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HOOVER REPORTING COMPANY, INC.
Official Reporiers
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DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

MEETING OF AD HOC CONSULTANTS REVIEWING

REGIONAL MEDICAL PROGRAM APPLICATIONS

Conference Room H
Parklawn Building
5600 Fishers Lane
Rockville, Maryland 20852

Wednesday, May 22, 1974

Panel B convened at 11:00 o'clock, aem., Mr. Peterson,

Chairman, oresiding.

PANEL B:
‘Mr.
Dr.
Dr.
Dr.
Mr.
Dr.
Dr.

Dr.

Kenneth Barrows, West Des Moines, Iowa
Joseph Hess, Detroit, Michigan

Albert Heustis, Three Rivers, Michigan
John Hirschboeck, Milwaukee, Wisconsin
Joseph de LaPuente

Charles McCail, Dallas, Texas

William Thurman, New Orleans, Louisiana

Paul Teschan, Nashville, Tennessee

Sister Ann Josephine, Notre Dame, Indiana

 
 

 

Regions:

CONTENTS

eee te

Maine

Motion
Vote

Motion
Vote 40

Motion
Vote 42

Albany

Motion
Vote

Northern New England

Motion
Vote

Connecticut

Motion
Vote

Central New York

Motion
Vote

Hawail
Motion
Substitute motion
Vote

Arizona

Motion
Vete

Motion
Motion amended
Vote

ht

AL

49

57
60

62

75
79

82

100
LOL

103

LL5
116

118
131
132
133
135

152
153

153
160
164

 

 
 

 

Regions (continued ): Page
Greater Delaware Valley 166
Motion | 175

Vote | 179

 
 

 

PROCEEDINGS

fe tee Nem at tm

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 what I see as the more nitty-gritty
details,

You have already heard from Herb and the review

guide that I hope all of you got, the kind of things that seems

to me is almost imperative that we individually and collective-

ly sort of try and keep in mind, the necessity for trying to
keep our focus on the overall region and its proposal, need

to try and couch our review in terms of the criteria and factor
which we specified as being the basis for our judgment.

Clearly if we try to look at very many projects, we are in trou
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 and staff will want to singl
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

A

1¢3)

 
 

 

4
in a number of instances with projects which staff has already
identified and perhaps others which you and in the applications
you have Looked at, there are some policy issues about which we
may not be able to resolve in our best tact at this juncture,
maybe simply to flag those.

And certainly the time that Herb dwelt I think on that
last table, he passed out to everyone, I guess the column C
we spent more time talking about than anything else.

That target amount, while it is not a formula, while
it is not an assurance that the region will receive that much,
I think yet in many ways Lt is going to have to serve as the
principal benchmark or backdrop against which we look at these
applications, rather than necessarily the much larger amount in
some instances that is being requested.

But in terms of the review procedure itself, we fave
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 who had their third numeral thorax within the past day
who isn't here, so there will be a few applications where we

ms

only have a single reviewer because of last-minute cancellations

 
 

 

5

In a few instances we have tried to get to someone
else. I knoy Bill apparently there was 4 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 brief summary sheets in your books,

not to have staff comments precede the reviewers, but rather

i
'
,

to follow as appropriate after the two reviewers have’ addressed
themselves to the applications.

I think in sitting down with Dick Russell -- where
is Dick? -- who is chief of the Western Operations Desk and
with Frank Nash 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 kina
of application. But generally we will Look to the reviewers
initially and any staff comment subsequent to that if appropriate.
Certainly apart from the two reviewers that will |
be 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, cther people
6

on the panel have where they may have them, or to get some
issues crystallized.

We will ask the two reviewers, in those singular tt
Sastances 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
end it is my understanding that each of you in the folders that
you had in front of you have about five or six blanks there.

We have got additional ones if anyone runs out, But subse-
Quent to each review, where Dr. Hess or Dr. Teschan is one of th
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
Wwe are going to try, as we get back on Friday, that will be one
basis upon which we will try and give the totalgroup 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 of
instances, regions WLLL also be submitting applications in July.
But we do need that.

I think we have heard enough about the kinds of

 

 

 
 

 

7
constraints that we are operating under. Not the least
of which are 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 have
tried to arrange these two panels so that at least in the gross
geographic institutional sense, people from Great Midwest are
looking at the eastern and western parts of the country than
vice versa.

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, HEUST IS: 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

 
 

 

8 |

: |

interest that-- if that does occur, that you acknowledge it, and

we will -- then the individuals can leave the room while thab —

region is being discussed. Hopefully that will not occur, be-

cause we tried to arrange the groups where the obvious conflicts
of interest would not arise. |

One final thing before we do get into the actual re-

view. I do need to know if there are any people, particularly |

the reviewers, who for whatever reeson will not be able to be

here on Friday.
Charlie McCell, when we asked him to participate in

this, indicated as part of his participation he had a long-

standing commitment that forced him to leave late tomorrow

 

afternoon, and thus I am going to have to make some adjustments
vis-a-vis the regions Charlie has been asked to participate in
the review. But if there are any others of you -- Paul.

DR, TESCHAN: I am paled on airline computers--

MR, PETERSON: That seems more Like a bowl of jelly,
from airline computers I have dealt with they are not that share.

DR. TESCHAN: Loused up so there is not much I can ao
about it. So Iwill let you know.

MR. PETERSON: You are going to Let me know if you
have to leave early? |

DR, TESCHAN: The reservation says we will be leaving

Friday morning.

MR. PETERSON: Okay.

 
 

 

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 England
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, BARROWS: I have a 4:30 flight on Friday.

MR. PETERSON: No, I think we calculated--

MR. NASH: We would Like to get to Northern New
England 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 steff that have departed MRP but have been brought back fo

this also have some crunches and commitments. We are going to

r

 
 

 

LO
have to do some adjustment there and I think I have identified
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 if there were any additional questions in
terms of details, procedures, or quite apart from details and
procedures, profound philosophical issues, some of which I
would be willing to take up at Lunch.

MR. BARROWS: 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 Atbany?

MR. BARROWS: Than I am on the last two, I hope to a
that Comorrow.

I think Paul is in the same boat. I don't imow about
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, L will, on sort of an ad
hoc spontaneous basis, at least in the beginning we have all
kinds of flexibility. When we get down to the last two appLi-
cations, our flexibility is considerably reduced as to the num-

ber of adjustments we can make,

o

 
 

 

LL

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
enother direction. Assuming they get the budget, will they
be able to fill the vacancies and do the job within the time
span 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 think affirmatively in the most
distressing circumstances and I think right now the stance
in many of the RMPLis 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

 
 

le

follow-on.

I am not nearly as mucn worried.

MR, PETERSON: There is only one thing I would have to
say, the issue Joe has raised, we did see the RMP's with the
announced phase out in January of 1973 go down in the aggregate
and there are obviously considerable variations here from
roughly 1400 full-time staff to about 700, In other words, last
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's were down in terms of program staff
about half of what they had been prior to the phaseout.

By January of this year they had picked up about 300
additional 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 end
of May. In December and January, I really couldn't see down
the tunnel for more than at the best six months.

So I don't think that answers your concerns, Joe,
but I think it is not irrelevant.

DR. HESS: I think i111 founded though it may be, we
must have some confidence between the Congress and Administra-

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 saying.

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 fact that this type of activity has proven itself to
be effective for doing a 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 make 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 what changes need to be made to get regions in
line.

SISTER JOSEPHINE: You know, in going over sone of
these applications, I have noticed in many cases where they were

looking for staff they picked up staff from CHP programs, which

 

 
 

 

14
to me is the direction toward the change in total administre-
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 sur-
facing during the next two days. We might kick off and I
thought 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, it dviously is not at the head or end
of the alphabet, neither the larger or smaller states, but that
is my rationale. Besides, Spence Colburn, that 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. McCALL: Be glad to.

MR. PETERSON: Okay,

 
 

 

MAING 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
strong leadership at the staff and advisory group Level. |
It comes through loud and clear this proeren makes
great plans not only in transitioning what is coming, but in
continuing and financial support from other sources. And I !
really don't think there is any-- there is no question raised 2
in my mind in terms of their conflict, in terms of their stated
objectives and 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 thet

was because of all of the vagaries of the past years that we |

have been going over and the excellence with which the orogran |

has been based, other sources of funds not only planned but

in hand and being utilized at the current time. So that that

needs to be Looked at when we come up with a figure or recom-

mendation. |
DR. TESCHAN: Who is the grantee? :
DR, McCALL: Medical-- 3
MR. PETERSON: Medical Care Foundation, Incorporated.
It is a private nonprofit corporation and has been |

since day one. |

DR, McCALL: I will confess when I received these two

i
i
}
'
|
t
 

 

16

volumes -- this is only half of it, oh, gracious (indicating) --
material, 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, and 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 ar

they trying to convince?
I received this other one from Caiifornia with the
other materiel, and I didn't really think they were trying to

convince anybody.

 

Beautifully done -- graphs, different styles in the
typewriter, different colored paper and so forth, And I Looked
at it with a negative prejudice.

DR. McCALL: I 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
had any need or basic population data.

DR. McCALL: ALL 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,

|

a
pw

 
 

 

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 paragraph into the number of things
that you mentioned, plus a few of my own. And on Maine, I
rated everything that was ratable in the good column except
for the reflection of needs identified by comprehensive
planning, which I put down as insufficient data. This may wel
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 great results as far as continuation pro-
jects at cost levels.

I was particular Ly impressed 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 as I understood it, at least to go into the

regular day-to-day operation of the program for the next fis-

cal year.

 
 

 

L&
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

4

refreshing one.

DR, MeCALL: No collaboration, but I obviously had
the same impression.

My recommendation wae funding maximum eligible.

MR. PETERSON: What about the other reviewers who
may have questions or comments about Maine? —

DR, HIRSCHBOECK: I don't have any comments about
the application. I haven't seen it. But I have always been
curious about the interface with neighboring states in
Northern New England, wnether this is well taken care 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 than 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, HIRSCHBOECK: How they relate,

MR, PETERSON: Maybe Spence or Frank have something
to say on that?

MR, COLBURN: Tney have been very close working
staff, three programs, tri-state who has New Hampshire and
Maine and Vermont, all of New England.

The New England program, 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, safety program, Now they are

A

moving into the area of establishing guidelines and standards

within the coronary care network for treatment. And I think this

is capitalizing on the success of that typeof activity in Ver
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 available 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 and said: This is what we want to

do; would you be willing to work along that?
That is the kind of regional program that I think is

carrying out the real mission.

DR, McCALL: 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 relationsh

 
20
Iam not quite clear, there are no functional (b)'s,
Chattergy has not done anything with the (b)'s to try to
© get them going or he has and they aren't functioning, or--
I 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). (b), (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 insuffictent data presented on what the
© (b)'s were 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. I do not recall that Maine is a
region where the CHP comments either were negative or pointed
a direction, but perhaps I am wrong.

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
ago.

I looked in the wrong column,

 

HOOVER REPORTING CO, INC.
320 Massachusetts Avenu-, NE.
Washinetan. D.C. 20902

 

 
 

HOGVER REPORTING CO, INC.

 

320 Massachusetts Avenue, NE.
Waehinatan NC INN?

eL

DR. McCALL: He’ really met with them ahead of time, |
the (b) agencies even came into the R& 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 misied you.

DR. TESCHAN: Trying to get a feel.

DR. McCALL: It seems they did.

MR. BARROWS: It would be awfully qifficult for us
to pull dollar 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 share
in the budget?

It sounds, for instance, this should be one of the
top ones.

MR. PETERSON: I am not sure when you say break them
down into groups of fives, what--

MR. BARROWS: Top --

DR. HEUSTIS: Aren't you thinking of this overall
assessment activity?

MR. BARROWS: If that is 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

 
 

 

22
recommendations. It is obvious if the recommendation exceeds
the total supply of money, there is going to have to be some
adjustment. But perhaps I can answer your question in part.

A

At least it was our hope that as a result of the review dis-

cussion and the rating sheets that hed been able at the time

“

ve get the two groups back together, be able to sort of display
literally what the two groups had come up with separately
and probably falling out into not unlike a bell-shaped curve,
there were some at one extreme considered among the better,
some at another extreme that were considered poorer, with
parentheticaily the amounts recommended for them, and I think
perhaps triparte -- again I don't-- but this we had hoped
to be able to do. Because I think it is difficult, because
‘some of this indeed is comparative.

DR. McCALL: And we are going to come back and Look
at what we have recommended here.

MR, PETERSON: That is our intent.

DR. McCALL: Set maximum rating, I would Like
$2 million requested. |

DR. HIRSCHBOECK: How do they deal with their fund- |
ing? They don't get as much as they have?

DR. McCALL: 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.

 
HOOVER REPORTING CO, INC.
320 Massachusetts Avenue, NE.
Washington. D.C. 20002

 

 

|

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 1f my--

DR. McCALL: About a million.

MR, PETERSON: The State of Maine has a little less
than a million people.

DR. HESS: I think that factor has to modify, put
into considerations.

Now, another factor is what, 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 Maine 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 themse Lves pretty well.
And that may be a reflection why they have got such a good
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 areas of the country. And Look at the

 
@.... CO., INC.

320 Massachusetts Avenue, NE.
Washington, D.C.20002

 

 

me

c4
relationship between funding recommendations, the size of the
population, and what we know about the health neeus of that
particular region.
If they have got a million people, just to give us 4

rougher index, and $2 million application, roughly $2 per

capita, RMP funding for that; et the 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
that 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 had 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 oyogram 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

maximum they should get when you Look at the overall.

ere

“H5
e

 
 

 

25

DR. HESS: These folks sound to me like people who
can make efficient effective use of money.

DR, HEUSTIS: This is really what came through to
mee

DR. McCALL: They are going to function if we don't
give them a dime. I think you shouldn't penalize them for that,

MR. BARROWS: That is important; as a taxpayer I hate
to see these bucks spent on the basis of need without produc-
tive use of then,

DR, HEUSTIS: I recognize need, but in these troubled
times it seems to me efficient productive use of money might
be things that would impress the Congress rather more than
taking another program that I reviewed that has a large need
and a large problem and not as good a program,

DR. HESS: I am not recommending putting a Lot of
money into a poorly managed program, but to carry this argu-
ment to a ridiculous level, if they could use $5 million, would

|
you give Maine $5 million just because they are a top-notch

progrem 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

 
@.... CO, INC.

 

320 Massachusetts Avenue. NE.
Washington, D.C. 20002

 

oe
co

to make some better judgment of all these things at this point).

MR, PETERSON: I think, you know, our judgmental
process which is collective and right now bifarcated,
I am not going to intrude too much on that.

Let me only mention one thing, Maine is requesting
slightly over $2 million. It ts one of the few regions which
has indicated to us tnis is their total package, so their
$2 million is not going to be a supplemental or additional, or
further request in July.

Their target figure, column C, was rough Ly S14
million. I think that again looking at it in terms of some
rough per capite, Maine indeed exceeded the national norm
at an earlier point in time by virtue of the fact that it haa
been considered a good program at the time we were steering
towards 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 a dime or not, so we have got between a dime atid $2 mibli

Would somebody Like to put somewhere between those
two points, perhaps lay a recommendation as to an amount on thé
floor?

- MR, BARROJS: That is the thing that bothers me.
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

tT

4

 
q@ REPORTING CO, INC.

320 Massachusetts Avenue, NE.
Washington, 0.C.20002

 

 

of money to be spent, it would be a Lot easier.

Just picking figures out of the air, 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 ail good conscious, more data is
available 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 all of the constraints. 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 have
needs, I would agree with you.

Some of these things on the basis of more information
we could cone 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

i

 
 

 

28

benchmark of a target figure, what 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 a

region that, in our judgment, without giving a specific amount
it should perhaps be above the target figure, whatever that
increment is.

I think we, egain, as staff, Dr. Pahl is the
Director, in the final analysis, who 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 operating with a great deal of lack of informa-
tion and the like. Amn that the pluses or minuses WLIL be in-
cremental rather than order of magnitude.

| It is more defensible to say let's give this region
20 percent or LO 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 the 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 and write all the imbalances
and inequities that may exist. Maybe3i.5 million recommendatia
does that, it is a little above requested, it reflects its

superior rating. If there are others, that is the ‘sense. And

 
@...... CO, INC.

 

320 Massachusetts Avenue, N.E.
Washington, D.C. 20002

 

25
1t 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: Iwas going to say in the past, the
previous procedure was to make a recommendation regardless of
the availability of funds. Then you know the distribution of
funds would be based on total recommendations.

MR. NASH: I think Dr. Pahl wanted some sort of
recommendation.

DR, HESS: I think it would be helpful if we go
through and we come to grips with a specific figure on each
project, and then come back if we want to adjust it at the end
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 along.

“DR, HEUSTIS: I would have great difficulty on
anything except political zrounds of recommending that you °
approve anything except the request. IT can-- if you asked me

to make a technical decision, the program is worthy of support,

 
HOOVER REPORTING CO, INC.
320 Massachusetts Avenue, N.E.
Washington, 0.0. 20002

 

 

30

If you ask me to make a political decision, there is
not enough money, then it seems to me the political decision,
at least as I see it, ought to be made at 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 the
other group, end I guess in 1969 or 1970. It was at the time
when theywre first beginning to get their resources together.
Ard I had an opportunity to stay several days and so a couple
of us went around and we visited in different places in the
state. And 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.

I was also impressed as we sat and talked with the
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 that has been 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 tyr
of all programs,

DR. HESS: No, I am not questioning the needs were
identified. I think that has been well done.

MR. BARROWS: Introducing the equity.

If we adopt this thing, what we are saying then is

 

UE
 

 

31
we have concluded 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 a human being who wrote a grant who
didn't add something to it.

DR. HEUSTIS: 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

i

me was the fact the only figure we have on this sheet is this

 
 

@..... C0, INC.

320 Massachusetts Avenue, N.E.
Washington, D.C. 20002

 

{

32
currently annualized level of what they are getting. This
doesn't take us back to what they did before they were cut,
and not having that information and not having the informa-
tion on how well they had spent their money pefore they were
cut, I 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 an 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 ofmoney and this actually isn't that.

MR, PETERSON: There are, as Frank points out, ina
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 C figure, which reflects
a percentage of the immediate pre-phaseout level 4s more indice-
tive of the kind of annualized level, approximating the kind
of annualized level that Maine and nearly all the other progrem
were operating on prior to January 1973.

But again, in.the interest of moving the discussion

 
@..... €0, INC.

