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                                          ANSCR"'PT             07     PROCE'i"'iDINGS


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                                                                             Ma y 2,"T    l@,74












                                            1-71@OOVER !IE-POR'I'I'@G COLNIPtkNY, INC.
                                                              Oilficial Reporters
                                                            Wasbir@gtoti, D.
                                                                5  6 6






  arc                          DEPARTMENT OF HEALTH, EDLTCATIOIJ AND WELFARE




                                  DIVISION OF REGIONAL BMICAL PROGRAMS


                                        AD HOC  REVIEW  COM4ITTEE






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

                                                      Friday, May  24,  1974

                               The meeting convened at 9:45 o'clock, a.m.,

                    Dr. Herbert B. PahL. Acting Director, Division of Regional

                    Medical Programs, presiding.


                    PRESENT:


                               Mr. Peterson, Chief, P&E

                               Dr. Winston  Miller,  Minneapoliso   Minnesota

                               Mrs  Jessie Salazaro  Albuquerque, New Mexico

                               Dr. Leonard  Schertis,  Baltimore,   Maryland

                               Mr. Joseph  de  LaPuente

                               Dr. Paul Teschan, Nashville) Tennessee

                               Sister Ann Josephine, Notre  Dame,.  Indiana

                               Mr. Kenneth Barrows, West  Des  Moines,  Iowa

                               Dr. Joseph Hess, Detroito Michigan

                               Dr, Albert Heustis,  Three  Rivers,  Michigan






                                                                      i n
                              Dr, John Hirechboeckp Milwaukees Wiscons
                              Mr. Robert Toomeyo Greenvillep South Carolina
                              Dr, William Vaun,, Long Branch, New Jersey
                              Mrs, Florence Wyckoff, Watsonvilles California
                              Mrs, Silsbeep Acting Chiefo O&D
                              Mr, chambliss,, Acting Deputy Director
                              Dr.  Herbert Pahl, Acting Director, DRMP

                              Mr.  Francis Nash, Eabtern Operations

                              Mr,  Richard Russell@ Western Operations

                              Mr.  Michael Posta, Midcontinent

                              Mr. Lee  Van Winkle, South Central

                              And others





                                             C 0 N T E N T S

                    Reports  by:                                               @e

                               Mr. tee Van Winkle
                              @outh Central)                                    7

                               Mr. Michael Posta
                               (Mideontinent)                                 it

                               Mr. Richard Russell
                               (viestern Operations)                          23

                               Mr. Francis Nash
                               (Eastern Operations).                          25

                    Discussion  re equity of treatment by   two
                    s ubcommit tees                                           36

                               Criteria                                         I

                               Oklahoma                                       43

                               Bi-State                                       45

                               Loulsia6a                                      47
                    Discussion re policy matters                              56

                                                                              60
                    @Recommendations to Council
                               Motion                                         6L

                               Recommendation amended                         71

                               Vote                                           77
                    Adjourned                                                 81






                                           P R 0 C E E D I N G S
                                             ---- - - - - - - -


                               DR. PAHL:  I would like to call this session of the


                     meeting to order.

                               There may be one or two of the committee still

                     getting a cup of coffee, but I understand some people had to

                     depart.  I believe we still have a reasonable amount of acti-

                     vity before we can conclude the overall meeting. But before  w(.,

                     go on further, I am sure all of you have probably  noticed  thal;

                          Silsbee has been able to join us this morningo  and  I  hop,

                     that we don't have any more relapses which we had the other

                     day,

                               Glad to have you back, Judy.

                               I guess probably one of the biggest disappointment

                     in her life was to miss the other day.  We will be busy

                     briefing her as to what is going on.

                               The purpose of this meeting really   is to have one  of

                     the panels inform the other what the actions  wereo very

                     briefly.  And any really important points that may be pertinent

                     to that action, each panel has had certainly a few very excit@.n

                     moments and some very difficult moments and I believe that

                     this information should be shared with the group as a wholes

                     because we are taking the full conunittee's recommendation

                     to the Council and also we hope to have all of you back for tiie

                     July review and you should all hear at this time what the

                     actions were.





                              It is clifficult'to do this, as you know from  past

                    experience, because having not shared in the full length

                    discussion and read the applications, you may feet that some or

                    the actions are overly harsh from what  your  present  lnform-
                    tion is. But that' information may be outdated by  18  months

                    or two years or so. So what I would like to urge  us  all  to

                    do is not try to reopen all of the sessions which we have

                    just gone through, but use this as an Information session,  Anil

                    I propose to do this in the following fashion,, and thetis

                    to, first, take Mr. Chambliss' group of applications and have

                    the two desk chiefs run down alphabetically the ones that

                    they were responsible form and give you the highlight and any

                    point wffch  they feel you should know.

                              Now, because we are still on the confidentiality of

                    information and conflict of Interest, I should say  that  when

                    your own conflict of interest region comes upo we  would  like

                    to have you out of the room.

                              These will be very short presentations; that  is,  a

                    few minutes on each. Because we have 53 and  we  are  heading

                    for getting out this morning.  So really don't wander clown  he

                    hall and start that long distance telephone call* It will almost

                    be an In and out.

                              On the other hand,, I believe that perhaps one or two

                    points may require more than that few minutest because there a@e

                    some serious considerations that have come to my attention, an,]





                    I believe you will perhaps want more than just a sentence or

                    two,  So that.you will be better prepared to understand the

                    applications as they come before you In July.

                              The other matter isot  least  Dr,  Teschan,  maybe  some

                    others, have some points you would like to  raise  for  group

                    consideration possibly formal recommendation for policy issues

                    for the Council and other matters.  So as soon as we finish

                    thist,@ie will be willing to entertain any kind of further

                    discussion on points to the staff or points  to  the  Council

                    that you wish to make.

                              Now, if that  is a satisfactory agenda, I am sure we

                    can proceed rather quicklyo and I would likes  first  of  alL.  to

                    ask whether that fits in with the way you feel we might best

                    convey a Large volume of information over two days.

                              .ALL right, first I would Like to ask, Bob.,  let's

                    take yours f lrst.

                              Do you have any general comment you  want  to  make

                    for the group about the total set of  applications,  and  then  we

                    will go right Into them?

                              MR. CHAMBLISS: Yes. I might  say  as  a  matter  of

                    general information that panel A  handled  the  applications  from

                    the South Central and Midcontinent areas.  We handled a total

                    of 28 applications and the total request from those applica-

                    tions amounted to $65.5 million.

                              The overall actions recommended from  this  panel,,





                   total $50 million$ $5Op273@913.

                             We are going to ask, then, for the respective branch

                   chiefs of the South Central and Midcontinent Branches  to  give

                   just a brief summary of  the individual actions taken by this

                   panel.

                             Lee,, will you proceed.

                             mR. vAN WINKTE:   I don't propose to get Into the

                   specific rationale behind this and how they arrived at these

                   decisions but basically I am just going to give  you  what  the

                   decision of the panel was.

                             On Alabama$ they considered--

                             DR, PAHL: Give time for people to go In  and  out  of


                   the room.


                             MP,. VAN WINKLE:  There is no one from Alabama.


                             DR. PAHL:  Just in general.  Okay.

                             MR. VAN WINKLE: In Alabama,, they  considered  this

                   to be an above average region and they recommended  funding  at

                   the level of $2,028,389.

                             There were no specific recommendations  other  than


                   that,

                             Flbridap no one here from there either,  Is  there?

                             This was considered to be a superior region  and  was

                   recommended at a funding level of $2.7 millions

                             Georgiat another region that was considered  to  be

                   superior, was recommended at'a funding level of  $3,,629o757.





                              On Georglas they don't propose to. come in In July

                    at all. This Is their total request.

                              Illinois was considered to be an above-average region,

                    was reea.,nmended for funding at $2,816,935.

                              Indiana was considered to be an average region, was

                    recommended for funding at $L.,121,159.

                              Memphis was considered to  be an above average region,

                    was recommended for funding at $2.6oo,ooo.

                              Michigan    I believe we have some people from

                    Michigan?

                              MR. CHAMBLISS.- Yes, we do.

                              DR. HESS:.)5ut I have no conflict of interest.

                              DR. HEUSTIS:  I come from Michigan,  I have no con-
  C!"
                    flilct of Interest.  Do you want me out?

                              DR. PAHL:  Please, if you will,

                              (At this point, Drs. Hess and  Heustis withdrew

                         from  the room.)

                              MR. VAN WINKLE:  Michigan was considered to be an

                    average region, was recommended for funding at the level

                    of $2.5 million.'

                              DR. -PAHL: Let the record show Dr. Heustis and Dr.

                    Hess have both left the room.  Thank you.

                              (At this point, Drs. Hess and Heustis returned to

                         the room.)

                              MR. VAN WINKLE:  Mississippi was considered to be a





                                                    led for funding at the level of
                     superior regions was recommend

                     $2.2 million.

                                North Carolina, considered to be a superior


                     regions recomme
                                     nded for funding at the  level  of  $2,375,522.

                                Northlands

                                (At this poin4 Dr.'Miller @ithdrew from the room.)

                                MR. VAN WINKLE:  Dr. Miller  has left the room.

                                Northlands was considered to  be a below average

                     region.  This largely'ha-d to do  with  staffing  difficulties.

                     Was recommended for funding at the level of $1.7 million.

                                (At this points Dr. Miller returned  to  the  room.)

                                IC. VAN WINKLE: Ohio Valley  was  considered  to  be

                     an average region,  recommended for funding to the level of

                     $2o3O5o636.

                              -'South Carolina was considered to be an average region,

                     was recommended for funding at the level of $2,2 million.

                                Tennessee Midsouth,


                                DR. PAHL:  Dr. Teschan.

                                (At this point, Dr. Teschan withdrew from the room.)

                                MR. VAN WINKLE:  Was considered to be an average

                     region,, was recommended for funding at the level of

                     $20133,972.

                                (At this point, Dr, Teschan returned to the room.)

                                MR. VAN WINKLE: Dr.  John  Hirschboeck  is  leavings

                                (At this point, Dr. Hirschboeck y,ithd,rev,,@from
                     the   room,)





                              MR. VAN WINKLE: Wisconsin was considered to  be  an

                    average region, was recommended for funding at the level of

                    $2 million.

                              Now, there was one common thread I think that  went

                    through all of these funding recommendations, in terms of some
                    reductions, is the fact that'irrespective of the  superiority

                    or excellence of the regions in many instances there was a

                    question whether the amount of work cut out could be accom-

                    plished in the amount Left. I think that was probably one

                    common theme that went through that.

