I
                                                 *1


                                               ISSUE PApr.'T

                                        REGIONAL MEDICZ-.L PROG@l,!S

                                             October 19, 1972


                                                      OFFI('.F-01:' 'I') F, r!l UA RY

                                                     0 c   er 19, 1972

      TO      :  The Secretary
                 Through OSIES

              :  Assistant Secretary   for Health and Scientific Affairs

      SUBJECT:  Decisions on Regional Medical Programs
                 ACTION k!E@!OPA@@@DUM

                 This Action '.Icr,,orandum develops alternatives  for  the
                 future of P,-',IPs and related @ll!) issues.  It is supported'
                 by a Summary memorandum  (Tab  i@),  and  by  considerable
                 back round material under Tab B.
                     9

                 ISSUES AND OPTIONS

                                             A.
                                          MISSION

                 ISSUE I.  WHAT  SHOULD  BE  THE  PRIORITY  FUTURE  MISSION

                            (ROLE) OF R-14P?

                 OPTION 14   IUIAP should become a pri-ncinal agency res

                             ponsible for i.,nnle:-,cnting change in  local

                 deliverv system (ir,.olemenL--ing aaencies for CHP and

                 other        components, '.\,IH, etc.) .

                 DISCUSSION

                 E 1-    --4-on o@-- restr4-ct@-r--@-;s on interference wi-t--h prac-
                                   anci 0- cat.c.,7orical e,-n-phaFis are ncces-

                   r   0


                  Page  2  The Secretary

                  PRO:  1.   Clearly separates planning from imple-
                             mentation.

                        2.   Consistent with TIS.MHA's mission in
                             delivery reform.

                        3.   Gives' it specificity without unnecessary
                             restriction.
                        4.   Has been successfu 1 in the past in impl6-
                             menting role.

                  CON:   1.  Makes it hard to evaluate.
                        2.   Difficult to provide Fedbral direction.
                        3.   Proposal to'eliminate categorical emphasis
                             and restriction against "interference" with
                  medical practice would be unpopular with ANIA and other
                  lobbying grou@s.
                        4.   Dependent upon emergence of an effective
                             local planning process.
                        5.   Would impose an  untested responsibility on
                             RMPs in terms of relationship to CHP agencies.

                        .6.. Lack of broad representation on Board.
                        ,,7. @IP has shown little interest in preventive
                             health issues.
                        8.   P14P has shown little interest in maternal
                             and child health issues.

                  OPTIO@L 2.  R:.IP shoul.(2,-contin-ue as is -- flexible, variable,
                              broad-authoritv which encourages providers to

                                 .  4
                  use ---hei--r c,,.-"n in.,t4-ati-ve to @ri-nc about chancre thev suD-

                  port.


                   Page  3   The Secretary

                   PRO:    1.  consistent  with  Departi,-en,--al  and  HEW/HSMHA
                               philosophy of decentralization and local
                   initiative.

                          2.   Allo,,e7s flexibilities so -Ehat-the program'. s
                               able to meet local needs in a local manner.

                          3.   Maintains flexibility for responding to
                               changing national priorities.
                          4.   Consistent with past nractice which has
                               achieved considerable professional and
                   Congressional support.:

                   CON:    1.  May not be highly responsive to HEW priorities.

                          2.   Evaluation is more cornlex when the program
                               is investing in a variety of ac-Liviries.

                          3.   Provides  Federal  support  -for   some   projects
                                                 WI, 4
                               and reforms for      -Lch providers should bear
                   the   cost (e.g.i   continuing   education   of    Physicians.

                          4.   No measurable natior.,.,7ide effect.

                   OPTION 3.  RMP should,rest@;ct its activities to "cate-
                                gorical are,-ts"-(heart, cancer, stroke,  idney).

                   PRO-.  1.  Political and Drofessional constituency easy
                               to identify and highly supportive.

                          2.  tasier to account for expenditures.
                          3.  ProvidE?s ocoorL--unitv for @,:orkirg relationship
                                              .---earch  and  control   p-carams,
                   and the liS.,'@!iA focus on delivery activities.

                   CO',@:  1.  Tends to @L@-ag,-).cnt delivery s@rstem - obstruct
                               c -A@ L'orts @o ii-.orove access.

                                                                             -ing
                                                                         T-@ i
                          2.                                it4o- 0-   ji


                 OPTIO!I 4.  P-P-IP should emr@hasi-ze improving the uti  li-

                              zation and productivity of manpower.