320 Massachusetts Avenue, N.E. |

Washington, D.C. 20002

 

 

‘23 :
Ona

along, we have got a situation here now where two reviewers,

‘one in effect has laid a recommendation on the tabtie for

$1.5 million, I heard AL indicate that 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. BARROWS: Did you say a real index of their
pre~crisis funding was this targetted available thing.

"WR. PETERSON: ‘That target figure is an extrapola-
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 supplementé
funds.

Maine, for example, had a good deal of activity
fund for a couple of years which now does turn up egain 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.

21

 
 

 

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 is, I would put the question
to the group.

Those in favor of the motion?

MR. BARROWS: 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 through the phaseout.

They lost a few, but basically it is pretty much
the same staff. .

MR, PETERSON: I wonder if I could ask the question.,

Those in favor of $1.5 miLLion?

(Show ofhands )

MR. PETERSON: Oh, we are going to have one of these.

No, divided --~ 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 and

 
35

five against.

MR, BARROWS: Could we put the $1.5 million on the
© hook and come back 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
available 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: On, 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--
16 still does, it adds up to $114 million. At the time we
did that, 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 table until after we have had

© @ chance to look at them all, and then we can look. at the

 

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320 Massachusetts Avenue, NE.

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320 Massachusetts Avenue, NE. ©

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“as
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request, we can Look at what you have got down here and then

“we can go through and decide what 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 we have had. Ard then begin to

adjust after we see the total group.

MR, PETERSON: Is that the sense of the group that we

lay recommendations as to funding amounts aside until Thursday
afternoon, Friday morning?

MR. BARROWS: No, we could strike a tentative figure
put LI 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 than $1,450,000 or $1,750,000,

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 short 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

>

 

 
 

 

ae
“i

coming here in the last chapter of this program, the structure
having.been designated, very fine people still here, but small
in nunbers, overworked, mechanism torn asunder. And even when
it-was there, we knew there were some inequities and some
things that needed correcting, we were working on.

It seems we ere 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 a new. bench-
mark, write all of this in terms of population and everything
else.

Not that I am not for doing those things; it seems
to me this is not the point in time at which we are armed with
and able to do that any better than taking all of the prob lems
and our disagreements about them, the foriner benchmark, and

using it as where we start, and then modify up and down in

 

light of what comes in here rather than trying to go back and

go through all of these and now come up with some sort of

|
new-- |
‘

MR. BARROJS: I wrestled with that in my own mind and

i

came up with this general feeling, whether right or wrong, any.
body can say, but I felt we had a responsibility to preserve

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 that extra money to

1a

 
@... C0, INC.

 

320 Massachusetts Avenur, N.E.

 

Washington, D.C. 20002

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the programs that are doing the top-notch job.

OR, HEUSTIS: Great.

MR. BARROWS: 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 short 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. BARROWS:
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 percent.

DR. THURMAN: I hope we won't have this emotional
kind of discussion with each application. A Lot of us would
Like to have more information than we have 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 understanding the programs as they exist have gone through

Living hell as far as from an organizational standpoint. But

 

I would keep a reasonable stability sajy--
 

 

oF

elther they have had the relationship and capability of
doing it, they have known their state, they have known their
capability -- but the only rationale -- I don't mean that in
a 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 midair pulling out a figure in May of L974 and I
was concerned in dune of 1972 doing the same thing, with the
same kind of program,

So that I think we are trying to find an excuse
for our inability to approach something in an irrational
fashion when we have always approached it in an irrational
fashion.

So that I just-- this sheet doesn't mean a damn thing
-- pardon me, ladies -~ doesn't mean a damn thing to me, becéuse
here is a 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 Maine are interested in it.

ts

These people have asked for $2 million. They have got one yea
of self-sufficiency for a small population. And then they
have got to carry these programs without us.

What more do we need to make a rational decision than
those facts?

MR. BARROS: I don't say this is going to be

 
@...0 C0, INC.
320 massachusetts Avenue,.N.E.

Washington, D.C. 20002
(202) 546-6666

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;
I'll be rational and split the difference.

MR, PETERSON: Is that a motion for $1.75 million?

DR, HEUSTIS: .31.75 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 I thirk
we do have the sense that all of these are tentative plus, minu
kind of motions, it is again a rough motion, it is again--
how many would concur at aL.75 mi Lion for the Maine RMP?

ALL those that do, show their hands.

(Show of hands)

MR. PETERSON: That motion is voted down also I

think, four tofive again.

 

ta
 

 

I don't know whether we are moving in the right
direction.
Do we have another motion?

. DR. TESCHAN: Let me fly this ones LO percent or
more of recommendation to Dr. Pahl that he consider Maine in
the top group; secondly, that he consider funding at more
than the approximate ratio that he has dealt with before, on
which these figures were completed, say something Like 10
percent or so more than that, on up to the totalamount of
the application, depending on availability of funds.

DR, HEUSTIS: I will support that.
MR, BARROWS: That sounds good to me.
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 a
political decision for which I do not feel qualified. I am
perfectly willing to make a political decision.

i
!
t
i

. DR. HESS: I think that Dr. Pahl wants from us a

;
!
!
4

figure and that for us to avoid the need for making that recom

mendation, difficult though it may be, even though it feels
@..... CO, INC.

300 Massachusetts Avenue, NLE.

 

Washington, D.C. 20002

DARA PEP COED

 

Like we are rolling dice, as we Like 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-
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 $1.6 million.

MR. PETERSON: We have a motion of $1.6 million.

Do we have a second?

DR.McCALL: Second.

MR. PETERSON: Question.

DR. THURMAN: Cali for the question.

MR. PETERSON: Call the question.

DR. HESS: Are you asking for?

MR, PETERSON: Yes, for those in favor, $1.6 million
five for and four presumably against.

Okay, the recommendation of this group, by painful
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 are cutting the melon without

y

 
 

@ REPORTING CO, INC.

320 Massachusetts Avenue, N.C. |

Washington, D.C. 20002

 

43
knowing how many shells we want to cut.

DR, TESCHAN: Right.

MR, PETERSON: Dick, you had wanted to say something.

MR, RUSSELL: Yes, Iwas a Little bit disturbed and
concerned during this discussion. It seems to me we are get-
ting two issues mixed up. One is the role @ this group in
terms of making recommendations for funding Levels; the other,
as Dr. Heustis talked about, was the political part of the
decision Dr. Pahl and the Administration will have to make in
making the funds actually available.

What I heard in this discussion -- I have no vested
tnterest in Maine whatsoever ~- here we have an application
that apparently is well put together, the projects do fit the
goals and objectives; historically this program has been very
strong. ALL the pleces fit together.

I think it is that type of information on which this
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 goin:
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 chance--

DR, TESCHAN: But, Dick, you are not helping, you

 
 

 

44

are at variance with the imperatives to come up with a number.

I am comfortable with that kind of embiguity, say
"noorah 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 have to go beyond where
we ere.

MR. PETERSON: Herb Pahl's decision in terms of de-

ciding signing a grant awerd, statement for Maine with a figure,

that is going to take place after the Council meets. -

 

I think with a Council that insisted upon a review

committee, kind of restructured review process, 13 new members |
that while it is true that the Council is in a sense the

formal recommender, I think they are going to have more aiffi--

culty coming up with numbers if we don't provide some bench-
i
mark for them. |

I think, Dick, at least in our skull sessions, in the
preceding days, you know, I think we can belabor 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 ere
no numbers, we aren'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
 
  

@..... CO. INC.
320 Massachusetts Avenue, NE.

Washington, 0.C. 20002
(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. McCALL: 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 ané@I like what you said and it seems to me even
though we have done it before, and I wasn't a party to it,

I may have gone along the same es you did. But it seems as
though if we give him the aimmund thoy if we have extra money,
this is what you do with it, this is who you give more and thi's
is who you take away, that is our primary function.

DR. TESCHAN:s I feel better about that.

DR. HESS: He is not bound to use these figures.

rs

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 igi,
he says, "But, haha, the Ad Hoc Committee, Advisory Council,
this is 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

 
@...... C0, INC.

320 Massachusetts Avenue, N.C.
Washington, D.C. 20002

fN GAG GERR

 

 

WU

get a program person to cut his budget so that he doesn't have
to make-the political decision.

DR. HESS: Al, just let me comment on that.

if I understand the purpose of this ad hoc review,
it is to bring some additional perspectives to bear on these
very complex issues and so to ask this group to welgh in our
minds es best we can all the various dimensions that should go
into decision making about, you know, this national program
on @ region by region basis, And that the most precise re-
flection of the summation of those judgments is in dollars
at this stage of the game. And that the role that the Director
and Council are not bound in any way, shape or form by those
recommendations, but nevertheless that is the most concrete
translation of judgment that we make. |

MR. BARROS: Pete, let me make a proposal that may
simplify this 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 I think
this is where we are going to have to wrestle with some issues
and set some guidance to ourselves as to howvwe operate.

It seems to me there are at least three things that
will go to the Council and Herb Pahl, at least there are
three inputs from this group. There is a number that may be the
softest and least offensive.

There may also be in most instances some kind of
half quantitative rating based on several people; and thirdly,
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, that there was 2 general, seneral
sense consensus that this was, all things considered, a com-

paratively good strong program that had Maine stability during

the period of the last 18 months. And I think, you know, it

 

1

is not as if the number is the only thing we are go ing to feet
him. I think we need to keep that in mind. So we are 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 that

 

are complete,as we are going to review then, that aren't going,

I

to have anything for the May ist review, or the July ist re viel.

I think that that is a consideration also, we have |

|
|
|

to keep in mind, and this is one of them and I th ink this is
@..... C0, INC.
320 Massachusetts Avenue, NE.

Washington, D.C. 20002
(202) 546-6666

 

 

very important.

MR, PETERSON: Well, I would like to ask 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
bellies 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
don't need any more? (Indicating)

MR. PETERSON: You can put them under the table.
Hand them behind you and somebody will put them back farther.

MR. RUSSELL: As usual, we will pass them on down.

(Taughter)

MR, PETERSON: I wonder if we could take Albany.
This is an instance where, by virtue of the fact of a recent
last-minute cancellation, we only have one reviewer, Mr.
Barrows, and move on with Albany then, since you said you were

best prepared for Albany.

 
 

@..... CO, INC.

320 Massachusetts Avenue, NE.

 

Washington, D.C. 20002 |

ALBANY 49

MR. BARROWS: That is a small tribute to my prepara-
tion, I assure you.

I think most of us on this committee can make
extended and culpatory statements of the same kind. that were
made on behalf of staff. I quite honestly had difficulty
in doing justice to five applications.

I say that in advance, because if I didn't say it,
you would detect it as I went along.

In any event--

DR. THURMAN: We won't be critical.

MR. BARROS: 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 @4-county program. The
grantee is the Albany Medical College. These were all the
figures, but I had to go by them.

Budget request was for $1,056,000, Their present
funding for half a year was $556,000 so about the same level
of funding they are seeking.

The director, Dr. Kraft, has 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

 
 

 

ow
interests and remarkable ~- includes education, labor, com-
munity agencies, business, and so One

Staff of 70 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 thing. I think that puts him in a
peculiar position to influence the whole process. And from
the looks of the staff, I think this is kind of a one-man
type of program, 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
what is reported. |

Past performance, the direction has been I think
quite acceptable. They made a prompt effective response to
the '7l change. Their track record is good; of 27 active
projects since '71, 12 are continuing with RMP support, but
10 they are flying under other support. Only two have termin-
ated.

Their goals and objectives are very well articulated
and very congruant, as the record shows the RMP mission.

The proposal situation to me better than average

 
D acces CO, INC.

320 Massachusetts Avenue, N.E.

Washington, D.C. 20002
. (202) 546-6666

 

 

DL
compliance with their own stated objectives. I had more
troublé with that factor. Everybody 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 objec-
tives. . |

There is no CHP agency in their area except in Weste
Massachusetts. They are working with that one. That
seems to be harmonious. And they are trying to get another
one off the ground. So I think thelr CHP agency relationships
are good.

I think they have got a reasonable chance of suc-
cess. Much, of course, is going to depend especially on these
programs designed to serve the underserved areas. Much
will depend on future funding from a variety of sources.

Ieame up with a good to excellent rating for the

total program,

I summarize it this way: ARMP has retained
essential 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! reviews
This is one we don't have 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

 
 

@..... CO. INC.

320 Massachusetts Avenue, N.E. |

 

Washington, D.C.20002

52
there are some of you who have some impressions, perhaps have
had some specific information about the Albany RMP. So
before I check with staff, I was wondering if there is any--
from the rest of the reviewers, whether there is anything
specific or general they want to add to what Mr. Barrows had
to say?

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
approaching 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
except 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 sey what is the proper problems for relating to

“other federal initiatives," that is particularly true in the

 
 

 

case of emergencies here.

-. Phe activities for which there has been $138,000
Looked to me to be fairly consistent in that they were more
preparing to get ready for entering the emergency systems
program than 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: Franc, do you or Norm have anything--

there were a number of projects Listed inthe summer here that

 

relate to HMO's, EMS, et cetera. Are there any significant

problems or policy issues that you see posed by these?

MR. NASH: I think the HMO, I belleve, is a feasible

study.

 

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

piaces that are few in number now where there is no major

 

 
 

 

5y
(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 indicat
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 application on July 1 for
new starts totaling about half a million dollars. This one,
this request totale just slightly over a million. Thus our
estimate at this juncture is that Albany will be requesting--
happens to be a couple of thousand less. Just about that
target figure. But the present application is for $1,056,000.

DR, TESCHAN: I wonder, management assessment, re-
view verification, if there is eny indication whether, in
essence, the grantee is behaving according to policy? Any
evidence on that?

MR, PETERSON: Norm, we did have some problems I
know some years ago, 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?

to

 

 
 

 

5D
MR, SIMONDS: That is one of the very early ones.
That has been several years ako, would have no relevance today.
MR, ANDERSON: We here, program staff, support
what Mr. Barrows said.
MR. PETERSON: Can you Lift that up four decibels?
MR, ANDERSON: During the phaseout period, they
were able to maintain pretty much the program staff, kept Lt
pretty much intact. The RAG did continue to meet oH 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 program as being
in the big middie group?
MR. BARROWS: The big~-
DR, TESCHAN: Middle group?
Would you put it at the top of everything you have
seen or bottom?
| MR, BARROWS: I would say probably top of the middle

group.

 

I was impressed with something concerning which I.
have mixed feelings, perhaps more than any other program
that Iiooked at. They have addressed themselves to the prob- _

lems of the underserved. That is a high risk type of activity.

j
i

So prospects of success are Low. Brownie points for trying

to do a good job are high. I come out with a stand-off on thas.

|
|
 

 

we
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: No.
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 a request only
for $1 million.

DR, TESCHAN: Yes.

MR, PETERSON: So I don't think we are--

 

DR, TESCHAN: I am sensitive to Sister Ann's point
|

here, that we have to consider the later -- perhaps after |
considering the later--
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

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 the 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-

i

quest and make our recommendation in those terms. So that I

i
|
i
|
|
i
:
 

 

guess I am saying --

DR, TESCHAN: Motion for $1,066,000 then, approxi-
mately.

MR. PETERSON: That is the maximun,

Yes, John.

DR. HIRSCHBOECK: These request figures include the
indirect costs as well?

MR. PETERSON: These are total costs I believe, that
is a battle I think I have finally won. We used to show you
people direct costs whichwas very deceptive. These are total
costs, direct and indirect, And that is what it costs to run
the Albany program.

DR. TESCHAN: Do you have 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. THURMAN: 50 percent on salaries.

MR, PETERSON: That is roughly what you are running
One |

MR, ANDERSON: 60 percent.

MR. PETERSON: Probably the best guess I will make
in three days.

DR. TESCHAN: The record ought to show that is one
of the things that kills a program in Congress. And we ought t

raise the question as to whether this isn't -the time for the

 
 

 

Albany group to recognize that fact, and see whether or not
they cah begin the staff processes necessary to get them ready
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 are 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: Thae are private nonprofit corpora-
tions established 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 negotiating 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
LO percent being a pretty good figure to put on it.

DR. HEUSTIS; I think Maine had a policy, if I re-
call correctly, of not being 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 are 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 at National Foundation on the
Arts and Humanities and I had three university presidents
sitting on that Councils Princeton, fellow just left the
University of Washington, and Brown.

I didn't realize what kind of tiger I had walked into.
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 14 months, I can see, of some stability, whether it is
a policy we are probably going to accept as regions take it

on themselves and many have, but Albany is not one that has

 

 
 

 

made any move to disessociate itself from a medical college
and sets up a nonprofit corporation.

It is a cost of doing business. It may indeed
have done the program harm. Again, a 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.

Dig I hear a motion recommending the amounts reques~
ted for this application, $1,066,000?

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.

(Shor of hands)

MR, PETERSON: Everyone.

Anyone against or abstaining? I think I saw nine
hands up.

ALL right, we have in an hour and ten minutes --
which comes out to 35 minutes per application -- disposed of
two easy applications. So while I am encouraged, I don't
think any of us ought to get overly encouraged. I think it
probably would be a good time to break for Lunch, as I say.

DR, THURMAN: Will we finish today?

 
 

 

MR. PETERSON: If we take some class action.

What would be a reasonable time to ask the group to |
reassemble? 1:15? 1:30?

DR, HESS: 1:15.

MR. PETERSON: Can ve try and be back by L:15.

We will start with Northern New England by virtue
of the fact Joe has a three o'clock deadline.

Thank you all so much,

 

(Whereupon, at 12:30 o'clock, p.m,, the meeting
was recessed, to reconvene at 1:15 o'clock, p,m., the

same day.)

 
 

 

NORTHERN NEW ENGLAND

AFTERNOON SESSION

(1:17 pem.)

MR, PETERSON: We were going to pick up with Northern

New England, but I did want to mention a 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

those rating sheets.

Secondly, to the extent that any of you have, as I

think perhaps Mr. Barrows 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 tnsist upon that.:

Because there has been 4 sreat deal, as you know, of Litigation

about correspondence and notes in Washington of late, and I
don't want to get into that.
MR. BARROWS: What was 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 and:

|

the Like, I think we can handle that and maybe I can ask Shirley

t

or someone, but to the extent you have got those kinds of probe

‘lems, let us have them and we will take care of that.
Finally, and this is really directed to staff, I
would appreciate it, for the benefit of Mrs, Chiang, that

when staff 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
support of program staff and selected continuation of on-going
projects. They will present some new projects that have 4
high priority in their July Ist application.

