request in July. i 1 Certainly that concern I have down, Joe. MR, MR, questions, may I have the question. Those concurring with tnat recomnendation raise their hend. (Show of hands) MR. DE LA PUENTE: Okay. PETERSON: If there are no other comments or PETERSON: That is everyone, including a weak "vea" from BiLL Thurmen or tired riding on the airplane? DR, MR. THURMAN: Tired. | BARROWS: If I were the coordinator, RAG chairmen up there, I would very much appreciete knowing the basis Lor our conservatism on continued funding and basis for relatively optimism on future funding. Will that be tronsmitted to them? MR, PETERSON: Let me make sure. I see no reason | that it wouldn't be. The basis for the less than requested wees still a concern with the overly richness of the data involve- ment in some of the projects. | | Is thet correct? Is thatan accurate reflection? : WR, DE LA PUENTE: ‘That is right. | MR, PETERSON: ALL right, having disposed of Northern New Englend, I would Like to suggest we try to move now to Joe, your moeting Lents until three. You are more than welcome to stay until then. _ On the otner hand, I am going to avoid bringing up any other regions this afternoon that you are reviewer on, £0 if you do want to lenve, feel free to do soa. He will be here tomorrow, I assume that. ! DR, TESCHAN: I am not ready to taik about West Virginia on the basis of the epplicaticn. I would have o little bit of past history, you know, previous contact. MR, PETERSON: I am not sure what you are sayings. DR. TESCHAN: I think it would be better if I hed a chence to reed the application. MR, PETERSON: Okay, What you are saying 15 we oust to put West Virginia until tomorrow. | We heve to get it in the morning, because Charlie McCall is going to heve to Leave I guess around two o'clock. DR, TESCHAN: Be happy to accommodate a busy collezsus. MR, PETERSON: Well, if we can't come to grips vwit-- if you prefer pubting off West Virgina until tomorrow morning, Iemwilling to do so,if that doesn't pose any problems for Cherlie. I wonder in thet case, though, how ere you fixed with Connecticut? DR, TESCHAN: Fine. MR, PETERSON: Because you are also a reviewer there. I thougnt since we were sliding with the easy ones, maybe we ought to teke a Look at Connecticut at this juncture where Al and you @re the reviewers. Al, you came second last time. I will let you lead off.this time with the nutmeg state, DR. HEUSTIS: Thank you, We Wii 2b oe Ue - | - saqtem te . ee m8 aah | DR. HEUSTIS: This application from Connecticut | { is the first of two epplications, and together they anticipate . | | | that these two amounts of money Will approximate $2.6 million, The current request provides for one year for centre lt staff or core steff, or progrem staff, which IT think I am using all interchengeably, although I know there are some Little tnuendos as feras differences, And there is approximately 50 percent level of increase requested for the core staff over the level, pro rated level of funding in which they have for the first six months of 1974. They have some two months request for continuation in fety each of 13 specific projects in eight program areas. ‘The only program area in which they have more than one project is in the eres of hypertencion, where there ere five. I hed some problems witn this document. I found it to be written in extremely gencral terms with very minimum attention to process. There was much recetition. Also it referred back from one plece to another, something that was allegedly covered in en earlier section. Some important things. And I just- : when i checked back at the earlier section, I had great difficut in finding. I couldn't help but get the impression they were trying to use ali of the right words they thought would Lmoross people. I couldn't help but getting the impression the Regional Advisory Group was following the lead of most people that were requesting projects and staff as well, rather than providing any direct and strong leadership in program develoo- ment. I saw no great evidence of any real central staff involvement in a true leadership role. It may well be there, put I just wasn't able to see it. . The predominant leadership seemed to come from the chairman of RAG. I hed to base my decision on he is: the fellow who responded to ell the problems and his response seemed to me again was not really how to adjust to the oroble:n or how are you wrong in bringing up the problem, but kind of why digvt you come to the meetings and if you had come to the _Ineebings, you would know all of these things. I could be very sympatnetic with his point of viev, but it didn't seem as though he really approached tnis grouo. Now, the Regional Advisory Group has been a well- rounded conpliment or woresentation including the reoresente- tives of 5(b) and the 1(a) agency that I could identify. One other reoresentative of a planning group on it. It was guite obvious that they, at Least at the time this document was written, they hadn't succeeded in getting comore- hensive health planning to understand or appreciate what tney thought they were trying to do. There are mony Letters from the planning foiks that helped to bring this out. They do have @ high med Lun and tow priority desig- netion or reting system for both accomplishment and for the request. But there ls no summation, whatsoever, that I found. It may be there, but I didn't find it. But no infor- metion whatsoever as to what kind of criteria they used for nigh, medium and low, in this eree, And it came out that most of the ones as far as they requested were high. I think eight out of the nine. And as fer as progress, there were five, and four or five highs and four mediums, There weren't any Lows. Then it referred to seven states hedpriorities which I hed one Gevil of a time finding. I finally found one tiny paragraoh in the middle of a page in which some very general 3 things were said about seven specific areas, but there weren'? t any specific short-term oriorities or objectives by which these seven important areas could be implemented. It is a new process which involves 4 number of com- mittees in the RHA and cays this took place over a period of time, and I certainly read by inference that there were meet- ings, that therewos a process. But very Little information about them, While quite a bit was made of the complex of workable system of regionalization, they were trying to carry out comolex yet workable-- (inaudible) -- and formal network }of cooperating institutions. . The reference to accomplishment was in very genera. terms. | I gathered that some of the projects which they hed started they continued funding, but the extent as well as the meaningfulness of the effort was unclear as well as it was also unelesr es far as continued funding as to which areas this hed elready occurred in or which area it was hoped for. | In general, Iwas not impressed with the staff activ.~ ties. For exemole, the central staff, as far as the raterial that was oresented, and on specific forum, it said something epout the staff plans will repidly unfold against becksround oc: the CRMP's program facilities and strategy and will further Gee CRMP's responsibilities to emerging national oriorities. This kind of language doesi't say very MUCNs Material reported what the stafr had done. Golly, it seems to me they must have done more than they wrot Gown. They developed 2a good staff. They achieved some alternate financing of programs, staff skills, assured centrel direction. They did do some plenning and specifically mentiones hypertension orogren end they claimed more effective coopera- tion with CHP. But egain, the nebdulousness of it all bothered INS e In rating, in thinking about this, fortunately Connecticut was not very nigh on my List. I rated program leadership from poor to adequate, equally unkind to program staff. Regional Advisory Group, except for the review pre- cess, gave the same kind of ratings for past cerformance end accomplishments, objectives and priorities, and feasibility-- beceuse I couldn't tell whether these folks had any feasibility of doing whet they said they were doling, because the thing thet I suspect is that in complete contrast to Maine, they must be doing some things they just did not put into the aopli- cetion, they just must be. I rated th n s as e poor application and as iar é& be _funding mechanism, we Will get to in a moment, it seemed to me they ougnt to be on the very short end of any funds that might be evailable and so forth. MR, PETERSON: Okay. DR, HEUSTIS: I did -- I was disturbed. Connecticut wes the first one of the five which I nad that I Looked at. I was so disturbed by it end by my reaction ~-- I guess I was disturbed by my reaction to it -- that I went pack ani took this sheet which we have here, this review sheet, end some of the criteria we used, and some of the background Judy hed, made myself a chart which I endeavored to not only pick out the main headings, but every one of the subhesdings the paragraph and tried to rate these good, fair, and poor, to see even though this Vas 8 subjective evaluation, was there eny -- were they just being too unkind. And it just come out the same way. Iam sorry, but that is the way it imoressed me. MR. BARRGIS: Doctor, let me ask a question for clarification. + Are the G se deficiencies you speak of, do they apoear mn to be the end resuit of a lack of leadership and management I I eaosbility and stafi? | DR, HERUSTIS: Yes, sir, and the RMP, i Again, I hope I thoroughly qualified this, all know is what I reed. : MR, PETERSON: I think I would Like to ask Paul, who r was the other reviewer on this, if he has what he would like to oO Q Oy cr oO een cT o I know, for example, Jonn Hirschboeck Was on a site visit 104 years ago in Connecticut. Paul, what do you have to add, subtract from, wheat you have neard Al say? DR. TESCHAN: I would like to add a couple of -- oh, supplementery points wnich will not change the basic tnem r don't think. | First ooint is as you read Connecticut, it is unique im my experience, having talxed to the predecessors of the oresent group also, in thet its basic ohiLlosophy says if health cere is going to be approved in a state, in any region, it is going to be done throvgn orimarily interinstitutional netwous starting from the university centers, and througn feculty type and educational contacts in community hospitals. If heaith care is then going to be benefitted as individual consumers in the state recelve it, it is going to be by those consumers coming to those centers influenced by this network. That is, there is virtually nothing other than tne outpatient department of the hospitals in which the full- time staff have been impressed by the orior history of Connec- ticut RMP. The individual amouleatory patient is going to be particularly penefitted, that is not quite true, there are exeeotions. But the overall driving basic thrust, that progren apprrently has been monocnromntie like that, at least as a funt- amental concept. Ib is quite different from many other Riri's. And I gatner Harold, stan Olson probebly had wrestling matches on this seme subject, but if anybody didn't know chat about Connecticut, that is one fundamental piece of it. Now, it followed from that that the budget has certain characteristics. It follows thet if you work at it you can find out of requested total amounts -- and my figures ere a little different, they are edded up a Little differently-- out of approximately, I came out with e figure of 942,000, you can find annualized rate, thet is this 1s six times the tuo-month rate just to get an annualized rate of their application. fo get out of 942,000, you can find about 180,000 that appears to be outside the immediate jurisdiction, elther of the CR&P staff or of Yele, or of the University of Connecticut. Thet is, how far out I don't know. I don't know whether this institute for health manpower is not a ehild or progeny of the universities; it may be. Could very well be. It mey be the EMS, I can't find the sponsor to be sure. It is stated as Yale University. It is a committee of some sort that appears to be a. _ sponsor. I ean't tell whether thet is a child of the univer sity. Otherwise, it appears all the cash is flowing into and throuch the universities and is not turning up witn inde- a7 QO pencent applicants or independent group. So you have to sort of figure whether you buy the fas uy eo ohilosopny end if you don't buy the philosopny, you are clin uphill eseinst the X years of '67, seven years of precedents thet istuetion, co that is one main point. ?) The other point is that the staff is missing a roy 7 A controller and is missing an evaluator. And our feelin G9 that those two seem to be critical. There are, you know, oo raise serious question whether the staff canmenage the business Jide a of the progran. TI would agree fully that the RAG chairman appears to | 4 t be the active person in Connecticut. Everything seems to hinge eround him and his activity, that that CHP is a disaster, | obstruction. | | I thought whoever wrote those letters in reply at ! leest, among all the words, seemed to do a professional joo | ebout Lining up the facts. I agree with your comments on the: argumentative nature of it, But there were I thought a good : deal of professional stence, documented, and seemed to be well done. : DR, HeUSTIS: CHP? | DR. TESCHAN: No. Many of the eveuments CHP brought vo were after the fact, almost written in Ignorance, bec use he was eble to show in that CHP's own district CHP members hec been contacted. Interview indicated that. Well, coming out to the other end of it, there are minor differences in the ratings. I felt that the feasibility was probably oretby high in view of a seven-year precedent that that kind of activi- ty does work, If I buy that, my problem is, 1s it 2 performance Does it sgeto up the pike? I think if you ere this far down, activities are ( feasivle, I looked at a below-average rating. However, I felu yh | Somewhere between 80 and 100 percent of the program staff funding, thet is two-year extension and year's extension of staff, either somewhere between 80 to LOO percent of that was at this point a reasonable step in order to carry them throusn, at Leest to their July LI application, with the contingencies that the steff positions be recruited for. And that the new application does need to be considered in terms of widened participation and initiative come in from elsewhere. I also feel the domination of university, which obVicCus- ‘Ly fron every corner of the thing, the theme ought to be estab~ lished as a precedent, it ougnt to be underteken, running by itself. And the eoolication orojects are primarily involving -students of varicus sorts doing orimarily theoretical studles, | rather tha heving something actually happen. So I think that, you knov, I would move to change the grantee and to get this influence totally excised in the course of the next Little bit, and to shift this thing over to a situation where other epplicants will have a chance to begin to do it. MR, PETERSON: Does that-- DR,. TESCHAN: The alternative is to stop the RiP funding. That is possible to do. MR, BARROG/JS: Do any of you fellows see any erospect of turning this thing around? (Laughter) MR. PETERSON: I wonder if I might help-- DR. TESCHAN: Guestion, turning it around -- if you mean turning it all the way around, £0 that all--~ MR, BARRGIS: Even sort of in the direction -- DR, TESCHAN: -- all the habits of the seven years are reversed, of course, is absurd. But I disagree with the notion ve are dealing with 4 LT wouldn't make this suggestion if I Chougnat this were & one-yeer orooosition. Lest year wedsalt with it as a one~ to three-year oroposition. I don't think that is right. e ao MR, PETERSON: I wonder if I might do this before I ask steff to comment, there may be one or two staff comments | ‘ then throw ib open for broader discussion. John, since you were on @ site visit, which was mede when? | t | DR. HIRSCHBOZCK: I think three years ago- t l MR, PETERSON: That Long ago?. ~ Everything hes been @ year and a-haif, two years ago. i DR, HIRSCHBOECK: I have to agree with most of) what Paul is saying, although I must say the grant idea, when RMP went into Connecticuts, it hed a good test, idenbtifyin:s every hospital in the nools with medical schools, 50 4 D o> full-time person is linked with the recical school and thet hospital, whether that is a workable thing in the United States. Whatever results have occurred Will perheps give the. eansven There is something thet has happened I think, but whether this is going to continue in the way that Clark orig-. inaLlly thought it was going to, of course, is not the case. I am particulesty impressed with the fact they etLLt don't have anybody in evaluation and their staff is lean. : -This is the major criticism, This is pretty much @ one-man show, es Dr, Clark left shortly after that. Morse is his Geputy. He has folloved through the sameway. So I don't think there is much more to cay. _ MR, PETERSON: Frenk or Spance, are there some specific things here including the CHP which -- at least one of then ~- MR, NASH: I think thet was the major thing, CHP really -- yes. MR, COLBURN: With regard to the chief of staff, they are not supporting those positions eny more. I think this request is to bring different chiefs into networks to exchanse. DR, HIRSCHBOECK: J. might say too, there was an on-~ going fight with the medical society. I don't know how that wlil end. 94 MR, PETERSON: It hasn't resulted in the seme pyrotecn- niques, letters -- they were more adv anced, they sent tele- grams to the Nationel Advisory Council. Nobody has phened us yet. Maybe because we don't have a phone in this room, I donts KNOW» Paul, I think, made one important factual kina of point. We are Looking here at a request which is essentially to continue e numberof on-going programs for just two months. DR, HEUSTIS: Just two months. MR, PETER RSCN: And then to continug somewhat exoand not a great deal,core staff,and we will orobably be taking 4 Loox et the lerger portion of the oleture in July. So that I think L nave heerd both Al end Peul, and some of the other “comments, I have phrases down like "Nob impressed, treuplea, below avereze rating, short end of funding.’ That certainly, I think we have got a cast as to how we would look at that larger portion in July oernaos. But we are looking at a relatively modest oortion in terms of duration and amount of 1 funding in this partic ular acgolication. Other comments, observations? DR, TESCHAN: Thet suggestion is to fill those vacen« cles. I think the waluator has to be in there. That is tre point. I Like the idea they have hed the evaluator separate from the planner inthe staff, 5 MR. NASH: ODr. Shan-- 1 think this Ls probably Dr. Clari’s evaluation on eveluation. He didn't want a single individual on his program staff to have that responsibility. I don't know if this comes through in his applica- tion, but he relied very heavily on the program planning, program setting, prioritizing, evaluation of activities, on a review evelvation commitee. I think another staterent should be made about this _region, they ere to be processed, certified by RMP. The basic reason is the staff aswell as previous site visits, almost everyone who reviewed the program agrees the evelvetion committee in Connecticut has done in the past end appears to still be doing those fucntions that we feel a resional edvisory group should be doing. For thet reason they have been so advised of this, or withheld their due process for that reason. DR, TESCHAN: I think you know my reaction to that would be that funding becontingent on getting that squared awey. N MR. NASH: It concerns me a Little bit because-- I certainly understand the concerns of this review group here because we have them also, but if you look at the current application onthe one hand and try to take action based on thi application to make seven yeers' history in that region, this { Pi o would present me a problem, perhaps Dr. McCail one, if this ic what the grouo wants to recommend. I would think the July application might be 4@ better olece-- t DR, TESCHAN: I think if it were approved in July, if wevere to look at the Connecticut application, and recom- mend funding thet show the ramifications and other issues turning up, IL think the message would be spelled out in dol- lars, spell it out. MR, NASH: Yes. MR. PETERSON: Any other comments, observations? DR, HEUSTIS: Is my arithmetic incorrect there + as a 50 cercent increese in the money, ona pro rated basis, re- _Quested for the central staff? MR, PETERSON: Iwill have to ask Prank or-- DR, HEUSTIS: Eveluator for tnose two important positions, I wonder what the dollar may be. They may well have made @ deta-- DR. TESCHAN: I don't have the data. DR. HESS: Is the funding sheet available, printout? MR, PETERSON: I thought you were going to ask a question about wnat wes the arithmetic really added up to? I was reminded of Mark Twein's man who only spelled a word ! one wey. DR. HEUSTIS: So six months award $168,000, one year request f MR, at it, elgnt t af or 3479,000, whicn at least according to my three times thet, or 50 percent. PETERSON: It doesn't seem right just Looking o twelve kind of junk, but I must say I am not thet fenitlier with the DR. I heve no UR sim months. MR, PETERSON: MR, BARROWS: 395-4755 DR, HEUSTIS: MR. BARROS: MR. COLBURN: in progrem starf out of program staff, rather than a That is whet i HEUST BARROWS: is] ve toi is Gue to the fact Staffing figure. Maybe there are other factors in this. bresidown than the total amount. On this sheet you show $297,000 ¢ I have that sheet, tog As compsred with what we are asking ' LT heves158,000 for six months. Summary orogrem to date. I knov one problem. One of the incre DHS activity was TPundea separate project. it has been for seven years. . DR, as the AM LATS NLEN @ DR, oo wee Sn Ae wo -DIS HE SUSTIS: COLBURN: 4 . ToC HAN : to Limit tn Oxay, Can some approach be made as at for two montns also. I think itis being done. It is a two-month figure. I am Looking on page 3. I see tne cattern is consistent with wha ety ny ny hod ne Pag MR, COLBURN: Pege 32 DR. HEUSTIS: Page 3, bottom of the page, $158,000 for six montns. | Next to the last Line above the total. And . 3479,000 for the full year. MR, COLBURN: Yes. DR, HEUSTIS: $159,000 times three is three undred m times =-- aimost 5479,000. MR. COLBURN: Oh, this request is for 14 months and _for projects for two months. ! In other words, take orogrem steff through 3675, 000 ° through June L975. MR, PETERSON: How could it be-- MR, COLBURN: C wa MR. CCLEUAN: It would be 12 months then, 12 montas oc: steff, two months for projects. DR, HEUSTIS: Something we don't have to worry atcul. I neve concern about it. | DR, TESCHAN: Do it right. MR. PETERSON: Yes. We always seem to be embarrassed. by numbers. Whether it is the Maryland Lottery or what have ; you, ib is never the right one. Given the nature of this application, which is for ae progrem eteff for 12 additionel months, but the limited number: of on-going projects for only two montns, thus totaling $637,000 volume, does anyone have a recommendation as to emount either of the reviewers or somcone else? DR, HEUSTIS: Would you care to commit yourself? DR, TESCHAN: Sure. I move to fund either between 50 and 100 oercent of the emount requested; namely, 80 to LOO percent of $636,220, with hopefully the conveying to-- perhnsos it is too Late to convey to the group concerning tneir July L apolication the concerns we have about it. DR. HEUSTIS: Do you feel strongly about the 80 to 100? Whnet about 30? DR, TESCHAN: I would be perfectly happy with 6&0 percent, oS x e ox co wR rH KH we id QO oe] 3 suggort 80, I would have trouble with 60 to LOO. DR, TESCHAN: The only reason for the Latitude, I know, snthly mnypotheticel a situation, The other feature, | if the funding doesn't have all the money needed to get these people for-- I feel tne salery Levels I think hypothetical -- DR. HESSL: They certainly have the option within the total funding esckage to reallocate. DR. TESCHAN: So SO oercent is fine. MR. PETERSON: GO percent if any aritnometic is worth @ dime, is ebout 5509,000, somebody had better check me, thoush ) LUY on that. DR. HRUSTIS: Did- you: make a motion? DR, TESCHAN: Yes, I move 60 percent fund of the request for a month. MR, PETERSON: We will say 5510,000, DR, HESS Theat is somewhat Low. oe MR. PETERSON: Your feeling is that is Low? Thet is e recomnendation. DR, HESS: That sounds Less than 80 oercente. LT eam questioning the arithmetic. DR, TESCHAN: 508,000. DR, HESS: You dropped it by one-sixth? DR, TESCHAN: It would be a fifth. DR, HESS: Okay, I guess that is right. MR, PETEACON: Is my arithmetic at fault? ' DR. HEUSTIC: No, DR, THURMAN: Second. DR. McCALL: Second thing you have done right. MR, PETERSON: Was that a second? . DR. THURMAN: Yes. MR, PETERSON: Is there any other comments, discus- sion, with respect to Connecticut? We have a motion and a second to provide funding, $500,000 -- 510,000 for this particular application, rocornini that a major additional amount, if IT can read, nearly BQ miLiloe j | ! ig anticipated in the July action, so we are dealing with the | | i Jy bali of the dos » et this juncture. C If there is no further discussion, let's cali the avestion. Those in favor of the recommended amount ? (Show of hands) MR, PETERSON: Unenimity. Okay, there is no need to asit about those who are against or those who ere abstaining. MR, BARRGIS: Agin, in order to seve a lot of extra. work on their cart and agony on our oart, it would be epprop- riete to tell them this future discussion would be contingent on | change in direction, | DR, HESS: Not change in direction. ALL they can | do is be more selective then they might heave been in what tney! submit, because they have to submit whet is already piped. One of the things so emusing ebout this discussion i: ve have two new reviewers who hadn't reviewed this region be- fore, they come up basically with the same answers iL have heard twice meype three times. There have been strong messages, including special site visits of that region, trying to turn them arounad, end it goes on and on. The comments, trying to turn this around one yeer, before you end up funding, is totally out. ALL you can do is cut off disapproval to~- DR. HEUSTIS: Help mese out. DR. HESS: Help them phase out. Evaluation, You ere not going. to get evaluation that means any~ thing in one yeer. MR, PETERSON: What I gather Joe is seyins, we are StLLL continuing to send @ message of essentially the same Kind. DR, HESS: Yes. Thumbing your nose in a sense, all direction they have gotten from the review committee, Council, staff, all the way down the line. DR, HEUSTI tw : Still give them 80 to 100 percent. MR, BARRCTS: Pete, how do you answer a phone when Senator Ribicoff calls up? MR, PETERSON: Cerefully and courteously. (Laughter ) I have never ned eae call from Senator Ribicoff or the other 99 members of the U.S. Senate, That doesnit Inean they don't call. MR, NACH Their staffs do, I want to assure you. ae MR, PETERSON: See, Frenk gets those calls. t suopose he at least starts where I do, courteously. DR, HEUSTIS: Is it possible, parenthetically -- nate I speak off the record for & moment? | MR, PETERSON: Yes, off the record. (Discussion off the record. ) MR. PETERSON: I don't think in most regions the aon 1 { 1 ! fieck ve have had in years past has not been essentially from ww ae a Congression al delegation, although there have been excapbichs to that. | | That hasn't been a mejor problem on @ region basis. I think we ere at enother juncture we have to make : cone of those crucial decisions. We can go on with another | region and if so, we are probably going to miss coffee. The I cefcteria is operated around here for the benefit of what, | | Iem not sure whom, help or customers, closes at three. | Ve can teke a quick ten-minute break, but I think | it would nave to be a quick break. I heer one vote. MR. NASH: ‘Two votes, MR. PETERSON: Ten minutes which would mean 2:35. Okey. (Whereupon, a snort recess Was taken. ) MR, PETERSON: We are missing Bill Thurman of the croup. Because I haven't had a chance to check witn Oo BLLL -- we still will have time for Hewall if BL1il wasn't really prepared. With him not in the room, since he is one of the reviewers, again to extemporize, perhaps we might pick «© ~ on Central New York, which you indicated, Joe, you were precares to address, and then we will pick up on Hawaii after that. | I that way we will take care of one of your additional regloncs Charlie, Central New York. ENTRAL NEW YORK ae DR, McCALL: Yes. | MR. PETERSON: I will Let you sort of be the second reviewer on that. Let's pick up on Central New York, then. Dr. Hess and Dr. McCall are the reviewers. Iwill let you lead off, Joe. Central New York, Syracuse. DR, HESS: First just some general comments. L had some difficulty getting a very good feel for ‘this program Irom the eoplication, and I have hadno prior personal history on the basis of site visit or having been in a primary or secondery reviewer on this region. I do have some vague recollections being in some dit- cuesions, but those are not of much value at this point. But what I would Like to do is just go over and com~ ment end convey, summerize for the committee's information 5 whet I have been eble to abstract from information available, g end then have this supolemented by Stolov who is famillar with the region. . First, in terms of program Leadership, I .ort of net a mixed feeling here, on the one hand, the application indi~ cates how active the RAG has been. The number of meetings, sometning Like 15 meetings of RAG in 12 months, and the RAG-- menocers of the RAG have been on the review committee and inti-~ mately involved with reviewing orojects and this type of thing. € So I think one can say that assuming this is true, that the RAG has been spending a lot of time on Central New York RMP activities, end it is stated that they reaffirmed their goals and priorities. However, I did not find in this particular epolication their goal statement. They do talk about major thrust which I would infer are Similar to goals, at least they have stated certain direc- tlons they plan to follow. DR. McCALL: Health resources, planning, regionali- zation, and primary core. OR. HeS55: Yes, So that there is that incongruity; the goels end priorities I do not find to use as a yardstick to meesure some of the other things here. They indiceted in en @rea they heve given due con- sideration to that. The progrem steffr is quite small, At the present time there ere Tive full-time orcfessionels, one part-time orofessionel. They propose to so up to eight, elght full- time professional and one part-time olus four other cersonnel, . Ay So it is a relatively small staff, & I vould gatner from some of tne background informe- tion, however, that the menesement skills of this steffr leave something to be desired, that there nave been concerns con- veyed to the staff from Council and from central RMP staff tha heve I guess to say mildly if not been completely acted upon o i r LGO ' accepted, and perneps comeonc, Mr, Stolov cen fill us in on thet. - | I mentioned the Regional Advisory Group. They have | had goals end priorities and the Listing of projects, oriority rankings have been given ineLuded in the application, but hoa | thet fits with their overe@ll priorities I can't determine. | Now, on terms of past performance and accomplishments, their report indicetes some things which to me are quite | xeiting. For exemple, Let me just read a garagreoh or two ‘here, “In the north erea of the region, that to me indicated | if they can take a major credit for it, L would consider it a rather substantial accomolisnment. The reoort states: "As a result of our efforts end cooperetion with health care inetitutions and citizens erougs | over 60 doctors heve come into the ares within the Last tro years, This is more then 25 percent of the total number oF cn ‘ doctors precticing in this eree, orior to our effort. Succes ful paysician recruitment can be abtributed to our widesoresd thrust.” . Then they list ten different activities in which the RMP engaged in that eree, which they believed were related, and somevhat Instrumente t in attracting the 60 new physicians into the area. I wiil just indicate one of these is a series of wotl beby clinic: develoced by citizens group using professionals LS © whose time is donated by institutions. Fro one L97e, the operation hes expanded to fifteen elinies in April 1974. So in this area, in particular, it seems they have @ re- marked le eccomolishment. They have a number of activities in the area of ori- mary care and in health education network they have actively been involved in EMS development in the region and SO One So that I think there are a number of programmic plv.