                             DR. SCHERLIS:  Sum total.

                             MR. VAN WINKLE:  $32o3ll,370.

                             That is all of these.

                             DR. PAHL:  Thank you very much, Lee.

                             Are there any comments or discussions of these

                   applications?


                             -YeE;.

                             DR. SCHERLIS:  This will come upo I am sure, as we

                   discuss other sections but looking at the target figure of

                   some 35-plus against the recommendation of $32.3 millions

                   does that mean we will have at the most $3 million for the Jul@

                   request?

                             I know it will add up In the different groupso but

                   is this the sort of calculation we will have to make in  terms

                   of what will be available in July?





                             DR. PHAL:  Yes,, I will go Into that at the end of

                    the full recitation here,,

                             DR.  SCHERLIS:, Fine. Thank you.

                             MR.  VAN WINKLE:  I 'could mention thatthe total May

                    request that was being considered here came to $41,159,472.

                             MRS. WYCKOFF:  For this group?

                             MR. VAN WINKLE:  For this particular  group,

                             DR. PAHL:  All right, thank you, Lee,

                             Mike, would you please take your group of regions,

                             MR. POSTA:  Just as a beginning, the  14 regions

                    from the Mldcontinebt Operations areas,, requested in their May
                    L application $24,436,527. Of this $24 million in request,

                    $17.,962..843 was recommended for approval

                             First region in this group Is Arkansas,

                            .DR.TESCHAN:  Would you get a little closer to the

                    mike.


                             MR. POSTA:  Okay.

                             Arkansas, reviewers felt this region was an average

                    one.  They were concerned with the lc6s of Dr. Silverblatt,

                    a top-notch coordinator; because of this they did not feel tha;

                    the full amount of $1,830,000 request should be approved.

                             As a result, their recommended figure was $1.5 mil-

                    lion.


                             Bi-state, St. Louis, reviewers considered Bi-state to

                    be average to below average.  The request of $10128,000,





                    roughly, was cut to $800.,Ooo.

                             This is approximately $71,000 below the projected

                    12-month funding level,'

                             Poor leadership, particularly with reference to  the

                    RAG involvement, was noted.  Theyhave never received triennial

                    tta@uss  Their track record was considered below average.

                             Coloracio-Wyoming.9  Colorado-Wyoming was considered

                    above average to-supe'lor.  Thetarget figure of $1,5 million
                                        r,
                    was recommended, which was about $280,000 less than was re-

                    quested.

                             Intermountain?  No problems.

                             This region was considered above average.  One

                    reviewer in individual grade sheets considered it superior,

                    They commented on the good staff.  However the application was

                    most ambiguous.  The region was considered to be overly funded

                    by some of the reviewers,, Including staff.

                             The panel recommended that $2 million of the $3.85 mLl

                    lion request should.be approved and this compares to $3,6 mil-

                    lion target for this region.

                             Iowa.

                             (At this point,Mr. Barrows withdrew from the room.)

                             MR. POSTA:  Iowa is considered above average to

                    superior.  The request was approved in the total amount reques-i-
                    eci of $1,061,349, which Is about 80 percent of the target

                    figure,





                                (At this point, Mr Barrows returned  to  the  room.)

                                MR. POSTA:  Kansas.  Kansas was considered average

                     to above  average, appro"ved $i,,633,380,, which is $1000000

                     less than requested.

                                This region had requested about  78 percent of  the.

                     target figure.

                                Louisiana?  This region was  conside red below average.
                     This never has achieved triennial status, It has    always

                     come in for an annual  type of an application.

                     Leadership Is  still  in question.  The coordinators on a haLf-....

                     time basis.  Howevero  the request of $985,?L2 was approved as

                     requested,, which is  77 percent of the targeted figure.

                               -Missouri.  This region was cons idered average region.

                     The reviewers felt that the region has improved significantly

                     over the Last several years,  As many of you are aware, this,.

                     particular region put an awful Lot of emphasis on computer

                     and hardware in the past.  They have completely gotten away

                     from this particular thrust and are getting into outreach

                     programming.  The MS needs and requests in this particular

                     application should be reexamined by the health service agency
                     staff.  The reviewers felt that the program staff was too high.

                     and that the application was considered to  be  too  ambitious,

                               The reviewers approved the targeted figure which was
                     @9

                               Approximately $7L5,000 was trimmed  from  the  budget





                     request.

                               Nebraska?  This region has never achieved  rienn a

                                      ny of you will recall, their  funding  was  cut
                     status and as ma


                     back aft-er the divorce from South Dakota several years ago.

                               The reviewers felt that the Nebraska's application wal@

                     the best they have seen to  date.  They  note  considerable  im-

                     provement.  And recommended a new funding Level in the amount oJ

                     $912.,000, which,, in essence,, was $50,000 below the  requested

                     amounts but over the target figure,

                               DR. PAHL:  Before we leavepmike, was that considered

                     an above average or superior?  General rating?

                               MR. POSTA:   I can't be sure.

                               DR. PAHL:  Okay.

                               MR. POSTA:  This region was reviewed by Mr. Thompson

                     and he commented on theapplication, but  I  don't  recall  seeing

                     his notes or his grade sheet.

                               New Mexico.

                               (At this point, Mrs. Salazar withdrew from the

                          room.)

                               M. POSTA:  Considered an average region by the

                     reviewers there was some concern  about  Dr,  Gayp  their  excel-

                     Lent coordinator Leaving.  Howeverp  the  panel  felt  that  the

                     region was still in good hands with Dr. Walsh's takeover.

                               This region will not be comin g in for  July  I  funds.

                               The target figure of  $1,644o754  was  approved,  which




                    was approximately @L.1 million under what was requested.

                               Two particular projects were noted.  The health edu-

                    cation for the public wasconsiderbd overly ambitious as far as

                    its funding request was concerned, and it was suggested that

                    an out-of-state group visit this partlo ular project.. give an

                    unbiased report, submit It back to the coordinator for possibL(

                    rebuclgeting to other areas,

                               Also the EMS'project-is considered to be well in exces

                    of double  the amount of the current application.

                               Most of the cuts were in those two areas.

                               (At this point, Mrs. SaLazar returned  to  the  room.)

                               MR. POSTA: North Dakota,, this  region  Is  considered

                    below average.  However, the reviewers noted that this has beet

                    the Lowest funded region of the  53.

                               The target figure of $582,5L7 was  approved or redom-

                    mended for funding., which is about $L80,,Ooo less than was   re-

                    quested.

                               OkLahoma, OkLahoma was  considered  average  to  below

                    average region. It  never  has  achieved  triennial  status,  The
                    target figure of $ltO62,237 was approved;  $320,000 was

                    trimmed from the request.

                               The reviewers felt that a new thrust in dealing with

                    hospitals  through regional development area districts was a

                    significant improvement over the old  thrust,  which  dealt  with

                    continuing education programming.





                               South Dakota.  South Dakota was g,ivenan outstanding

                    review.  The reviewers felt  thi-s- region-r-as you recall earlier,

                    I had mentioned the divorce  with  Nebraska?  Both  regions,

                    Nebrask4 and South Dakota,  have definitely improved.  Maybe

                    the divorce was great.  Anyway it was given an outstanding


                    review,


                               The applic-ation was approved in the amount requested

                    of $729,417, which Is over the targeted figure.

                               The target figure in this particular  region  was
                    $571..095.

                               Texas,  This region took the longest of any in our

                    paneL,, well over an hour.  It was sort of a unique request.

                    They did request 98 percent of the targeted figure and had

                    stated in the application that they would not be coming in

                    with a July application assuming this particular application

                    was approved.

                               The application was for $2,333,1531,

                               The'reaL,'-problem as the reviewr saw it was that

                    approximately $1.5.miLlion of the request was in the form of

                    an open ended contract calling for five programmatic areaE! froli

                    which requests for proposals would be submitted to the various

                    consumer and provider organizations  within  the  state.  We

                    were apprised at the last minute that about 62 applications

                    had been received, responding to tho6e requests for proposals
                                                 C>                                 .9

                                t of $6.2 million.  And the RAG had requested the
                    in the amoun





                    review committee to allow them approximately $1.4 million,,

                    $1.6 million considering about $200,000 of the request was in

                    the form of a  developmental  component  to  give  them  approval

                    to check on June 28th at the RAG meetings and to submit to the

                    regional medical program form 15's which are your summary

                    sheets, form 16 your budget   sheets. So that  they  could  begin

                    those contracts promptly and get a full 12 month project

                    period behind them.

                               Considerable debate took place and it was decided


                    that the review committee could not in all due conscience


                    approve an open ended application of this sort.  They wound up

                    by approving $1.1 million at this  time  which  would  take  care

                    of the continuation activities  and  theirogram  staffo  and  had

                    recommended that this be brought-to the attention of the Council

                    that meets in June  with the proviso that after the RAG reviews

                    their 62 or more contract proposals and submits the 15'sand

                    16's intoDRMP by July 10th, that this body, the Review Committee,

                    would be able to review them so that funding could begin immedj-

                    ately after this next review body would meet.  So that they

                    would not have to "o again to the  ugust review.

                               DR. PAHL:  Thank you very mucho Mike.

                               Sister Ann.


                               SISTER JOSEPHINE:  I am sorry, I am so used to responc-

                    ing to Intermountain, I  did n ot move to Indiana.

                              .(Laughter)





                               DR. P.AHL:  We are glad to have you with us, Sister.

                               (Laughter)

                               Is there any general discussion on the applications

                    that Mik-e has gone over?

                               DR. HESS:  I would just comment that listening to what

                    little qualitative comments we hacl@ that I would guess that, ii

                    generalo your group used the rating system a little bit

                    more liberally than ours did.

                               It Is hard to tell,, but I would just raise that

                    comment.  Maybe as you hear the other half, you might keep

                    that in  mind.


                               I think one of the important things we ought to do

                    now Is to look at the matter of consistency of rating and con-

                    sistency of fundino- decisions between the two subcommittees.

                               DR. PAHL:  Dr. Scherlis.


                               DR. SCHERLIS:  I think in all fairness to our group,

                    we want to  be considered extraliberal or noneredibLe,,i4e have


                    never been accused of that,

                               Our group never reached decision as to average or

                    superior.

                               I was wondering how you all arrived at those.  I

                    thinkyou   got a f lavor from what we said, then decided we reall@

                    meant they were superior.  We did not as a group really say

                    these  things.

                               MR. VAN WINKLE:  I took these off the rating.





                              DR. SCHERLIS:  Got it off the review rating?