The program is committed to addressing community
problems and the development of their solutions. By now they
have developed 2 cardiac care management system, a respiratory
disease communications network, a high risk infant care and
transportation system, and a stratezy for addressing emergency
medicel services issues.

Their present thrust will be that of encouraging and
developing community involvement in program development, in

program planning, and in program evaluation.
|
The region is particularly involved in the continued

i

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 doing

 

 
 

 

it through the support of providers engaged in improving their
programs towards the maintenarme of established guidelines.

They have Linkages with the Department of Medicine
at ‘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 management
of the program, but also in the development: and support of sub-
stantial program priorities. The Regional Heart Management
Committee, for example, includes 29 standing members, and
they have continued their activities during the last 12 months,

The present core staff includes eight persons, four
of whom have advanced degrees. Their staffing pattern eppears
to be very similar to that existing prior to the phase-out
order.

| The present vacancy pattern may represent an oppor-
tunity for the director to develop a staffing pattern more
consistent with his future program plans.

Their present request is for a core budget of
$432,800, including $292,800 for salaries and wages. ‘Their
request for the seven projects envisaged amounts to $687,000,

for a total request of $1,039,670. This represents approximate l

 
 

 

4O percent core staff activities.

The core staff, however, is continually involved in

the support of disease management committees.

| Their present application is for $1,039,670. It is
estimated that their July L 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. I was
very much impressed with the type of projects that they have:
a regional end-stage kidney treatment program, a project to
increase the capability of rural ambulance and emergency room
personnel, a regional program for high-risk infants and
mothers, a regional respiratory disease program, an ambulatory
pediatric care project, a voluntary problem-oriented health
care information system, and a program addressing the sources
of communication among school children.

Ih summary, this region possesses a@ good track record
in obtaining community support for its activities. They want
to shift their program emphasis to improve primary care and
strengthen community level organization.

Presently they are involved in providing an environ-
ment where quality assurance can become a 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 and the level of support that they Will probably receive.

This is not to detract from how much I was impressed
by this region in terms of ho 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 PUENTE: Yes.

 

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 fashion,
if you might want to briefly address Northern New England and |
then I will ask staff if they have any comment before we open
it up to the whole group. |

DR. THURMAN: I had your enphasis--- first of all, |
since our site. visit, there has been e change of directorship.
The new person seems to be a relatively strong leader. There
has been stability of a corporation now where there wasn't
before, which was one of the recommendations that was made
at the time of the site visit. :

One of the strong continuing strengths as Joe indi--
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

at the site visit have not truly been carried out and many
 

 

Of
people here know that Vermont or Northern New England had
more data Chan anybody in the country, including Census Bureau;
And the feeling was that RMP money did not support that ina
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 wouid 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

O......

this now is that when we were up there before, the state Liaiso
were not well worked out as far as continued support for many
of these programs. This is now very clearly defined and vork-

ing Quite vell.

staff is quite small. Staff goal, 10 percent of the
total money related to the project, but that doesn't come out
in their proposal, It is written, but that is not the way the
figures come out.

I th ink the projects in essénce 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

 

ta
 

 

0d

priorities with this application and I think that they will
with the others. rf

I have just two concerns. The first is each of the
projects is overbudgeted for what they’ expect to accomplish
in a period of time; and the second is they clearly state in
the application that core staff should be LO:percent of the
project and yet it is almost 50 percent of the project. So
that I think subsequent to the time that expense and our group

were up there, this program has made a Lot of changes in ref-

 

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 then.

I would support everything Joe said.

MR. BARROWS: Could you identify on this List of
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 pri
mary data program, And 030 is again data base program related

to the school system, but was already available to them. |

i

So those are the ones that still have a heavy -- thet

is nothing -- when were we up there, '72 August, you should
|

have seen it then, It was nothing but one floating base of

data. So I think this program hs come a Long way and certainly
 

 

deserves--

MR. BARROIS: You say these items are too fat in the:
data 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 hasten to point out is essentially a continuation of
program staff and some ongoing, previously ongoing projects.

It totals a Little over a million dollars. We have
an indication from Northern New England that they will be in
for almost-- for roughly $800,000 worth of activities, all nev,
with their July submission. So that it is a Little difficult,

I suppose, to deal with what is no more than 60 percent of

what we anticipate, altnough this is sert of core and on-going

activity.

Spence or Frank, do we have any 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: Okay.

Frank.

MR. NASH: No, I don't have anything to add.

MR. BARROWS: Let me ask a question.

MR, PETERSON: Okay.

 

r

 

 
 

 

ry
MR. BARROWS: The continuation request is based on
some things that have been suggested, are really not all 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
dollar figure of what their July application contains. |
DR, THURMAN: IL think through their application,
you feel strongly they are coming in more in the priority
line. It never specifically says that as Frank saySe But
their proposals that they are discussing in the distance an
their actual application for continuation indicate that they
will be much more in the line of priority, rather than this
Groupe. :
MR. BARROWS: I take it you would be Lnelined to
be more generous with what 1s coming up than what they are
asking forhere.
DR, THURMAN: Correct. I am interested in seeing
what Joe's proposal is. I think I vo uld 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 as RMP,

. :

because Scetal Security rules, and so on, permit funding there,
And yet, on the other hand, wewere told this morning that, you
know, their restrictions are essentially lifted, so whatever
was being done two years ago 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 state it very felitiously.
There was, 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, and some other aspects, |

One of the things that we have as a matter of rou-
tine, l guess, in the earlier award we made, sort of a formula
basis during the past year, have had to do, is, in effect--
here I am groping for words and perhaps some of the other stefr
can be a Little more clear on this. a, |

As you know, under the Social Security, those Social
Security amendments, the reimbursement for the actual end stage
treatment, dialysis, transplantation, is restricted to certain

approved facilities and if facility is not approved, they have

to request an exception under what are stLiLl interim

f
 

 

regulations I believe.

In the process we have, in effect, told regions that.
before you go ahead and fund anything, you need to make sure
vis-a-vis that particular institution sponsor, et cetera,
that this is a facility that either has or-- you know, the king
of approval for reimbursement under Medicare or is in tne
process of getting an exception.

I am not sure that really answers your question.
But we certainly -- we have not in our previous approvals

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 program were to
continue, RMP, for two, three, or four year, we would orobab Ly
see a downswign in that as reimbursements arrangements begin
to possibly begin to pick up the other costs, the kind we have.

| 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 addressed

reimbursement.

Indeed, they have tried to get a quality because of
the Limitation of where centers are. .
The instructions we have here I think are very ex-

plicit in saying we don't fund things that will result in new

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 rational patient flow, so that
the right kind ofpatients relative to their stage of renal
disease reach the right 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, that is very-- I mean, if that is substantiated,
thet is great.

We were wondering where additional funding of those |
things is. We were concerned SSA, in dealing with these things

ard in the regulations, totally ignore one of the most impor-

 

tant contributions; namely, the organiz ation of the patient

fiow, And we are disturbed about that. It seems to me there

is a big job for RMP to do in that

| DR.HESS: I was a Little confused about that statement
because RMP never was,or supposedly, in business of subsidizing

direct patient services, although in a sense they also were. :

Any time you train people to care for patients to

some extent you are subsidizing it, but the bulk of it was in.
organizational wors developing a plan, the working out of--

collaborating relationships this kind of thing we are talking

about.
 

 

I have, you know, wondered whether if indeed
that was being picked up by some other mechanism. So it is
just unclear.

MR, PETERSON: I think our concern, RMP's concern at
this juncture is that the kind of what you referred to as
indirect subsidization sort of activities not continue or be
created in an. institution or facility that doesn't have or
isn't likely to have the patient care reimbursement under it.

A sidelight, if you will, it is not relevant to this
application, but there is almost a separate quality of care,
many PSRO arrengements being established for end stage renal
disease treatment, And thet is what Spence and some of the
steff left here ere working on specifically in BOA,

We find that in many of the regions, these local re-
view boards -- that is I believe what they are called, isn't
it, Soence, but they really have a quality assurance function
among other things, that local review board at the regional
level will be handled out of the HEW regional offices; that
in neny regions they are turning to existing kinds of RMP
arrangements, resources, people that have been collected to
estabtisn thet.

That is not true across the country, but certainly
in some states -- I recently was in California where there
would be a number of such local review boards. And that pro-

cess is being greatly facilitated by the kind of planning

 

 
ee

 

 

resource develooment and people have been pulled together
under the aegis of the CaLifornia RMP in connection with some
of its end stage 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 yourall. I don't know what I would do without
yous

(Discussion off the record.)

MR, DE LA PUENTE: The cheirman will have to check

me on this. But it would go something Like this:

Thus $700,000, at thisstage of the game, with strong

 

recommendation for maximum funding on the July 1 application,

i

if they are the types of request from the size of our expec- |

tation.
| MR. PETERSON: Let me make sure I heard that; more
importantly that all of the othewheard it.
$700,000 recommended at this point against
a slightly over $L million request, but with a strong corollary
recommendation that the anticipated $800,000 request that we
will see in July and you people WiLL be Looking at then be looked

at if the proposals in a very fair light; is that the sense of

 
 

it, Joe? |
MR. DE LA PUENTE Yes, that is about the size of it.
DR, TESCHAN: Second.
MR, PETERSON: Is there any discussion on that?
Yes, Al.
DR. HEUSTIS: Iwas 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 that were indicated as having
perhaps more than their necessary sshre of checks, it adds
up to a substantial number.

Then I Like what you said about the program staff

 

pernaps thinking twice about filling the vacancies and reacting
to the other, and it seemed to me that maybe you were being

—

a little generous recommending $700,000, |

The figure I had tentatively written down was 3600, 009,
I was wondering could I have your comment as to why you chose |
the seven rather than perhaps six?

MR. DE LA PUENTE: In the splrit of having them

make their own choice, $100,000 figure I had in mind, to per |

i
i
i

mit them to get staff if they feel it will fit with the new
orojects that are going to come out in support for them, giving
them sort of the benefit of the doubt. So they can do their |
own administration. And not fully saying go and fill all the

vacancies and go full fledged. But that was the only reason.

 
 

 

ft

DR. HEUSTIS: You are not bothered by the 25 percent
for program or central staff rather than the 10 oercent which
they say 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,

43 percent.

Does that not bother you or didn't it bother you when
you made your recommendation? That is probably where our agif-

ference is.

MR. BARROWS: Discrepancy of that magnitude, I wonder
if there could be an error? |

DR, HESS: In the accounting.

DR. TESCHAN: First of all I think unless you have a
enormous program, primarily contractual work, to run a progren
on 10 percent I think would be e Little unusual, especially
when you see the developmental activity staff should be in.

I think LO percent would be unrealistically low.

DR, HEUSTIS: Ian not disagreeing, put this is what

they seid in their program. This is all I am going by.

DR. TESCHAN: I think that would be a mistake,

 

 
 

 

DR. HESS: The total staff is 14 ceople. Buik has
to be for orogrammatic activities, not for staff personnel.

MR. DE LA PUENTE: This is what happened, the way L
figure pefore is actually 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 it a program or core
staff, council -- they support -- it is a group of staff that
spends an 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 percent would be too much
definitely, in my opinion, if it was just staff managing the

_ projects or being supported by the RMP,

If it is the staff doing what I call intramural
support and supporting some of the activities, then it is
not really 40 percent, 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 reguest proposal subsequently warranted. I
guess there is a concern of the group that the $400, 000-oLus
may be @ Little on the large side certainly in terms of the

action taken today, but again if one looks at the $800, 000

 

 

 
 

 

request which may be coming in that that perhaps could be
expressed.

Are there any cther comments?

MR, DE LA PUENTE: I would Like to include in there
comments of Dr. Heustis, concerning personnel situation in the
ward problem.

MR. PETERSON: Okay, that concern be expressed.

MR, DE LA PUENTE: Right.

MR. PETERSON: Particularly until action -- we don't
know how many projects they will have to manage until their
new activity is looked at in July.

You know, it is possible the group's action would be
much Less than what they request in July.

Certainly that concern I have down, Joe.

MR, DE LA PUENTE: Okay.

| MR, PETERSON: If there are no other comments or

questions, may I have the question.

 

Those concurring with that recommendation raise
their hand.

(Show of hands)

MR, PETERSON: That is everyone, including a weak
"yea" from BLLL Thurmen or tired riding on the airplane?

DR. THURMAN: Tired.

!
i
i

~

MR. BARROWS: If I were the coordinator, RAG chairma

up there, I would very much appreciate Knowing the basis for

our conservatism on continued funding and basis for relatively

 
optimism on future funding.
WiLL that be transmitted to them?

MR, PETERSON: Let me make sure. I see no reason

uF

that it wouldn't be. The basis for the less than requested wa
still a concern with the overly richness of the data involve-
ment in some of the projects.

Is that correct? Is thatan accurate reflection?

MR. 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
West Virginia.

Joe, your meeting isn't until three. You are more
then welcome to stay until then.

_ On the other hand, I am going to avoid bringing up
any other regions this afternoon that you are reviewer on, SO
if you do want to leeve, feel free to do so.

He will be here tomorrow, I assume thate

DR. TESCHAN: I am not ready to taik about West
Virginia on the basis of the eoplication.

I would have ea little bit of past history, you know;
previous contact.

MR. PETERSON: I am not sure what you are saying.

DR, TESCHAN: I think it would be better if I had a
chence to read the apolication.

MR. PETERSON: Okay. What you are saying is we oughe

¢

 

 

 
to put West Virginia until tomorrow.

We have to get it in the morning, because CharLie
McCall is going to have to leave I guess around two o'clock,

DR, TESCHAN: Be happy to accommodate a busy colleague.

MR, PETERSON: Well, if we can't come to grips wit--
if you prefer putting off West Virgina until tomorrow morning,
I am willing to do so, if that doesn't pose any problems for
Charlie.

I wonder in thet case, though, how are you fixed
with Connecticut?

DR, TESCHAN: Fine.

MR. PETERSON: Because you are also a reviewer there,
I thought since we were sliding with the easy ones, maybe we
ought to take a Look at Connecticut at this juncture where
Al and you are the reviewers.

Al, you came second last time. Iwill let you lead
off.this time with the nutmeg state,

DR. HEUSTIS: Thank you.

 

 

 

 
 

U UN INDE LG Ue —
. |
DR. HEUSTIS: This application from Connecticut

is the first of two applications, and together they anticioate
: |

that these two amounts of money will approximate $2.6 million.
,

The current request provides for one year for central

staff or core staff, or program staff, which I think I am using
all interchangeably, although I know there are some Little |
inuendos as faras 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 th
each of 13 specific projects in eight program areas. The |
only program area in which they have more than one project is
_in the area of hypertension, where there are five. |

I had some problems with this document, |

I found it to be written in extremely general terns |
with very minimum attention to process.

There was much repetition. Also it referred back
from one place to another, something that was allegedly covered

i

in an earlier section. Some important things. And I just- |
when I checked back at the earlier section, I had great qgifficult
in finding. I couldn't help but get the impression they were —

trying to use all of the right words they thought would impress
|
people. |

i

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 develop-
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 had to base my decision on he is: the
fellow who responded to all the problems and his response
seemed to me again was not really how to adjust to the problem
or how are you wrong in bringing up the problem, but kind of |
why didtt you come to the meetings and if you had come to the

_meetings, you would know all of these things.

I could be very sympathetic with his point of view,

 

but it didn't seem as though he really approached this group. |
Now, the Regional Advisory Group has been a well-
rounded compliment or wpresentation including the representa-
tives of 5(b) and the i(a) agency that I could identify.
One other representative 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 compre-
hensive health planning to understand or appreciate what they |
thought they were trying to do. |

There are many letters from the planning folks that
 

 

helpeé to bring this out.

They do have a high medium and Low priority desig-
nation or rating system for both accomplishment and for the
request. But there is no summation, whatsoever, that

I found.

It may be there, but I didn't find it. But no infor

mation whatsoever as to what kind of criteria they used for
high, medium and Low, in this area, And it came out that most
of the ones as far as they requested were high. TI think eight
out of the nine. And as far as progress, there were five,
and four or five highs and four mediums. There weren't any
lows.

Then it referred to seven states had priorities which
I had one devil of a time finding. I finally found one tiny

paragraon in the middle of a page in which some very general

 

things were said about seven specific areas, but there weren't
any specific short-term priorities or objectives by which these
seven important areas could be implemented.

It is a new process which involves @ number of com--
mittees in the RHA and says this took place over a period of
time, and I certainly read by inference that there were meet -
ings, that therewas a process. But very Little information
about them.

While quite a bit vas made of the complex of

workable system of regionalization, they were trying to carry

 
 

 

out complex 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
had started they continued funding, but the extent as well as
the meaningfulness of the effort.was unclear as well as it was |
elso unclear as far as continued funding as to which areas
this had already occurred in or which area it was hoped fore
In general, Iwas not impressed with the staff activi-
ties. For example, the central staff, as far as the material |
that was presented, and on specific forun, it said something
ebout the staff plans will rapidly unfold against background of
the CRMP's program facilities and strategy and will further :
a CRMP's responsibilities to emerging national priorities.
This Kind of language does’t say very much.
Materiel reported what the staff had done.
Golly; it seems to me they must have done more than they wrote
down. |
They developed a good staff. They achieved some
alternate financing of progrems, staff skills, assured central
direction. They did do some planning and specifically mentionsc
hypertension orogram and they claimed more effective coopera- |

tion with CHP. But egain, the nebulousness of it all bothered ©

TMC a
 

 

In rating, in thinking about this, fortunately
Connecticut was not very high on my List. I rated program
leadership from poor to adequate, equally unkind to program
staff.

Regional Advisory Group, except for the review pro-
cess, gave the same kind of ratings for past performance and
accomplishments, objectives and priorities, and feasibility--
because I couldn't tell whether these folks had any feasibility
of doing what they said they were doing, because the thing

that I suspect is that in complete contrast to Maine, they

‘

must be doing some things they just did not put into the appii
cation, they just must be,
I rated this as @ poor eoplication and as far as
_funding mechanism, we Will get to in a moment, it seemed to
me they ought to be on the very short end of any funds that
might be available and so forth.

MR, PETERSON: Okay.

 

DR, HEUSTIS: I did -- I was disturbed. Connecticut
was the first one of the five which I nad that I looked at.
Iwas so disturbed by it end by my reaction --
I guess I was disturbed by my reaction to it -- that I went

back am took this sheet which we have here, this review sheet,

and some of the criteria we used, and some of the background

 

Judy hed, made myself a chart which I endeavored to not only

1

pick out the main headings, but every one of the subheadings of

i
i
:
{
the paragraph and tried to rate these good, falr, and poor,
to see even though this Was a subjective evaluation, was
there any -- were they just being too unkind. And it just
came out the same way.