- es in terms of accomplishments that they deserve eredit for. I heve spoken sbout the objectives and oriorities. The oroposel, I heve had a Little difficulty relating to tioned, there are no objectives, oriorities; there is the progremmic thrust. But I would gather most of those program~ me thrusts are core steff activities rather than project reletes ectivitles. The feasibility, I have some difficulty judging ther one. Their past performance has been reasonably good. I would think thet in these types of things they have done previously, coordination, organization type of things, that you know they have got a pretty good track record and eprobab Ly is feasible, The CHP relationships appear to be reasonebly good, aitnough it is indicated that duc to the time constraints, AY i u that ell these have not been specifically reviewed by CH? | prior tO submission, elthough there Was some indication there | 1aVe peen some teleohone contacts, some effort at Liaison with CHP during the time available. My overall essessment of the program was that it iss < I would rank it in average category with some pluses and some minuses, the pluses in terms of some of the things they have been eble to accomolish, the minuses mainly being in the meanegenent erea which in part I think is reflected by the ‘rebure of the oroposal, tne way the propose l is put together and orgenized. I sort of hed the feeling oerhaps they may be a some what better orosram then the proposal reflects, and I am not Sure. But as I indicated, I am impressed with some of the ? things that they had done end they are reporting on. So perhs I cen stop there. MR. PETERSON: Okay, Charlie, you were the other. yeviever on this one. 5 DR, McCALL: ALL right, sir. Just a few comments to basically agree wth Dr. Hess! evaluation, There is e tone in the rather poorly put together a proposal, optimism end enthusiasm, which I think most of us Li to see, thet you couldn't tell from this aoplication how well founded that optimism end enthusiasm were, however, and he nas elready elluded to, well, the small staff in cpite of pany orojects, multiple activities, without goals projected. Tt is a fregmented program, doesn't hang together well. But it's eccomplished in sort of a short-gun way many things, but with the multiple activities related to small staff 1t does reise serious guestion of capability of monitoring such diffuses activity and fiscal manegement thereof, | One place in our evaluation Dr, Hess and I differed, _f checked degree of CHP. relationshnio, ! Nothing from the CHP in here. Application says whet the process is, but the only thing we are asking for here is reelly a continuing application. They really aren't re- Q viewed nov, but some 64 propcsals are to be reviewed by CHP. C So I felt that I couldn't reelly say that that wes plus or minus at this particuler point. And lest question, they heve the arthritis proposal in here. This is legitimate, 1 suppos OD , es & continuation OQ project. Jerry cen tell us whether that creates any problems. MR, PETERSON: Okay. Do you have any sort of sum- mary, one word, one phrase impression of the region, Charlie? Yours was sort of averase, some pluses, some minuses: DR. HESS: Yes. DR, McCALL: I also had him as an average region, mw of almost exactly. I think ve would have the same pluses and LLU minuses. MR. BARRG/S: Before we get around to numoers, may I ask, budset 100 -~ 20 percent, 3S147,000; EMS radio communi- cations. Is that the purchase of equipment or is that something else? MR. PETERSON: Jerry, would you react first to the arthritis point? MR, STOLOV: As far as I know, the only project we felt did not get CHP comment wes the hypertension to’ some -Cime constreints up there, As the arthritis, I have not been in contact with the Arthritis Review Group. They are taking into considere- tions whether or not CHP did respond to it and they will, throveh their own mechenie, message to Council or others, will let us know whether (b) comments were missed. But the only project thet hasn't been seen or reviewed in the region wes the hypertension project. As to the EMS, the EMS we put in the items to be looked at in terms of only the mobile units were rot part of the recvest, and interestingly enough, the RAG looked at tne mobileunit almost as e second project end rated that Low, but gave the Bey stations a higher orlority, as you see in thelr apolication. This wes a tag-on through local pressure, to the Eis TY, councils which they are supcorting. So total BMS is not just w Gye eguipment, bub to continue their EMS councils end also to go to complete the base station network, but they slipped in the mobile units to Let Washington make the decision. This is the vay I interpreted ite MR, PETERSON: How much of thet particular $147,000 is mobile units nerdvere? MR, STOLOV: 536,150. One point not mentioned, which is a plus, is this Is based on local matching. Very strong goint for the region, the Oo . eguioment vas Locally inmatened. cing in outside funds, much of this snared Tunding. And they heave had e pretty good record of-- hey heve Listed «é nunber of activities, they nave etarted, Which are now phased out &@S iar as RMP funds were concerned, so they do nave a good record of getting things started, orgenized, going, and finding other funding sources. I think they certainly deserve credit for that. MR. BARRCIS: Is that outside sugoort for this $147,000 mobile unit and so on? Vv, . STOLOV: What wes your question? Was there Leta mn me ao XN outside support? 50 percent matching on form 16. MR. WASH: Wheat they did, Mr. Barrows, tne first part of the EMS activity they agreed with the hospitals in pay helf of the costs of com- Jeg the erea to purchase half o municetions eaquipment if the nos pibels would pub up the other 1 | Le ‘7 heif. Now, they are proposing I think to do essentially the ( same thing on this. MR. PETERSON: 300, 000 olus, Local funding in the vhdéle conjury of EMS activities. an application Re ta Wheat we have here, of course, i i i i ( i i whien is largely continuetion, thatmay be a Little misleading. There are only @ couple of small new projects. We have an | - $800,000 application with just a very small amount of new acti- vity. | | Some of the continuation, I think it is particulerly true of the ENS, is continuation at an expanded level of eund- 2 4 ing. You will note from your table that we have an estimate us Centrel New York is soins to cane to ue in July with like @ mii lion dollars plus in new ectivities, while they are requesting now roughly -~- not Guite 3600,000 against a target, overall : terget figure of roughly esain a million dollars. Were there eny other things, Jerry or Frank, of significence, policy issues, major problems or other things we want to point out to the group? : MR. STOLOV: By and large, the CHP relationships hav been sod. In fact, they are the subcontractors to the Ems councils, Again, the hypertension was an oversight. We don't know the arthritis, As to the management assessment, the gentleman ran oy LL D who prepared the report is eway doing other management assese~ mont today. We have only received e brief feedback on 1b. MR, NASH: Do you have any general ideas? MR. SIMONDS: Didn't even talk to him about ite Nothing about lt. UR, STOLOV: It eppears the fiscal management end Wes ntanmed muah tmoraved eee . | considered much improved or Found satisfactory uoon review. | There were other menazement problems related pos- | “os sibly to now the director conducts his business, eb cetera “ but the mejor thing we did want him to focus in on wes the Ynere is Just one other thing. Goals, objectives, and priorities were forwarded to the region through the lest { lebter from council es not being systematically jdentified. Based on that we do have thab and the Director, hig ansver to. this wes that he pub staff on to do modified review process, rether than redesign his goals, objectives and priorities. So that is where it stands now. He stili nas not, oo the best of our satisfaction -- or my satisfaction -- enanged the goals, objectives and oriorities, but at the same time he does address it in his project. MR, PETERSON: Are there any other comments, objec- tions, observations from the review opancl members? MR, BARRO!S: I would Like to esk one. If in the light of the relatively modest rating this program has come up with, if we were to scale back there with a request here, would it have any wholesome effect on making them ea Little more selective or e Little sharper on their nev ? project epolications? DR. McCALL: They are going to have to be fairly selective, they indicate they have Sy -- MR, BARROWS: They are going to ask for another 800. MR, PETERSON: They ere coming in with astatement of SL miliion. You know, this may have changed. Ob vious Ly “it hee if you Look at the EMS, One of the recent eheracter- | tsties of Central New York wes thet it tended to have a lot of $10,000, 525,000, So thet C4 may not edd up to, you Know, much more than a miilion dollars. I don't know, but that cer- teinly was true in the recent past. MR, STOLOV: I think it wes 33.9 million, edds up to ebout 33 million now. We estimate about a million. I can't answer your duestion. I think the review committee nas to further discuss je CT * MR, PETERSON: I think what we are faced with in many cases here certainly is for all practical purposes things are in the pipeline and moving out there and may not have had | fineLl RAG action, but nothing we do or say by and large in bores of July epplications, if IT got on the phone with the Senator from New York this evening, which I em nob about to do, ard we hed something very definite to tell Centrel New York or ¥ty GO ne C2 ea cr any other region, [I think the timing is such that application we are going to see in July is pretty well seb, DR. McCALL: Simply I don't know how many dollars, ve would limit the number you could fund and limit the numoer | of activities that would be monitored satisfactorily. | DR. HESS: They will elready, if their performance | on the July application is the same as they will already neve prioritized those project applications so when decision is mode, they will alreedy nave the framework for making their rich set funded and wnich don't. So in that sense they ere vell orsanized and prepared. MR, PETERSON: And the group in that sense would have some rougn notion that if you gave them 50 or 69 or 90 percent of the request, how that would fall out, roughly. DR, HESS: Yes. MR, BARROWS But giving them, say, $7O0Cp0O0 or 3600, a02 they ere asking for now wouldn't whet their appetite for the remainder. 2 MR, PETERSON: I can't answer tnat. DR. HESS: I would like to get to a recommendation. MR, PETERSON: Certainly. DR. HESS: In going over the applications, it seems to me I could oick out -~ well, approximately }180,000 worth of epplications that most of which are Low oriority on their list end which would not do great damage to the program in my estimation. And would still give them $200,000 more than they are currently operating on and there is another batch coming down the pike for July, and would require them to be selective -- for this batch -- and then we can further exercise some selective advice via funding Level in the July batcn. I think that would-~ you Know, we can deal with them in fairly what [I would consider fairly even-handed and wo equitable fashion. So I would Like to recommend $615,000 for this particular package. , DR, TESCHAN: Second. MR, PETERSON: 615,000 against the request of not quite 3600,000 at nt santm, DR. HaSS: Thet's right. DR, McCALL: I wes going to say recommend $600,000, DR, HEUSTIS: Iwill support his. Mine was the seme, MR, PETERSON: Did I hear e second? DR, TESCHAN: Second. MR, PETERSON: Olay. We have ea motion and a second. Is there any more discussion or comment witn respect to Central New York? If not, those in favor? wow oO hea s (Sh f heads) ws MR, PETERSCN: Again, I think I see unanimity. Okey. if think we are again doing reasonably well unas; not very good circumstances, I would Like to, because we have spent all of our time thus fer with resions that are at least for our adminis- trative purposes in the Bester. Operations Branch or Des I would like to switch ovr focus, if you can, for a moment across the continent end take up at least one or two regions out of the Western Branch. I eovlan't set much farther eway, i thought we would try Hawaii for starters, John end Bill Thurman ere the reviewers on that, Iomight ask you to iek off on that, John, I believe JOU were on the site visit out to Hawaii. | : i { | i , OR. HIRSCHBORCK: Yes. MR. PETERSCH: You have lost your tan I see. That wes sufficiently longs aco, DR, HIRCCHBOECK: Yes, Thatiras January. Well, the regional medical probram of Hawaii, as I review this application and read correspondence of what has reacoened since our visit, Ll am pleased in the very positive che of direction and improvement in the affairs of the program the So although the history has been turbulent .in the past, it scems there is some opcortunity now to see some pro- gress being meda with new Lleadersnio,. The present coordinator, Satoru Izutsu, was @ coordiczse- tor for the Fecific Basin Program. He is now, since Mey Ist, coordinator of the Haveli. The staff is quite stable, There have been no serious decertures es a result of pnaseout activity, WY teff i ~ t2 presently full-time equivalents of 1575 with proposed expension. The question of program leadership I think is nov somewnat resolved in thet the coordinator seems to have taken over,well -- certainly tre way the apolication was put togetner, if this is an example of his ability to teke over, think this is one evidence. There is a new rate chairman and the relationship of the grantee esency epparently has also been approved. 