                              NR. VAN-WINKLE:  That's  right, not as the group*

                              DR. SCHERLIS:  Final block.

                              DR. PAHL:  This represents staff,  analysis of the

                    rating group results.

                              DR. TESCHAN:  The question concerning the Texas

                    discussion which I thought was extremely interesting,  I  note

                    from the sheet here th@,y-@ are triennial status.

                              I was wondering whether that set of provisos for

                    review here of the 15's and 16's was in accord  with  triennial

                    management policy? I would gather that that  has  been  decided

                    lnthe first group, so it is just for information as to whe-

                    ther or not that essentially takes from a  triennial  approved

                    region decision up to this group?

                              It is a policy question.

                              DR. PAHL: Yes. I think It had to do  with  the  mag-

                    nitude of the funding. I wasn't in on  the  entire  discussion.

                    Pe'rhaps somebody can- elaborate. But'I think the problem  here

                    wasnot-- the question was not to remove flexibility from a

                    region, but it was such a -- I don't remember the exact amount

                   but it was such a large amount that I gather the  panel  didn't

                    really feel that it could handle the decision making  with  the

                    informationthat was at hand,


                              Judy, do you have something to contribute?

                              MRS. SILSBEE: I have a question.  I  was  wonde@  ng




                    if the same consideration had been given to the Georgia appli-

                    cation which was somewhat similar?

                             DR. PAHL:  Perhaps that can be answered  here,

                             Lee,has the same consideration been given 'to-.'the

                    Georgia application?

                             I&R. VAN W INKLE:  We cl id nt ha ve the same d if f I c u It I e,,

                    with Georgia.  The Texas application did not have sites.  It

                    did not have project directors.  It did not have budgets.

                    The Georgia application was full blown.

                             MRS. SILSBEE:  Except It Is still under review which

                    is the only difference.

                             The principle is the same, Lee, In both those appli-

                    cations.

                             MR, VAN W INKLE:  It did not come out, Judy, in the


                    discussion.

                             DR. TESCHAN:  I would respond  to that by saying

                    your answer, Lee, Is entirely satisfactory to me.

                             DR. PAHL:  Yes, Dr. Miller.

                             DR. MILLER:  It might be brought out again that we h).d

                    rather extensive discussions about this Issue, and in several

                    RMP's -- not Georgials as I recall either.  Maybe we didn't

                    pick It up - the principle of whether a region under the

                    present system would be allowed to have the equivalent of a

                    developmental funds slush fund., fund of money awarded to them

                    without us knowing what they were going to use it for exactly.





                               I think although we didn't ever pass a motion   to that

                    effe ct, there was general agreement in  our  group  that  we could

                    not authorize a bloc of  grant components  in  this  review-


                    process,

                               We have trouble defining some  of  these as to whether

                    they were block grant components or not.  Some of them     come

                    awfully close In other ways. But  anyway  this  was  the  issue

                    that we grappled 'With and Texas@ was the outstanding  and  the

                    most extreme examples

                               DR. PAHL:  Perhaps Dr, Heustis.

                               DR. HEUSTIS:  I would ask Dr. Miller  if  you  would

                    be willing to correct the record for  his  words  and  delete

                    that little     few adjectives he used after the word

                    "developmental grant"9  It  bothers me.

                               I wouldn It want to even say the word.

                               (Laughter)

                               DR. MTLLER:  Yes, I am happy    to do that.

                               DR. PAHL: -All right, that constitutes the findings

                    of panel A. I would like to ask  Mr.  Peterson  if  he  would

                    care to introduce,mke any general comments concerning panel BI

                    And then proceed along the same  lines  with  the  individual

                    applications.

                               MR. PETERSON:  Panel B was transcontinental in scope

                    having looked  at 25 regions handled by the Eastern and Western

                    Desks. As its  chairman  I  was-very  pleasantly  surprised,





                    perhaps not the word but by the serious self-disciplinecl

                    way in which this group,operated in the face of the same      con-

                    straints that I am sure panel B was under except for lack     of

                    information, time, and what have you.

                               I think it will be clear  as'you hear from  Dick  and.

                    Frank, but the panel judgments and   actions were more nearly

                    critical than otherwise.

                               We did re-review our  actions  this morning on some

                    sort of overall comparative basis, but    only in  three  cases

                    were some minor      10 percent changes made in  the  recommencla-

                    tions that previously had been taken by  the  panel  in  the  two

                    prior days.


                               Since we are probably going to be breaking and

                    everybody is  going to be running off, I  would  also  like  to

                    take this opportunity now, rather than trying,ti seize it,

                    later on, to say one other thing. I  think  at  a  time  when  the

                    federal government and Public  Service  Is  held  in  generally

                    lower esteem than it has for along, long time      The credibility

                    of this government and the public's faith  In  it  would  be  far

                    greater if they could see the kinds of actions that are

                    taken by groups like this to see,:,the submerged. part  of  the

                    iceburg, not that tip that attracts the headlines.      For   that

                    reason I would like to say thanks to panel B and all    of the

                    groups, both personally and professionally.

                               DR. PAHL:  Thank you, Pete.





                                Dick, why dori It we take your  applications   first?

                                MR. RUSSELL:  All right.

                                DR. PAHL:  And proceed along as we had before.

                                MR. RUSSELL:  I Will go alphabetically.

                                Arizona was considered a below average program;

                     funding  recommendation,is  $860oooo,  which  is   approximately

                     64 percent of its request.

                                The reasons  for this action, one is   that the  program

                     is not in conformance  with the RMP grantee Regional      Advisory

                     Group policy.

                                Two, the program Is under an extreme    influence,

                     perhaps'control-of a key representative of the     grantee.

                                The third area  is  the  questionable   effectiveness

                     of the coordinator.

                                While there are some  indications,,changes  are   being

                     brought about in the program,    this  is  attributed  primarily

                     to the deputy of the   program who has brought about some change,,;

                     however, with the history of  this  program,  the  group  came  up


                     with this recommendation.


                                California.

                                (At this point, Mrs. Wyckoff withdrew from the room'*)

                                MR. RUSSELL:  Let the record show Mrs, Wyckoff

                     excused herself.

                                In the initial review which was yesterday, Califonirt

                     was rated as an above-average  -recion,  and  it  was  recommended




                   that it be funded in the amount requested, $8sL7Os374.

                             MR. PETERSON:  Are you going to indicate--

                             MR. RUSSELL:  I am getting Into the record, Pete,

                   the gro@,o did reconsider the action in California this morning,

                   and inview of the rating and the needs of CaLiforniao the

                   group decided to reduce the amount recommended for  California

                   to $7,353,000, which was a 10 percent reduction  in  the  amount

                   requested.


                             The third program is Hawaii
                             (At this point, Mrs. Wyckoff returned to  the  room.)

                             MR. RUSSELL:     and Hawaii was considered an average

                   rating,  This Is primarily due to the recent change of coordina-

                   tors who has done a tremendous job in a reasonably short perloi

                   of t@o


                             It was recommended. however, that Hawaii be funded

                   at $I,l million.

                             Mountain States Regional Medical Programs which covers

                   Idaho, Montana, Wyoming and Nebraskao was considered  to  be  an

                   above average to superior region.  There was some concern

                   perhaps that the budget was inflated.  And the panel recom-

                   mended a reduced level of $2,150,000,  And there was Indications

                   staff should get additional information on the budget which

                   we feel very comfortable in doing.  I know we can get this

                   before Council.

                             The Oregon Regional-Medical Program was rated as a




                    superior region.  Recommendation was in the amount requested

                    $10201,357.

                              The Washington-Alaska program was rated as a superior,

                                                                oO77,311.
                    region with recommendation as requested, $2

                              And I believe that is all six of them.

                              DR. SCHERLIS:  Do you have a total on that?

                              MR. RUSSELL:  No, I am sorry, I do not.

                              DR. PAHL:  Frank., would you please then take the

                    regions that you have and describe them briefly to  us,

                              MR. NASH:  All right.

                              Albany -- can you hear me, Pete?  Albany was viewed

                    as a superior region in all respects; recommended funding leve

                    was $io66,ooo.

                              Central New York was an average regio,n; reco@nda-

                    tion for fundino, was $615,000.

                              Connecticut, below average to poor, funding Level

                    recommended $510,000,

                              Greater Delaware Valley, rated as above average

                    region, and recommended funding level was $2.3 million.

                              Lakes area was rated as below average to average

                    program; recommended funding level was $1 million,

                              That figure,was arrived at by taking the current

                    Level and deducting the cost in the application of all pro-

                    jects that had been funded for at least three years, plus one-

                    half the cost of proj-eets requesting two years supports which





                    they had several,

                              Maine, this was the superior region in all respects;
                    recommended funding level here was'$L.7 million, $1,760.,Ooo.

                              DR. SCHERLIS:  Hold it.

                              MR. NASH.@;.'. Yes.  Let the record show Dr, ScherlJ-s


                    excused himself.

                              (At this points Dr. Scherlis withdrew from the

                        room.)

                              DR. PAHL:  Frank, that changed.

                              MR. NASH:  Yes.  This, the recommendation by the

                    panel yesterday for @ne was $1.6 million.  This  was reconsid-

                    ered in our meeting this morning and final recommendation was

                    for $I,,76oooooo which Is about 90 percent of their targeted

                    figure) and this Is the only application we expect to get froo

                    Maine.

                              Maryland, recommendation for Maryland was for terming.-

                    tion of the program.  This was based primarily on the four

                    Items; one was lack of direction by the RegionaLAavisory Group.

                    Two was lnspective coordinator.  Three, disinterested or

                    self-serving grantee.  And four, end product of supported
                    activities in the'past period would be useless.

                               am sure you will want some discussion on that.

                              DR. PAHL:  I think this Is one of the points why we

                    did want to have the total group involved because this obviously

                    Is a very serious recommendation. And I certainly would





                    entertain any discussion by the committee even though a number

                    of 'ou have not been involved in' the details, but to raise any
                       y

                    questions of those who were involved in this or for  further

                    clarification before this recommendation is passed on as a

                    committee recommendation to the National Advisory CounciL,

                              All right, if not, Frank, will you proceed with the

                    other applications.

                              MR. NASH:  Metro, D.C., this was considered to  be

                    average to above average region.

                              (At this point Dr. Scherlis returned to the room.)

                              MR. NASH:  I think the panel-noted improvement In thiE

                    region over the past years.

                              Funding level recommended, $1.1 million.

                              Nassau-Suffolk -- anyone here'from Nassau-Suffolk?