I am sorry, but that is the way it impressed me.

MR. BARROWS: Doctor, let me ask a question for
clarification.

Are these deficiencies you speak of, do they appear |
to be the end result of a lack of leadership and management
capability and staft?

DR. HEUSTIS: Yes, sir, and the RMP,

Again, I hope I thoroughly que Llified this, all I
know is wnat I read.

MR. PETERSON: I think I would Like to ask Paul, who

—

 

 

was the other reviewer on this, if he has what he would Like to
add to it.

I know, for example, John Hirschboeck was on a
site visit LO4 years ago in Connecticut.

Paul, what do you have to add, subtract from, what
you have neard Al say? |

DR. TESCHAN: I would like to add a couple of -- ony,
supplementary points which will not change the basic them I
don't think. |

First point is as you read Connecticut, it is unique

1
i

in my experience, having talked to the predecessors of the

 

 
 

 

present group also, in that its basic philosophy says if
health care is going to be approved in a state, in any region,
it is going to be done through orimarily interinstitubtional
netwous starting from the university centers, and through
faculty type and educational contacts in community hospitals.

If health care is then going to be benefitted as
individual consumers in the state receive it, it is going to ob
by those consumers coming to those centers influenced by this
network.

That is, there is virtually nothing other than the
outpatient department of the hospitals in which the full-
time staff have been impressed by the prior history of Connec~-
ticut RMP. The individual ambulatory patient is going to be
particularly benefitted, that is not quite true, there are
exceotions. But the overall driving basic thrust, that prograi
apparently has been monochromatic like that, at least as a fund-
amental concept. It is quite different from many other RMP's,.
Ana I gather Harold, Stan Olson probably had wrestling
matches on this same subject, but if anybody didn't know that |
about Connecticut, that is one fundamental piece of it.

Now, it followed from that that the budget has
certain characteristics. It follows that if you work at it

you can find out of requested total amounts -~ and my figures

t
1

are a little different, they are added up a Little differently

out of approximately, I came out with a figure of 942,000,

 

 

 
 

 

you can find annualized rate, that is this is six times the
two-month rate just to get an annualized rate of their
application.

: To get out of 942,000, you can find about 180,000
that appears to be outside the immediate jurisdiction,
either of the CR&P staff or of Yale, or of the University of
Connecticut.

That is, how far out I don't know. I don't know
whether this institute for health manpower is not a child or
progeny of the universities; it may be. Could very well be.
It may be the EMS, I can't fing 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 can't tell whether that is a child of the univer-

sity.

 

Otherwise, it appears all the cash is flowing into
and through the universities and is not turning up with inde--
pendent applicants or independent group. , |

So you have to sort of figure whether you buy the 2
phi Losophy and if you don't buy the philosophy, you are ¢ Limb ing
uphill against the X years of ‘67, seven years of precedents i
that istuation, so that is one main point. !

The other point is that the staff is missing a
controller and is missing an evaluator. And our feeling is

that those two seem to be critical. There are, you know, I

 
-

raise serious question whether the staff canmnage the businegs

of the program.

~

I would agree fully that the RAG chairman appears tq

r
vw

be the active person in Connecticut. Everything seems to hinge
around him and his activity, that that CHP is a disaster,
obstruction.

I thought whoever wrote those letters in reoly at
least, among all the words, seemed to do a professional job
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 areuments CHP brought
up were after the fact, almost written in ignorance, bem use
he was eble to show in that CHP's own district CHP members had
been contacted, Interview indicated that.

Well, coming out to the other end of it, there are
minor differences in the rating.

I felt that the feasibility was probably pretty

 

high in view of a seven-year precedent that that kind of activi-
ty does work. If I buy that, my problem is, is it a performance

Does it seto up the pike?

I think if you are this far down, activities are

1

|
feasible, I Looked at a below-average rating. However, I felt

 

 

 
 

Yu
somewhere between 80 and LOO percent of the program staff

funding, that is two-year extension and year's extension of

staff, either somewhere between 80 to 100 percent of that was
at this point a reasonable step in order to carry them througn,
at Lleest to their July L application, with the contingencies
that the staff 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 ‘obvious:

i
Ly from every corner of the thing, the theme ought to be estab-

|

lished as a precedent, it ought to be undertaken, running by

|
itself.

And the application projects are primarily involving |

students of various sorts doing primarily theoretical studies,

rather tha having something acbuaily happen.

So I think that, you know, I would move to cnange
the grantee and to get this influence totally excised in the
course of the next Little pit, and to shift this thing over

to a situation where other applicants will have a chance to

begin to do it.
MR, PETERSON: Does thet=«
DR, TESCHAN: The alternative is to stop the RMP
funding. That is possible to do. |
MR, BARROWS: Do any of you fellows see any prospect:

of turning this thing around?

 

 
 

 

(Laughter )
MR, PETERSON: I wonder if I might help--
DR. TESCHAN: Question, turning it around -~ if
you Heat turning it all the way around, so that ali--
MR, BARROWS: 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 we are dealing with e
one~yeer story.
r vouldn 't make this suggestion if I thought this
were @ one-yeer proposition,
| Last year wetealt with it as a one- to three-year
oroposition. I don't think that is right.
_ MR. PETERSON: I wonder if I might do this before
I esk staff to comment, there may be one or two staff comments,
| then throw it open for broader discussion.
— John, since you were on @ Site visit, which was
made when?

DR. HIRSCHBOECK: I think three years a&§0.

MR. PETERSON: That Long ago?

 

Everything hes been @ year and a-half, two yeers QSOs
DR, HIRSCHBOECK: I have to agree with most of.
whet Paul is saying, although I must say the grant idea,

when RMP went into Connecticut, it had a good test, identifying

every hospital in the schools with medical schools, s0 @

 

 
 

ww

full-time person is linked with the medical school and that
hospital, whether that is a. workable thing in the United
States, Whatever results have occurred will perhaps give the
anewea
There is something thet has happened I think, but
whether this is going to continue in the way that Clark orig-
inaLly thought it was going to, of course, is not the case.
I am particularily impressed with the fact they still
don't have anybody in evaluation and their staff is lean.
-This is the major criticism. This is pretty much a@ one~man
show, as Dr. Clark left shortly after that. Morse is his
deputy. He has followed through the sameway. So I don't
think there is much more to say.

MR. PETERSON: Frank or Spance, are there some

 

specific things here including the CHP which -- at least one
of them --

MR. NASH: I think that was the major thing, CHP
really -- yes.

MR, COLBURN: With regard to the chief of staff,
they are not supporting those positions aay meres

‘I think this request is to bring different chiefs
into networks to exchange.

DR, HIRSCHBOECK: I might say too, there was an on-

going fight with the medical society. I don't know how that

will end.

 

 
 

9

MR, PETERSON: It hasn't resulted in the same pyrotebh-

i
|
i

niques, letters -- they were more adv anced, they sent tele-
grams to the National Advisory Council. Nobody has phoned us
yet. Maybe because we don't have a phone in this room, I don't
‘know.

Paul, I think, made one important factual kind of
point. We are Looking here at a request which is essentially
to continue a numberof on-going programs for just two months.

DR, HEUSTIS: Just two months.

MR, PETERSON : And then to continug somewhat expand
not a great deal,core steff,and we will probably be taking a
look at the larger portion of the picture in July. So that
I think I have heard both Al end Paul, and some of the other

“comments, I have phrases down Like "Not impressed, troubled,

 

below average 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 perhaps. But we are Looking at a
relatively modest portion in terms of duration and amount of
funding in this particular application.

. Other comments, observations?
DR. TESCHAN: That suggestion is to fill those vacan~
cles.

I think the waluator has to be in there. That is the

point.

i

I like the idea they have had the evaluator separate,

 

 
 

 

ps)

from the planner in the staff.

MR. NASH: Or, Shan-- I think this is probably Dr.
Clark's evaluation on evaluation. He didn't want a single
individual on his program staff to have tmt 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 evaluation committee.

I think another staterent should be made about this

. region, they are to be processed, certified by RMP,

The basic reason is the staff aswell as previous
site visits, almost everyone who reviewed the proeram agrees
the evaluation committee in Connecticut has done in the past
and appears to still be doing those fucntions that we feel

a regional advisory group should be doing.

 

For that reason they have been so advised of this, cr

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

away.

MR. NASH: It concerns me a Little bit because--

'

i

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 this

i
i
i

application to make seven years' history in that region, this

|
I
|
|
|
 

 

yu
would present me a problem, perhaps Dr, McCall one, if this is
what the group wants to recommend.

I would think the July application might be a better
place--

DR. TESCHAN: I think if it were approved in July,
if wevwere to look at the Connecticut application, and recom-
mend funding that show the ramifications and other issues
turning up, I think the message would be spelled out in dol-
lars, Spell it out.

MR, NASH: Yes.

MR. PETERSON: Any other comments, observetions?

DR. HEUSTIS: Is my arithmetic incorrect there was
a 50 percent increase in the money, ona pro rated basis, re-

guested for the central staff?

MR, PETERSON: I will have to ask Frank or--

DR. HEUSTIS: Evaluator for those two important
positions, I wonder what the dollar may be. They may well have
made a data--

| 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 what was the arithmetic really added up to?

I was reminded of Mark Twain's man who only spelled a word

one way.

DR. HEUSTIS: So six months award $168,000, one

 
 

 

Fl
year request for $479,000, which at least according to my
arithmetic ts three times that, or 50 percent.

MR, PETERSON: It doesn't seem right just iooking
at it, eight to twelve kind of junk, but LI must say I am not
that familiar with the figure.

DR. HEUSTIS: Maybe there are other factors in this.
I have no breakdown than the total amount.

MR, BARROS: On this sheet you show $297,000 for
six months.

MR, PETERSON: I have that sheet, tog

MR, BARROWS: As compared with what we are asking for

*

395-479...
DR. HEUSTIS: I have$158,000 for six months.

— MR. BARROTS: Summary program to date.

 

MR, COLBURN: I know one problem. One of the increese
in program staff is due to the fact DMS activity was funded :
out of program staff, rather than a separate project.

That is what it is. Staffing pattern is consistent with what
it has been for seven years. |

. DR. HEUSTIS: Okay. Can some approach be made as fer
as the AMS--DMS to Limit that for two months also.

MR., COLBURN: I think itis being done.

DR. TESCHAN: It is a two-month figure.

DR. HEUSTIS: I am looking on page 3. I see the

ch

158,000.

 
 

 

MR. COLBURN: Page 3?

DR, HEUSTIS: Page 3, bottom of the page, $158,000

for six months,

Next to the last line above the total. And

$479,000 for the full year.

MR. COLBURN: Yes.

DR. HEUSTIS: $159,000 times three is three undred

times -- almost 479,000.

MR, COLBURN: Oh, this request is for 14 months and

_for projects for two months.

In other words, take program staff through $675,000

through June 1975.

MR. PETERSON: How could it be--

MR. COLBURN: wuestion of requested support for

staff through June 1975 and projects through August 1, 1974.

DR, HEUSTIS: But the staff starts first of June LOTS,

MR. COLBURN: It would be 12 months then, 12 montns

staff, two months for projects.

DR. HEUSTIS: Something we don't have to worry about.

I have concern about it.

N

DR, TESCHAN: Do it right.

we

|

i
}
t
}

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

i
{
|
 

a7

program staff for 12 additional months, but the Limited number
of on-going projects for only two months, thus totaling
8637, 000 volume, does anyone have a recommendation as to
emount either of the reviewers or someone else?

DR, HEUSTIS: Would you care to commit yourself?

DR. TESCHAN: Sure. I move to fund either between
80 and 100 percent of the amount requested; namely,
80 to 100 percent of $636,220, with hopefully the conveying
to-- perhaps it is too Late to convey to the group concerning
their July IL application the concerns we have about it.

DR. HEUSTIS: Do you feel strongly about the 80 to
100? What about 80?

DR. TESCHAN: I would be perfectly happy with 80
percent.
DR. HEUSTIS: I can support 80, I would have trouble

with 680 to LOO,

 

DR. TESCHAN: The only reason for the latitude I know
it is slightly nypotnetical a situation. The other feature, !
if the funding doesn't have all the money needed to get these

people for-- I feel the salary levels I think hypothetical --

total funding package to reallocate,

‘DR. TESCHAN: So 80 percent is fine.

DR. HESSL: They certainly have the option within the

 

MR, PETERSON: 80 percent if any arithmetic is worth

 

a dime, is about $509,000, Somebody had better check me, though
 

 

LUYU

on that.
| DR. HEUSTIS: Did- you: make a motion?
DR, TESCHAN: Yes, I move 80 percent fund of the
request for a month.
MR, PETERSON: We will say $510,000.
DR, HESS: thet is somewhat low.
MR. PETERSON: Your feeling is that is Low ?
That is a recommenda tion.
DR. HESS: That sounds Less than 80 percent..
I am questioning the arithmetic. |
DR, TESCHAN: 3508 ,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, PETERSON: Is my arithmetic at fault?
DR. HEUSTIS: No,
DR. THURMAN: Second.
DR. McCALL: Second thing you have done right.
YR, 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,

37

$500,000 -- $10,000 for this particuler application, recognizine

that a major additional amount, if I can read, nearly 32 milLliior

3

 
 

 

is anticipated in the July action, so we are dealing with the
tail of the dog, at this juncture.

If there is no further discussion, let's call the
question.

Those in favor of the recommended amount?

(Show of hands)

MR. PETERSON: Unanimity.

Okey, there is no need to ask about those who are
against or those who ere abstaining.

MR, BARRGIS: Ag.in, in order to Par lot of extra
work on their part and agony on our part, it would be approp-
riate to tell them this future discussion would be contingent bn
change in direction.

DR, HESS: Not change in direction. ALL they can

do is be more selective then they might have been in what they

 

submit, because they have to submit what is already piped.

One of the things so amusing ebout this discussion is
ve have two new reviewers who hadn't reviewed this region be- ;
fore, they come up pasically with the same answers I have
heard twice maybe three times. There have been strong
messages, including special site visits of that region, trying)
to turn them arounad, and it goes on and on.

, The comments, trying to turn this around one year,

before you end up funding, is totally out.

ALL you can do is cut off disapproval to--

DR. HEUSTIS: Help these out.

 
 

DR. HESS: Help them phase out. Evaluation.

You are not going to get evaluation that means any-
thing in one year.

MR. PETERSON: What I gather Joe is saying, we are
still continuing to send a message of essentially the same
kind.

DR. HESS: Yes. Thumbing your nope in a sense, all
direction they have gcetten from the review committee, Council,
staff, all the way down the Line.

DR. HEUSTIS: Still give them 80 to 100 percent.

MR, BARRGIS: Pete, how do you answer a phone when
Senator Ribicoff calls uo?

MR, PETERSON: Carefully and courteously.

(Laughter )

I have never had a call from Senator Ribicoff or
the other 99 members of the U.S. Senate. That doesn't mean
they don't call.

MR. NASH: Their staffs do, I want to assure yous

MR, PETERSON: See, Frank gets those calls. I
suppose he at least starts where I do, courteously.

DR, HEUSTIS: Is it possible, parenthetically -- may
I speak off the record for a moment?
| MR, PETERSON: Yes, off the record.
(Discussion off the record.)

MR. PETERSON: I don't think in most regions the

 

 
 

 

fiack we have had in years past has not been essentially from

a Congression al delegation, although there have been exceptions

to that.

That hasn't been a major problem on @ region basis.

I think we are at another juncture we have to make
‘one of those crucial decisions. We can go on with another
region and if so, we are probably going. to miss coffee. The
cafeteria is operated around here for the benefit of what,
I am not sure whom, help or customers, closes at three.

We can take ea quick ten-minute break, put I thine
it would have to be a quick break.

I hear one vote.

MR. NASH: Two votes,

MR, PETERSON: Ten minutes which would mean 2:35.

Okay.

(Whereupon, a short recess was taken. )

 

MR, PETERSON: We are missing Bill Thurman of the
Broup. Because I haven't had a chance to check with
Bill -- we still will have time for Hawaii if Bill wasn't
really prepared. With him not in the room, since he is one

of the reviewers, again to extemporize, perhaps we might pick +

i
i

“
ky

on Central New York, which you indicated, Joe, you were precared

to address, and then we will pick up on Hawaii after that.

I that way we will take care of one of your additional regions

~~

Charlie, Central New York.

 
 

 

CENTRAL NeW YORK ~~.

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.

I had some difficulty getting a very good feel for
‘this program from the application, and I have had no orior
personal history on the basis of site visit or having been in
a primery or secondary reviewer on this region.

I do have some vague recollections being in some d1i&-
cussions, but those ere not of much value at this point.

But what I vould Like to do is just go over and com-
ment and convey, summarize for the committee's information
what I have been able to abstract from information available,
and then have this supplemented by Stolov who is familiar
with the region.

First, in terms of program Leadership, I -ort of get
a mixed feeling here, on the one hand, the application indi-
cates how active the RAG has been. The number of meetings,
something like 15 meetings of RAG in 12 months, and the RAG--
members of. the RAG have been on the review committee and inti-

mateLy involved with reviewing projects and this type of thins

 
 

 

So I think one can say that assuming this is true,

thet the RAG has been spending a Lot of time on Central New
York RMP activities, and it is stated that they reaffirmed
their goals and priorities. However, I did not find in this
particular application their goal statement.

| They do talk about major thrust which I would infer
are simllar to goals, at least they have stated certain direc-
tions they plan to follow.

DR. McCALL: Health resources, planning, regionali-
zation, and primary care.

DR. HESS: Yes, So that there is that incongruity;
the goais and priorities I do not find to use as a yardstick
to measure some of the other things here,

They indiceted in an area they have given due con-

sideration to that.

 

The program staff is quite small. At the present
time there are five full-time professionals, one cart -bime
orofessional. They propose to go up to eight, eight full- |
time professional and one part-time plus four other personnel.
So it is a relatively small staff, |

: I would gather from some of the background informa- |
tion, however, that the management skills of this staff Leave
something. to be desired, that there have been concerns con- |
veyed to the staff from Council and from central RMP staff that

have I guess to say mildly if not been completely acted upon o

pen cee anes
 

 

bw
accepted, and perhaps someone » Mr. eeoiey ean fFLLIL us in on
that. - .