22 cad eo a we ae re L' OF aw MD It seems to be a criticism a small clique was iil and I a operating the regional medical progrem ar Haw think tnis is pretty well gone now with these changes. As far as the program starf is concerned, it is a reasonably geod staff. They have en economist there wno even es a result of tne visit I wasn't quite clear in my own mind just wnat hi m~a role was other than perhaps work in tne protvlem of cost control. | The rest of the steff hed strons community interest end certainly the man involved in charse of the Pacific Basin now ceemed to have everything well in hand to take over the responsibility. The Local involvement of the staffwlth other agencies seems to be Guite evident. This is not an ivory tower starr. They seem to be involved in many, many things 19 hasn't changed very mucn Regional Advisory Grov a Sinee its inception until recently. It's I think an everage regione! advisory group es I know then, Review evaluation of orojects wes carried on with 2 speciel committee or project implementation and evaluation com- mittee, This seems to be done almost apparent from the Resgionel Advisory Grouo, Past performance and accomplisnments, prosram has had its troubles. It perhaps has not risen to the challenge of greet opportunities that oresents itself in this far-flung progrem, where innovative ideas may have been experimented with. It hes been using more traditional approaches to many health care services, and much of this, of course, is rignt ithin Hevaii itself. ms oa Ros Only recently, according to the applications that are in this particuler package, has there been a great spurt of projects for the Pacific Basin; the new projects are being proposed for the Pecific Basin. Truly not great in Goller amount, but they are for the benefit of specific people. Tne objectives in priorities-are, again, as I said, vather traditional and ve think there might be others they could come up with es @ result of the opportunities, inerease in medical program, They are fairly, fairly rational, I will reed some of them: Ercovreze innovative erransements for organizetion of heelth services, methods of financing, reduce unnecessary duplication of health resources, encourese improved productivi of individvels and organizations, and so on. The prooosal itself is for the continuation oF some on-going projects that were started this year, and a number of. new projects. They intend to have substantial packase.in for the duly Ist review. Ag to the feasibility of this particular program cerrying out its program functions, likelihood of orosogerity, 6 Ll I orosress, I think under the new leadership we will have a chanes 1 ' to see whether there will be imorovements. Onn L think that in seneral things look pretty optimisti compared to what they were before. CHP reletionships, certainly here is an area of ereat improvement. Tnis is evident in the application. Under the old regime the relationship with the CHP, HaC, was almost nonexistent, althoush the director of the CHP was a member of the visory group, yet collaboration at a working level { a t woe eoperentiy not very evident. | And now I notice in the epolication that there is ver active criticism end comment about the various projects that heve been procosed in this particular epplication. The whole proplem of CHP in the PacificBasin is an unknown quantity as fer as I am concerned and there is only a re) << oO te he one (2) agency in Hawailen Iclands itself, so that it is unusual type of situation to deal with, although this is @ very ective GHP egsency at the so-called state level. My overell essescment is I would say averege with possible improvement in the near future as a result of the change in menegement direction. MR, PETERSON: Thank you, John. I wonder, because of the ‘long history of Hawaii, the: kind of problems that we hae had there, I had intended, in spite of my best intentions, had forgotten, I had intended to depart on this one from our format and wes going to ask Dick Russell initially to fill you in, because there have peen so many Gevelopments Literally within tne last few months. And if you have no objections, Bill, I will try and make that nalf good and ask Dick to perhaps fill in some of the packsround very Quickly as it relates to Hawaii and tne developments Literally of the past two, three, or four months since the new coordinator came on April 1, I think it was, rather then Mey I. £7 Tt is ea matter of months in any case. Dick. MR, RUSSELL: I think Dr, Hirschboeck has covered L some of the coints very well. I would Like to say that this particuler eoplication put together under the direction of the deputy prior to oad 99 um Dr, Lzutsu 2 ssuming coordinetorsnio. Unfortunately the deputy is still operating unaer che old philosophy tnat anything was fair. There is going to be & lot of money. He still hadn't gotten the message about whet the problem had been with the orograim -- he has it now. The Regionel Advisory Group hag not yet come to the maturity of setting oriorities, This has been done by a small sroup, plenning-implementation-evaluation committee. I think they try to do a good job, but it is all on 2 persons s criterie. In view of this, Dr, Igutsu is now orienting Regional Advisory Group, few renbers as well es the old member. and at their June -- I think it is June 25rd meetings, they are going to reset priorities, I think 35 letters of intent they have now that will orobebly come in as projects as well as those projects in this apolicetion., In other words, by that time he hopes to get some sort of system wnere the Regional Advisory Group will in an objective manner vet priorities. Iwee in Heweii for a week with Dr, Izutsu, and it @ comoletely new program, no doupt ebout it. Leadership nere is unbelievable. He has whioped the staff into shape, They are certicioating snering information wonich before tne informs: 1 aff nor was it shared with tne eT re? oO = = Os uo pam oO eT re) ~ n a > oO > as cr on > PY © «3 tO cr oo 1 Oy Regional Advisory Group. It was a clidue, no doubt about thar. The RAG hes been revamped. Dr. Izutsu has gone bace to our advice letter, which ceme out of the November 1973 visit. Mr. Berrovs wes on it. He has gone back -- Dr. tirschboecs had « copy of a progress report. Ali IT can sey ic wnat ne says in there is indeed fact. The Heweall Medical Association is nov very willing to be LavoLlved in the progrem in view of the absence oF the former coordinator. The University of Haweii School of Medicine, Dr, Rogers is very much interested in being involved now @5 voll os Mr, Michael, dean of the School of Public Health. CHP relations, nignt end day, it is really great, The community's image to the RMP has changed in the gix.or seven weeks -- he tells the same story to everybody and that is a rarity in that RMP, We have just recently, as was noted in the summary here -- there is @ duplication between trust territory, ceredrel cancer projects, and one that has been submitted to MCI, 21 ‘yorved with NCI steff. NCI staff is in touch with Dre Leubeu. find he is plugging the trust territory again with NCI, and this is the type of-- he is really the REY, now has become facilite- tor which it nes not been ell these years cs between hosoitals -- hospitels never met before be- epuse nobody ever callea them tozsetner. Thereis a grentee relationship with relation bo RIP thet's very good. We had some concerns because the execu- tive director of the Research Corporation of Hawaii wes -- what do you call Lt -- oroctor? Dr, Leutsu, some were con- cerned there might be this type of influence on Dr, igutsu. I set in a meeting between these two men. Dr. Izutsu gave Lv straight from the shoulder with the grantee es with enyboay. It is unbelievable what he has done. There are some weak spots in the staff. Or. Izuteu in seven weeks hasn't had time to cure ell of the ilis of the past, bub no doubt in my mind he will. DR, TESCHAN: What is the population? MR, RUSSELL: Of Haewall? DR. TE AN: Of the region. MR, RUSSELL: 100,000 in Hawaii. MR, PETERSON: 100,000? I think it is over @ mil- of ~ » island jion in the Honolulu. MR. RUSSELL: 600,000 in Honolulu? BRR, PEPERSOU: And trust territory. And all that sroat big expense of blue water doesn't add a heck of 6 -Lot. Limagine e million when you add sand erebs -- we spent occeslonal pear-drinkxing sessions in 1945, There mpy be ceople there now, weren't many then. MR, RUSSELL: Not many people, bub it is a 3 million square mile area. MR, PETERSON: Sister Ann, who often thinks tte distenees coming from the vest, Maine, Utah, and even flasxe I think, cele by comperison to what in one sense is the turr ic the geography of the Haweli AMP, Bill, you were the other reviewer on this. L wonder additional reinforcing/sub- of comments, both to whet Dr, Hirschboeck what you have in the way of tracting kind and Dick have mentioned? THURE “pad ANS . ie There ere two points that have cone over here, three points I would make, and that is com- munication situation, Dick has discussed, is very obvious the y nave not really talked to people and they recognize this. I em svre they will teke care of it. They still don't understand the priorities. They are ill defined end they are working on that. I think the last thing thatdisturbs you about the thing, e1Li of us knew this before from when Len. Shirlis and others went to Hawaii, was when projects terminated, no- thing ever nepoened from then on, you know. Nothing ever cere of the projects thet vere Tunded in the past. Anal think that is going to be the real thing here, Really it depends on whether or not they develop If they can't develop Hewail erojects, this is going to be still not @ Sood orosram,. Oo 2 oy © cA re Q « Aimost everything they heve out in there is MR, RUSSELL: I did just get the minutes of the plen- ning-implementation-evaLluetion committee, what point thay are screening -- lest week they were letters of intent. Here one hears comments, we Will consider this if these three letters of intent are teken, worked together, as « single project. So this type of thing is occurring You know, here, egoin, when we talk about unifled health plenning, that Hawaii cf all the states, because of Les geosreohny, is in excellent position to pull the resources together end work together. ~ think this is the type of direc- tion Dr, Izutsu is going to give the program. MR, PETERSON: Me. Berrows, I didn'treallze you had been on the site visit. MR, BARROWS: Ivas. As these fellows found it, I found it comoletely fascineting, positive sure for me. The program is hard to compare with the ones we are scustomed to first in terms of geography, when you start thins- ing ebout the Pecific Basin. AsT recall, it is something Like seven nours flignt time to get to the nearest point fron- Honolulu, end co you can't be making deily calls-- the Pacific Basin is terribly toush from enything we are familiar with Yo economically and socially Therefore for nealth resources, it is elmost wholly desendent on government operations. bet on There ig no private, to provide health cere. it quite unicue in that respect. 21f, the islands are onysicelly td 7 OQ wv b = cr 9 trt wh 4 %3 he. r be or oe separted, wnich poses some problems for them You can't have ambulences shuttling back end forth, that kind of thing. And then on top of ell of this, their social attitudes still reflect considerable Orientel influence, and they Loox at things a Little differently than the way they do in Chicaso, Maybe they shouldn't under our creed, but it just happens to be that vey, So I think when you look et Hawaii, youhave got to Look at thet es this is a unique --~ judge on its own merits an not necessarily compare it. MR, PETERSON: Any comments from the other reviewers: DR, HEUSTIS: Has the word got to the new edminis- tration about the great ooportunity thet Dr. Hirschboeck mentioned for innovation on the part the staff had raised, nere is « real fertile fleide Lam thinking tat you had such @ thing off the coest -of Maine, not 7 miles away vutb shorter distance, they pub e. nurse With ea television connecting her to the mainland, things Like this, where she can geb-a less well trained person can get consultetion. Hes Hevail thought of enything Like this? Can they be stimulated to do-- MR, RUSSELL: We are talking apout two programs; We talking ebout the progrem in the Stete of Hawaii, we are also talking about the second orogrem whien is tne Pacificbesin. So I have to ask,. you know-- DR, HEUSTIS: I just underetood from comments, I hed not reed -- the comments about the great opportunity for snnovebion apparent ly from the standcoint at least I heard the reviewer sayine wes not exploited -- taken advantage of, capitelized on, DR. THURMAN: I think my answer for that would be ‘ fae da hae UY yes, in the progress report the new man has just forwarded, he sces what hes been talked ebout over and over ageine And 1 think fromthe way he writes, he has got the moxy to pull it off, . DR, HEUSTIS: Okay. DR, THURMAN: He understands wnat you are saying end what we have said in the past about it. So I would feel comfortable, he may get egg on his face but I think he knows whet we ere talxing about, yes. DR, HEUSTIS: Just corollary, does he need support ‘from us, helo getting the egs on his fece? OR, THURMA: I think Mr. Ru sseLl is providing thet support in @ very meaningful way. Putting grease skids under the lest man was 4 very essential tning. MR, RUSSELL: Yes, I think he could use support Pron the revievers. You know, quite frankly, no one quite knows tne prob Lens we have had there. If one looks et this type of application, the tyoes of projects in this application, and a new Girection tnat the progrem staff is going totake, facilitators, 1t seems to me this is perhaos where they might want to concentrate a Little bit more on perhaps in the future than being so project oriented es in the past. DR. HEUSTIS: If in some way, in whatever way is appropriete, he could get some enc nouregement so that he could go to whoever the traditionalists are and simoly say this ig what the Regional Advisory Grouse or the Council or the staff whink I should be doing in getting support, sometimes this is helpful. DR. T tet {URMAN: It might be worthwhile for us to cone sider in our proposel he be asked to consult with those who | ere beyond tne treditional realm. As Mr. Russell indicated, the Suy who just took over the school of public nealtn out there 1s an innovative senemer for delivering health care. It is his big beg. I think if we were to push Dr, Leutsu toward this men-- MR. RUSSELL: They are already together. I sat in a joint meeting with them, together. DR, HEUSTIS: 4 fellow Like this needs all the sugport he can get to keep somebody from Knocking him down. DR. HESS: He only hes e year to go, so farses we know, under this carticuler program. So I think our entnustiean for you Know, soecific recommendations for getting all geared up and wound up have to be temoered by thet Life seen. DR, HEUSTIS: Something is going to be there. DR, HESS: Yes. But it sounds to me Like this guy Will find his way in. Figure out wnat can be done. SISTER JOSEPHINE: Two things I heave been impressed, two weys of getting a progreato bone up is either to deny funds or pressure the poor coordinator to leave. 