                              This, the recommendation for this program was  for

                    termination and due to some problems with the Regional Advisor5

                    Group$ their Lack of direction and Leadership, the fact they

                    have had three coordinators within the past year or two, there

                    was great concern over the leadership.  Capacity of the present

                    coordinators problems between RAG and grantee  organization,

                    again this was a recommendation for termination.  They may want

                    to discuss this.


                              DR. HESS:  An Important factor, there Is another

                    very Important factor too that was notrmntioned; that Is, the

                    lack of a capable staff on board which to my mind is a  very






                    central concerns


                              MR. NASH:  Thank you.

                              DR. HESS:  The unlikelihood they can recruit capable

                    staff and do anything in the time available.

                              DR. PAHL:  Thank  you.

                              Mrs. Wyckoff.

                              MRS. WYCKOFF:  I would like to ask about both of thes(

                    that are recommended  to be phased out.  I would like to ask

                    about  both of these that are recommended to  be  phased  out.

                              Wou Id you say that the principal reason Lay  with  the

                    traumatic effect of the cutback on'their  programmer  was  it

                    clue to something internal that couldn't be corrected regardless

                    of what happened?

                              DR. PAHt,':  There are a number of people In the

                    room who I believe might contribute to  that.  But  Dr.  Heustis

                        his @hancl up first.

                              Does that pertain  to responding to  Mrs.  Wyckoff?

                              DR. HEUSTIS: I think I  can  do  this.  The  procedure

                    in these areas was of long standing and  failure  to  respond

                    over a considerable period of Years with diligent staff effort

                    and previous recommendations ofthe Advisory Council, this

                   was taken careful considerate, deliberate way  with  full  under-

                    standing that staff and Council were reasonable  people  and  if

                    they accepted the recommendation they would make such arrange-

                    ments for an orderly termination of the program as in their





                   Judgment was best.
                             DR. PAHL: Pardon me, before we proceed  further,  I
                   think the chair has erred in not asking Dr. ScherLis to remain

                   out of the room probably during this discussionend I  have  a

                   feeling it may go on for just a few minutes.

                             Don't wander away too far, please, Dr. Scherlis,

                             Sorry, that was our error,
                             (At this point Dr. Scherlis withdrew from the room.)

                             MR. BARRCWS:  Our arrival at this decision,occurred

                   with great deal of anguish and discussion.  We were influenced
                   by another very important consideration, the upcoming  course
                   of planning. It was pretty well concluded that the  new  pro-
                   gram, whatever it is, would be better off to start from scratct
                   than to have this ineffective building block to work on.

                             DR. PAHL:  We certainly appreciate having that com-


                   ment,

                             I believe there are some others who may wish to
                   comment on this.  For examples Mrs. Silsbee or Mr. Nash and

                   others who have been involved.
                             Judy, would you care to make any comments?
                             Does staff have any comments to add to this discussion

                   at this point?

                             Mrs. Salazar.

                             MRS. SALAZAR:  I have a question, Dr. Pahl.  What is
                   the timeframe In which- these two re-ions are tobe terminated?





                               What type of on-going funds and what amount would

                    they have  for. appropriate termination?

                               DR. PAHL: I can't  answer  that  question  because

                    I haven't  been in on these discussions unfortunately.

                               Dr. Heustis.


                               DR. HEUSTIS: The committee  left  the  timeframe--

                    really, we thought It ought to be done as soon as it could be

                    done in orderly fashion and Left the  specific  timeframe  up

                    to staff and Council,

                               DR. PAHL:  Dr. Teschan.

                               DR. TESCHAN: Yes, and we also  said  probably  the

                    present budget would have sufficient funds to assure an

                    orderly phaseout and.if not, the  recommendation includes

                    language, as I recall ito to ask, Council to afford the region

                    sufficient funds for an orderly phaseout.

                               MR. PETERSON:  Yes,. the words early and orderly

                    are part of the recommendation without being specific in

                    terms of 30 days or 90 days.

                               DR. HEUSTIS:  We felt so strongly about this, we wanc;e

                    to be careful and not water it downwith the full understanding

                    that we were dealing with reasonable people as far as the

                    staff ancl-the Council were concerned, and they would take the

                    orderly process.

                               DR. PAHL:  Thankyou.

                               Is thelvfur.ther discussion on this applicatiod?





                             If not, Frank will return to the rest of the applica-

                   tions.


                             MR. NASH:  Okay.
                              (At this point, Dr. Scherlis returned to the room.)

                             MR. NASH:  New Jersey, this program was considered

                   to be superior in all aspects. The funding level originally
                   recommended yesterday was for $2.9 mil Lion,  @ow, that brief'..,

                   meeting this morningo the recomm endation was changed, the

                   final recommendation being $3ol9OiOOO.

                             N@i York Metro, this was considered to be an average

                   program with funding recommendation of $2.5 million.  -Also

                   going with that is recommendation to Council that If dollars

                   areavailable, New York Metro be given a high priority to receive

                   additional funds.

                             This was an application for over $7 million and about

                   half cfthe activities were proposed for two-year support.

                             Northern New Englando this was considered to be an
                   average program; recommended they have a funding level of
                   $700,000.  And that the region be given advice to terminate

                   support of their data collecting activities there,

                             Puerto Rico was considered to be an above average
                   program, recommendation for their funding level was  69518 2.

                             Rochester, Rochester was judged to be a superior
                   program with funding recommended of $3,061,471.
                             DR. HESS:  Explain that.  That is mainly for staff.




                   They have $1 million for projects coming in, that  accounts

                   for 'low figure.

                             NR. NASH:  This was really all they asked for, this

                   particular application, because they only asked for staff

                   support and continuation of ongoing activities.   Their July

                   application will be considerably in excess of that.

                             Susquehana VaLley seems to be a below-average region,

                   As a matter of ra-cuo i'Delie've 'the panel had some serious

                   reservations even as to the viability of this program.

                   Recommendation here was for $400,000.

                             This primarily to support staff and very small amount

                   for projects.

                             Tri-state., this was considered to be a below average

                   to average retion. The panel had many questions  I  believe

                   which we were unable to resolve.

                             The panel highly recommended a site visit be made to

                   this region prior to Council meeting.

                             The recommendation for funding was $800,000.  And I am

                   assuming it was the Intent of the panel that should the site

                   visit get some of these other questions resolved, then that

                   figure could be raised prior to recommendation of  Council.

                             Is that correct?

                             Virginia was considered to be an average  region,

                   Funding level recommended was $1 million.  A,nd with advice to

                   us that we express concern to the region, particularly over




                     their ability to fill the many vacancies that they listed in

                     their program staff budget.

                               West Virginia was considered to be   a superior
                     program. The recommended fundinm level was exactly what    they
                     requested In this first application, $663,132.  This is    basicel-

                     ly a program staff support plus two small projects.

                               The region will be coming in in JuLy with   a much

                     larger application.

                               Western Pennsylvania, this was considered to be an

                     average program. The recommended furfi ing  level  for  Western

                     Pennsylvania was for $1.2 million,, Plus  $170,285  to  support

                     the Mahoning Shenango HEC project in Ohio.

                               DR. PAHL: Is there  any  further  question  or  clarifi-

                     cation on these?


                               Dr. Teschan.

                               DR. TESCHAN:  I would like to refer again to the

                     Arizona application and to ask if the reporter  clarify  --  as  I

                     recall, in our panels Arizona was thecnly  program  which  at  thE

                     time of the processing had not completed  its  rev  ew  process

                     certification and I  believe  our  recommendation  started  out

                     to be that there  be no further allocation unless that process


                     were completed.

                               During the discussion, however,  we  found  that  indee@

                     that project was well under way,, that some of the influences

                     that would be inappropriate under the -August  L972  policy  were,





                   as a matter of fact, being rectified. And the question  I  have

                   is whether your notes and recollection Is that the  recommenda-

                   tion of panel B was somehow contingent on the completion

                   after process that was already underway.

                             The question I am simply sort of raising is the issue

                   of approving funding for a region that has not  been  certified.

                             Do you recall that, Dick?  Where are we in that?

                             MR. RUSSELL: I don't recall  it  that  specifically.

                             I will ask Mrs. Sadin If she will comment on this


                   discussion yesterday,

                             MRS. SADIN:  No  I think what we said was their

                   RAG was going to meet and at the next RAG meeting,, they  were

                   going to consider the revisio'n, already looked at the  revision

                   of bylaws.  They needed 30 days before they consider this

                   would take place.  It has not taken place, but they said it

                   Will.

                             DR. TESCH-AN: I think it is almost a truism.  I

                   don't th ink there Is any issue here particularly, but I

                   gather it is understood or we should understand and make clear-

                   ty a matter of record that review process  certification  will

                   be essential for Arizona before dollars will f low. In  other

                  words, it seems to me that is a basic assumption under which th@

                   regions need to operate.

                             DR. PAHL:  That would be a recommendation to the

                   Council, then the Council condition on the grant award,





                                                                      se restric-
                             Underthe court orders staff may no.t.impo

                   tions, but we may obviously.carry out any Council conditions or
                   grant awards and this recommendation would be taken to the

                   Council. , That is my understanding.

                             DR. TESCHAN:  But the application, Ins truction  or

                   the current cycle says clearly all applicable policies will

                   continue to apply except those specific interdictions which

                   had been specifically rescinded,

                             DR. PAHL:  That is correct.

                             DR. TESCHAN:  I have no evidence August 1972 policy

                   does not apply.

                             DR. PAHL:  Yes, Dr. Heustis.

                             DR. HEUSTIS:  I think it might be in order to clarifj

                   what we did this morning and to -,make, perhaps panel A undex-

                   stand the three rather modest changes that were made.

                             Staff over the evening took the material which we had
                   prepared yesterday and organized it with all of the superior

                   projects together and above average, thenfigured out some

                   percentages.  And so we tried to take a look at the numbers we

                   had come up with on an Individual basis yesterday and to see

                   whether In fac-t we had treated them In context with what we

                   thought the process and merit indicated.

                             That was the reason for the relatively minor changes

                   that were made this morning.  I think it was a good device

                   and helped some of us to see things all in perspective.





                              DR. PAHL:  Than@ you very much.

                              Are there other comments from anyone  concerning  the

                    activities or conclusions reached by either of the paneLs?