I mentioned the Regional Advisory Group. They have
had goais and priorities and the listing of projects, priority
rankings have been given included in the application, but hai

thet fits with their overall priorities I can't determine.

ta

Now, on terms of oast performance end accomplishment
their report indicates some things which to me are quite
exciting. For example, Let me just read a paragraph or two
‘here. "In the north area of the region," that to me indicated
if they can take a major credit for it, I would consider it

a rather substantial accomplishment.

 

The report states: "As a result of our efforts and
j

cooperation with healtn care institutions and citizens groups |
|

over 60 doctors have come into the area within the last to
years. This is more than 25 percent of the total number of

doctors practicing in this area, prior to our effort. Success~

ful physician recruitment can be attributed to our widespread

thrust."
, Then they list ten different activities in which the |

RMP engeged in that area, which they believed were related,
and somewhat instrumental in attracting the 60 new physicians |
into the area. |
Iwill just indicate one of these is a series of well

I

baby clinics developed by citizens group using professionals

|
|
4
 

 

whose time is donated by institutions. From one 1972, the
operation has expanded to fifteen clinics in April 1974.
So in this area, in particular, it seems they have a roo
narkab le accomplishment.

They have @ number of activities in the area of pri-
mary care and in health education network they have actively
been involved in EMS development in the region and so on.

So that I think there are a number of programmic plus-
es in terms of accomplishments that they deserve credit for.
| I have spoken about the objectives and oriorities.

The oroposal, I have had a little difficulty relating to

t
I

specifically the proposal, the projects to -- well, as I men- |
tioned, there are no objectives, priorities; there is the
progremmic thrust. But I would gather most of those program-
me thrusts are core staff activities rather than project related
activities.

The feasibility, I have some difficulty judging that
one.

Their past performance has been reasonably good,
I would think that 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 probab ly
is feasible.

The CHP relationships appear to be reasonebly good,

although it is indicated that due to the time constraints,

 

 
LUV
that all these have not been specifically reviewed by CHP
prior to submission, although there was some indication there |
have been some telephone contacts, some effort at liaison with
CHP during the time available.

My overall assessment of the program was that it Is--
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 able to accomplish, the minuses mainly being in the
management area which in part I think is reflected by the

‘mature of the proposal, the way the proposal is put together

and orgenized,

 

I sort of had the feeling perhaps they may be a some
what better program than the proposal reflects, and I am not

Sure.

 

But as L indicated, I am impressed with some of the
things that they had done and they are reporting one So cern os
I can stop there. |

MR. PETERSON: Okay, Charlie, you were the other
reviewer on this one,

. DR, McCALL: ALL right, sir.

Just a few comments to basically agree with Dr. Hess!

i
!
1

evaluation.

. There is a tone in the rather poorly put together
|

proposal, optimism and enthusiasm, which I think most of us Like

to see, that you couldn't tell from this application how well

 

 

i
1
|
‘
}
 

 

|
founded that optimism and enthusiasm were, however, and he |
has elready alluded to, well, the small staff in spite of mans
orojects, multiple activities, without goals projected. | !
It is 5 fragmented program, doesn't hang together well. But !

it's accomplished in sort of a short-gun way many things,
’ |

but with the multiple activities related to small staff it does
raise serious question of capability of monitoring such diffuse

|
activity and fiscal management thereof. . |
One place in our evaluation Dr, Hess and I differed,

_I checked degree of CHP. relationship. !
| Nothing from the CHP in here. Application says |
what the orocess is, but the only thing we are asking for here
is really a continuing application. They really aren't re-
viewed now, but some 84 propcsals are to be reviewed by CHP.
So I felt that I couldn't really say that that was
plus or minus at this particular point.
And lest question, they have the arthritis proposal
in here. This is legitinate, I suppose, as a continuation
oro ject. Jerry can tell us whether that creates any problems.
MR. PETERSON: Okay. Do you have any sort of sum-
mary, one word, one phrase imoression of the region, Charlie?
Yours was sort of averege, some pluses, some minuses!
DR. HESS: Yes. |

DR, McCALL: I also had him as an average region,

almost exactly. I think we would have the same pluses and sam

“ ws
 

 

Liv
minusesS.

MR. BARROJS: Before we get around to numbers, may
I ask, budget LOO -- 20 percent, $147,000; 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 was the hypertension to’ some
‘time constraints up there.

As the arthritis, I have not been in contact with
the Arthritis Review Group. They are taking into considera-
tions whether or not CHP did respond to it and they will,
through their own mechenie, message to Council or others,
will let us know whether (b) comments were missed, But the
only project that hasn't been seen or reviewed in the region
was 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 not part of
the request, and interestingly enough, the RAG Looked at the
mobileunit almost as a second project and rated that Low, but
gave the Bay stations a higher priority, as you see in their
application.

This was a Cag-on through Local pressure, to the EMS

couneils which they ere supporting. So total EMS is not just

 

 
 

 

equipment, but to continue their EMS councils and also to go
to complete the base station network, but they slioped in the
mobile units to let Washington make the decision. This is the
vay I interpreted it.

MR, PETERSON: How much of that particular $147,000
is mobile units hardware?

MR, STOLOV: $36,150.

One point not mentioned, which is a plus, is this is

based on local matching. Very strong point for the region, their

equipment was Locally matched.

DR. HESS: Bringing in outside funds, much of this is

shared funding. And they have hed a pretty good record of--
vell, they have listed a number of activities, they have
started, which are now ohased out as far as RMP funds were
concerned, so they do nave a good record of getting things
started, organized, going, and finding other funding sources.
I think they certainly deserve credit for that.

Oe MR. BARROJS: Is that outside sugoort for this
$147, 000 mobile unit and so on?

' MR, STOLOV: What was your question? Was there
outside support? 50 percent matching on form 16.
MR. NASH: What they did, Mr. Barrows, the first

part of the EMS activity they agreed with the hospitals in

the area to purchase nalf or pay he if of the costs of ccm-

munications equipment if the hospitals would put up the otner

 

 
 

 

half, Now, they are proposing I think to do essentially the
same thing on this.

MR. PETERSON: $300, 000 olus, Local funding in the
whéle conjury of EMS activities.

What we have here, of course, is an application
which is largely continuation, thatmay be a Little misleading.

There are only a couple of small new projects. We have an

- $800,000 application with just a very small amount of new acty-

vity.
Some of the continuation, Il think it is particularly

true of the EMS, is continuation at an expanded level of fund-

~

%

ing. You will note from your table that we have an estimate ti

Central New York is going to cane to us in July with like a mil-

lion dollars plus in new activities, while they are requesting
now roughly -- not guite $800,000 against a target, overall
target figure of roughly again a million dollars,

Were there any other things, Jerry or Frank, of
significance, policy issues, major problems or other things
we want to point out to the group?

MR, STOLOV: By and Large, the CHP relationships have
been 00d. 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

 

 
 

 

LLD
who orepared the report is away doling other management assess-~
ment today. We have only received a brief feedback on it.

MR, NASH: Do you have any general ideas?
MR, SIMONDS: Didn't even talk to him aboub it.

Nothing about it.

U

MR. STOLOV: It appears the fiscal management end Was
considered much improved or found satisfactory upon review.

There were other management problems related pos-
sibly to how the director conducts his business, et cetera,
“but the major thing we did want him to focus in on was the
fiscal management aspect.

There is just one other thing. Goals, objectives,
ang priorities were forwarded to the region through the last

letter from council as not being systematically identified.

 

Based on that we do have that and the Director, his ansver to}
this wes that he put staff on to do modified review process, |
rather than redesign his goals, objectives and priorities.

So that is where it stands now. He stiil has not, to
the best of our satisfaction -- or my satisfaction -- changed :
the goals, objectives and priorities, 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 panel members?

MR BARROIS: I would Like to ask one.

If in the light of the relatively modest rating this

 
 

 

prozrem has come up with, if we were to scale back there with
a reguest here, would it have any wholesome effect on making
them a Little more selective or a Little sharper on their new
project applications?

DR. McCALL: They are going to have to be fairly
eélective, they indicate they have By --

MR, BARROWS: They are going to ask for another 800.

MR, PETERSON: They are coming in with astatement
of 3L million. You know, this may have changed. Obvious Ly

it has if you Look at the EMS, One of the recent character-

 

istics of Central New York vas that it tended to have a lot of

emall invitational contract type proposais, you know -- $5,000

|
i

$10,000, $25,000. So that 6&4 may not add up to, you know,

much more than a million dollars, I don't know, but that core
tainly was true in the recent past.
MR. STOLOV: I think it was $3.9 million, adds up |
to about $3 million now. We estimate about a million. 2
I ean't a ever your Question, |
I think the review committee has to further discuss
it.
MR. PETERSON: I think what we are faced with in man

cases here certainly is for all practical purposes things are |

in the pipeline and moving out there and may not have had

final RAG action, but nothing we do or say by and large in term

of July applications, if I got on the phone with the Senator

 

?

/
 

 

from New York this evening, which I am not ebout to do, am
we hed something very definite. to tell Central New York or
any other region, I think the timing is such that the cast of
application we are going to see in July is pretty well set.

DR, McCALL: Simply I don't know how many dollars,
we would Limit the number you could fund and Limit the number
of activities that would be monitored satisfactorily.

DR. HESS: They wiil already, if their performance
on the July application is the same as they Will already
.have prioritized those project apolications so when decision
is made, they will already have the framework. for making their
decisions about which cet funded and which don't. .So in that
sense they are well organized and prepared.

MR, PETERSON: And the group in that sense would

 

have sane rough notion that if you gave them 50 or 60 or 90
percent of the request, how that would fall out, roughly.

DR, HESS: Yes,

MR. BARROWS But giving them, say, $700900 or $800, 0

they ere asking for now wouldn’t whet their appetite for the
remainder.
MR. PETERSON: I can't answer that.
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 pick out -- well, approximately $180,000 worth

the

neN
Ji

 
 

 

of applications that most of which are low priority on their
List and 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
batch.

I think that would-- you know, we can deal with
them in a fairly what I would consider fairly even-handed and
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 $800,000 at this juncture.

 

DR, HESS: That's right.

DR, MecCALL: I was going to say recommend $600,000,

DR. HEUSTIS: I will support his. Mine was the sate.

MR, PETERSON: Did I hear e second? |
DR. TESCHAN: Second. |
MR, PETERSON: Okay. |
We have a motion and a second. Is there any more

discussion or comment with respect to Central New York?

If not, those in favor?

(Show of heads)

 
 

 

MR. PETERSON: Again, I think I see unanimity.
Okey. I think we are again doing reasonably well undey
not very good circumstances, |
I would Like to, because we have spent all of our |
time thus far with regions that are at least for our adminis-
trative purposes in the Easter: Operations Branch or Desk,
I would Like to switch our 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 couldn't get much farther away. :
I thought we would try Hawaii for starters, . :
John and Biil Thurman are the reviewers on that.
I might ask you to kick off on that, John. I believe

you were on the site visit out to Hawaii,

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DR. HIRSCHBOHCK: Yes,

MR. PETERSON: You have lost your tan I see. That
was sufficiently long azo.

DR. HIRSCHBOECK: Yes, That #s January.

Well, the regional medical erobram of Hawaii, as I

review this application and read correspondence of what has

 

raopened Since our visit, I am pleased in the very positive change
of direction and imorovement in the affairs of the program there.
So although the history has been turbulent in the
past, it seems there is some opportunity now to.see some pro-
gress being made with new leadership.
The present coordinator, Satoru Izgutsu, was a coordinsa-
tor for the Pacific Basin Program, He is now, since May Ist,

coordinetor of the Hawali.

The staff is quite stable. There have been no

 

serious departures as a result of phaseout activity.
Staff is presently full-time equivalents of 1575
with proposed expansion,
| The question of program leadership I think is now
somewhat resolved in that the coordinator seems to have
taken over,well -- certainly the way the application was put |
together, if this is an example of his ability to take over, Li
think this is one evidence.
There is a new rate chairman and the relationship of

the grantee agency apparently has also been approved.

 
 

 

It seems to be a criticism a small clique was
operating the regional medical program of Hewaii and I
think this is oretty well gone now with these changes.

As far as the program staff is concerned, it is a
reasonably good staff. They have an economist there who
even as a result of the visit I vasn't quite clear in my own
mind just what his role was other than perhaps work in the
problem of cost control. |

The rest of the staff had strong community interest
and certainly the man involved in charge of the Pacific Basin
now seemed to have everything well in mand to take over the
responsibility.

Tne Local involvement of the staffwith other agencies:
seems to be quite evident. This is not an ivory tower staff.
They seem to be involved in many, many things

Regional Advisory Group hasn't changed very mucn
since its inception until recently. It's I think an average
regional advisory group es I know them,

Review evaluation of projects was carried on with a
special committee or project implementation and evaluation con:
mittee, This seems to be done almost apparent from the
Regional Advisory Group.

Past performance and accomplishments, program has
had its troubles. It perhaps has not risen to the challenge

of great opportunities that presents itself in this far-flung

Les

 
 

 

progrem, where innovative ideas may have been experimented
with, Ib has been using more traditional approaches to many
health care services, and much of this, of course, is right
within Hawaii itself,
Only recently, according to the applications that
are in this particular package, has there been a great
spurt of projects for the Pacific Basin; the new orojects
are being proposed for the Pacific Basin. Truly not great in
doller amount, but they are for the benefit of specific
people. |
The objectives in oriorities-are, again, as I said,
rather traditional and we think there might be others they
could come up with as a result of the opportunities, increase |
in medical progran,
They are fairly, fairly rational. I will read some

of them: Encourege innovative arrangements for organization

 

of heaith services, methods of financing, reduce unnecessary
duplication of health resources, encourage improved productivity
of individuals 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 package.in for :
the July Ist review.

As to the feasibility cof this particular program

carrying out its program functions, likelihood of prosperity,

 
 

 

progress, I think under the new leadership we Will have a chances
to see whether there will be improvements.

I think that in general things Look pretty optimistic
compared to what they were before.

CHP relationships, certainly here is an area of
great improvement. This is evident in the application. Under
the old regime the relationship with the CHP, H&C 4 was almost
nonexistent, although the director of the CHP was a member
of the advisory group, yet collaboration at a working level
Was aposrently not very evident.

And now I notice in the application that there is very
active criticism end comment about the various projects that
have been proposed in this particular application.

The whole problem of CHP in the PacificBasin is an

 

unknown quantity as far as I am concerned and there is only
one (b) agency in Hawaiian Islands itself, so that if is a very
unusuel type of situation to deal with, although this is a !
very active CHP agency at the so-cailed state level. |

My overall assessment is I would say averege with
oossible imorovement in the near future as a result of the
change in management direction.

MR. PETERSON: Thank you, John.

I wonder, because of the ‘long history of Hawail, the

kind of problems that we hae had there, I had intended, in

 

spite of my best intentions, had forgotten, I had intended to

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‘
 

 

depart on this one from our format and Was going to ask Dick
Russell initially to fill you in, because there have been s0
many developments Literally within the last few months. -
And if you have no objections, Bill, Iwill try and make that
half good and ask Dick to perhaps fLLlL in some of the
background very quickly as it relates to Hawaii and the
develooments literally of the past two, three, or four months
since the new coordinator came on April 1, I think it was,
rather than May 1.

It is a matter of months in any case.

Dick. | -

MR. RUSSELL: I think Dr. Hirschboeck has covered
some of the points very well.

I would Like to say that this particular application

was put together under the direction of the deputy prior to.

 

Dr, LIzutsu assuming coordinatorsnip.
Unfortunately the deputy is still operating under the

old philosophy that anything was fair. There is going to be a
|

lot of money. He still hadn't gotten the message about what
i
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the problem had been with the program -- he has it now.
The Regional Advisory Group has not yet come to the |
maturity of setting priorities. This has been done by a
small group, planning-implementation-evaluation committee.
I think they try to do a good job, but it is all on @ cersonal

criteria.

 
 

 

In view of this, Dr. Izutsu is now orienting

tT!

Regional Advisory Group, new members as well as the old member
and at their June -- I think it is June 23rd meeting, they
are going to reset priorities,

I think 35 letters of intent they have now that will
-probab Ly come in as projects as well a those projects in this
apolication.

In other words, by that time he hopes to get some
sort of system where the Regional Advisory Group wit in an

objective manner set priorities.

ta

Iwas in Hawaii for a week with Dr, Izutsu, and it i
a comoletely new program, no doubt ebout it, Leadership here

is unbelleveble. He has whipped the staff into shape, They

are participating shering information which before the informa

tion was not shared with key staff nor was it shared with the

 

Regional Advisory Group. It was a clique, no doubt about that.

The RAG has been revamped. Or. Iautsu has gone back:
to our advice letter, which came cut of the November 1973 |
visit. Mr. Barrows was on it. He has gone pack -- Dr.
Hirschboeck had a copy of a progress reoort. ALL I can say is
what he says in there is indeed fact. |

The Hawaii Medical Association is now very willing

to be involved in the program in view of the absence of the

former coordinator.

The University of Hawaii School of Medicine,

 
 

 

Dr. Rogers is very much interested in being involved now as
well as Mr. Michael, dean of the School of Public Health.

CHP relations, night and day, it is really great.

The community's image to the RMP has changed in the
six.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 2 duplication between trust territory, cerebret
cancer projects, and one that has been submitted to NCI. IL
“worked with NCL staff. NCI staff is in touch with Dr, Izutsu.
And he is plugging the trust territory again with NCI, and this
is the type of-- he is really the RMP, now has become facilita-
tor which it hes not been all these years. He is having
meetings between hospitals -- hogpitels never met before be-

cause nobody ever called them together.

 

Thereis a grantee relationship witn relation to
RMP that's very good. We had some concerns because the execu-
tive director of the Research Corporation of Hawaii was --
what do you call it -- proctor? Dr, Izutsu, some were con
cerned there might be this type of influence on Dr, Izutsu.

I sat in a meeting between these two men. Dr.
Izutsu gave it straight from the shoulder with the grantee as
with anybody.

It is unbelievable what he has done.

There are some weak spots in the staff. Or

 
 

 

Izutsu in seven weeks hasn't had time to cure all of the ills
of the past, but no doubt in my mind he will.

DR. TESCHAN: What is the population?

MR. RUSSELL: Of Hawaii?

DR. TESCHAN: Of the region.

MR. RUSSELL: 100,000 in Hawaii.

MR, PETERSON: 100,000? I think it is over @ mil-
lion in the Island of Honolulu.

MR. RUSSELL: 800,000 in Honolulu?