2 hen we at ee - r MR, RUSSELL: He just happened to resign were out there. DR, HEUSTIS: Thet's right. MR, PETERSON: John, do you have a recommendation? DR, HIRSCHBCECK: J will make a recommendation thet meybe we approve the $1.5 million. MR, PETERSON: That is the full amount tnat tney sre recvesting tnis time. They are coming in we understsnd, and I think Dick hes mucn better intelligence on tnis _resion then we do on most, in terms of whet is likely to be coming ine They ere coming in with another request in July, which will perneps beer more of the imprint of the new coord. tor, the reconstitute of RAG, et cetera. Roughly e half mil- lion dollars. I em reading my figures correctly. We probably, over the two sessions, will be looking at close to a s2 million pacwese; three-quarters of it is re- quested et this time, egeinst, egain, a benchmark or terget figure of about $1.5 million. DR, THURMAN: I am going to have to take issue wita e fellow reviewer and sey I would cut this $1.1 million to @L1,.e@ million to Let's see if he can do all the things we ere looking at. That is the only place I would disagree. I think i6 needs our approvel and support, but I think o1.5 r s million, although they are already at 3937,C000 -- he is ina ' situation now where I think with edequate sbaff support, he ean bring about a change in this program even thovghnh it is only for ea year, to answer Joe's question. But I think $1.5 million is a little more than they will be able to utilize if they ere coming in with another haif-a million dollars. DR, HEUSTIS: Thaty would Leave some money to teke care of the half million. DR. THURMAN: Yes. IT would put it at $1,1 million, 4 o oO re poe oO < oO e \ DR, HIBSCHBOECK: I think I agree with you. DOR, HEUSTIS: I support your motion. MR. BARRONS: I think they might relax a little bit. It might go too far. Give them a Little bit of encouragement. DR, THURMSN: I would make a substitute motion of $1.1 million. DR, HIRSCHBOECK: =f second it. MR, PETERSON: John seconds that. I gather one of the important things we want to convey, because we ere talking about a dollar figure, but thet the group, end presumably the Council, if it listens to your advice and what have you, tha the group feels that the oro- grem is at Least showing indications of moving in the right direction. be We are going to ask the new coordinator to do whet J L352 MA. he has probably elready started to do, sterted to looking beyond the traditionelists out there; so th O figure of Bl.L | million, which has not been voted on yet, we need to be care- ‘ t \ ful tnat isn't interpreted as a largely negative signel if f 7 \ heerd the discussion. | it has been moved and seconded we recommend $1.1 mile Lion in this cese, Are there any other comments, observations, or ' \ | 4 | t | | QO S QO ga ct I o 3 cA about Hawaii RMP in this application? Poa Lf not, will those in favor, if they will raise t theise nand elther one will do. (Show of hands) Mk. PETERSON: ‘cain -- I don't know whether it is the leteness of the hour or monotone of the chairman or what, but | we seem to be drifting into the complacency of unanimity DR, THURMAN: Never, never. Iwas going to try possibly to put a Little Life into the meeting by suggesting that if we have dealt with Hawail now, we might pick-up on another one of the Western Desk regions. This happens to be Arizona, Paul Teschan, by virtue of Dr. James not being able to be here, will be the only reviewer. I think staff will have some comments here. But if it is satisfactory with everybody, we will move from Heveil end the blue Pacific to the soutnwest and take a Look at Aricona, which I think ils one of the fastest growing states in the Union. Paul, ARICA . L3dD DR, TESCHAN: In contrest tothe fastest growing state in populetion, I find the application a fairly pedestricn production The epplication is for program staff and for six projects, five of which are continuing. There are evidences of three more coming to the end | of funding in the process of working up the various pages of the form, In going over the application, we are unable, really, .to find whet program gosls and objectives have been stated, There is moreover in some of the ancillary informe- | tion we were sent in the summary of program status, issues t © 7 bey raised by steff on he besis of their visits, et cetera, that a @& review verification is pending, oending conformance to 5 @ < SS tA 5 2 -SEUS are that tne bylaws need mn Loe DRHP policy. And the a end the RAG rembershiop needs better representation, The apolication silent on the subject of bylevs bs wa tw bylews revision or anything about the process. The RAG membership, the application is silent on ,the guestion of RAG membersnio change. : The membership continues to have 18 individuals. They tend to show at the rete, according to the application descri tion, of LL to 12 per meeting. And in looking at the member- ship of the RAG, one does not get the impression that the twee hee princloal lesdersnip of health -- of the health forces in Brizone are in fact members of the EAL Ng e There ere issue 0” of racial balence and i am not @ good enough geographer of Arizona to tell how geosreohic the belence is. But it would appear the issues that are reised in thet document ere still with us as far as I can teLl from the epplication, no cnange at all. Now, the staff is indeed stable since L967 end you set the cense that there is not, as e matter of fact, some~ where between the coordinatorh4G chairman, executive. committec, -ability for progrem leadership and direction in line with ae least the administrative issues having to do with review pro- cess verification. On the other mand, there ere issves of exoension of health service sites having eccess continuetion pro, fect for one more year, extension of medica l mencovey @ recruitment progran extension for one more yoer, and a fairly locelized health information diel-eccess type of orogram, wnieh by the title itself provides health education which is eiso scheduled for extension. There is BMS project and hypertension control oro- ject. There is a carry-over into two more counties of a strer- tococeal infection projech control project. There is in addition a rather surprisingly, ft think. from the buildup, epparently @ cessation of the continvetion education service area project. It comes to the end as we sce it in the end of 1974 secording to the application. However, I think in supplemental information I got neross that I have just received and nave not carefully studied, it may be that there is a further extension of that, because in the epplication on pege 19 the RAG suggests that there should be meintenarée of activity in the continuing education service erea project. help on that particular ooint!, 5 ~L nave to ask for staf oerticulerly in how there is ectuelly organized, in vicw of the fect there sopeer to be in the sites pages 19 separate cormmi bte's< . | in various opleces vwhicn are supposed to identify local needs and eselst in development of tnose local programs. 5: fre tnose rural? DR, TRSCHAN: Well, I would imegine small communities. They ere not in Phoenix end Tucson primarily by any meens. They ere scattered out qui tte widely. The inberesting festure about that particular oro face statement, however, why TF an smoliguous about it, why I thought | sts discontinuetion ves e plus, is because the evaluators, at leest the capacity for evaluation, pase 61 of the epplication, c say there ere at Least three basic changes that heve-- two bas. chenges have to be made to que »Lify for further RMP supoort beyond June 30, 1974. Did you vant to clarify? I certainly wander sr und that one, because thet is the state the application is in. MRS, ADIN: The CESA program, they are goins to continue reaueste July 1 b The stef though 1 the stet senerél, society 3t for three more months witnout additional funds G umtiiL it 0g ets a complete review. They may come in ut I am not sure. They have hed problems with ite f feels that it should change its emphasis even t Goes heave that many committees and it is throughout e. They also feel the medical school, university in should have taken over some of it, or some medical or some other orofessional organization. In order to helo the staff, they asked en outside in e, ed hoe consultent, to come in and evaluate CESA. nan unfortunately for staff, the outside committee felt it wes marvelous, end recommended to nAG that it igs a very iyity end ought to be continued. And I was at the éG meeting where all of this was beings discussed. The way tney hand lea edditio ‘th was, es Il sald, just asked for two months without o If they do come in egain, there pe a different emphasis tnat it not-- emonasis just wne put some of this for sone well,severel things, one is that there be a different in terms of need, patient care need, rather than 6 you thing you would Like tolmnow. Two is the university and health orofessionals money in themselves. find they were going to have ready by duly Ll. That is why-- but ib is not in here y right now. DR, TESCHAN: I mentioned this simoly to say it a) a pea nai funding: have oe comolete review of the CHSA crosgrés. 139 seemad to me that the comments mode right here mowed me more staff, I had been developing ea fairly mdestrian picture of steff function and ell of a sudden I come across some very good 'sort of either it shapes up or we don't continue ub" and I thought thet is great, that is a plus on that, And I Wes seeing the thing end based on the erminal date here. And they ere basically seying the thing so I won't go furtner on So I am sort of at a questionmerk on program leaders fos -shio under insufficient basis, Thst really is oretty Limited | a i judgment. It is hedsing one's bets pretty severely. vu a ca . But it looks to me as if-- it looks Like there imy Lo : rn + apy re. some OLluseés, mayoe some mi muses. I vould sey I cen't quite-- it sounds like the staff is moving particularly because of their access projects, exten= sion projects. It Loows like the staff nas more life in it \ then the epolication would sugsest end that the RAG is inede-~ O quate to deal with this situation. So I teft the leedershio in questionmark, progran OD hes GS ih oO staff probably satisfactory, and it is because there are and mnuses, end that the Regional Advisory Group has to set goals, objectives and priorities, they have got to come to with the review process requirements, the bylaw system, he} pes Yr .@) 2 and I don't have any evidence that they know how to do tecnni- cal review. I don't have evigence. wm been review verification visit, whicn I think it is very relevant MRS, SADIN: Yes. Okey MR, PPTERSON: We are back recently, I guess it nee 8 couple of months now. EQS, SADIN: One month. MR, PETERSON: One month -- she has in Arizona, ones cf c> this consideration and I wonder if you -- IT am not sure at while jJunet EOCe ure, Paul, DR, TESCHAN: I am going to finish up reading-- bid MR, PETERSON: Why don't you do that, then there er ne comrent. DR, TESCHAN: Thet would allow you to comment as you MR, PEYERSON: Chay. DR. TESCHAN: In past performance, it added up co be satisfectory I thought in the sense that substantive ems of evellebility and access, I didn't get a sense there hes been any inout from the resion in the defining of Lt. > They did leunch renal, and so fortn. They got funding art termnin ation, continuetion funding for this. So it wes from a poor to good on that. thet, Cbjectives and oriorities, azain we don't have for progrem. And that note was noted in CHP corres- pondence, which was in this application very extensive. Also the arguments back and forth are very interesting. We will get to that in a moment. The oroposal, I cimply y Wasn't eble to Getermine what the explicit objectives and so on Were, and I have the dis~+ binet feeling, agein CHP comes up here, in terms of 6le), the CHP has been virtually silent in any useful way. That is to say, when this ccmes to the CHP, + say something to which Dr, Malnik should address the program, o they don't help him. Wheat they do is complain after the fect tn Loud and somewhet, oh, vitupe -rative Language whieh doesent t help anything in particular. _ I should edd at tnet point the corres oondence between the director and the CHP, various CHr's, igs very interesting, tn thet where the replies nave been has beenvery substantive. You get a feeling there is a orofessional exgert who xnovs how to reoly, now to deal with the situation, in those erguments. Feasibility, we felt what was going on could be et a »Low-averege situation. m oO a OD it this wa @ achieved, I It currently, based on their reGuest, has nearly YQ percent of tne total pudset will go to program staff as we vo“ ee the story. You Know, deoending on wnich numbers you use. GS wt But it looked like e high Gegree, high amount at most of the oO activities are eitner Arizona RMP steff-- there are two pro~ grems cut of the toteL of $1.3 million; namely, to the tune of) 5 3207,009, which appears to be the League of Cities end Towns LA * Arizona Heert Assoclation, of Medicine or the RMP. There ere two College come 388,000. So there is of Medicine type activities MR, E. TERSON: Do you want to but elso the issues that review verification? It was MRS. SADIN: it wes Actuelly I spent 4 MR, PETERSON: CLL LOO. MRS, SADIN: ‘There ere several times-~- sometimes we leave too little to our reviewers. I do remember e review proce ess. verification reoort, DR, TESCHAN: One up. MRS, SADIN: I do have it. We were there at actually several steges or our re-~ view process. One is where they just provide staff essistenc in the deveLooment of @ saw one where-- this wes their ed hoc committee, review committee And we care beck akacta stag ® that ppeered to you mate croject, in an aporelsed tater, 142 are not either the College of Medicine proposais which a large proportion of RMP in College in the application. Thank you. comments on what Paul may have seid, as a result of the mede in April-May. spent both times lot of time in Arizona lately. ‘rees with you. Californie ES project development, ana we project, met. We sew three different sbeses. caw 2 ? cD this is wnheve Their review reelly is pretty good. Their starr asecistents is good. Their technical reviewers -- as a matter of fect, the technical reviewers had much to sayebout this canticular potential, they were Looking at all of those commencn, were taken into consideration and modified by the time it came Girect, so they did meke those changes. Your comment sbout RAG, we neve been sendi fetter (n to frizone yearly ebout their RAG comeosition. The RAG has remained more or less the same since it started-- DR, TESCHAM: Appointed by whom? MRS, SADIN: Appointed by the dean of the Medical sehoci, Now, tney ned edraft of revised bylaws é@nd a ne) o a Gecided to shelve it beceuse of VASA, When wewere there before the review visit, tney sald they vere not contoralng. They ere now revising -~ they heve to nave 30 days before tney cen consider eny changes, that is in thelr bylaws. They know, it is caid in their letter bhey must revise their bylaws end they will, And their revised bylows of which we have seen aGraie and which trans-manesement has seen, Locked at, to conform, On the other hand, we have indicated