                              Dr. Hess,

                              DR, HESS: Yes, I would like to have us  spend  a  few

                    moments on what I @ould consider one of  the major items of

                    business for us to attend to this morning and  that is the equi by

                    of treatment by these two subcommittees*

                              I am particularly concerned- about those with  whom  we

                    have dealt harshly and on the other end of the  scale.  I   would

                    like to just raise one question about one region  that  may  have

                    been treated by panel A more generously than would have happen@d

                    had they beenreviewed by panel B.

                              Because'I think this  is something we have to be

                    very much concerned about when  we break down into.putlic  sub-

                    committees this way, that the decisions that come out  are  not

                    too much a function of which group reviewed a particular regioi.

                              Now, perhaps let's take them one at a  time  and  let's

                    take the easiest first.  That Is, I would like to raise a ques-

                    tion about intermountain and its level of fundlng,whichp as

                    I understand, Is $2 million. It was rated  as  an  above  average

                    to superior regions according to my notes,  They apparently

                                                              to $2 million, and
                    are funding, their annualized rate) close

                    they were granted $2 million.

                              Well,it is $1.8 I guess.





                              Ardthey are going.to be comeing in with -- let's see--

                              MR. POSTA:  Between @400,000 and $500,000.

                              DR. HESS: $500,000 -- for another  half  million  in

                   July,  that will have to,be dealt with,

                              This region does overlap to somedegree with Mountain

                   States and does it  overlap with Colorado-Wyoming at all?

                              SISTER JOSEPHINE: Yes.

                              MR. POSTA:  Yes, s'ir,

                              DR. HESS:  Okay.

                              Is there some way of knowing on a sort of FTE concepG

                   how many people this region'serves?

                              MR. POSTA:  I believe Lee has got the po pulation

                   charts back here.


                              MISS RESNICK:   It is complicated as Dr.  Hess  sug-




                            ,.NR,.POSTA:  That is six states involved,,right?

                              MISS RESNICK:  We know it covers all of Utdiand

                   a portion -- small portion of Colorado,,a  portion  of  Montana

                   which is part of the Mountain States--

                              MRS. WYCKOFF: And Washington-Alaska  has  also  some

                   turf problems.

                              DR. HESS:  With Intermountain?

                              MR. CHAMBLISS:  Yeso they are also a part of it.


                              MISS RESNICK:  But since I am not the reviewer and aLs,


                   wasn't called on to support the population distribution I am




                   a little hesitant to quote'anumber of figures.  I don't know
                   what went into their programs as they developed their estimate

                             And how they gcttogether.
                   of nee

                             I think there Is a three-region committee that looks

                   at it from that Point of view, isn't it, Mike?

                             MR. POSTA: Yes. For your information, in  panel  A.

                   what did come up was the turf problem that we have had for  a

                   number of years with the three regions concerned, and on  May

                   gthp the coordinators of all three regions got together along

                   with their RAG chairman and went over everything that they

                   have in the hopper at the  Prb.Sent time: what they are fundingo

                   together with the May I requests together with the request for
                   the use of the $6.9 million that was restricted and went

                   through allof the applications to be assured that one  region
                   knew what the other one was doing, and got their endorsement.

                             They approved everything In the application with the

                   exception of ten activities and those ten activities could

                   not be funded until this group got together againand they

                   have two definitely scheduled meetings a month from now,

                   the first one, before actually funding consideration would be

                   given to any of the approvals that would come forth from Coun-


                   cil.


                             I don't exactly understand--

                             DR. HESS: Maybe it is not an answer able question.

                             MISS RESNICK:  I have some better figures on the





                     population.  We estimated last spring that the Intermountain

                     program roughly was responsible for $1.9 million.  That took

                     into account Utah, a portion of Wyoming, a small portion of
                     N6Vdda',' a'piece of Idaho, and a piece of Montana.

                               It Is very rough.  We have a map that kind of

                     overlays and so on,

                              DR. HESS:  All right.  That sounds fairly reasonable.
                     And Idon't have any real question about thatv about. that re-

                     gion.  Iam satisfied.

                              DR. SCHERLIS:  May I interrupt for a moment?

                              I am trying to discern the relevancy of that Issue.
                     -Are pu suggesting we should give dollars per population that
                     would make our task very easy2
                              DR.HES@:  No, that should not be the only basis, bu
                     -1-think'-we do have to look at the amount of money going into a

                     region in relationship to not only the population,, but the

                     quality of the program, needs to peoples the other resources

                     'they have towork with.  And all these factors ought to enter

                     into our judgments about what is appropriate. And  that  we

                     should not take a narrow vision and look at the quality  of

                     the program.alone, as the sole criterion upon which to base

                     judgment.

                              So I am satisfied-- And I know that we  have  been looc-

                     Ing at quality andwe have got your rating and all that kind of
                   thing, but I do think that we have to not be unaware of  the'




                     number of pe ople to be served and the kind of Problems that

                    exist in the region.
                              MRS. SALAZAR:  Dr* Hessp would You speak to the Poirt
                    then of, in my view, certain element of inconsistency in the
                    elimination of two regions this morning?
                              These reaions have people in them and they are still
                    in existence.

                              DR. SCHERLIS:  Shall I leave the room again?
                              Will YOU stop that for a moment?
                              DR. PAHL:  Off the record.
                              (Discussion off the record.)
                             DR* HES8:  Okay, I think my concerns at  the high
                    level are satisfied,  Now I am concerned about some of the
                   actions or recommendations that our group made in relationship
                   to Isome ofIthe-- well, Ithink we need to share this a litt-le
                   more in depth,
                             Also I think I would raise a question as to whether
                   Some of the regions that group A revieweC. if in fact we as a
                   group as a whole are going to follow that and support the
                   recommendations of panel A, Whether or riot similar recommenda-
                   tions ought not be'niade for one or two regions reviewed by pan(i
                  A.

                             I got the A and B mixed up, but maybe You can follow
                  the sense of what I am saying.
                            Too.. based on-your discussion, the two that I thought





                   ought to be looked at again in light of this factor are

                   Louis iana and Bi-state.  And questionmark Oklahoma.

                             Now, I think the most efficient way  to  do  this  is

                   to Look at the criteria  which group B used for making the

                   recommendations and ask  group A how those  criteria  apply  to

                   those regions in question.
                            .,The reason I single those out,, number one, the region3

                   are still on annual status which means there is a rather long

                   history of not performing very well or they would be on

                   triennial:tatus,

                             And number twoo they were--well, again,, as I listened,

                   I wondered if maybe we as a group were a little bit more
                   strict in our application of the rating criteria than group A.

                   And so therefore the rating of average or below average may not

                   mean the same for the two groups.

                             So could we just review   now the basis for our recom-

                   mendations on the two  regions were,  one,  the  unsatisfactory

                   nature of the current. leadership,  program  staff  Leadership;

                   number two, the leadership of the RAG and feeling of weakness

                   at that leveL, thirdly, the status of the grantee; and fourth,

                   the role of the grantee -- fourthly the nature of the program

                   specific projects which were put forward as representing the

                   implementation of a program concept.

                              DR. PAHL:  Before we proceed, Dr. Teschan has a

                   comment and question.





                              DR. TESCHAN: I want  simply  to  amplify  or  illustrate

                    those four points didn't come out   of the air.  The  first  three

                    will.be recognized by I hope everybody here  as  almost  a  direct

                    quote from page one of the August 1972 policy as to what are tt.2!

                    essential ingredients of an RMP.

                              You have got to have a  coordinator  who  is  capable,

                    You have got to have a RAG that  functions.  You  have  to  have

                    a grantee that will stay in  its  fiscal  administrative  box.  And

                    to that, then, the committee appropriately in my view, added

                    the outputs in terms of dollars in and what then happens Is

                    In the region in terms of project as staff activity result.

                              So this wasn't an arbitrary set-- it Is simply

                    c I ti'ng the ground rules on which all regions need to  be  judged.

                              MR. BARRC)WS:  Plus the  consideration the  new  program

                   would be'better off without having this to--

                              DR. P-AHL:  Dr. Scherl is., I believe, has a  comment,

                    before we respond to what those points wer  in  hese cases.

                              DR. SCHERTIS: I admire the fact  you  have  set  up  what

                    appear to be rather rigid criteria. I  think  it  is  the  Interp-

                    retation of these.criteria of the individual proejcts that

                    obviously you have to fall down and have to fail,

                              Because as we are speaking for the coordinators who

                    are resigning, seekina, other positions, who  have  found  other

                    positions, I think a great deal of our  response  to  these  appli-

                    cations admittedly is based on rather soft sand, as far as




                                                                          14 j

                    trying to be as rigid as we might be a year or two ago.  We
                    don't have the potential ability of saying, well, we will let

                    them vet started and site visit them.
                        C>

                              We don't have the potential threats in terms of the

                    careful supervision.

                              We lack the central staff,, on and on and on.

                              Ancl a great deal of the determinations here, regar

                    less of what we can hope or assume we use these criteria
                    really become more qualitative and less quantitative, I think
                    that goes without saying, just as some of the criteria used

                    are-rather ephemeral in terms of utilizing them.

                              Let me speak to Oklahoma.  I think this is one of the

                    three al-'nce T was a reviewer.

                              DR. PAHL:  Why don't you proceed with  Oklahoma., since

                    you were the reviewer?

                              DR. SCHERLIS:  Yes. I site visited Oklahoma, and

                    this is a program that has changed very significantly since the

                    time that I site visited It.

                            The rating of average minus is probably taken from
                    my formal review,.that I handed In and this was based In great
                    measure upon my recollection of the area as it was when I

                    was last there and what I could deduce from the document.

                              Remember that none of us at this time have the bene-

                    fit of.the very carefully documented pink sheets we used to

                    have which I found to be extraordinarily good,  And we don't





                    'have the evaluation of all the preceding letters, site visit,

                    documentation and so on,

                              There Is little question in my mind  that  Oklahoma

                    has moved from what was essentially a post-graduate training

                    program, educational parade, through the statelinto what I

                    think now is a very exciting potential network for better

                    medical care through the area.

                             @They have a new coordinator,  The program that he has

                    designed here I would view as being something that could fit

                    into whatever survives, whether It Is regional  medical  program

                    or regional planning councilp or comprehensive bulk programs :)x

                    what have you; theseere networks which I think will  lead  to

                    better care in Oklahoma.

                              I don't reach this decision Lightly.   It was pretty

                    well forced on me after a very vehement, active   discussion,

                    and I.  for one, support the ree6mmendation'that has been


                    made.

                              The grading of average minus was from  my  original

                    sheet. In terms of the discussion that took place  here,  I  was

                    impressed with the fact that this group has  changed  directions

                    significantly, what I will think will be very  helpful  whatever

                    form planning takes and whatever form actual  application  takes

                    in this region as far as whatever survival will be of RNP.