MR, PETERSON: And trust territory, And all that
sreat big expanse of blue water doesn't add a heck of a -lot.

I imagine a million when you add sand crabs -=- we
spent’ occasional beer-drinking. sessions in 1945.

There may be people there now, weren't many then.

 

 

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MR. RUSSELL: Not many people, but it is a 3 million |
square mile area. |

MR, PETERSON: Sister Ann, who often thinks tre
distances coming from the west, Maine, Utah, and even Alaska
L think, pale by comparison to what in one sense is the turf oF
the geography of the Hawaii RMP, !

Bill, you were the other reviewer on this. I wonder
what you have in the way of additional reinforcing/sub-
tracting ‘kind of comments, both to what Dr. Hirschboeck

and Dick have mentioned?

DR. THURMAN: There are two points that have cone
 

 

over here, three points I would make , and that is com-
munication situation, Dick has discussed, is very obvious
they have not really talked to people and they recognize this.
Tan sure they will take care of it.

They still don't understand the priorities. They
are ill defined and they are working on that.

I think the last thing thatdisturbs you about the
thing, a11 of us knew this before from when Len. Shirlis
and others went to Hawaii, was when projects terminated, no-
‘thing ever happened from then on, you know. Nothing ever”
came of the projects that were funded in the past. Anal
think that is going to be the real thing here.

Really it depends on whether or not they deve Loo

 

some Hawaii orojects.
If they can't develop Hawaii projects, this is soins
to be still not a good program.
Almost everything they have put in there is basic.
MR. RUSSELL: I did just get the minutes of the pten-
ning-implementation-evaluation committee, what point they |
are screening -~- last week they were letters of intent.
Here one hears comments, we will consider this if

these three letters of intent are taken, worked together, as é

single project. So this type of thing is occurring.

 

You know, here, again, when we talk about unified

health planning, that Hawaii of all the states, because of its

|
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geography, is in excellent position to pull the resources
together and work together. I think this is the type of direcr
tion Dr. Izutsu is going to give the oroeran.

MR, PETERSON: Mr. Barrows, I didn'trealize you had
been on the site visit.

MR. BARROWS: Iwas. As these fellows found it,
I found it completely fascinating, positive sure for mey

The program is hard to compare with the ones we are
acustomed to first in terms of geography, when you start think-
ing ebout the Pacific Basin. AsI recall, it is something Like
seven hours flight time to get to the nearest point from-
Honolulu, and so you can't be making daily calls-- the Pacifid
Basin is terribly tough from anything we are familiar with
economically and socially. Therefore for health resources, it
is almost wholly dependent on government operations.

There is no private, to provide heaith care. It is

 

 

 

quite unique in that respect.

 

Back into Hawaii itself, the islands are physically
separted, which poses some problems for them You can't have
ambulances shuttling back and forth that kind of thing.

And then on top of all of this, their social attitudes still
reflect considerable Oriental influence, and they Look at
things a Little differently than the way they do in Chicago.
Maybe they shouldn't under our creed, but it just happens to be.

that way.

 
 

 

So I think when you Look at Hawali, youhave got to
Look at that as 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 adminis-
tration about the great opportunity that Dr. Hirschboeck
mentioned for innovation on the ‘part the staff had raised,
here is a real fertile field?

I am thinking that you had such a thing off the coast

-of Maine, not 7 miles away but shorter distance, they put a

Op ee

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nurse with a television connecting her to the mainland, thi es.

Like this, where she can getea less well trained person can

get consultation.

Has Hewaii thought of anything like this? Can they |

be stimulated to do--

MR, RUSSELL: We are talking about two programs; We

talking about the program in the State of Hawaii, we are also

talking about the second program which is the PacificBasin.
So I have to ask,. you know--
DR. HEUSTIS: I just understood from comments, I

had not read -- the comments about the great opportunity for

innovation apparently from the standpoint at least I heard the

reviewer saying was not exploited -- taken advantage of,

capitalized on.

DR, THURMAN: I think my answer for that would be

é

he
a
 

 

eee

yes, in the progress report the new man has just forwarded,

he gees what has been talked about over and over again. And I

think fromthe way he writes, he has got the moxy to pull it off
. | DR, HEUSTIS: Okay. ;

DR, THURMAN: He understands what you are saying
and 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
what we are taiking about, yes.

DR, HEUSTIS: Just corollary, does he need support
‘from us, help getting the egg on nis face?

DR. THURMA: I think Mr. Russell is providing thet
support in a very meaningful waye Putting grease skids
under the last man was a very essential thing.

MR. RUSSELL: Yes, I think he could use support from; -
the reviewers.

You know, quite frankly, no one quite knows the
problems we have had there.

If one Looks at this type of application, the types
of projects in this application, and a new Girection that the |
orogram staff is going to take, facilitators, it seems to me
this is perhaps where they might want to concentrate a Little
bit more on perhaps in the future than being so project
oriented as in the past.

DR. HEUSTIS: If in some way, din whatever way is

aopropriate, he could get some encouragement so that he

 
 

 

er -

could go to whoever the traditionalists are and simply say
this is what the Regional Aavisory Group or the Council or
the staff whink I should be doing in getting support,
sometimes this is helpful.

DR. THURMAN: It might be worthwhile for us to con-)
sider in our proposal he be asked to consult with those who
ere beyond the traditional realn.

As Mr. Russell indicated, the guy who just took over
the school of public health out there is an innovative
. schemer for delivering health care, It is his big vag. - I
think if we were to push Dr, Izutsu toward this man-- ~

MR. RUSSELL: They are already together. I sat in
a joint meeting with them, together. |

DR, HEUSTIS: A fellow Like this needs ail the

f

 

support he can get to keep somebody from knocking him down.

DR. HESS: He only has @ year to go, so fara we
know, under this oarticular orogram., So I think our entnusiasn
for you know, specific recommendations for getting all gearea
up and wound up have to be tempered by that Life span.

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 what can be done. |

SISTER JOSEPHINE: Two things I have been impressed 5

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two weys of getting a progranto bone up is either to deny

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funds or pressure the poor coordinator to Leave. |
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i
 

 

MR. RUSSELL: He just happened to resign when we
were out there,

DR, HEUSTIS: That's right.

MR. PETERSON: John, do you have a recommendation?

DR. HIRSCHBOECK: I will make a recommendation that
maybe we approve the $1.5 million.

MR, PETERSON: That is the full amount that they
are recuesting this time. They are coming in we understand ,
and I think Dick has much better Lnte LLigence on this
.region than we do on most, in terms of whet is Likely tor be
coming in.

They are coming in with another request in July,

which will perhaps bear more of the imprint of the new coordin:

tor, the reconstitute of RAG, et cetera. Roughly a half mil-
lion dollars.

I am reading my figures correctly.

We probably, over the two sessions, will be looking
at close to a 32 million package; three-quarters of it is re-
quested at this time, against, again, a benchmark or target
figure of about $1.5 million.

DR. THURMAN: I am going to have to take issue with
a fellow reviewer and say I would cut this $1.1 miLlion to
$1.2 miilion to let's see if he can do all the things we are
looking at. That is the only place I would disagree. I

think it needs our approval and suggort, but I think 31.5

%

 

 
 

 

million, although they are already at $937,000 -- he is ina
situation now where I think with adequate staff support, he
can bring about a change in this program even though it is
only for a 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 are coming in with another half:a miliion dollars.

DR. HEUSTIS: Thaty would leave some money to take
care of the haif million.

DR, THURMAN: Yes. I would put it at $1.1 million,
_L believe. _

| DR, HIRSCHBOECK: I think I agree with you. -

DR, HEUSTIS: I support your motion.

MR, BARROWS: I think they might relex a little bit.
It might go too far. Give them a little bit of encouragement.

DR. THURMAN: I would make a substitute motion

of $L.1 million.

 

DR. HIRSCHBOECK: I second it.

MR, PETERSON: John seconds that.

I gather one of the important things we want to
convey, because we are talking about a dollar figure, bul thet:
the group, and presumably the Council, if it Listens to your
advice and what have you, tha the group feels that the pro-
gram is at least showing indications of moving in the right

direction,

We are going to ask the new coordinator to do what

 

 
 

133
he has probably already started to do, started to Looking
beyond the traditionalists out there; so the figure of $1.1
million, which has not been voted on yet, we need to be care-
ful that isn't interpreted as a largely negative signal if I

heard the discussion.

It has been moved and seconded we recommend $1,1 mil
lion in this case,

Are there any other comments, observations. or
questions about Hawaii RMP in this application?

If not, will those in favor, if they will raise
their nand either one WLLL do. :
(Show of hands)

MR. PETERSON: Again -- I don't know whether it is the

lateness 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.
MR, PETERSON: Never? |
Iwas going to try possibly to put a little Life into
the meeting by suggesting that if we have dealt with Hawaii |
now, we might pick-up on another one of the Western Desk

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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 Hewail |

and the blue Pacifie to the southwest and take a Look at

 

 
 

 

Srizona,. which I think is one of the fastest growing states

in the Union.

Paul.

 
 

 

J

RIZ OWA . 135

7

DR. TESCHAN: In contrast tothe fastest growing
{

state in population, I find the application a fairly pedestrian
production.

The application 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 forn,

In going over the application, we are unable, really,
- to find what program goals end objectives have been stated.

There is moreover in some of the ancillary informe- :
tion we were sent in the summary of program status, issues
raised by staff on the basis of their visits, et cetera, that
@ review verification is pending, pending conformance to

DRMP policy. And the issues are that the bylaws need revision

 

and the RAG membership needs better representation,
The application is silent on the subject of bylaws,
bylaws revision or anything about the process. !
| The RAG membership, the application is silent on the
question of RAG membership change. - |

The membership continues to have 18 individuals. mney

tend to show at the rate, according to the application deserip-
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

principal Leadership of health -- of the health forces in
 

 

LOU
Arizona are in fact members of the thing.

There are issues of racial balance and I am not a
good enough geographer of Arizona to tell how geographic
the balance is. But it would appear the issues that are
raised in that document are still with us as far as I can
tell from the application, no change at all.

Now; the staff is indeed stable since L967 and you
get the sense that there is not, as a matter of fact, some -

where between the coordinatorPAG chairman, executive. committee,

-ability for program leadership and direction in line with at
least the administrative issues having to do with review pro- :

cess verification.

 

On the other hand, there are issues of expansion of |.

health service sites having access continuation oproject for one
4

I

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more year, extension of medical manpowey & recruitment program
extension for one more year, and a fairly localized health |
information dial-access type of program, which by the title
itself provides health education which is also scheduled for

extension.

There is EMS project and hypertension control pro-

'

ject. There is a carry-over into two more counties of a strec
tococcal infection project control project.

There is in addition a rather surprisingly, I think

 

from the buildup, apparently a cessation of the continuation 3

i

|
education service area project. It comes to the end as we see

tt in the end of 1974 according to the application,
 

 

LOI
However, I think in supplemental information I got
across that I have just received and have not carefully studied,
it may be that there is a further extension of that, because 2
in the application on page 19 the RAG suggests that there
should be maintenance of activity in the continuing education
service area tiie a . |
i have to ask for staff help on that particular point,
oarticularly in how there is actually organized, in view of the
fact there appear to be in the sites pages 19 separate committees
in various places which are supposed to identify local needs
and essist in development of those local programs. -
MR, BARRGYS: Are those rural?
DR, TESC CHAN: Weil, I would imagine small communities.
They are not in Phoenix and Tucson primarily by any means. |
They ere scattered out quite widely. |
The interesting feature about that particular orojecs
statement, however, why I am ambiguous about it, why 1 thousht |
its discontinuation was a plus, is because the evaiuators, at
least the capacity for evaluation, péege 61 of the application,
say there are ey least three basic changes that have-- two bas
changes have to be made to qualify for further RMP support
peyond June 30, 1974.
‘Dia you want to clarify? I certainly wander ayo und
that one, because that is the state the application is in.

MRS. SADIN: The CESA program, they are going to
 

 

continue it for three more months without additional funds
requested until it gets a complete review. They may come in
July 1 but I am not sure. They have had orob lems with Lt.
The staff feels that it should change its emphasis even
though it does have that many committees and it is throughout
the state. They also feel the medical school, university in
general, should have taken over some of it, or some medical
society or some other professional organization.

In order to help the staff, they asked an outside
‘committee, ad hoe consultant, to come in and evaluate CESA.
I guess unfortunately for staff, the outside committee felt
it was marvelous, and recommended to RAG that it is .a very
good activity and ought to be continued. And I was at the RAG
meeting where ell of this was being discussed. The way they

handled it was, as I said, just asked for two months without

 

edditional funding have a complete review of the CESA program.
If they do come in again, there be a different emphasis that
it not-- well,several things, one is that there be a different:

i

emphasis in terms of need, patient care need, rather than

just what you think you would Like to lnow.

Two is the university and heatth professionals :
put some money in themselves. And they were going to have all
of this ready by July 1. That is why-- but it is not in here
for money right now,

DR, TESCHAN: I mentioned this simply to say it

 
 

 

139
seemed to me that the comments made right here mowed me
more staff. I had been developing a fairly edestrian picture |
of staff function and all of a sudden I come across some

very good ‘sort of either it shapes up or we don't continue it,

iH

and I thought that is great, that is a plus on that. And I wa
seeing the thing end based on the terminal date here. And

they are basically saying the thing so I won't go further on

 

that.

So I am sort of at a questionmark on progrem leeder-
-shio under insufficient basis. That really is pretty Limited
judgment. It is hedging one's bets pretty severely.

Bub it Looks to me as if-- it looks Like there may be
some pluses, maybe some minuses.

I would say I can't quite-- it sounds Like the staff
is moving particularly because of their access projects, exten-
sion projects. It looks like the staff has more Life in it
then the application would suggest and that the RAG is inede~_
quate to deal with this situation.

| So I left the leadership in questionmark, progran

staff probably satisfactory, and it is because there are pluses
and minuses, and that the Regional Advisory Group has to set
goals, objectives and priorities, they have got to come to
grips with the review process requirements, the bylaw system, .
and I don't have any evidence that they know how to do techni-

cal review. I don't have evidence.
 

 

MRS, SADIN: Yes, Okay.

MR. PETERSON: We are pack recently, I guess it has
been a couple of months now. | |

MRS, SADIN: One month.

MR, PETERSON: One month -- she has in Arizona, on

review verification visit, which IL think it is very relevant to

this consideration and I wonder if you -- I am not sure at wh
juncture, Paul.

DR. TESCHAN: I em going to finish uw reading--

MR. PETERSON: Why don't you do that, then there are

some issues staff might comment.

DR. TESCHAN: Thet would allow you to comment as you

MR, PETERSON: Okey.

DR. TESCHAN: In oast performance, it added up to
be satisfactory I thought in the sense that substantive
orobiems of availability end access, I didn't get a sense
there has been any. input from the region in the defining of i
They did launch renal, and so forth. They got funding after
termination, continuation funding for this. So it was from
poor to gocd on that.

Objectives and priorities, again we don't have
that, for program, And that note was noted in CHP corres-
pondence, which was in this application very extensive.

Also the arguments back and forth are very

a

cb

*

 

 

en
 

 

interesting. We will get to that ina moment.

The proposal I simply wasn't able to determine what |
the explicit objectives and so on were, and I have the dis- :
binet feeling, again CHP comes up here, in terms of 6(c),
the CHP has been virtually silent in any useful way.

That is to ey when this comes to the CHP,
say something to which Dr, Malnik should address the frogram,
they don't help him, Whet they do is complain after the fact
in Loud and somewhat, oh, vituperative language which doesn't

help anything in particuler.

I should add at that point the correspondence between

 

the director and the CHP, various CHP's, is very interesting,
in that where the replies have been has beenvery substantive.
You get a feeling there is @ professional expert
who knows how to reply, now to deal with the situation, in
those erguments.
Feasibility,we felt what was going on could be
achieved, I felt this was a below-average situation.
It currently, based on their request, has nearly
4Q percent of the total pudget will go to program staff as we
see the story. You know, depending on woich numbers you use.
But it Looked like a high degree, high amount at most of the
activities are either Arizona RMP steff-- there are two pro-
grams out of the total of $1.3 million; namely, to the tune of
$207,000, which appears to be the League of Cities and Towns 11

|
i
{
 

 

L142

Arizona Heart Association, that are not either the College
of Medicine or the RMP.

There are two College of Medicine proposals which
come to $88,000.

So there is @ large proportion of RMP in College
of Medicine type activities in the application.

MR. & TERSON: Thank you. |

Do you want to comment on what Paul may have said,
but also the issues that appeared to you as a result of the
review verification? It was made in April-May.

MRS, SADIN: It was spent both times.

Actuaily I spent a lot of time in Arizona lately.

MR, PETERSON: Climate agrees with you. California,

too,

 

MRS, SADIN: ‘There are several times-- sometimes we
leave too Little to our reviewers. I do remember a review

|
process verification report. |
,
DR. TESCHAN: One up. |
MRS, SADIN: I do have it. |

We were there at actually several stages of our re-
view process. One is where they just provide staff essistence
in the development of a project, project development, and we
saw one where-- this was in an appraised project, this is where

their ad hoc committee, review committee met. We saw that

stage. And we came back later, saw three different stages.

 
 

 

Their review really is pretty good. Their staff
assistant is good. Their technical reviewers -- aS @ matter
of fact, the technical reviewers had much to sayebout this
particular potential, they were looking at all of those comments,
were taken into consideration and modified by the time it |
came direct, so they did make those changes.

Your comment about RAG, we have been sending Letters:
to Arizona yearly about their RAG composition, The RAG has

remained more or less the same since it started--

DR. TESCHAN: Appointed by whom?

MRS, SADIN: Appointed by the dean of the Medical
school,

New, they had edraft of revised bylaws end they
decided to shelve it because of VASA, When we were there
before the review visit, they said they were not conforming. |
They are now revising -- they have to have 30 days before they
can consider any chenges, that is in their bylaws, They Know »
it is said in thetr letter they must revise their bylaws and
they will.