                 P'RO:  1.  Consistent with HEW philosophy-of cost con-
                            tainment and delivery reform.

                        2.  Progress in this area cannot be achieved
                            without the input and. involvement of pro-
                 viders.

                        3.  Encourages a closer relationship between the
                            production of health manpower and their actual
                 performance or utilization, i.e., relationship between
                 education and health services delivery.

                 CON:  1.  Could be done well only with a consistent
                            Federal health :,-anpo-@,7er 'strategy.  Otherwise
                 might produce scattered, inconsistent activities.

                        2.  Creates  resistance  from   educational   insti-
                            tutioiis which regard  this  as  their  area  of
                 responsibility.

                        3.  Creates bureaucratic turf problems a la AHEC'S.

                        4.  Proposed emphasis on "produc   @iV4 ty"    raises
                                                           L.
                            the question of whether we really know enough
                 to accomplish this, and if we do, can we really capi-
                     .  t
                 talize on it      manipulate the system enough to use it.

                 OPTION 5.   '-UAP should.beco7pe the agency responsible for.

                             aidina local  arouses  to  oraanize  and  audit

                 review              a4-red at assessiii,,r and assuring quality

                 of care throughout the countrv.

                                    a.,,,--' L' @,,D       i-@1L-,cnc--d bv


                 Page   5  The Secretary

                 PRO:   1.  Necessary  to  develop  mechanisms  for   mea-
                            suring quality that are workable and acceptable
                 to providers and the community.

                        9. ?Iizo.-qqArv tn  nroviae  corrective  action  in
                            response to deficiencies identified by
                 quality monitoring.
                        3.  only provider influenced groups will be ef-
                            fective in this area.

                        4.  Efforts  to  develop  peer  review   mechanisms
                            require  extensive  resources   and   technical
                 assistance  to  raise  the  level  of  understanding  of
                 quality  monitoring,  and  start   initial   development at
                 the State or community level.

                        5.  National  interest  in   developing   quality as-
                            surande activities.

                        6.' National need for technical    assistance   in
                            quality assurance..

                        7.  Consistent with professional    interest    in
                            many IUIP groups and staff.

                 CON:   1.  Difficult to measure results.

                        2.  The costs of this effort might better
                            be borne by provider groups than HEII.

                        3.  Local PSRO groups may not accept RMP       in-
                            Volvement.

                        4.  Many P-,NIP'smay resist-- assignment.

                 OPTIO-,-4 6. i@,,!P should became a@c;nc@7 responsible for

                             monitor--ng qualit,.! of care.


                 Page 6 - The Secretary

                 PRO:  1.  Federal need to  take more positive leader-
                           ship to provide  an alternative to or im-
                  lenent PSROs and quality  assurance mechanisms which
                 p
                 completes the cycle of: (a)  development  of  monitoring
                 systems; (b) actual monitoring itself;, and (c) correc-
                                          iAnn+-i-F-ic3tl rlpfir:i.p-ncv.

                       2.  All pro-arguments in o@tion 5.
                       3. The  most  appropriate  existing  institution
                           which relates to a greater range@of provider
                 groups than just medical societies, as in PSROS.

                 CON:   1. Not all -@lPs are equipped to handle this
                           responsibility.

                       2.  Raises the Question of whether providers
                           should dominate regulation of their own
                 activities.

                       3.  Monitoring or regulatory power would jeop-
                           ardize relationship that MiPs have developed
                 with providers.
                           Would probably limit P-NIP to that  activity
                           because PL@IP would occupy an antagonist  role
                 with provider colleagues.

                       5.' Most R.NlPs would probably resist  assignment.

                 OPTION 7.  PDLD should be eliminated comnietely-.

                 PRO: 1. In  times  of  budget  stringency  substantial
                           money could be saved.

                       2.  Provider urinated @rrour)s fill not bri,na about
                           major ciange in delivery s,,,s"--e.,i.

                       3.  See criticisms of Program in Section       of
                           T r_-ilb B.


                 Page 7   The Secretary

                 CON:  1.  Has taken 5 years to develop a workable
                           link between Federal Government and pro-
                 viders of care; this would be lost.

                       2.  Provides a flexible implementing mechanism
                           at the community level to worK on proDiem
                 areas.

                       3.  May not be politically viable.
                       4.  See Program Strengths in Sectibn'I of
                           narrative.