                              I could detail the document.   I would say this,  I

                    was most impressed with the change. I had viewed If Oklahoma




                    had come in this way two years ago, it would be by now one

                    of the better states.
                              It is very heavily provider oriented, but I
                    think one year to go, this would be a more fruitful way of

                    moving than in another direction.
                              DII. P.AHL:  Thank you very much,, Dr. Scherlis.
                              Is there further discussion concerning the Oklahoma
                    application from staff@or other committee members?
                              Dr, Hess, I think that is responsive,
                              DR. HESS: I am asking is there reason for optimism.

                    I think that is putting It in a nutshell.

                              DR. SCHERLIS:  It has changed markedly.
                              DR. HESS:  The only question I would ask,, you don't lia,

                    to elaborate--
                              DR. PAHL:  These are  Very valid points.  This is the

                    purpose for this session.  It is In order.
                              DR. SCHERLIS:  I was asked at the meeting how I reacti-
                    &d the conclusion and I wished that I had had your points
                    score to use. I said It was a guts reaction In a great degree,
                    and I think all of us eventually have to come to that honest

                    admission.
                              DR. PAHL:  If there is nothing further In Oklahoma, E
                    believe one of the other regions that could bear some discus-

                    sion was Bi-state,
                              I am not sure whether the reviewers of Bi-state are






                    here or not.


                              MR. POSTA:  No.

                              DR. PAHL:  Theno Mike; could you be  responsive

                    to Dr.Hess' points and perhaps just clarify a little  bit

                    further some of the thinking that went on with  Bi-state.

                              MR. POST.A:  Well, I think In my earlier summations

                    it was as succinctly put, they did come In with an application
                    of $L,@l million, and they were cut back to $8oo,ooo, which

                    Is not only well below the targetted figure, but about

                    $7L,000 below the projected L2-month funding level  for  this
                    region. And that was, In my opinion, a punitive action.

                              Now, whether that action was as punitive as panel B

                    would have taken would be up.for debate.

                              DR. HESS:  The question I would raise is, you know,

                    to try-to bring some consistency into how we deal with regions.

                    Is there a staff and a RAG that can effectively use  that

                    $700,ooo-$8oo,000 next year?  And, you know,  have  something

                    worthwhile to come out of it that justifies that amount o

                    money and justifies continuing that RMP?

                              MR. POST.A:  Well, Doctor, I think the main concern

                    again is the past track record of this regi@  which  has  not

                    been too good.

                              Now . we do have reason to believe that Dr. Felix

                    will be coming onboard to serve as coordinator,  -And I am sure

                    that many of us in the-room know Dr. Felix. He  does  have  a




                   terrific track record himseLfe  And will be and has been  in-

                   volved to a degree in the application which was  drawn  up.  And

                   some of the activities that he has go t certainly the-- I shoult
                   relate staff feels that $800,000 is not an excessive figure.

                             DR. HESS: Your basis for optimism is Dr. Felix?

                             MR. POSTA: At this times yes,, sir.

                             DR. HESS:  Something will depend upon which to

                   base optimism.  That is all I am looking for really.

                             DR. PAHL: I@- there any f urther discussion or  commen

                   by anyone on Bi-state?

                             If not, let's turn our attention to Louisiana,  And

                   again, I am not certain who the reviewer on the  committee  was.

                             is there any comment from the committee on Louisiana)

                   or perhap4 Mike, we can turn back to you,

                             Go ahead, Mike.

                             MR.POSTA: Louisiana did come in  with  an  application
                   of $8oo--$985,000, which was 77 percent of its targeted

                   figure.

                             This is a private corporation that Is the grantee.

                   They do have a terrific track record as far as expenditure of

                   funds,  They have had very little unexpended balances,

                             The Indirect cost rates have been extremely nill in

                   this particular region. It has been well managed. They  do  have

                   a couple of outside consultants who have stayed with the program

                   since it was terminated.





                                                                           140


                              Staff ancl the review rs felt tha t this region accepted
                                                   e

                    the termination orders or the phaseout  orders  very  strictly,

                    And when they said close down, that is exactly what they

                    decided 'to do, is to close down.

                              However, in the State of Louisiana, they have to

                    notify the Secretary of State within six months.of termination

                    to carry out that termination or liquidation.

                              In the meantime, we got a continuation order to

                    continue as a result staff did carry on. They  did  hire  a  few

                    more,people. They brought  back  their  deputy  director.  How-

                    ever, at this time the staff Is limited  in  scope*  They  have

                    hired four additional  peopld-  Dr..Sabatier,  the  coordinator,

                    is back on board, about 50 percent of the  time.  I  can  truth-

                    fully say-in visiting the region two months ago with Mrs,

                    Zi2lavsky, that the chairman of the Regional Advisory Group

                    and the chairman of the evaluation committee of  this   particu-

                    lar progra mare exceptional people.  And  their  Regional  Advi-

                    sory Group does function quite actively and does not fund pro-

                    grams unless they are.@ exceptionally well monitored  from  the

                    start. That is, they do not fund just to  be  spendino,  federal


                    money,


                              DR. HESS:  I guess my question the main thing I

                    would ask is are they doing appropriate things  for  people  In

                    the region and is there good leadership there?

                              In other words, are things looking-- is there a





                    basis for optimism for next year?

                              MR. POSTA:  That-is speculative, Doctor.

                              Based on 50 percent of the cootdinator's times based

                    on the fELct this is a corporation that would be phased out

                    on time with no expectation that this corporation will

                    continue as a grantee, the,same as many of our say universi-

                    ties will continue to function,ancl will be able to monitor
                    toward the enclp I think all of this was considered when the

                    overall comments or grading to this region was below average,

                              DR. PAHL:  Thank you, Mike.

                              Sister Ann.

                              SISTER JOSEPHINE:  Your last comment kind of preempt3

                    what I am going to ask.

                              Over the years I have heard us from  time to time
                    concerned and particularly 'indirect costs and  direct costs
                    also,  when a university is the grantee agency.  And in terms
                    of utilization ofi.cl6LIarb'@to'pr'ovicle-services and development
                    of programs, it has been the experience of this program that
                    where the grantee agency was other than the university we

                    got more dollars down in.services and in programs,
                              Your last comment was a Little disturbing to m

                    wonder are we going to reflect on that experience and do you
                    think reflecting on it, itis going to probably 'appear in the
                    new guidelnes for whatever this new model is that Is going to

                    be developed?




                                                                           50

                              DR. PAHL:  I think.I can answer for Mr. Posta and say-

                              MR. POSTA:  I had' hoped you would.

                              (Laughter)

                            -DR. P-AH L:    a number of us are hopeful that the

                   experiences will be translated into action as we  go  into  thiB

                   new phase.

                              Mr. Rubel., who isn't here this morning, I think would

                   say that in his various task forces that he has set up internal

                   ly to try to plan something concerning the organizational

                   framework and direction and policies, he has :@:ineluded a  num-

                   ber of people -- for instancemr. Peterson Is In charge of one

                   of the subcommittees working with Mr. Rubel  in  designation  of

                      sible health service areas.  And we have
                   pos                                          RMP people  on  all

                   of these little subcommittees.

                             Unfortunately beyond the agency Level I  am  not  cer-

                   tain howmuch of what we talk about will survive, but there is

                   a very real intent to try to take the best from both the

                   CHP and RMP and Learn from it.

                             I think there is some reason for optimism in this, but

                   when one comes to a specific point, such as the one you are

                   referring to, I don't have any first-hand information. Maybe

                   someone in the room knows, but we are concerned with maximum

                   impact, with available doLlarso and utilization of skills and

                   techniques that have been developed.

                             I think in many cases the Congress is going to be






                    more alert to this than possibly some of the elements in the

                    administration.


                               SISTER JOSEPHINE:  I think I am a little sensitive

                    0-n :this point, maybe oversensitive.

                              But I-remember a number of years ago we were just

                    doing a little study on one of the OEO programs and It took
                    $6o,ooO to get $1,000 down to the people.  It is disturbing.

                              DR. PAHL:  Yes.  Yes4 We are having a meeting at the

                    other end of  thehall oh arthritis center  program  and  yesterday

                    afternoon that same discussion came up as we look at the

                    available dollars and what can be done to have an impact, and

                    then see the cost-benefit.  So that there are many groups

                    that are recognizing we have to reconsider -this and I do hope

                    we benefit from It.


                              Bob.

                              MR. CHA14BLISS:  Yes.  I thin@ Sister, and there is

                    some indication that there will bebenefits from   past experience s

                    in that in the new legislative prooo,@,als, the operating agencies

                    are shown to be nonprofit corporations, that deals  I  think  spe-

                    cifical ly with the question that you were raising  about  the  in-

                    direct cost.

                              There will be a new set of grantee types under the

                    new legislation,, that is as it is now proposed.

                              DR. PAHL: To return to the business  at  hand,  I  would

                    like to ask if there is any further discussion on any of the




                                                                          52

                    findings, recommendations on the applications, because if

                    not, then the chair,W-Ill understand that the findings and recon

                    niendations which have been made and discussed here are those


                    which are adopted by ti ie committee and will be passed on to th@,

                    NationaL Advisory Council.

                              Mrs. SiLsbee.


                              MRS. SILSBEE:  Dr. Pahl, I would like to suggest

                    that the gist of.this discussion that has taken place  in  terms

                    of the bounce between 'the two, be sort of a preamble to the

                    Council, which will have an opportunity to look at all of the

                    actions again,'that this might very well be kind of a caveat

                    that the committee gives to the Council In looking at the lndi -

                    vidual actions.


                              DR. PAHL: Yes. I think as  is  customary,  staff  does

                    try to reflect as welles we understand what we hear for the

                    Council, so that they can act in an intelligent fashion  on  the

                    various recommendations. And we are sensitive  to  the  problems

                    that you labor under in two separate'groups,

                              We had no choice but we will try to reflect the

                    various interpretations and shades and interplay of feelings

                   .not only by the sheets but by all the record that is here in,

                    the staff in the room.  So I think you should be assured of thil

                              Dr. Miller.


                              DR. MILLER:  Could you give us an overall summary

                    picture of what we have done noiq?




                                                                            53


                               How much did we approve and--

                               DR. PAHL:  I am delighted to do that.

                               DR. MILLER:  How does it look in terms  of  the  July


                     process?

                               DR. PHL:  Ye.-,, I am delighted to Co that.  Because by

                     coincidence, it makes calculation which I had  made back in

                     March appear very brilliant when really it was just sheer

                     coincidence.