that we cen't certify until-it is done. So that will be taken care of, At their last RAG meeting they-did vote to increase their RAG membership by six. And they indicated that these really the (b) esents telling what the needs are. six members would be from ereas not presently within the state, both seosrephically and nonprovider tyoes. And this, again, | is in the next letter, Ur. Malik, after review process. ! There was another visit, that was in January, and I made thet one with Dr. Gannon, who used to be in our Council he ned visited Arizone wilh us before; this was done, because in their supplemental applicetion, waich showed they really had made e lot of changes since their pre~phaseout applications, | oO we wanted to make sure they really did it and it wasn't on onper. find tnere were a lob of changes. Their RAG ned recommended, for instance, they work an with CHP and they hed visited end worked with CHP, So this 1 wn It mey not be true of Fnoenix and Tucson, remote | ereas of the state they ere working there. At their BRAG : : ' meeting, ec LI ingieated in that SUMMALY I gave you this morning there wes e lot of discussion ebout wnat Dr. Hees mentioned this morning wnicn is, you know, the cost; do you spend 3350,000 in remote areas where there are 150,000 people, or do you concentrate on South Phoenix, areas that are higher density pooulation? ! Theat can be a philosophical question. Again, in remote~- they are,what they are trying bo do is provide services and provide sites and provide where you can't support a professional now, they can't support one pro- fessional -- it mey not work out if you are going to do Lt pax i i t | t ! | y persone DR. HESS: This is an example of where I think sup- port ought to go. They have unusual obstacles and limited resources. MRS, SADIN: Yes. = DR. HESS: And I think this is where RMP ought to be playing a Limited role in whatever it sees. If government doesn't play at least a facilitating role, it will be a long time before people get access to healtnr services, Maybe you are misinterpreting what I am sayin 09 MRS, SADIN: No, I am not. I say you couldn't do it on @ population besis, DR, HESS: You have to take geography, neecs, and Ob stacles that have to be overcome into account. : MRS, Sf0IN: That, by the way, is part cf the orce- gram staff budget, even though termed an activity. So the orosrem staff budget is kind of not a true budget. It could just es well do a project. Your comments on leadership are kind of interesting because it is kind of yes and no. I don't know if I go off the record or not. (Discussion off the record.) MRS. SADIN: RAG grantee policy will be taken care c- if they pay any attention to their advice letter, and I imagine they Will. What you do about the coordinator I don't Know. Their review process, as far as staffing is Quite thorough. And in terms of objectives, that is really kind of ironic, because one of their main criticisms, when we were there, just before phaseout, was that they hed the most beautiful chart on the walls which is still there -- I guess always will be. (Laughter) Showing not only just goals, but objectives, sub- objectives, sub-sub-sub-sub-objectives. It reminded -- one or the visitors commented it looked Like somebody ali dressed up and no place to go, So they nave that. DR. DR. TESCEALN: It is in the book, but it doesn't come through. MRG, SADIN: It is in ell their other books, + They do have very eloduent obje sctives. oO be e ty} 3 tA oO tS ie at I recommended, wes thinking of recommending, wes something Like ¢€O percent or so of request. Funding aporoximately 6&0, you Know -- we go back and forth, up and down on this. But something Like 60 percent of the request. In order to particulerly get the message that we encourage their move out of the metro ereas, that is to say it seems to me & movement is afoot which has a reason for being supported. We went to be sure that if the group feels thet is the case, if we want to do this, that they get that message end not cther messeges, that eli the funding, eb cetera, chould be contingent on the verifications that you have just already certified, so that this appears out of it. That there should be some attempt to possibly in terms of the : total funding to double vo on staff if they can, because the sbe in © ff costs relative to the total request is pretty high, elthoveh I em not now telking about-- not core project so much But L think with the new appiication-- MRS. SADIN: They are also putting some people out és area reorecentetives,. DR. TESCHAN: es, I saw thet. SISTER JOSEPHINE: May I ask, what is the possi- bility of seeing thi recommendation thet they inove out of the | metrpoliten area and some of the other recommendations you : ! meade, the fect trey ere complying with it, to be visible : by the time of the next review; is that realistic? MR, PETERSON: It is in the pipeline now. That is the problem, Sister Ann. I think the only way it might be minimally heated, helpful, would be if there is a lerge variety of activity and they were to sort of teke that into account in their ori- i i ority setting or the mix that they submitted -- but really, Ti | think if we don't have anything in the pipeline or the drawing poerd thet fits this, they aren'S going to have it again, ldo regerdless of how instant that communication is, and how Yorce-~ ful, now heated. Time Just von't allow. DR, TESCHAN: I would like to ask one critical question. When you Look at that group of 12, and now adding the 6 more you nave just said, it is obvious Dr. Duvall is going to be the dominent personality in the group. MRS, SADIN: He hes been, wes, I was at the RAG mees- ins. He does turn votes around. DR. TRESCHAN: You say he is a leader? MRS, SADIN: He is not going to be on the RAG any mMOre « DR. THURMSN: He is also not going to cnange his rule. MRS, SSCIN: Probebly not, One of our recommendations is that they not do their prioritizing verbally as 1t does hapoen tremendously. MR. BARROWS: Would you clear why you want é€ 3 cb oO Or shift to their rurel arece, you heve two things to go on, end opportunity. Weed in rural areas is frustrating, no question. I don't think people have been working on for Do years -- in terms of opportunities in the metropoliten areas, it geems to me there is kind of a swinging mood to get things done, to improve the delivery system. DR, TESCHAN: Two answers to that. If I understand strong sceliad what they ere talking go by on the that there is feeling ment end new services get togetner end make for the new orofession. moving in that directli about, what Little gossamer Onrases tt ide of those some possibility of personnel reeruLt- to be established when rural communi ties attractive en or oossible. Life style So I have the feeling something is Ones Secondly, the swinging mood you «re talking about in my vlew probably coulé be assistance rather is elreedy moving and to function. WR. VTE a ALES og P ty THURMAN the closest to Connecticut yeer in and year out, recommends in the hes cnansed. MRS, SADIN: you Know, everybody else, said, ell of these thi elocuent things, then dolla “NNT ms ERSO! ele On medicel school end hov puk nov taken cere of with precious Little yr yesources. In other words, thet there gre elreeay resources there eny other-- It seems tonee-- to me Arizona is orobaoly the review committee has ever feces fnd we have always rade tnese very tlLons about how tne program could nob be damned if I see now it Tt has. Iwes on that site visit wita, wunen words were said. Ang as L you know about having all these as5 5 - fae - aa ot ” . neaving-- same stari, same coordinate: seme chairman of the RAG Yor six-plus years, then it was totally in the medical school and it isn't now. DR, THURMAN: Where I disagree with you is they still think it is. They think they control-- | | MRS, SADIN: They control because dean of the | fedicel Sehool exvvoints isembers of RAG, iam saying in their reviwed bylews, they are changins their RAG grentee relationship. ! DR, THURMAN ALL I am really seying is -- Dick, peer me out of I am rignt or wrong -- every time we have discussed Arizong, review committee staff has been enthusiastic, review committee hes been cessimistic. And I still sit here and sey jn ell thet time it ain't changed one Little bit. rr? MRS, SEDIN: Tne funny oart is fT em being én advocete right now and it is certicularly funny, because in the office, i; i I am usually not. But they heve mede some changes, they really heave. DR. THURMAN: It must have vote those people 80 percent of the money they nave requested when you nave 2 soy sitting in the driver's seat six years can't tell you the tine of dey. Tnat continues to strike me és something short of ridiculous. MRS, SADIN: He runs the program. MR, BARROS: Who is current chairman of RAG* MRS. SADIN: Running for state legislature. No,vay DR ma Tg Meh e PeawaA Nes From of circunventing es Run by. Monte. and vill be run by Monte until the dey it dies. DR, TESCHAN: ts for the new RAG on the basis of the new bylaws to make a The answer to thet in practical terms the doy it started it has bem run by Monte change in the director. If the’ grantee doesn't agree with that, to change grantees. In other words, it is appropriate action is that of | the RAG, DR. THURMAN; DR, THESCHAN: eceveet on thet one. MR. sides in this -- feel of times PETERSON a Mhtrbeen months. That is your 3 little like Bill, some kind of recommendation. VLEW e I tend to heve I heard this Well, I do feel a Llttle -- noe 2 a before, bub that doesn't get us off the neea to ir ba 2 Chm bes couple We heve a o1.3 million request here, an indication “~ that in the case of Arizona rougnly another 3400,000 will be coming in in July for a total of about 3 million, which is s 7 targzet figure, benenmark that I have been referrins day. I heard, earlier, Peul, say something ILlike about not in the form of a 1.7 motion, million, very close -- slightly above that so-ca I heard you 5 t 80 percent -- which is really giving me enother function, if you people talk in percentage terms I have a second function, figure out what 80 percent of $1.3 million is. In my eritnmetic, which I hope will be checked again that wes Like $51,060,000, Now, that was not in the form of a recommendation, but et least that translates your SO percent you were thinking outloud ebout LO minutes ago into a figure. Do you or someone else vant to make a recommendation as to the funding recommendation here? MR, BARROWS: I like that, because it is not in round nombers and it sounds as if it is sclentific. (Laughter) r, AY DR, TESCHAN: Of course, it isscientific. Deep balance & between the oluses and tne minuses. MR. PETERSCd: I nave always told my children never to fib in even numbers, ‘Tt is not as credible as if you say 83, If you say 83, people think you know what you ere talking about; but sey 100,ceople question you. Chariie. DR, McCALL: Did we have that as a motion we are considering or are you asking for & motion? ‘MR, PETERSON: I don't know whether-- Paul, do you want me to treat your SO percent,eas $1,080,000,as a motion? DR. TESCHAN: Sure. | MR. second. MR. MR. 9 ve say) PETERSON: Thet is a motion. We don't n BARRCTS: Second Lt. PETERSON: Mr, Barrows seconds it. Do we heve any additional discussion? DR, MR. How mendation? McCALL: Call for Question. PETERSON: Okey, call the question. many would concur with that $1,080,000 recom- (Show of hands) t—~ ae hend up, AL? DR, wD Lily to be sure, & Tha PETERSON: Four. Since we Lost one-- was your HEUSTIS: No, sir. PETERSON: I didn't think so, but I just wanted ince we amdown to an even numbered froud. t unfortunately -- not unfortunately -- that will not carry. DR. HRUSTIS: Make your motion. I will sugoort Lt. See if we have any strength. DR, strong starr $700, 000-::500, 000. DR. THURMAN: If we can go forward with one more, Letter for the 5,647th time, recommend for 8800, C00 | HEUSEIS: I will support it. | PETERSON: We heer $800,000, Is there a second? HEUSTIS: Second it. ao DR. HESS: That is below tne current level. DR, THURMAN: Which is the exact point. We have aivays tried to cudgel people by firing the director or not giving them money. SISTER JOSEPHINE: I have to go back to the main discussion. You know, L almost feel we are on the horns of the dilemma of the Prodigal Son. We sre encouraging all of these people with hundreds of thousands of dollars, and we were very hesitent to reward a well organized program, I think we have to Look at tne philosoony we ere implementing. DR. TESCHAN: Iam in the further dilemma, I am delignted that in the fremework and history we heave had with the setting, leedership you just have been describing tnat the chenge in the bylaws has happened and change in the RAG has sone under Way. Sure; we would like to have some other things em I would be much more satisfied with a much more dramatic devel- opment in several dimensions. But the reason I made the motion specifically before wos to split a balance so there is an element of reward, that is why I dilated on the point of mak ine sure thet reward idea got down to them, DR, HESS: Let me say if this can be coupled with the recommendation that the projects having to do with infer- ring definition of whet these projects are, expansion health service site, that is reaching out to underserve and extencec LD | | medicel manpower, that those you know are-- agein, thb is dipping into the prerogatives of the local region. But ny con cern is if we cut the totel, what is it going to do to those things? That if we can covple this with some advice, those we see as extremely worthwhile activities, that we would, you know, encourage they support, then I would feel better about thet. But L em concerned ebout the possibility of, you know, diluting that tyoe activity. mo pos ta DR, THURMAN: Asein, ore of my concerns, there in tne United Statesthat nas better survey of the = oO tra cr a er oO Sricona. Why ere they asking for more They can tell you right down to the guy who Lilted the tube yeeterdey wnet is wrong. : DR, HESS: Except I understood tnis wes pased on oric: mentation of getting services out to the ceop le, DR. THURMAN: I nave to admit I have nov read it as tnoroughiy as you did. But I didn't see that as implementation. DR, TESCHAN: Unfortunately all I read has very Little solid evidence ofwnat really is going to hagoen. I have read ouite a number of these, hed @ tot of stirring ex~ periences about a tot of taliz, no documented action. When you have the evaluator. you have to hire, you L56 didn't get this kind of thing in the writings. MR. BARROWS: Could we accommodate these varying viewpoints with o sherply reduced budget, such as has been proposed, coupled with a statement that if these promised changes they have started are really reflected in their new propote is we may look more generously on their next go-round, would that have any impact with them? DR. HEUSTIS: Next go-round is almost in the oloe- line. DR. TESCHAN: Tnat should be a memo to us. (Laughter) DR, HESS: Is there going to be time after the : ies Council acts for eny communication or rearranging of priorit-e: of orojects that are already written up by the regions? MR. PETERSON: Againg-- DR. HESS: Is that out of the question? MR. PETERSON: It seems to me very Little, Joe, es a practical matter. Our Council, and we would not de communicating by and Large with any RMP based just on @& review committee action, our Council meets the fourteenth-fifteenta of June and esain, given the best of all worlds, instant, good communication. And assuming the receiver on the other end with minimum of dissonance-- you know, most of the RAGs wi! have just, you know, they wiLL have taken their action. The a stuff will be flowing from a committee room into a set of s ree typewriters to becom @ final application. So I think ag a realistic matter, it is unfortunate but I think it is no, we can't communicate significantly at | this juncture. In one sense I think-- this wes your remerk -- that kind of advice is almost correctly more of 4 memo for the record to remind ourselves in July than doing any good in terms of really making a difference with wspect to &rizone'’s -- or anyone else's July L application. DR, TRSCHAN: I would like to ask Mrs. Sadin if I ean wheat would be the impact of this budset there? Whet Kind of steff investments in these furgamental | chenges et this late, late date-- after all, it is more than : nearly two years since the policy came into effect, June 1972 when Coureil first oassed the fifth-sixth of June, finally came out of the Councils office in August, or at least published as of, the thirty-first of August 1972 policy wes | out, Okay, this is May 1974, just a Little late in the day. The staff probably has been charring at some kind of a bit, Iam just wondering whet would happen if we sent @ curteiled budset? 