                 OPTION 8.  @TIP should be eliminated as a Federal ldro-
                            gram; corresoondinq funds should  be  applied

                 to health revenue sharing.

                 PRO:  1.  The Secretary has made a preliminary deci-
                           sion to this effect.

                       2. In addition to the PSROs under Olo-uion 7,  the
                           revenue sharing approach is probably more
                 acceptable,  olitically, than outright elimination of
                             p
                 the program.

                 CON: 1. Has taken 5 years to  develop  a  workable  link
                           between Federal Government and providers of
                 care; this would be lost.

                       2.  Provides a flexible implementing mechanism
                           at the community level to work on problem areas.

                       3.  May not be-politicallv viable.
                       4.  See Proqram Strengths in Section  I  of'narra-
                           tive.


                  Page 8   The Secretary

                  RECOY@@@ENDATION

                  Primary t@lission

                  Secondary @Lllission

                  Not Reco,-j-.ended

                  RATIONALE

                  CONCUR

                  NONCONCUR

                  CODLMENTS AliD SUGGESTIONS


                Page  9   The Secretary

                                            B.
                               DECENTPALIZAmfION AND FLPI4DING

                ISSUE II.  G!Vr_Tq H's RECO,@P4EI\IDA'I'IUNS AS I10 Rmv M.Ltiti-Lui@,

                            WIIAT SHOULD BE THE EXTENT OF DECENT.RALIZA-

                            TION OF AUTHORITY TO THE LOCAL R-MPS?

                DISCUSSION

                This issue is closely related to ISSUE I     MISSION.

                OPTION 1.  CoTn.Dlete local autl-ioritv.

                PRO: 1.  Most  nearly  consistent  with  Administration
                          philosophy of decentralization.,  State  res-
                ponsibility, and local initiative.

                      2.  Most acceptable to the'@iPs and     provides.
                      3.  Most compatible with relating to local-ne@eds,
                         . objectives, and resources, and resultant
                local.variations in approach and priorities as deter"
                mined'by CYIP.

                CON:  1.  May  not address priorities set by identified
                          RYIP mission.

                      2.  In face of funding.constrain@us and nossible
                          cutbacks, i@ is unreasonable to expdcl-- rapid
                reorientation in line with new mission  in  absence  of
                Federal direction'.

                      3.       have little imnact on na+--ional objectives.


                 Page  10  The Secretary

                 OPTION 2.  Partial, with local P-NiPs having latitude
                                      e specific nronosais within the
                 broad priority areas as established by their redefined

                 mission and local CHP plans.

                 PRO:  1.  Still reasonably consistent with Adininis-
                            tration philosophy of decentralization.

                        2.  Compatible with relating to local needs,
                            variations, and CIIP planning.
                        3.  Helps assure that @vP activities will
                            address broad national priorities.

                 CON:   1.  V7ould not be as acceptable to RMPs and
                            providers as oation 1.
                        2.  V7ould not necessarily, insure that all local
                                                  .Z
                            PIlPs would adequately address each of the
                 several- broad priority areas, e.g.,, monitoring of
                 quality of care.

                 OPTION 3.  Minimum decentralization -- discretion
                             re best methods of carrvinq out a strong

                 Federal directive.

                 PRO:  1.  i-loul-d most nearlv insure that local iulPs
                             address broad priorities.
                        2.   Important in achieving missions which
                             warrant continuing support of !U-'AP.


                   Page 11    The Secretary

                   CON:  1.  Totally inconsistent with HEI@ deitentraliza-
                              tion philosophy of local initiative to meet
                   local problems.

                          2.  unlikely that providers would willingly ac-

            z             3.  Runs counter to actual     long-term trend of
                              increasing decentralization to local MLPS.

                   OPTION  4. Determine national objectives at the Federal

                              level;  assign  to  CHP  responsibility   for   deter-

                   mining  the  degree  to  which  national  objectives  are   being

                   met in the various States, and  assign  k@-6  @%IP  a  major  im-

                   ple,-.ehtina  resDonsibilltv  for  realizing   national   ob@ec-

                   tives in accordance with CHP determination of relative

                   needs.

                   PRO:  1.  To  make  a  decentralized   system   accomplish   na-
                              tional objectives.  There must be a clear arti-
                   culation of these objectives; the CHP agency is the appro-
                   priate  mechanism  for  evaluating  State  and   local   circum-
                   stances and problems in the light of national objectives.