                               The total figure that apparently the/two panels

                     have  approved with the various modifications this morning

                     comes out to be aIrecommendation of $85,047,297 for June Coun-

                     cil awards. If Council goes along  with  all  committee  recom-


                     menclat,@ons.

                               This is from an anticipated amount available for boti

                     June and August awards of $114 million -- let's just leave it

                     at $114 million, because you will recall  from  the  discussion

                     I had the other day, because of the unsettled state of the
                     litigation, we are still talking about between $109 million

                     and $114 million,

                               If, however, we-do have the  $114  million  available

                     for support of RIAP recular type programs, the recommendations'

                     $85 million asa result of this committee meeting would represe,'Ii

                     usina, 74-1@ percent of the total available funds.

                               This is very encouraging.  Because back in March we

                     had to establish an allocation mode between the June and




                                                                          54

                    August Councils and we had arbitrarily at that time  set  aside

                    7@ percent, precisely, for,June and 25 percent for August.

                    And at that time we didn't know-- we hadn't even issued the


                    Instructions for regions to prepare applications.  -And we also

                    didn't knoi4 within $30 million how much would be available  to

                    us*

                              So as I say, It is sheer acc ident and not due to som@

                    Texas instrument  that was hidden away somewhere.

                              So basically you have approved 75 percent of probably

                    what would be the dollars available to us.

                              If the Litigation does award $5 million to  the Deparb.

                    ment for some of-its other purposes, which are certainly

                    directly connected with the forthcoming phase, this would still

                    bring us within about 79 percent; your recommendations would

                    be about 79 percent of the total funds available.

                              So that come your July meeting and the August Council

                    me are right oh target with about the proper ration if  you  go

                    back to my 75/25 percent.

                              Dr. Schertis,

                              DR. SCHERLIS:. @,ny of these projects will st,4
                                                                            .rt

                    as of a certain date, but obviously won't reach full  staff  or

                    full operation for a significant period of time after that.

                              What happens to those funds which are left either at

                    a local level or at a national level as of July 1975,  give  or

                    take whatever period of time the extensions are?





                              DR. PAHL:  The only strict requirement which the

                    Administration has placed on this is that RMP's may not in-

                    cur obligations beyond June 30, 1975.  Thus contracts can't-@be
                    written beyond that le'gth of tineand there comes a moni-
                                          n

                    toring and surveillance issue at hand, which is the same one

                    that any prorrre,m faceei@which we faced last year as prorre,.m is

                    scheduled to terminate and how do you handle on-going activitiE!.@

                              We are.'ac'u-iv'ely involved, as I think I mentioned yes-

                    terday, in trying to get the-Aelministration to put forth what

                    a federal responsibility is.

                              I don't believe we have the exact answer., but in

                    general, over the coming monthso all.'Of us who are involved in

                    headquarters operations truly believe that there will be

                    mechanisms developed and guidelines developed that moneys would

                    be able to be spent for the purposes intended and there will be

                    continuation of monitoring and surveillance,

                              We certainly don't wish to see contracts entered into

                    and then June 30, 1975, everything terminated again.  And we

                    are trying to plan since we have a whole year ahead, the answer

                    isn't here, but that is the clear intent and interest.

                              Novi, with the business of applications aside, I

                    believe, I know Dr. Teschan has one or two points which he

                    would like to bring to the committee's attention and perhaps

                    there are other matters of business before we adjourn,


                              Mr. Barrows.




                                                                            56

                               MR. BARROEIS:  I just wanted to take one  moment  to

                    say on behalf  of ray fellow reviewers how much we  admire  the

                    strength and dedication that staff has exhibited during this

                    extremely trying time.

                               You have got.a great bunch  of  people  here,.compe-

                    tent.  They are straight arrows and whom you can believe.

                    We hope you can keep your team together.

                               (Applause)

                               DR. PAHL:  Well, on behalf of the staff, it is a   pLee-

                    sure to hear it.  I  already know it, but I do thank you very

                    much.


                               There is nothing we can do without the staff that we

                    have.  They have been extremely loyal under circumstances whict

                    you recognize as difficult and which Indeed has been the case.

                    So thank you very much.

                               That is one of the rewards for being one of the

                    faceless.,nameless bureaucrats, able to accept that on behalf of

                    the   staff.


                               Dr. Teschano would you like to bring up the points wti@

                    you mentioned to me before the meeting for committee discussior?

                               DR. TESCHAN:  Sure.

                               Ken Barrows has just preempted point one.

                               I look at Ken for having said it the way it needed tc

                    be said.


                               The matters that I think we might consider as a orouf)
                                                                                 C:)




                                                                           57

                    are som recorlmendatior-is to Council, generally three.    One

                    we have already dealt with I thinks and might go without sayin7,

                    but I hope that Dick and others who  were  preparing  these  things

                    might also focus again on  the point that we do  need  to  reiter-

                    ate that we would recommend strongly to  Council  the  whole  facts

                    in the matter of thooe;policies that your RMP'B has used throu,7,t

                    the years and I refer  specifically to the  August  30th  issuance

                    of Council for 1972,  that they be very sure that as a matter

                    of fact each region is  in compliance with that policy before

                    funds are allocated,   That is to say, that  that  can  accommodate

                    a firm contingency.

                               I think that is not only  correct  from  everything

                    I have said, but it is also a fairness and human -- Its'

                    essential intrinsic Integrity in  the  program  be  maintained

                    so that all of the regions are dealt with thesame way,

                               I am very sensitive to Dr. Hess' concerns on that

                    and I think we did a good job.  I was satisfied and learned a

                    lot in Listening to how we dealt with that particular issue.

                               This is raised much in that same viewpoint.

                               Now, the other two things I happened  to  have  written

                    out I am going to leave copies with Herb here in  just  a  minut-e
                    and they are issues that also came up in our discussions in bo@t

                    panels undoubtedly, but I want to  put  the  following  little

                    comment; that is, while I am sensitive and meet at every hand

                    in all of the discussions I have the kind  of  thing  Dr.  Schorti3





                    pointed out we just seem to have this year left, Lord  knows

                    the coordinators have been faded with that in their  regions

                    and in discussions with 'one with the other.  But the critical


                    issue is I think we have to look  at the context of the era

                    in which we Live and not .zimply be caught in what appears to

                    be the near-term procmrammic potential or efforts.

                              We are bold on every side that RNP Is going to finisi

                    so our job here is to give i't a decent burial and to utiLize

                    funds as well as we can, and allow slippages because Lord

                    knows there are slippages.

                              I would take the-other view that we are not dealing

                    with the next year.  We are dealingin history up to this

                    time, and we are dealing with many years to come in which this

                    particular year is one of several turning points.

                              I don't think thi-ols a one turning point; I think It

                    Is one of several turning points.  Therefore, I feel if we

                    are going to conduct our business responsively we need to

                    conduct it with a clear recognition that what we do now and the

                    integrity with which we do it must necessarily influence to an

                    unknown, but to some degree what happens hereafter.

                              So that when we have considered some of the regions

                    and when we sounded a little bit pedantic, perhaps, in citinm

                    the August 1972 policy, that you have got to have  these  ele-

                    ments and there has to be regional support within  the  region

                    and a good imave in a region for a region to warrant continual o




                                                                          59


                    et cetera.  We have done that with the notion that If the


                    RMP in a region is goin@ to be useful for something hereafter,

                    then it needs to have that quality of Image or quality of

                    function in a region that is going to be worth something to

                    build around as the foLlow-on version, following RMP, et

                    cetera,

                              It is terribly lmportant.that the issues and profes-

                    sionalism and quality which are so clear in the  superior  region

                    application particularly, be the hallmark in contrast to all th(

                    other alternatives of which there are plenty.

                              So it is really on that basis that I feel the

                    Council now has a particularly vital turn in the road,  a  fork

                     n the road to confront. Either the Council can take  w@  t  to

                    me seems to be a defeatist attitude in saying, welL. we are

                    only here to occupy space and to while away the  hours, or  the

                    CoLAncil can contribute in some small measure to tidying up the

                    situation.  And in strengthening the regions for  the  transition

                    period.

                              Therefore, it Is with that in mind that there are


                    two statements in perhaps somewhat-- well, there are  two  state-

                    ments that in my view this group might consider for recom-

                    mencation to the Council for a formal policy statement  to  the

                    region. In other words, it is not just a  recommendation  to  the

                    Council, but recommendation Council take these and  issue  them

                    as- guidance policy to the regions in the country for their




                                                                          bO


                    implementation and guidance, it  is a two-step operation.

                              First of these has'to do with getting ready for the

                    next phase.  And a statement which says that might.read some-

                    thing like this:

                              "In view of legislative developments now underway fo-Y

                         further evolution of RMP, In association with the CHP and


                         HIIL-Burton programs, in the interests of national health

                         planning, Council ':encourages RMP's to develop brganiza--

                         tional readiness, structural changes,  and any remaining

                         regional relationships which'ar-e appropriate to lead,,

                         participate in and accommodate the anticipated new opera-

                         tina- structures and requirements. The purpose  of  this
                           C>

                         orientation is to preserve for the new formats within

                         the states and regions  the  capabilities and voluntary

                       .cooperative  relationships  which  the-RMP experience  has

                         created."

                             That  sounds a little platitude an  'a-Itruistic, but

                    I think if we have  organizational  structural arrangements in

                    a regions that defeats the region's capabilities  in  getting

                    ready, being an appropriate participant in the new development,

                    that those  organizational changes should be made.

                             The second recommendation for Council policy and the

                    request to HEA, as I understand, might read like this -- and

                    It has really to do with CHP's -- it might read like this:

                              '@ihile recognizing legislative mandate and DRMP





                         regulations regarding R14P-CHP  relationships  Council

                         requests that the national CHP leadership  transmit  to

                         areawide CHP (b) agencies nationally the  mandate  for

                         fully reciprocal relationships with  RMP'S,  especially

                         in calling upon RMP assistance for professional and

                         technical input Into ongoing CHP plans development;

                         and In the interests of fairness and  full  reciprocity

                         Council furthermore agrees and instructs ad hoc R@IP

                         review committee and staff to set aside any influence o

                         negative CHP comments upon an RMP application unless the

                         commenting CHP(B) agency has provided the R14P with, one.,
                         the criteria and a description of the (b) agency review-

                         and-corament process
                                              and two, a List of the (b) agency

                         objectives and priorities upon which at least  a  part of
                         the RMP response should be focused."

                              DR. P.AHL:  -All right, thank you.