2 MRS, SADIN: You know, I am Leaving Mondey and I em. (Laughter } MR. PETERSON: Leaving DERP. 15d MES. SARIN: Leaving DRMP. I em going back to Arizona, because you have your problem of-- you are talking about, you mentioned RAG policy --+ ILwes at the RAG meeting where f mentioned they were not in | conformence. They have to be in conformance. And Dr. Duvall, | who cet next to me, seid, ‘then I was in Washington, I ergued ageinst this policy." He says this to the whole »4G, Now, you dontt get an instant reaction on, Well, okay, Mrs. Sadin, we ere going to do that tomorrow." bh You heve these fectors to deal with. And I think they are real factors. DR, TESCHAN: They are real factors. DR. THURMAN: It is. Real factor. We never want to undercut staff, Never be in thet position. DR, THURMAN: You Know, from sitting in before we have elways come back and said, "How is it going to affect MRS, SADIN: I think staffs morality could be up-~ Lifted now, esoecially Billy Vv. and some of the others who nave reelly been trying real herd to work with the area-- Lt is their push thet has done this. They are the ones who were trying to terminate CESA,. It is the staff, you know. Aaa they got an outside committee to try to help them and it Gidn't work out. LY : DR, TESCHAN: And they do ib against every obstacle. MRS, SADIN: Every obstacle in the world. It is | staff thet is trying to do it. I would hate to punish then. On the other hend-- DR, McCALL: Maybe if we up this to $860,000, cur- rent level -- MR. BARROWS: I could go along with that. DR. MeCALL: And et the same time get a strong Mes~_ sage, not satisfactory with, you know, recognizing some progress, some change, at least not cut them below their current level. UR. HESS: Let me ask another question, Are their projects prioritized in any way or cen you tell? MRS, SADIN: Yes. They nave it in the appiication, And, you know, expansion of service sites was the Lowest priority. DR, TESCHAN: Progrem staff was number one, as I recall. DR. THURMAN: Yes, it is. DR. HESS: Thet is natural, but what about going from this? MRS, SADIN: One was program staff, two was hyper- tension; seven is the lowest. Streptococcal infection -- no, EMS wes three, four was streptococcal infection, consumer education is five, manpower recruitment is six, and expansion seven. That was Gone verbally, eas I said, and I really think they would not have errived et this priority rating if it had been done by written document, I really think people ta changed their minds, But nevertheless, those are the prioritie you have in this application. DR, THURMAN: R&M has supported that streptococcal infection ed nauseum. It never should heveeven started. MR, BARROWS Dr. McCall, is that a motion? MR, PETERSON: I think Bill did, he threw out $800,609 . and I don't know whether he regerded that as 4 motion or whether he would be willing to edjust his motion to $860,000. DR, THURMAN: So move. DR, TESCHAN: Second. MR, PETERSON: We talked initially about rougnly 31.1 million, now we ere down to 3¢60,000 level. I just throv it out for consideration because I didn't wa ant to extend this caution much longer if we can -- We seen to be coming to e@ decision. I think one of the things thet again we need to kees in mind as a possibility here, and others, that one could possibly make a grant award, whetever the sum, with some dad te My fairly specific conditions in terms of some things that h be met or reflected, or they didn't get that full amount. That is, again, & possible option thet you may want to think ebout. LOL | { DR. HESS: Whet I em concerned ebout is that priority listing, the things are going to be cub are the ones that I would be most interested in seeing kept in. Now, if that somehow, with the award letter, you | know, the feeling, thinking -- they ought to reconsider those priorities. We feel in light, you know, of the need of the region, the study that went into developing those particuler projects, that theyougnt to consider giving a higher orlority.: ‘eant't tell than to give them, but strongly suggest they give high priority to those two projects, I would feel better, rimcais DR, TESCHAN: But they are on annual review status / 5 and I think -- ty we ® eH bi UY co. o- <1 is) bk a bk ta the last review, thougn, isn't Lb? | | DR. TESCHAN: The point I am saying is the degree cr * fon ny ~ co of nationel intervention in locel prosram is diftere: not? DR, HESS: They still are on annual. DR, TESCHAN: I don't know whet status is now. MRS, SS£DIN: They were, it was taken back. | { MR.RUSSELL: We too have the same problems with this. i We finally esked steff, prought this to the committee and to the Council, triennial status was taken away from this progrems. DR. HESS: That modifies it, then you do have a better-- DR, TESCHAN: But do you? That is the plan. Do you | \ | | i LOC nave more intervention here than on triennial-- MR, RUSSELL: Yes. Depending on the degree. In teking away the triennial ctatus, the next tive the program is being reviewed a year later was to be based on Council's gite visit. And then being phased out -- Or, Cannor went, and we are really not quite sure what happened, ere we? MRS, SADIN: Yes. DR. HESS: The issue is whet is our status invwtla- tionship to being able to offer edvice to them about changing their priorities? Is that legitimate with them being in annual ebtetus or is it nob? R, RUSSELL: I think very legitimate, because, 4s Rebecce pointed out in the Letter going back to the review process, it wes suggested that they grioritize their-- well, projects by ballot or scmething to this effect. And we can elweys suggest they go back and do it. I dont mean trey have to. MR, BARROWS: They nave to follow whet this guy says anyway. MRS. SLDIN: There were people there saying, “sonsidering what you just said, I will change my vote." MR, BARROJS: That is what I mean. It seems to me you ere fooling around with esteb- lished policy if we attach internal constraints on RAG — 6 to through this grant. But is it possible for staff to informelly cay thet these ere the questions that occurred inthe review committee and if you want to a a little bit better, the next time you had better-- DR. HESS: There is no "next time.” | 1 i 1 | t | | MR, BARROWS: There is when they come in for duly Is DR. HESS: It is too fate. MR, BARRCIS: No, if staff communicates now-- MR, PETERSON: Can't communicate now, I think this. action hes got to be confirmed by Council. Let me egain, to try to get us off both the subst oS tive end time dilemmas, would there be any recognizing that it is not the usual order of the day, either now or in the pest, Would the group cernsos want to, in @ sense, cartially punt to the Council on this saying we do feel either x amount or somewhat lerger amount, provided thet a couple of the things we think ought to be of high priority, if there is some essurance thet they remain in? That one project you ére talking about, Joc, is really a significant amount of money, $339,000 or whatever it is. The health sites in remote ereas DR, HESS: Yes. MR, PETERSON: Otherwise I think we are-- you know. DR, HEUSTIS: Excuse me. Before we do tnis, would Qe~ you call for tne question on the motion to see if we ere going to get -- 1o4 | MB, PETERSON: ALL right, let's @il for the ques tion on the motion: $860,000, ALL those in favor raise their hends. (Show of hands) MR, PEDERSON: Seven. And I think in one sense, the) problem has been resolved. MR, BARROWS: This brinss up the numbers, though, to bring up anotner Council policy question. Taking tne who te | past history of review committees and councils dealing with the regional progsrems, is it appropriate to be too severe in 0. swings -- this is an old problem and is this the right time to epoly an entirely new, narsher solution than in the past? : DR, HEUSTIS: This is the thing we really leave to ; the Council. It is their responsibility. : MR, BARROWS: It is their baby, not ours.’ | DR, TESCHAN: Do you think it is possible to move on ry this connection, that the approve at this level, recommends tne funding to the RAG in Arizona that the COOL, 2, and 3 be .funded. It doesn't say how much, but it clearly states level of priority, They can rearrange the budget. Does that help? MR, PETERSON: Well, I think that is the kind of first advice that you people -- if that is what you are sug- gesting we ought to give to Council and ifCouncil feels 1605 strongly in the sameway, then TI think that again, as advice, we ougnt to be passing it on to Arizonoe DR, TESCHAN: I so move, DR, THURMAN: Second. MR, PETERSON: Okay. That is on Ll, 2, and 3, those three projects. Okay. krizona is our record for the day -- 50 minute regio There may be some correlation between oroblems and time. I wonder, do we went to try and put one more? We heave pub one more region under our belt tonight. MR, BSRROWS: Do you heave an easy one? MR, PEPERSON: No, I didn't necessarily have an easy one. I thought since -- I guess it was AL or somebody eerlier in the dsy was wondering what we did when Senator Ribicoff celled, I thought ve might escalate to potential cell. end discuss grester Delawere Valley. DR, THURMAN: Wonderful. MR, PETERSON: Hither John or Bill or Joe, feel ready? I think you indicated youwere ready on that, Joe. GREATER DELAWARE VALLEY L166 DR, HESS: I read most of it. SCN: Do you want to Lead off? Both of you I know vere in on the site visit. I was ‘on. Bub that has been a long time ago. Greater Delaware Valley. MR, HESS: Well, there have been changes in leader-~ shio since I wes there on site visit. The new coordinator is Dr, Dean Roberts, who had been the coordinator for Hanaman -- pernaps I had better give a Little becksround here for this YeBZlones This region was organized basically around the five Philedeichnia medical schools and the zrantee is the Univers sity: | City Health Sciences Center, which is 4 kind of consortium cf itubions which was gotten together for funding educetionel inst of educational and related programs end research and so fortn. The initial district was the medical schcols which toc Lesdersnio and got the program going. a - the initi This region and many others, the oroblem then was “to bring in a br onder palence into the leadership and manage- ment of the program. And that was one of our concerns when I was there-- were we tosethery Bill? DR, THURMAN: With Pete. MR, PETERSON: December '7e I believe. - DR. THURMAN 1726 MR. PETERSON: Or ‘71. Loy DR. THURMAN: ‘Yl. DR. HESS: &nd we were concerned about trying to bring a better belance into the management program. We also recognized that there were some good thing going on there, but that there was probably unduly heavy medics! school involvement still et that point. | One a the good things I felt at least that had hap- pened was that the schools had Looked over the entire RMP end hed divided up responsibilities for organizing, supporting and working with health cere institutions, providers throughout tine regions. There were five areas within the total regicn whnien were the responsibility ox a given medical echool in terms of providing support. They have developed area offices, you mignt say satellite offices, in eech of these Live regions, Which, es L understand it, are not medical school controled, but medical schools do relate to these coordinating offices. And they have been doing a Lot of orgenizational planning, coordinating ‘work in each of the areas. So thet from that standgoint the region is quite well developed, well organized. Going down the major criteria, the program eedee ship, at the time of our site visit I was quite favorably impressed with Dr. Roberts. I don't know whet his performance has been since he hes been in that job, but he seems to be 2 man with a good background, seemed to be reesonable, and Krov how to proceed, Ir. Wolfe, still is the cheirman of the RAG, and again seemed to be I believe, was the RAG chairman then, gt Or- ward-Looking, had the best interest of the region at heart, He at that time was dean, now he is vice president for planning of -- I forget the name of the school, or college, But it is en upstate-- MR. PETERSON: Ib Berre area. DR. HESS: So he w ares end brovsnt that One of n of the executive representative. end a bit, nov, The program staif, steff when you consider both steff. There is something SO it is a this is a large population area of high density, including Philadelohia, end the surrounding area. I don't have population figures here, but my guess is people, so that that would require fairly large steff to try 1S there is a broader representation on tne larse st it is probably in the neighborhood of five or six million ! i | | up in the Seranton or Wilkes- aveay from the Philadelphia cers oective, our concerns at that point was the domination committee of the RAG by the medicel school Thet seens to me to have been balanced out RAG they have a rather large crogram the central staff plus the eres like-- is it 27 all told? aff. But also we have to consider bo cover the many organizations, institutions and prob lems | thet ere there. The Regional Advisory Group has been quite active. They subd {ivided into executive committces and in addition, there are area committees that relate to the area coordine- tors end loolx at the problems with each of these five areas of the region. They do have a set of goals, objectives, and prior-~ ities end the apolication is well put together in that every project rele to agoal and objective. So you know they know nov to think end mansse in those terms. Tneir past performance, there have been a number or activities in the City of Philtadelonis , metropolitan aree, as well eas in the outstate resions, that have been effective in bringing together health care providers and try to improve both the quality end accessibility of care. 8 sizeable one, both in terms of pote ma The crooosal number of projects and in dollar amounts. Most of them seem to be fairly well thought out. And appropriate for the region. | Feasibility is e Little bit difficult for me to { estimate, but my feeling is orobably with the experience of She \ | group and so on, that tnese ere things that could be done. The CHP relationships generally seem to be quite good es near as I could tell from the document. Maybe the staff will have some other comments, but it seems to me a L(V good working relationsnip petween the CHP and RMP, My overall assessment of the regior,as based on this. wes above averege considering the complexity of the region and s one question thet was @ continuing: t e+ the orgenization. There problem or issue, leb me not necessarily 6 problem, there wm ao tes is a lerge proportion of the funds still going to the medical school. And I was surprised at the aoparently high salary levels, at Least compared to our senool, of some of the people who are paid partly through the RMP budget. | I have no wey of knowing whether comme surate servi-e ces ere being rendered by those on cart-time RMP salary. DR, TESCHAN: How many part-time professionals ere there? &é lot of woole + DR. THURMAN: Fifty-two altogether, about ten or twelve. MR, PETERSON: Ten or twelvee Iam trying to recall how many it was vhne we were up there. That a be somewhat Less, but it has alwseys been é@ -phenomenon of the GED program, I guess it has always raised some guestions in a Lot of people's minds. But I think it is twelve, roughly, my count, if thossa figures are correct. Bill, how ald GED revisited look? | DR, THURMAN: I think I would second what Joe seid from the standpoint Roberts was a stronger person and one of f ‘secretaries. ‘So that -is egain an unreal situation. L71 the few strong people we saw on our initial visit really, so | I think that could do nothing but help. The Regional Advisory Group is still largely @ one- men reo LbLonship and that is Wolfe himself, who does run it and runs it reasonebly well. I think that they have developed some new projects, but they have largely used ideas from other people and other ang heve added minimum innovation to it. O 6 ° C8 * oo fa They have not terminated some projects again they yere ecked to terminate multiple times. Il acree with Joe's assessment, I would just “o> enonesize the points he made; that is, there was not e single medicel school budget in this whole prooosal, that ib realistic thing, ard one of them, for instence, they have nad> the cheirman of preventive medicine getting 50 percent or nis salary for running @ community hypertension program in one sac- ment of the Pennsylvania community, end that is not realistic. \ i Where we don't have professionals, we are paying Some of tne projects are overfunded, but. I think their enalysis of their orograms and progress they have made sinee we were there is significent. I think they have come a Longs wey. DR. TESCHAN:. How is the RAG appointed, do you know L72 DR, TRSCHAN: You wouldn't necessarily pick it uc here. MR, PETERSON: I don't know. Spence? MR, COLBURN: They have their own nominating com- mittee. They do have institutionel representation, that tyoe of thing -- is that what you are getting at? a roars There is guerenteed representation from the Medic Sehool on the RAG, elso on the executive committee. But ell six schools are not represented -- in fact, I don't think ye heve more tnen three medical schools reoresented. TAOS DR, HESS: That is reduced substantially. tea MR, COLBURN: Policy Board of Directors used to cell all of these shots, now they have e true executive committee. oO Doesn't have ea great deal of experience, DR, HESS: Ten cart-time medical school pro ofessionals at the doctoral and master level, so they are not all onysi- cians. Some with master degree. DR, TESCHAN: I just was summarizing the general notion oart-time people ere dreadfully hard to keep track of, especially when they are orofessionals. MR, BARROWS: Am I right in reading these figures, °: CO four segments of the university-based staffs total about 3250, 000. : DR, THURMAN: You are. hi MR, BARRG'S: That is a helluva Lot of money. MR, PETERSON: Used to be 3600,000. DR, THURMAN: I was gsolng to say you aint seen nothing yet. MR. BARRGIS: Let me ack a question, They are in area vith a lerge underserved population.’ Have they address themselves from that? DR, THURMAN: Yes. DR. HESS: They got into that from the very beginn. i> 1 their efrort. MR, BARROGIS: Ib is not ell bed. KR, PETERSON: I wonder, Seence or Frank, if there were ony particular ascects of this apolicetion -~- I don't recell wno it wes thet mentioned now whether it was Bill or That is where the medical schools have put a Lot of ‘a ose Rs i 1 I Lilte Joe eboub some project that may have gone beyond whes we con- sider to be the normel funding period, Council did nave a ¢ of generally not to exceed three years, Whetner you have any comment to that question, which = thousht I heard reised specifically, or any otner significant point policy issue or problem as staff has perceived them with respect to GEA? MR. COLBURN: As I recell, they nave several new About the time we phased out, they were fitting en application for review. They were phasing out continuing activities. They went on the shelf. When they were instruc~ ted to phase out, they discontinued the other activities end the mogram vas almost just, you know, an inch eway from being completely out of business in August of 1973 when they started beating programs on a monthly basis, spoon-feeding on | 3 Querterly basis; so you have grossly here the new projects in the epoplication not reviewed. DR. HESS: Ten continuous and ten new. R, PETERSON: I notice from our summery sheets which, needless to sey, I em not very conve rsant with any of these epolications in any detail, but most of the projects haa elicited CHP reviewing comments, Tnere were a couple where they hed not. We do have Tom Smith nere from the Philadelpnia Regional Ofri.ce. I don't kiot whether you, Tom, hed any particuler informntion with resoect to CHP comment or relationships in this eree; soecifically, greater Delaware Valley, Philedelonic. TOM: To the best of my knowledge the relationshics were reasonably good. MR, PETERSON: The chief CHP agency, of course, is Philedelophiea end there also happened to be an experimentel system there, Thereis also another one greater up north, Qs Representative Floo MR, BARROWS: We came up with the conelusion this LfD vas pretty spporopriate? DR. HESS: Yes, I rated it overall above average. DR. HEUSTIS: Budget somewhat inflated? DR. THURMAN: I think so, They are asking for 32.8 million and they have been at 31.7 million, and they really -- exactly half of the project continuing project. Many of them in the year phased down. ‘They said that very clearly this is the lsst year of suppory elther they will be terminaticas . or supported by someone else. So that I tend to say yes to that all the time. DR. HEUSTIS: Woenever indicated? DR, THURMAN: Not neceeserily. I do it when it is t not indicated. It is a fault. I think it is over~inflated. MR. PETERSON: We do have -- this epplication is roughly @ 52.6 million request whicn, as Bill points out, wes f venly can) V oO considerably above; their sort of funding level now is r edual to the sort of tarset figure we have nad an indication that they are going to-- Greater Delaware Valley is going to be coming in with a rougnly bi.3 million second phase two request which would put this progrem at least in terms of its request in the 34 million range, so asoinst that backdrop I don't know whether either of the reviewers has a recommendaticc. DR, HESS: I have a figure. DR, THURMAN: Go ehead. y DR. HESS: I would recommend $2.3 million, waich L/o : recognizes that this is the good region -- reasonably good | region, rated above average, seems to have good Leadersnip,. They heve got a large population, many underserved, who need essistence. They seem to be addressing those problems. Also I was aware of the July Ist estimate reelizing that there is going to be another big batch coming in at that | time, And this seems to me is @ $600,000 increment over their current Level, which is rather substantial. It seems to me to be a feirly reasoneble comoromige.. MR, BARRGIS: 35 percent boost, is it that strong? | Over where they are now? MR. PETERSON: Avein, Mr. Barrows, I don't-~ it does seem to me that the oresent six months funding rete in meny regions, that could be column one which is 4 Pune tion 2 of times two. It has one sense of reality and the other; ic vi rn does reflect-- it nides sore things in some instances and . } certeinly is not indicative in most instances, including tnis one, the Kind of level the regional is functioning at pre- Jenuary 1973. MR, BARROWS $2.3 million would reflect wnat per- centage increase over-- I try to get this feelfor other programs, DR, HESS: I personally feel they have management ability to use that. MR, BARRGIS: What percentage increase? DR, THURMAN: That would be 86 over 17. I am not a mathemsticlarte MR, PETERSON: A Little more than a third, | MR, BARROGIS: Seventeen isn't eae real figure. DR, HEUSTIS: These white sheets show a billion one hundred thousand plus for a six-month budget, so that is real- istics; L74 to 674 present one, six months; multiply that by tuo. You are not too far avay from $2.3 million. MR, BARROWS: That kiad of move-- DR, HEUSTIS: ‘Thereis a good deal of difference between the material in the white sheets and the other on this printout, Great difference. MR, BARROWS: Your recommendation if the white sneer is rignt, keeo this ebout where they are. DR. HEUSTIS: No, give them a Little bit more. MR. PETERSCH: TI have got to cry helo to staff here. Whet are we talking ebout* MR. NASH: I am not talking about the one on the orintout; I am talking ebout the one -- this sheet here (indicating). Is this an accurate fisure? DR. THURMAN: Is that figure accurate? MR, COLBURN: Pediatric, pulmonary -- is that added in there? Included there? MR, PETERSON: It may well have earmarked funds. Also 3170,000-- L790 MR, COLBURN: You are right about SL.6 million. After gite visit. That is what we recommended. They were funded at that level, so half of thas wouls be $900,000, And they had sbout $400,000 for pulmonary, thet. is pretty close. DR, THURMAN: Mr. Chairman, my recommendation is $200,000 of f from his, but I have no concern about Joe, say 52.3 million. I vas th inking $2.1 million. But I can easilr Live with 52.3 million, because I think this is a good pro- Sram. MR, PETERSON: Do you two want to telk together for 30 seconds? DR. THURMAN: I second the motion. MR, NASH: Ib you want to include with that doliar figure recommendations, eny further recommendations fro 4 5 oO [oy wt a 9 ' committee so fer as removing additional funds from the school? DR. HEUSTIS: You ere speaking to Dr, Hess? MR, NsSHs Yes, =I v DR, HESS: This I didn't think was something we reall have enough information on now, but I think perhaps the concerns as to whether or not the region is getting value recelved for the money that is soing to medical school now, the RAG may or mey not need a Little muscle to take a look at that. Ié is nerd to ask that kind of question unless you have got some LY reason for acking it. But I personally don't feel I am in position to weve a judgment on this. I don't know. : MR. PETERSON: But you do see that as-- DR. HESS: Potential concern, MR, PETERSON: Despite the fact figure is down from) $600,000 to $250,000. DR, HEUSTI 4 obviously. You would think he would be more busy carrying out his edministrative vwork-~ didn't sound very reelistic. DR. HESS: Sse, there may be some compensating fac- + ome tors. He may have some of nis people doing some running end for budgetery purpoces, you know, Lt gets too mucn of a hastle to out somebody on part-time salary for so end so. DR. TESCHAN: That is very optimistic. Cur exper- jence is the opposite. DR. HESS: ft may be justified. DR, TESCHAN: Here is where a site visit would b O helpful. DR. McCALL: Still talking about unknowns? QO MR. PETERSON: Yes, expressed, it seems to me ta DR. McCALL: Tne way it i as far as we can go now. Call the question. MR, PETERSCN: Tnose in favor of the motion for 32.3 million with indication ofconcern, fed back, about the : You geve Peul about 50 percent salary ! 180 still Guerter of a million doliers of medical schools, all those in favor’ (Show of hends) MR. PETERSON: We still didn’t manage to slip out of the comolacency and unenimity. It is ten til five. As your chairmen I am at your beck aid call. Do you want to go on with still another? Loam pre peared to do thet. If you want to wrap it up for-- ho JR, BARROS: I have some homework to do. I would just as soon vwrep iv up. DR, THURLGN: TI have a quicky -- no, I will conceive MR, Wnet is your Quicky? DR, THURMAN: Puerto Rico. It's a quicxy. | i i 4 i | i } { { \ MR, FETGRSCN: We ere reelly talking about e ten or DR, THURMAN: At tne most, yes. AT. sop caw. oT MR. PETERSON? 2 cr a is @ very unusual-- would that do too much violence with your needs? MR. BARRCGIS: No. MR, PETERSON: I hadn't orogremmed Puerto Rico, but let's oull Lt out. The reviewers ere on that, in addition to Bill -~ let me see that sheet of caper acain, BILL -- I Gon't think ve would do violence if we confirm our review Lol and recommendation with Jill in the morning. Again, I don’ think it is going to take that much time first thing in the morning, BLLI. DR, THURMAN: I don't mind putting it off. UR, BARRCWS: It might be eae Little more courteous. | MR, PETERSON: Yes Oxey. Before we leave, a couple of things here. Feel free to leave your materials in the room. On the other La Secordly, I did have e note handed to me late this aftercoon. If any of you did not use RTRs if you olease -- that is the grein IBM card that buys an airolane tickeb -- if you would return them to the desk, to Mrs. Leventnal, if there | | are any tnet were not used. Before we breek, on the other nand, i would Like to aa ed cr s heve your indicetion of what time we would Like to get star By my calculations, we reviewed eight regions todey which means ve have 17 to go. We did not really start the review process until well after eleven. We convened at eleven end L tock some time with generalities. So on the one hend, we are not in my view terribly in arrears. On the other hend, we dont have a lot to coast on. I don't know now they ere doing, but IT just figure We would beenead of them. Loe DR, TESCHGLN: I would like to start about 6:30, MR, PETERSON: ALL right, ©:30 with a pledge to dispense with Puerto Rico end Californl. before nine. DR. HRUSTIS: And California will only take ten minutes. ct ro oO st MR. PETERSON: I know, and you are reminding me mm Ls a very simole application at this juncture. It is one cf the fou regions which the Council, along with Arizona and Hawell, expressed some grea at concerns about last November; it ves site visited. PLLL Thucman vee on ib and I think witnout telling his story, it happens to be a site visi t that came bacx more then alleying the kinds of concerns the Councilhad et tne oo Gime. Okay, with tnat, I went to certainly express my poreciation for your diligent wor. boday. & personel thanks and I would only make the plea, at this juncture, it iss plea rather than intimidating request. If you haven't given me your review sheets for those resions which we have Looted at, would you please let me have them before you go nome, then I will be able to take them back up to my office, Thank you and we will see you at 8:30, this half of the room. Whereupon, et 4:53 o'clock, p.m., the meeting recessed, to reconvene at 6:30 o'clock, a.m., Thursaey, Mey 23, 1974.)