                          2.  The capabilities of @IP will be most effectively
                              used through supporting the achievement of such
                   objectives, and catalXzi-ng the provider sector in that
                   direction.

                   C O'.%, 1.  The conccr)L-. c .4 health  revenue  sharinct-and  de-
                              centralization  is  to  recognize  State   and   local
                   objectives %NThich may be di-'-4erent from national objectives.


                Page 12 - The Secretary

                      2.  A stru@ture such as   that proposed in this
                          option would so limit R-TVIP that provider
                interest and support would be lost.

                RECOI,Lll@lEli'DATION

                RATIONALE

                CONCUR

                                                           ...  .........

                NONCONCUR.                                      ......

                COI,IMENTS Al'iD SUGGESTIONS


               ISSUTI III.  Hol,.' SI-'OUTD FU@@DS BE APPORTION-rD/DISTRIBUTED

                          TO THE LOCAL @,4Ps?

               PRO:  1. Improves review of individual proposals against
                        priorities.

                    2.  Alloiqs better coordination of related activi-
                        ties; helps minimize unnecessary duplication
                        of effort.

                    3.  Minimize local patronage and bias.

               CON:  1. Administratively cumbersome and costly HEW
                        role.

                    2., Unlikely to correlate funding with local.
                        needs and pro"-.1-c-'s as there would he a ten-
               dency for those P@,.'--Os and s@.o.-isorina institutions (e.a.
               medical schools) 7.ost pro@@icienk-- in grantsr,,ansh--'L-o and
               with the greater resources to obtain a larger share of
               the funds.

                    3.. Would not utilize the considerable local tech-
                        nical review and decision-makihg capacity and
               structure that has been created by the -@',IPs over the
               past six years.

               OPTION 2.  Comoetitiv6 nrocram basis.

               PRO:  1. I-,7ould provide better incentives for @,..'L.Ps to
                        address Priorities.

                    2.  Would encourage a hiah level of competition
                        and, ti'ius,           better activities.

                    3.  Would help overcome the criticisms (CONS)
                        OIL


                  Page 14 - The Secretary

                  CON:  1.  Would  reduce  'Llexibility  once  programs
                             approved; @IlPs would tend not  to  be  as
                  fully  and  rapidly  responsive  to.possible  changes
                  in priorities.

                        2. Would tend to  reward  stronger  Pl@lPs  and
                             not weaker ones.

                  OPTION 3.  Competitive basis with sel'ected-earmarks.

                  PRO:  1.  Earmarks would provide incentives needed
                             to spur local R,:.IPs to engage in activi-
                  ties addressing  high  but  less  popular  priorities
                  (e.g., quality of care  monitoring) that many of them
                  ,otherwise might be reluctant to undertake.

                        2.  Closely coincides with present mode.

                        3.   Offers advantages similar to Option     2.

                  CON:  1.   Earmarkina, once resorted to, sets a    prece-
                             dent for further earmarl,-ings; at the  same
                  time  it  is difficult to get rid of previous earmarks
                  even though  they  have  outlined  their  usefulness.

                        2.  Disadvantages similar to Option 2.

                  OPTION 4.  Use a formula-basi-s.

                  PRO:  1.  Consistent with HElq position on local
                             initiative.

                        2.   Provides 'Local P-@-@.Ps with significant
                             4Llexibility,

                        3. --Store nearlv results in an equitable
                             Q'is-"ribu@- 01-1 0-@ -@u.,,c3s to all @7'-Os.


                 Page  i5   Tne becreLary

                 CON:  1.   Lill--tle or no incentive to use funds to
                            address national priorities.
                        2.  Diflicult to develop a formula adequately
                            takina into account potential resources
                 and needs  in various specifl;.c'priority areas that
                 would be equitable to all States.,

                 OPTION 5.  On a formula basis'with selected earmarks.

                 PRO:    1. liould allocate specified sums for special
                            priorities.
                        2.  Provides fiscal equity to all areas.
                        3.  Would recruire P@lPs to develop proposals
                            within each earrar,'-,ed area, even if that
                 resulted  in funding sc-.ne i,7ea'@er pro3ects in one
                 given prioritv area at the e>:pense of additional
                 stronger projects in another.

                 CON:  1.  Earmarking, once resorted to,      sets a nrece-
                            dent for fur4@-her-earmarks; at   the same time
                                            4
                 it is difficult to get r."d of earlier ear.-.arks that
                 have outlined their usefulness.