And their revised bylaws of which we have seen Graft.
and which trans-management has seen, looked at, to conform,

On the other hend, we have indicated that we can'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
 

 

six members would be from areas not presently within the state,
both geographically and nonprovider types. And this, again, 2
ts in the next letter, Dr. Malik, after review process. ;

There was another visit, that was in January, and
I made that one with Dr. Cannon, who used to be in our Couneit,
he hed visited Arizona with us before; this was done, because tn
their supplemental application, which showed they really had
made a lot of changes since their pre~phaseout applications,

we wanted to make sure they really did it and it wasn't on

paper. And there were a lot of changes,

Their RAG had recommended, for instance, they work
~
with CHP and they had visited and worked with CHP, ‘So this is

really the (ob) egents telling what the needs are. .
It may not be true of FPnoenix ana Tucson, remote
areas of the state they are working there. At their RAG
meeting, as I indicated in that summary I gave you this mornine,
there was a Lot of discussion about wnat Dr. Hess mentioned
this morning which is, you know, the cost; do you spend
$350,000 in remote areas where there are 150,000 people, or bo
you concentrate on South Phoenix, areas that are higher densits
population? |
That can be a philosophical question.
. Again, in remote-- they are,what they are trying to

|
|
|
|

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 may not work out if you are going to do it per

!
i
|
i
 

 

L45
person.

DR. HESS: This is an example of where I think sup-
cort 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 health
services, |

Maybe you are misinterpreting what I am saying.

MRS. SADIN: No, I am not. I say you couldn't do it
on @ population basis.

DR. HESS: You have to take geography, needs, and ob-

stacies that have to be overcome into account.

 

MRS, SADIN: That, by the way, is part of the pro-
sram staff budget, even though termed an activity. So the |
prozren staff budget is kind of not a true budget.

| Lt could just as 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 zrantee policy will be taken care of

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.
Ana in terms of objectives, that is really kind of ironic,
because one of their main criticisms, when we were there, just
pefore phaseout, was that they had 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 of’
the visitors commented it looked like somebody all dressed
up and no place to go. So they have that.

DR. DR, TESCHAN: It is in the book, but it doesn't
come througn.

MRS, SADIN: Ib is in all their other books.

They do have very eloquent objectives.

DR. TESCHAN: What I recommended, was thinking of
recommending, was something like 80 percent or so of request.
Funding approximately 80, you know -- we go back and forth,
up and down on this. But something Like 80 percent of the
request.

In order to particularly get the message that we
encourage their move out of the metro areas, that is to say
it seems to me a movement is afoot which has a reason for

being supported. We want to be sure that if the group feels

1

 
 

 

thats is the case, if we want to do this, that theyget that
message and not other messages. that all the funding, et
eetera, should 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 up on staff if they can, because the
staff costs relative to the total request is pretty high,
although I em not now talking aboute- not core project so much
But I think with the new application-- |

MRS. SADIN: They are also putting some people out
as area reorecentatives.

DR. TESCHAN: Yes, I saw that.

SISTER JOSEPHINE: May L ask, what is the possi-
bility of seeing thi recommendation thet they move out of the
metrpolitan area and some of the other recommendations you

made, the fact they are complying with it, to be visibdle

 

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,

t

helpful, would be if there is a large variety of activity

and they were to sort of take that into account in their ori- |

ority setting or the mix that they submitted -- but really, I.
think if we don't have anything in the pipeline or the draw ing.
|

t

board that fits this, they aren't going to have it again,

|
|
|
i
 

 

LAG
regardless of how instant that communication is, and how force
ful, how heated. Time just won'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 have just said, it is obvious Dr. Duvall
is going to be the dominant personality in the group.

MRS, SADIN: He has been, was, I was at the RAG meet
ing. He does turn votes around.

DR. TESCHAN: You say he is a leader?

MRS. S&DIN: He is not going to be on the RAG any
MOLE «

DR, THURMAN: He is elso not going to change his
rule.

MRS, SADIN: Probably not.

One of our recommendations is that they not do
their prioritizing verbally es it does happen tremendously.

MR. BARRO/S: Would you clear why you want 6

shift to their rural area, you have two things to go on, need

and opoortunity. Need in rural areas is frustrating, no
question.

I don't think people have been working on for bO
years -- in terms of opportunities in the metropolitan areas,
46 seems 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

 

t
 

 

“what they ere talking about, what Little. gossamer ohrases
go by on the progress side of those statements, I get the
feeling that there is some possibility of personnel recruit-
ment and new services to be established when rural communities.
get together’and make an attractive or possible Life style
for the new profession. So I have the fee ling something is
moving in that direction. |

Secondly, the swinging mood you are talking about
in my view probably could be taken care of with precious Little
essistance rether then dollar resources. In other words, that
is already moving and there are already resources in that aren
to function.

MR, PETERSON: Are there any other--

DR, THURMAN: Yes. It seems tom--

MR, PETERSON: Bill.

 

DR, THURMAN: It seems to me Arizona is probably
the closest to Connecticut the review committee has ever faced
year in and year out. And we have always made these very
strong solid recommendations about how the program could not
exist in the medical school and how be damned if I see how Lt
has changed. |

MRS, SADIN: Is has, Iwas on that site visit with,
you Know, everybody else, when words were said. And as I :

said, all of tnese things, you know about having all these

eloguent things, but not having-- Same staff, same coordinator:
i

1
t
|
i
 

 

same chairmen of the RAG for six-oplus years, then it was total iy
in the medical school and it isn't now.

DR, THURMAN: Where I disagree with you is they stilt
think it is. They think they control--

MRS, SADIN: They control because dean of the
Medical School eyooints members of RAG,

a am saying in their reviwed bylaws, they are changing
their RAG grantee relationship. |

DR, THURMAN AIL I am really saying is -- Dick, bear
me out of I am right or wrong -- every time we have discussed
Arizona, review committee staff has been enthusiastic, review
committee hes been pessimistic. And I still sit here and sey
in ell that time it ein't changed one Little bit.

MRS, SADIN: The funny part is I am being an advocete
right now and it is oarticularly funny, because in the office,
I am usually not. But they have mede some changes, they really
have.

DR. THURMAN: It must have vote those people
80 percent of the money they have requested when you have a euy
sitting in the driver's seat six years can't tell you the time
of day. That continues to strike me as something short of
ridiculous.

MRS, SADIN: He runs the program.

MR. BARROWS: Who is current chairman of RAG? :

MRS, SADIN: Running for state Legislature.
 

 

No.way of circumventing.

DR. THURMAN: Run by Monte.

Fron the dey it started it has bem run by Monte
and will be run by Monte until the dey it dies.

DR. TESCHAN: The answer to that in practical terms
is for the new RAG on the basis of the new bylaws to make a
| change in the director. If the’ grantee doesn't egree with
that, to change grantees.

In other words, it is appropriate action is that of
the RAG.

DR, THURMAN: Thirteen months.

DR. TESCHAN: That is your view. i tend to have

ceveat on thet one.

 

MR, PETERSON: Well, I do feel a Little -- not taking
- {

sides in this -- feel a Little Like Bill, I heard this a couple
.

of times before, but that doesn't get us off the need to make

some Kind of recommendation.

We have a $1.3 million request here, an indication
4

that in the case of Arizona roughly another $400,000 will be
coming in in July for a total of about $Lle7 million, 31.8
million, which is very close -- Slightly ebove that so-called
target figure, benchmark that I have been referring to all
daye

I heard, not in the form of a motion, I heard you

earlier, Paul, say something Like about 80 percent -- which is

 
 

 

really giving me another 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 arithmetic, which I hope WiLL be checked again,
that was Like $1,080,000.

Now, that was not in the form of a recommendation,
but at Least that translates your 80 percent you were thinking
outloud about LO minutes ago into a figure. |

Do you or someone else want 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 scientific.

(Laughter )

DR, TESCHAN: Of course, it isscientific. Deep balan

between the pluses and the minuses.

 

MR, PETERSOY: I have always tola my children never

to fib in even numbers. It is not as credible as if you say

83. If you sey 83, people think you know what you are talking |

about; but sey 100,people question you.

Chariie.

DR. McCALL: Did we have that as a motion we are
considering or are you asking for a motion?

MR, PETERSON: I don't know whether-- Paul, do you
want me to treat your SO percent, as $1,080,000,as a motion?

DR, TESCHAN: Sure.

c

 
 

 

LDS

MR. PETERSON: That is a motion. We don't have 4
second.

MR. BARROWS: Second it.

MR. PETERSON: Mr. Barrows seconds it.

Do we have any additional discussion?

DR, McCALL: Call for question.

MR. PETERSON: Okay, call the question.

How many would concur with that $1,080,000 recom-
mendation?

(Show of hands)

MR. PETERSON: Four. Since we lost one-- was your
hand up, Al? .

DR, HEUSTIS: No, sir.

MR, PETERSON: I didn't think so, but I just wanted
to be sure, since we aredown to an even numbered grouo,

That unfortunate Ly -- not unfortunately -- that
wiLl not carry.

DR. HEUSTIS: Make your motion. I will support it.

 

See if we have any strength.
| DR, THURMAN: If we can go forward with one more,
strong staff letter for the 5,647th time, recommend for $800,000
$700, 000-$809, 000.
DR, HEUSTIS: I will support it.
MR, PETERSON: We hear $800,000, Is there a second?

DR. HEUSTIS: Second it.

 
 

 

Lb

DR, HESS: That is below the current level.

DR. THURMAN: Which is the exact point. We have
vlways 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, I almost feel we are on the horns of
the dilemma of the Prodigal Son. We ere encouraging all of th
people with hundreds of thousands of dollars, and we were very
hesitant to reward a well organized program, I think we have
to Look at the philosoohy we ere implementing.

DR. TESCHAN: I amin the further dilemma, I am
delighted thet in the framework and history we have had with
the setting, leadership you just have been describing that the'
change in the bylaws has happened and change in the RAG has
gone under way.

Sure, we would Like to have some other things and 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 was to split a balance so there is an

element of reward, that is why I dilated on the point of making

sure that reward idea got down to them,
DR, HESS: Let me say if this can be coupled with

the recommendation that the projects naving to do with infer-

ring definition of what these projects are, expansion healtn

service site, that is reaching out to underservea and extended

a

 

co
 

 

155

medical manpower, that those you know are-- again, thb is

E

dipping into the prerogatives of the local region. But my con
cern is if we cut the total, what is it going to do to those
things? That if we can couple 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
that.

But IL em concerned about the possibility of, you
know, diluting that tybe activity.

DR, THURMAN: Again, ore of my concerns, there is
no stebe in the United Statesthat has better survey of the

needs of the State of Arizona. Why are they asking for more

They can tell you right down to the guy who filled

the tube yesterday wnat is wrong.

 

DR. HESS: Except I understood this was based on prior
study, prior dete, This is not more survey; it is actual imple-
mentation of getting services out to the people.

DR. THURMAN: I have to admit I have not read it as
thoroughly as you did. But I didn't see that as implementation.

DR. TESCHAN: Unfortunately all I read has very |
Little solid evidence ofwhat really is going to happen. I
have read Quite a number of these, hed a Lot of stirring ex-

periences about a Lot of talk, no documented action.

When you have the evaluator. you have to hire, you

 
 

 

156
didn't get this kind of thing in the writings.

MR, BARROVS: Could we accommodate these varying
viewpoints with a sharply 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
proposals 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 oipe-
line.

DR. TESCHAN: That should be a memo to us.

(Laughter)

 

DR. HESS: Is there going to be time after the

}

Council acts for any communication or rearranging of priorities
of orojects that are already written up by the regions?
MR. PETERSON: Again,--
DR. HESS: Is that out of the question?

MR, PETERSON: It seems to me very little,

 

Joe, a8 a practical matter. Our Council, and we would not be.
|

-communicating by and large with any RMP based just on a review
committee action, our Council meets the fourteenth-fifteentn
of June and again, 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 willl
have just, you know, they will have taken their action. The

stuff will be flowing from a committee room into a set of

 
 

 

typewriters to becom a 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 was your
remark -- that kind of advice is almost correctly more of a
memo for the record to remind ourselves in July than doing
any good in terms of really making a difference with respect
to Arizona's -- or anyone else's July lL application.

DR, TESCHAN: I would like to ask Mrs. Sadin if I
can what would be the impact of this budget there?

What kind of staff investments in these furgamental
changes at this late, late date-- after all, it is more than
nearly two years since the policy came into effect, June 1972
when Council first oassed the fifth-sixth of June, finally
came out of the Councii:s office in August, or at least
published as of, the thirty-first of August 1972 policy was
out. Okay, this is May 1974, just.a Little late in the day.
| The staff probably has been chaffing at some kind
of a bit.

I am just wondering what would happen if we sent a
curtal led budmet?

MRS. SADIN: You know, I am leaving Mondey and I am
giad.

(Laughter )

MR. PETERSON: Leaving DMRP.

 
 

 

153

MRS. SARIN: Leaving DRMP.

I am going back to Arizona, because you have your |
problem of-- you are talking about, you mentioned RAG policy --
Iwas at the RAG meeting where I mentioned they were not in
conformance. They have to be in conformance. And Dr. Duvall,
who sat next to me, said, ‘When I was in Washington, I argued
against this policy." He says this to the whole nAG,

Now, you don't get an instant reaction on, Well,
okay, Mrs. Sadin, we are going to do that tomorrow."

You have these factors to deai 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 that position.

DR. THURMAN: You know, from sitting in before we
have always come back and said, "How is it going to affect
staff?" |

MRS, SADIN: I think staffs morality could be up-
Lifted now, especially Billy V. and some of the others who
have really been trying real hard to work with the area-- it
is their push that has done this. They are the ones who were
trying to terminate CESA, It is the staff, you KNOW.

Aad they got an outside committee to try to heip them anda Lt

didn't work out,

 

 
 

 

Loy

DR. TESCHAN: And they do it against every obstacle,

MRS, SADIN: Every obstacle in the world. It is
staff that is trying to do it. .I would hate to punish them.
On the other hand--

DR. MoCALL: Maybe if we up this to $860,000, cur-
rent level --

MR. BARROWS: I could go along with that.

DR, McCALL: And at the same time get a strong mes-

sege, not satisfactory with, you know, recognizing some progres

some change, at least not cut them below their current level.

DR. HESS: Let me ask another question. Are their
orojects prioritized in any way or can you teLL?

MRS. SADIN: Yes. They have it in the application.

‘And, you know , expansion of service sites was the
Lowest priority.

DR. TESCHAN: Program staff was number one, as I
recall.

DR, THURMAN: Yes, it is.

DR, HESS: That 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 was three, four was streptococcal infection, consumer

education is five, manpower recruitment is six, and expansion |

seven.

 
 

 

buy
That was done verbally, as I said, and I really
think they would not have arrived at this priority rating if

it had been done by written document, I really think people

{
i

oOo
TH!

changed their minds, But nevertheless, those are the orioriti
you have in this application.

DR, THURMAN: R&M has supported that streptococcal
infection ad nauseum, It never should haveeven started.

MR. BARROWS: Dr. McCall, is that a motion?

 

MR. PETERSON: I think Bill did, he threw out $800, C09
|

and I don't Know whether he regarded that as 8 motion or woether
he would be willing to adjust his motion to $860,000.
|

i
|
|
i

DR. THURMAN: So move.
DR, TESCHAN: Second,

MR. PETERSON: We talked initially about roughly

31.1 million, now we are down to 9860,000 level. TI just throw
it out for consideration because I didn't want to extend bats
caution much longer if we can -~ we seem to be coming to a
decision.

I think one of the things that again we need to kee
in mind as a possibility here, and others, that one could
possibly make a grant avard whatever the sum, with some
fairly specific conditions in terms of some things that had bo
be met or reflected, or they didn't get that full amount.

That is, agein, a possible option that you may want to think

about.
 

 

Lol

DR. HESS: What I am concerned about is that priority
listing, the things are going to be cut 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 particular
projects, that theyought to consider giving a higher priority.
Can't tell than to give them, but strongly suggest they give
high priority to those two projects, I would feel better.

DR. TESCHAN: But they are on annual review status
and I think --

DR. HESS: This is tne last review, though, isn't

Lt?

 

 

 

DR. TESCHAN: The point I am seying is the degree

of national intervention in local program is different, is it
not? , |
DR, HESS: They still are on annual.
DR. TESCHAN: I don't know what status is now.
MRS. SADIN: They were, it was taken back,

MR.RUSSELL: We too have the same problems with this,

 

We finally asked staff, prought this to the committee and to
the Council, triennial status was taken away from this progren
DR. HESS: That modifies it, then you do have a better--

DR, TESCHAN: But do you? That is the plan. Do you |
 

 

Loc

have more intervention here than on triennial--

MR. RUSSELL: Yes. Depending on the degree.

In taking away the triennial status, the next tine
the program is being reviewed a year later was to be based on
Council's site visit. And then being phased out -- Or, Cannon
went, and we are really not quite sure what happened, are Wwe?

MRS. SADIN: Yes.

DR. HESS: The issue is what is our status inwla-
tionshio to being able to offer edvice to them about changing
their priorities?

Is that legitimate with them being in annual status
or is it not?

MR. RUSSELL: I think very Legitimate, becauSe, as 7
Rebecca pointed out& in the letter going back to the review
process, it was suggested that tney mioritize their--
well, projects by ballot or something to this effect, And we
can always suggest they go back and do it. I dont mean they
have to.

|
MR, BARROWS: They have to follow what this guy says

anyway.

MRS. SADIN: There were people there saying,
"considering what you just said, I will change my vote."

MR. BARROS: That is what I mean.

It seems to me you are fooling around with estab-

lished policy if we attach internal constraints on RAG

 
 

 

163

through this grant. But is it possible for staff to informally

say that these are the questions that occurred inthe review
committee and if you want to fair a little bit better, the nex
time you had better-- -

DR. HESS: There is no "next time,”

MR. BARROWS: There is when they come in for Suty Ls

DR, HESS: It is too late,

MR. BARROWS: No, if staff communicates now--

MR. PETERSON: Can't communicate now. I think this
action has got to be confirmed by Council.

Let me again, to try to get us off both the substan-
tive end time dilemmas, would there be any recognizing that
it is not tne usual order of the day, either now or in the
past, Would the group perhaps want to, in a sense, partially
punt to the Council on this saying we do feel either X
amount or somewhat larger amount, provided that a couple of
the things we think ought to be of high priority, if there is

some essurance that they remain in? That one project you are

 

‘talking about, Joe, is really a significant amount of money, :
$339,000 or whatever it is. The health sites in remote areas.
DR. HESS: Yes.
MR. PETERSON: Otherwise I think we are-- you know,
DR. HEUSTIS: Excuse me. Before we do this, would
you call for the question on the motion to see if we are going

to get --

cr

 
 

 

164

MR, PETERSON: All right, let'sa@Li for the question
on the motion: $860,000, ALL those in favor raise their
hands.

(Show of hands)

MR, PETERSON: Seven. And I think in one sense, the
problem has been resolved.