                 OPTION   6.  Use a combination for,-iula-comnetitive basis.

                 PRO:   1.  Provides a financial base for long-term
                            commitment to professional staff.

                        2.  Provides for comt)ctiti-on.

                 CON:    1. @lav have programs :-,ending  stronger projects..
                                        i.-4on and          weaker nontrior'l@@v
                            .Lor co@cet
                 pro4ect--s o---@- ol-:


                  Page 16    The Secretary

                  RATIONALE

                 CONCUR

                 NONCONCUR

                 CO,7,4,MENTS @ND SUGGESTIONS


                                  -retary'
                 Page 17    The Se-

                                              C.
                              ORGANIZATION OF LOCAL @!P @,-TIT

                 ISSUF, IV.  FRO,",l @@l;@-T CAT--(-70PIES OF PEOPLE SITOULD -m.Y.E

                             LAI-,7 REQUIRE REPRESE@-4T2\-TIO!@ ON THE BO-A-RD?

                 OPTION 1. Providers, consu,-,,ers, elected'  officials,

                             low income consumers,  third  narties,  and

                             CHP.

                 PRO:  1.  Encourages well rounded board composition.

                 CON: 1. May be  too  restrictive  to  be  practical  in
                           all the areas.                   I

                       2.  Providers may feel under-represented.

                 OPTIOL@L 2. Providers, consumers,  elected officials,

                             low income consumers.  (Eliminates from

                 Option 1 third party and CIIP representation.)

                 PRO:  1.  Third party and consumer representation are
                           redundant.

                       2.  CHP representation  on board is not neccssarv
                           i--- the-/ rovic,.,., and    on, or .-ev-Lc-w
                 and approve R2.1p projects.

                 CO@": 1.  T'-.i-.-d @,-@r'L--ic3 an-!. C 1: po,., '-d@ @4--4 --nt ners-
                                                                       -hat
                           pectives on p.-c@;-Dic-.n areas and ,Driorities 4%-
                      !--o be a--'d--cssed bl,:


                 Page 18 - The cc-cre,'-ary

                 OPTIO@'@ 3.  Provi--Ie--s, c-.nstz7,crs, elected officials,
                             and C,,'-D.   (.@,his Option eliminates desig-
                 nation of low inco,-e consumers from Option 2.)

                 PRO:  1.  Provides more flexibility for organizing
                            boards.

                 CON:  1.   Low income consumers often experience dif-
                                    ,-%Toes o@ oroble-,rs than do other con-
                            ferent 4 -z     L
                 SU-T.ers and therefore might provide a good balance to
                 the   board.

                 OPTION 4.  Provi--Iers, consumers, and   low income con-

                             sumers.   (This Option deletes specific men-
                 tion of elected officials from option 2.)

                 PRO:  1.  More flex4-blc               2, an@. allo,.is for
                            elected
                 tion, without specifically                them.

                 CO"L%I:  1.  Elected officials often are an important
                            source of support for the program as well
                 as sensitive to local issues and pressures.

                 OPTION 5.  Providers and nubli-c renresenl-atives.

                 PRO:  1.  'i'llost flexible.

                       2.  Permits (-,,ach-State to put together most
                           effective groti,3 1-@or tl--eir o@-:n particular
                 arca.

                 CO,@:  1.  !@v not a@@urc broa@, representation or
                           r z, 1 eT,-= -r  s


                  Page 19     The Secretary

                  RECO@',@!E@@"DATIO'i

                  RATIO.@I.ALE

                  CONCUR

                  NONCONCUR-

                 COZ*IENTS A@ID SUGGESTIONS


                Page 20   The Secretary

                ISSUE V.  SIIOULD-    POLTCY BOARD ITAVE A MI.I !U.-,I

                                    -T CO"cU-!@-!:-]R P7@RTICIPATIO@N?
                          P,EQUIPIE@--@i

                OPTION 1.  Yes (20 -oercenL@-)

                PRO:  1.  Shows a clear commitment by the Department
                          to consumer representation.

                CON:  1.  Reduces flexibilit,,,; may not be necessary.

                      2.  May be useless tokenism.

                OPTION 2.  Yes (33 1/3 percen4,-)

                PRO:  1.  Shows a stronaer co.@-nitinent to meaning-
                          ful consumer participation and involvement
                in decision making.

                CON:  1.  Same as CON 1, Option 1.

                OPTION 3.- Yes (51 percent

                PRO:  1.  Sho@-is strong commitment to consumer repre-
                          sentation.

                CON:  1.  Same as CON 1, Option 1.
                      2.  llav      relall--ionsh-'@:-,,s with providers and
                                         has develop I" over, the past
                five years.


                   Page 21 - The Secreta.--v

                   OPTIO,@', 4.  Nlo reauirc-ei,,t.

                   PRO: 1. Most 'Lle;('@b4Llitl,

                               T)ri i-)nf- hAA7P i-n                    at
                               this time.

                   CON:  1.  Discredits HE@7 commitment to consumer
                               participation.

                   RECOI..r.!-vYDATTC)N

                   RATIO-',i;,.LE

                   C O'i%C U R                                          .........

                    o@@COI.ICUR

                   C 0


                  Page  22   The Secretary

                  ISSUE VI.  SIIOULD TPE LA,q TZEQUIRE rj@ll" TO HOLD P'UBL'IC

                              HEARIi,'@,C,S ON PPOPOSED @,.IP ACTIVITIES?

                  OPTION 1. Require RMP to hold T)ubl.ic  hear3-nqs'  in  ad-

                              vance 0.4 aoT)rovinc,,         projects.

                  PRO:  1.  This would provide an opportunity for effoc-
                             tive public involvement.

                  CON:  1.  This  would  unnecessarily   duplicate   existing
                             reviews.

                         2.  CHP should provide the primary form for
                             public  corjrent  on  proposed  governmentally
                  financed.actiVitic--s in the health care field.
                         3. Public  hearings  directed  to  the  review  of
                             individual projects would,be unduly cumbersome.

                  OPTION 2.   Require RI-,IP to hold public hearings  on  a
                              general  outline  of  proposed  programs  but

                  not with resnect  to  awards  for  individual  -projects.

                  PRO:  1.   Provides  appropriate  opportunity  for   public
                             input in a,sir@.pler and more expeditious manner.

                  CON:   1 . Ilearin,,js of this sort would  be  too  abstract
                             .@o be effective.

                         2.  See CO@'is under option  1.


                  Page 23    The Secretary

                  OPTION 3.  Authorize but do not require public hear-

                              ings.

                  PRO:  1.  This would permit RIlPs to tailor the use of
                             the pui.)lic hearing  pro'Gess appropriately to
                  the nature of the issues that are under consideration.

                  CON:  1.  If left optional, the public hearing      process
                             would probably rarely be utilized.

                        '&IENDATION
                  RECON',

                  R7iTIONALE

                                                               .  ..........
                  CONCUR

                  NONCONCUR                                        .....  .

                  CO@LLIENTS AND SUGGESTIONS


                   Page 24    The Secretary.

                   ISSUE VII.  SHOULD R'-.@ll LEGISL.ATIO-,,l @r(--.UIRE CHP APPROVAL

                                AS A PRECONDITIO'RT FOR F@I"DING RMP PROPOSALS?

                   OLITA"@l%l 1-.  l@,cqu4-r-- CIIP --pproval.

                   PRO:   1.  Strengthen CIIP.

                          2.  Establishes planning as a precondition for,
                              and controller of implementation.

                          3.  Reasonably assures that Federal money will
                              not he used in a manner inco.-apat
                                                                  ible with
                   other  relevant.programs.

                   CON:   1.  Heavily restricts the provider.role;     may
                              be unacceptable to providers.

                          2.  CliPs are not qualified, technically,    to con-
                              trol provider-spor-,E:orc-d @ro-ects not to res-
                   pond in a  timely fashion; therel@ore,"this would not be
                   a realistic requirement.

                   OPTION 2.   Provide for revic@@7 and cop.,@.ent, but not

                               for an approval (i.e., veto) authority.

                   PRO:  1.  Less  restrictive and, hence, more acceptable.

                          2.  CHP should, at a minimum, have a review and
                              comment role.

                   CON:   -1. CIIP should have a  strongc-r..role.t-han mere
                              reviews., a.-id cor-Tr@c- n t.

                                                    r
                          2.                        c        @-'L I i n greasons
                                       t         C,  6 at  'a


                   RE, Co,.',-,-IENDATION

                    RATIONALE

                                           .  . . . . . . . . . . . . . . . . . . .
                    CONCUR

                    NONCO14CUR
                                                                      .  .........  ...

                     COI,R.IENTS AND SUGGESTIONS

                                                                         ..........