MR. BARROWS: This brings up the numbers, though,
to bring up another Council policy question. Taking the whole
past history of review committees and counclis dealing with
the regional programs, is it appropriate to be too severe in cur
swings -- this is an old problem and is this the right time
to apply an entirely new, harsher 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 ia
this connection, that the approve at this level, recommends the
funding to the RAG in Arizona that the COO1, 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 feeis

 
 

 

165
strongly in the sameway, then I think that again, as advice, wd
ought to be passing it on to Arizona.

DR, TESCHAN: I so move.

DR. THURMAN: Second. |

MR, PETERSON: Okay. That is on 1, 2, and 3, those
three projects. Okay.

Arizona is our record for the day -~ 50 minute region
There may be some correlation between problems and time.

L wonder, do we want to try and put one more?
We have put one more region under our belt tonight.

MR. BARROWS: Do you have an easy one?

MR. PETERSON: No, I didn't necessarily have an
easy one. I thought since -- I guess it was Al or somebody
earlier in the day was wondering what we did when Senator
Ribicoff called, I thought we might escalate to potential call
and discuss greeter Delaware Valley.

DR. THURMAN: Wonderful.

MR. PETERSON: Either John or Bill or Joe, feel

ready?

I think you indicated youwere ready on that, Joe.

 
 

 

GREATER DELAWARE VALLEY 166

DR. HESS: I read most of it.

MR, PETERSON: Do you want to lead off?

Both of you I know were in on the site visit, I was
‘on. But that has been a long time ago.

Greater Delaware Valley.

MR. HESS: Well, there have been changes in leader-
ship since I was there on site visit. The new coordinator is
Dr. Dean Roberts, who had been the coordinator for Hanaman --
perhaps I had better give a little background here for this
regione

This region was organized basically around the five
Philedelghia medical schools and the grantee is the University
City Health Sciences Center, which is a kind of consortium of
educational institutions which was gotten together for funding
of educational and related programs and research and so forth.

The initial district was the medical schools which book
the initial leadership and got the program going.

This region’ and many others, the problem then was
to bring ina broader palance into the leadership and manage-
ment of the program. And that was one of our concerns when I
was there-- were we together BiLL?

DR. THURMAN: With Pete.

MR. PETERSON: . December '72 I believe.

~ DR. THURMAN: '7e.

MR. PETERSON; Or '71.

 
 

 

167

DR, THURMAN: ‘71.

DR. HESS: And we were concerned about trying to
bring a better balance into the management program.

We also recognized that there were some good thing
going on there, but that there was probably unduly heavy medic
school involvement still at that point.

One o the good things I felt at least that had hap-
pened was that the schools had tooked over the entire RMP and
had divided up responsibilities for organizing, supporting and
working with health care institutions, providers throughout the
regions. There were five areas within the total region which
were the responsibility of a given medical school in terms of
providing support.

They have developed area offices, “you might say
satellite offices, in each of these five regions, which,.as
I understand it, are not medical school controlkd, but medical
schoois do relate to these coordinating offices. And they
have been doing a Lot of organizationai planning, coordinating
‘work in each of the areas. So that from that standpoint the
region is guite well developed, well organized.

Going down the major criteria, the program leader
ship, at the time of our site visit I was quite favorably
impressed with Dr. Roberts. I don't know what his performence
has been since he nas been in that job, but he seems to be a

man with a good background, seemed to be reesonable, and know

 

nL
 

 

168
how to oroceed.

Dr. Wolfe, I believe, was the RAG chairman then,
still is the chairman of the RAG, and again seemed to be for-
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 an upstate--

MR, PETERSON: It is up in the Scranton or Wilkes-
Barre @rea.

DR, HESS: So he was away from the Philadeiphia
area and brought that perspective.

One of our concerns at that point was the domination
of the executive committee of the RAG by the medical school
representative. That seems to me to have been balanced out
a bit, now, and there is a broader representation on the RAG.

The program staff, they have a rather larse program
staff when you consider both the central staff plus the area
||staff.

There is something like-- is it 27 all told?

So it is a lerge staff. But also we have to consider
this is a Large population area of high density, ine Luding
Philadelohia, and the surrounding area.

I don't have population figures here, but my guess
is it is probably in the neighborhood of five or six miilion

people, so that that would require fairly large staff to try

 
 

 

to cover the many orgenizetions, institutions and prob lems
that are there.

The Regional Advisory Group has been quite active.
They subdivided into executive committees and in addition,
there are area committees that relate to the area coordina-~
tors und Look at the problems with each of these five areas
of the region.

They do have a set of goals, objectives, and prior-~
ities and the application is well put together in that every
project relates. to agoal and objective. So you know they

know how to think end manage in those terms.

 

Their past performance, there have been a number of |
activities in the City of Philadelphia, metropolitan area,
eas well as in the outstate regions, that have been effective
in bringing together health care providers and try to improve |

both the quality and accessibility of care.

The proposal is a sizeable one, both in terms of
number of projects and in dollar amounts. Most of them seem
to be fairly well thought out. And appropriate for the region.

Feasibility is a little bit difficult for me to
estimate, but my feeling is probably with the experience of the
group and so on, that these are things that could be done.

The. CHP relationships generally seem to be quite
good as near as I could tell from the document. Maybe the

staff will have some other comments, but it seems to me a

 
 

 

L(U
good working relationship between the CHP and RMP.

My overall assessment of the region,as based on this,

was above average considering the complexity of the region and,
the organization. There is one question that was a continuing
problem or issue, let me say not necessarily a problem, there
is a large proportion of the funds still going to the medical
school. And I was surprised at the apparently high salary
Levels, at least compared to our school, of some of the
people who are paid partly through the RMP budget.

I have no way of knowing whether commensurate servi-
ces ere being rendered by those on part-time RMP salary.

DR. TESCHAN: How many part-time professionals are
there? A Lot of wople?

DR. THURMAN: Fifty-two altogether, about ten or
twelve.

MR. PETERSON: Ten or twelve.

 

I am trying to recall how many it was when wevere
up there. That may be somewhat Less, bub it has always been a
-phenomenon of the GED progrem, I guess it has always raised |
some questions in a Lot of people's minds.

But I think it is twelve, roughly, my count, if those
figures are correct.

Bill, how did 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

 
 

 

L171
the few strong people we saw on our initial visit really, so
I think that could do nothing but nelp.

The Regional Advisory Group is still Largely a one-
man realtionship and that is Wolfe himself, who does run it and
runs it reasonably well.

I think that they have developed some new projects,
but they have largely used ideas from other people and other
programs and have added minimum innovation to it.

They have not terminated some projects again they
were asked to terminate multiple times.

I agree with Joe's assessment, I would just
emphasize tne points he made; that is, there was not @ single
medical school budget in this whole progosal, that ba
realistic thing, end one of them, for instance, they have nad

the cheirman of preventive medicine getting 50 percent of his

 

salary for running a community hypertension program in one Ses~
ment of the Pennsylvania community, and that is not realistic.

Where we don't have professionals, we are paying
‘secretaries. So that is again an unreal situation.

Some of the projects are overfunded, but I think
their analysis of their programs and progress they have made
gince we were. there is significant. I think they have come
a long way.

DR. TESCHAN:. How is the RAG appointed, do you know

that?

 
 

 

172

DR. TESCHAN: You wouldn't necessarily pick it up

here.

MR, PETERSON: I don't know. Spence?

MR. COLBURN: They have their own nominating com-
mittee.

They do have institutional representation, that type
of thing -- is that what you are getting at?

There is guaranteed representation from the Medical

School on the RAG, also on the executive committee. But ail
ix schools are not represented -- in fact, I don't think
we have more than three medical schools represented.

DR, HESS: That is reduced substantially.

MR, COLBURN: Policy Board of Directors used to call
ali of these shots, now they have a true executive committee. |
Doesn't have @ great deal of experience.

DR, HESS: Ten part-time medical school professional
at the doctoral and master level, so they are not all physi-
cians. Some with master degree.

DR, TESCHAN: I just was summarizing the general
notion part-time people are dreadfully hard to keep track of,

especially when they are professionals.

!
MR, BARROWS: Am I right in reading these figures, ti

four segments of the university-based staffs total about
$250,000, °

DR. THURMAN: You @re.

L

ca

~
4

 

é
comment to that question, which I thought I heard raised

 

 

Lio

MR. BARROS: That is a helluva Lot of money. |

MR, PETERSON: Used to be $600,000, !

DR. THURMAN: I was going to say you aint seen |
nothing yet.

MR. BARROIS: Let me ask a question. They are in-an
area with a Large underserved populetion.” Have they addressed
themselves from that? |

DR. THURMAN: Yes. |
DR. HESS: They got into that from the very beginning.

That is where the medical schoois have put a Lot of
|
their effort. !
MR, BARROJS: It is not all bad. :
MR. PETERSON: I wonder, Spence or Frank, if there |

vere any particular aspects of this application -- I don't
recall who it wes that mentioned now whether it was Bill or
Joe about some project that mzy have gone beyond what we con- |

sider to be the normal funding period, Council did have @ polite;

of generally not to exceed three years, whether you have any

specifically, or any otner significant point, policy issue or
problem as staff has perceived them with respect to GHA?

MR. COLBURN: As I recall, they have several new

projects.

About the time we phased out, they were fitting an

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 and |
the wogran was almost just, you know, an inch away from being
completely out of business in August of 1973 when they started
peating programs on a monthly besis, spoon-feeding on

a quarterly basis; so you heve grossly here the new projects
in the application not reviewed.

DR, HESS: Ten continuous and ten nev.

MR, PETERSON: I notice from our summary sheets

 

which, needless to say, I am not very conversant with any of
these applications in any detail, but mos t of the projects haa
elicited CHP reviewing comments, There were a couple where
they had not.

We do have Tom Smith here from the Philadelpnia
Regional Office. . .

I don't knor whether you, Tom, had any particular
information with respect to CHP comment or relationships in
this area; specifically, greater Delaware Valley, Philadelpnie.

TOM: To the best of my knowledge the relationships
were reasonably good.

MR. PETERSON: The chief CHP agency, of course, is
Philadelphia and there also happened to be an experimental
system there. Thereis also another ore greater up north,
Representative Flood.

MR, BARROWS: We came up with the conclusion this

 
 

 

was pretty appropriate?
DR, HESS: Yes, I rated it overall above average.
DR. HEUSTIS: Budget somewhat inf lated?
DR, THURMAN: I think so. They are asking for

$2.8 million and they have been at $1.7 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 ig the last year of suppor§ either they will be terminatl.
or supported by someone else.
So that I tend to say yes to that all the time.
DR. HEUSTIS: Whenever indicated?
DR. THURMAN: Not necessarily. I do it when it is
not indicated. It is a fault. I think it is over-inflated.
MR, PETERSON: We do have -- this application is

roughly a 32.8 million request which, as Bill points out, was

 

considerably above;their sort of funding level now is roughly
equal to the sort of target figure we have had an indication
that they are going to-- Greater Delaware Valley is going to |
be coming in with a roughly 31.3 million second phase two

request which would put this program at least in terms of its)
|

request in the $4 miilion range, so against that backdrop I

$

don't know whether either of the reviewers has a recommendatic
DR. HESS: I have a figure,
DR, THURMAN: Go ahead.

DR. HESS: I would recommend $2.3 miilion, which

 

wee
Mies

Ne
 

 

L'/6
recognizes that this is the good region _- reasonably good
region, rated above average, seems to have good leadership.
They have got a large population, many underserved, who need
assistance. They seem to be addressing those problems.

Also I was avare of the July Ist estimate realizing
that there is going to be another big batch coming in at that
time. And this seems to me is a $600,000 increment over their
current level, which is rather substantial.

It seems to me to be a fairly reasonable compromise.

MR, BARRGIS: 35 percent boost, is it that strong?
Over where they ere now?

MR, PETERSON: Again, Mr. Barrows, I don't-- it
does seem to me that the present six months funding rete in
many regions, that could be column one which is a function
of times two. It has one sense of reality and the other; it
does reflect-- it hides som things in some instances and
certainly is not indicative in most instances, including this !
one, the kind of level the regional is functioning at pre-
January 1973.

MR, BARROWS: $2.3 million would reflect what per-
centage increase over-- I try to get this feelfor other PLOSLams.

DR. HESS: I personally feel they have management |
ability to use that.

MR, BARRG/S: What percentage increase?

DR, THURMAN: That would be &6 over 17. I am nota

 
 

 

L//
mathematician.
MR. PETERSON: A Little more than a third.
MR, BARROWS: Seventeen isn't a real figure.
DR. HEUSTIS: These white sheets show a billion one
hundred thousand plus for a six-month budget, so that is real-

istic; L74 to 674 present one, six months; multiply that by

 

two. You are not too far away from $2.3 million.
MR, BARROWS: That kind 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 sheet:

:
f

is right, keep this about where they are.

DR. HEUSTIS: No, give thema Little bit more.

MR, PETERSON: I have got to cry help to staff here.

What are we talking about?

MR. NASH: Iam not talking about the one on the
printout; I am talking about the one -- this sheet here
(indicating).

Is this an accurate figure?

DR, THURMAN: Is that figure accurate?

MR. COLBURN: Pediatric, oulmonary ~- is that added
in there? Included there?

MR, PETERSON: It may weLl have earmarked funds.

Also 3170,000--

 
 

 

178

MR, COLBURN: You are right about $1.8 million.
After gite visit, That is what we recommended.

They were funded at that level, so half of thebwouid
be $900,000, And they had about $400,000 for pulmonary, that
is pretty close.

DR, THURMAN: Mr. Chairman, my recommendation is
$200,000 off from his, but I have no concern about Joe, say
$2.3 million. Iwas th mking $2.1 million, But I can easily
live with $2.3 million, because I think this is a good pro-
gram.

MR, PETERSON: Do you two want to talk together for
30 seconds? |

DR. THURMAN: I second the motion.

MR. NASH: Ib you want to include with that dollar
figure recommendations, any further recommendations fron

committee so far as removing edditional funds from the medical

i
{

school?
DR, HEUSTIS: You are speaking to Dr Hess?
MR, NsSH: Yes.
DR. HESS: This I didn't think was something we real
have enough information on now, but I think perhaps the concer
as to whether or not the region is getting value received for
the money that is going to medical school now, the RAG may or
may not need a Littie muscle to take a look at that. It is

hard to ask that kind of Question unless you have got some

 

te

J
 

 

L79
reason for asking it.
But I personally don't feel I am in position to
make 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, HEUSTIS: You gave Paul about 50 percent salary |
obviously. You would think he would be more busy carrying
out his administrative work-- didn't sound very realistic.
DR. HESS: See, there may be some compensating fac-
tors. He mey have sone of his people doing some running
and for budgetery purposes, you know, it gets too much of a
hastle to gut somebody on part-time salary for so and so,
DR. TESCHAN: That is very optimistic. Our exper~

lence is the opposite.

ty

DR. HESS: It may be justified.

DR, TESCHAN: Here is where a site visit would be
helpful,

DR. McCALL: Still talking about unknowns?

MR. PETERSON: Yes.

DR. McCALL: The way it is expressed, lt seems to me
as far as we can go now. Call the question.

MR. PETERSON: Those in favor of the motion for

$2.3 million with indication ofconcern, fed back, about the

 
 

 

180
still querter of a million dollars of medical schools, all
those in favor?

(Show of hands)

MR, PETERSON: We still didn't manage to slip out
of the complacency and unanimity.

It is ten til five. As your chairman I am at your
beck md call.

Do you want to go on with still another? I am pre
pared to do that. If you want to wrap it up for-- |

MR. BARROWS: I have some homework to do.

 

 

 

would just as soon wrep it up,
DR, THURMAN: I have a quicky ~-- no, Iwill conceive--
MR. PETERSON: Whet is your quicky?

DR, THURMAN: Puerto Rico. It's a quicky.

MR, PETERSON: We are really talking about a ten or

fifteen minute discussion,

DR, THURMAN: At the most, yes.

MR, PETERSON: It is a very unusual~- would that do
too much violence with your needs?

MR. BARRGIS: No.

MR. PETERSON: I hadn't programmed Puerto Rico, but
let's pull it: out.

The reviewers ere on that, in addition to Bill --
let me see that sheet of paper again, Bill -- I

don't think we would do violence if we confirm our review

 

 

 
 

 

181
and recommendation with Jill in the morning. Again, I don't
think it is going to take that much time first thing in the
morning, Bill.

DR, THURMAN: I don't mind putting it off.

MR, BARROWS: It might be a Little more courteous.

MR, PETERSON: Yes

Okay. Before we leave, a couple of things here.
Feel free to leave your materials in the room. On the other
hand, if you are going to be doing homework with them, you
obviously can't do that.

Secondly, I did have a note handed to me late this
afternoon. If any of you did not use RTR& if you please --
that is the grain IBM card that buys an airplane ticket -- if
you would return them to the desk, to Mrs. Leventhal, if there

are any thet were not used.

 

Before we break, on the other hand, I would like to |

i

have your indication of what time we would Like to get started.
By my calculations, we reviewed eight regions today
which means we heave 17 to go. We did not really start the
review process until well after eleven. We convened at eleven
and I took some time with generalities, So on the one hand,
we are not in my view terribly in arrears. On the other
hand, we dont have a lot to coast on.
I don't know how they ere doing, but I just figure ve

would beehead of them.

 
 

 

182
DR. TESCHAN: I would like to start ebout 8:30.
MR, PETERSON: ALL right, 8:30 with a pledge to
dispense with Puerto Rico and Californh before nine.
DR. HEUSTIS: And California will only take ten

minutes.

MR. PETERSON: I know, and you are reminding me that:

is a very simple application at this juncture. It is one of
the few regions which the Council, along with Arizona and
Hawaii, expressed some great concerns about last November;
it was site visited.

BLLL Thurman was on it and I think witnout telling
his story, it happens to be a site visit that came back more
than allaying the kinds of concerns the Councilhad at the
time.

Okay, with that, I want to certainly express my

personal thanks and appreciation for your diligent work toaey.

I would only make the plea, at this juncture, it is
plea rather tnan intimidating request. If you haven't given
me your review sheets for those regions which we have Looked
at, would you please let me have them before you go home,
then I will be able to take them back up to my office.

Thank you and we will see you at 8:30, this haif
of the room.

(Whereupon, at 4:53 o'clock, p.m., the meeting

recessed, to reconvene at 6:30 o'clock, a.m., Thursday,

May 23, 1974.)

 

my)