                              DR. TESCH.AN:  I would like to move the acceptance of

                    these, or for any purpose,

                              DR. PAHL:  Thank you.

                              Perhaps the committee would like to  discuss  the

                    first of these in order, or have the first one reread.
                                                             7

                              What is the committoe's       am sorry in a  sense

                    that so many of our members had to departs because  I  think

                    these issues are Important ones, and I am also sorry Mr. Rubel

                    is not hero for the closing session, because I believe that he




                                                                                62


                     would have been quite impressed  to  see.  the  kind  of  activities

                     and discussions that have ensued over this period,       And   also,

                     of course, with this theme which is something which we are

                     all,concerned with, the' reciprocity of action.

                                But  beyond  tt iat, what is your desire in this matter?

                                Woub you care to discuss these?

                                Dr.   Scherlis, you look like you are  about  to  make  a


                     comment.

                                DR.  SCHERLIS':  Sort of digesting what you said.

                                I anree completely with every word you said and woul(i

                     be pleased to second.


                                My big concern is really what effect this would have

                                -As all the people at this table have, I have been on

                     site visits where   you have contact with various (b) agencies

                     and-(a) agencies,   and I must confess  that  in  terms  of  profes-

                     sionalism and in terms of objectives and goals, I hav     e  to  say

                     one can point to   rare instances, at least in the space that

                     I have been able   to visit,  where  (b)'agencies  or  (a)  agencies

                     have been relatively effective

                                My big concern is really  what  will  happen  to  all  of

                     the work which RMP has accomplished?

                                I remember when RMP's first started, trying to

                     describe  what-regional  proper.@venture,iqas..  These  words   were

                     meaningless to  me.  I  'think  in  terms  of  their  effectiveness,

                     the various projects that  wecarried  out  only  speak  to  a  small




                                                                           63

                    part of the accomplishment.

                               I strongly support both statements.  I just question

                    what will  happen to them.

                               Perhaps you can alert us to what you view as the

                    probability as to what will emerge from CHP and RNP and

                    Hill-Burton at this time.

                               I am more impressed with both the planning and pro-

                    fessionalism and the discernment of need by RMP  as  compared
                    to the (b) agencies and (a) agencies, even those communities

                    where they are supposedly relatively affected.

                               I think- there Is an obvious need for these groups

                    worV,Ing, together.

                               This Is a problem not only of logistics, but day to

                    day political strategy and this is where I have a real concern

                               I am more impressed with the relatively objectivity

                    of RMP's as compared to the relative lack of  objectivity  of
                    (a) and (b) agencies.

                               The sorts of letters that you read and request after

                    request from the regions in terms of the review process of (b)

                    agencies and (a) agencies, we like that. But  we  don't  like

                    this one.  We like that one; that one is just great.  And you

                    come away with you just don't know what the basis for the

                    evaluations are and this is where I would strongly support both

                    of your statements.

                               I would just -hope that they would do more than just




                                                                           64

                    go to the CounciL.   I viould hope that whoever sets policy,

                    whoever that mioht be$ whatever dark room,  that  somewhere  this

                    would -glimmer in and possibly shed some light on what  could  be

                    a very complicated prot-,ess,

                               DR. PAHL:  Well, without responding completely

                    to your question, because again I don't think that  I  can  speak
                                           i
                    from a nonbiased point, of view, I do believe that. from our  ob-

                    servation of what It is we do in RMP, relative to  what  I  see

                    happening In CHP'S, I  must say that as the  program  director

                    here, I subscribe to  everything you have just said.

                              We are trying to work more  closely  in  headquarters

                    relationship. We have been Interested in  trying  to,  as  you

                    know  strengthen the CHP individual agenci
                                                                es, planning pro

                    cesses.  I honestly don't know  6ut of my personal experience of

                    one program that has actually tried to do  more  to  cooperate

                    with and support another program than RMP has throuah the years,

                    the comprehensive health planning effort.

                              And it is only recently that the headquarters staff

                    have been interacting and that is as a result  of  this  fune-

                    tional reorganization that is going on.

                              I think the statement is a very  good  statement.  I

                    would be pleased to give it maximum impact  within  the  agency

                    because I know there are many Individuals who  feel  the  same

                    as you have expressed that there is an imbalance  hero  in  the

                    way this is being discussed, looked at.  -And to the extent thau






                     the Council would like to adopt   this as a  recommendation,,

                     whether they would or not this is what we are trying to do

                     as staff.  But I think it could have some greater force if


                     it w  e a Council recor@noation.


                               Perhaps I shouldn't say anything about the first one

                     since we haven't discussed that point..

                               So from staff point of view, we would not be adverse

                     by any ,neans to @akin  such a recommendation  to  Council,  and

                     I believe a recommendation by them to the -Administrator and he@,.d.

                     quarters staff, and perhaps  higher  throu-h  the  Department
                                                               C)

                     could, again, bring to the attention of peo-ple the feeling and

                     sense not only of this group, but  of  the  entire  organization

                     tiat is connected with the RMP program.

                               This has been said over and over again.  This is ano-

                     ther way of saying it.  But it   is a good t-ime to say  this

                     because it is important.  -And  I believe that it could have so,,n()

                     impact and it should be said,  because I think what is being

                     stated is true.  So ,aany times the RMP's have tried to assist

                     and get the advice of the local agencies and in fact  have

                     found that there is very little relative to the kind of streng-il

                        and there are many good reasons for this.  It is not deraean-

                     ing the CHP (b) agencies by any means; there are a good  many

                     reasons. But all of this should go toward providing a  better

                     future for all of us.


                               I thinkwe are looking to the future, not trying  to




                                                                                66


                      investigate what happened in the past.

                                 DR.  SCHERLIS:  Point  of  information.  As  you   made

                      the motion, where did you wish this to be transmitted to

                      Council or to Council and to appropriate agencies?

                                 DR. P-AHL:  It can be both.


                                 DR. SCHERLIS:   It can be both?


                                 DR. TESCH-AN:  I felt the first   step,  formal   Council

                      recommendation, that  then  becomes  instruction  to  staff  to  get

                      the message at the staff level here.  But I am more concerned--

                      well@ equally concerned  at  this  point  that  the  regions  have

                      strong Council  backing  and  I  recall  clearly,when  Council  made

                      a statement, I don't think Council ever understood how

                      impressive  that  was  to  coordinators,  regional  advisory  groups

                      et   cetera.

                                 This Council pronouncement of encouragement, et cetei,e

                      more or less I expect from region to regions but generally had

                      a lot to do with how we shaped our sort of concept of how we

                      should be conducting business.

                                 So while intangible,  I  feel  it  has  a  terrifically

                      important potential impact and particularly now.

                                 So a' strong move to Council, and if Council then

                      says it, it becomes  encumbent  on  staff  as  executors  to  some

                      extent@ on Council  advice,  that  that  would  carry  forward  in

                      the further deliberations.

                                 DR. PAII L: I presume  this  recommendation  would  be  a



                                                                           67

                    recommendation by Council to the Assistant Secretary of

                    Health, because obviously our Council has no responsibility

                    over comprehensive health planning but through  the  Assistant

                    Secretary of Health.  A'nd there could be coordination of efforts

                    within the bureaucracy*


                              Sister Ann.

                              SISTER JOSEPHINE:  Yes, I too would Like to support

                    this type of acuiviuy.,  And, you know, in reflecting  back  on

                    the program and in reflecting on something that came to me

                    in a note from one of the members here, you knows the

                    Regional Medical Program has had something of a Year of Camelot;

                    you know, we return to Camelot.  And the knights retUrnod

                    and the armies of the Middle East shing up -- (laughter)

                    but, you know, it is so gratifying to me to see we still dream

                    dreams and that the innovative program, you know, still has


                    that spark.

                              I believe that we canltsay a thing too often, because

                    one day someone might just listen ancT hear it is what  we  are

                    saying,

                              I would think  it is very important that  gets  wide-


                    circulation.


                              DR. PAHL:  Mrs. Wyckoff.

                              NRS. WYCKOFF:  I agree wholeheartedly with that


                    statement.

                              I hope somethin@ can be done so this conversation and




                                                                            68

                     this resolution we have will be passed along in such a

                     way that it will not be lost  through the decentralization

                     process that seems to be contemplated,

                               I was very sad to hear you all act as though you

                     were goino- to be gone very sood.

                               DR. P-All L: Not everyone, just--

                               NRS. WYCKOFF:  It just means HEW regionalization,

                     which is very aii'f'eren t from our R14P re'gionalization,
                               I hope that;something can be put in the mill  so  that

                     this  will not be lost in the dreadful shook of pulling the

                     center magic apart.

                               DR. PAHL:  I hope so.

                               I don't think this is the point, to get into that,

                     But  it.is quite possible that under new legislation be that

                     enactment of extension legislation for the  individual  programs

                     or  health resources planninc, legislation, unless there is quit-

                     a different environment I suspect the Department  will  probably

                     make the determination that this program should be decentral-

                     ized in the regional offices and our staff-fully understand

                     this, And this would mean basically very few individLats

                     would actually go to regional offices, because they would firfcl

                     satisfying work locally which most of them would prefer  to  do,

                     so that would mean positions would go to regional offices.

                     Our staff would be reduced in members by that amount and

                     functions would be shifted to regional office and the




                                                                         69

                    character of the program I would have to say I think would

                    probably suffer In the initial stages at leasto because there

                    would be many new faces handling RMP responsibilities in the

                    regional offices.

                              14RS. WYCKOFF: Will decisions be made at the region-

                    aL level for many of these things we are now making?

                              DR. PAHL:  Yest that is what@i s contemplated.
                              ICS. WYCKOFF:  That is the thing,

                              DR. PAHL:  We will have National Advisory Council,

                    that will come back.

                              IM. WYCKOFF:  If that is kept in the legislation.

                              DR. PAHL:  There are so many if8.  But the armo ur

                    is not completely rusty.

                              Dr. Hess.

                              DR. HESS:  I fully support these two recommendations

                    in principle and would just like to suggest a possibility

                    of an amendment to each of them. The first one, as I thought

                    about that, 1 wondered if I were an RNP coordinator, how

                    would I respond to such a general directive when you don't

                    know what it is you should.be shaping up for or moving toward.

                              Ana so the amendment would be that if Council apla-o.v@E

                    this, that it be part of Council and/or staff responsibility t)

                    keep the regions informed so that they will know, you know,

                    be In receipt of advice as to how best to prepare for this kin@i

                    of transition.




                                                                          70

                              Novi, I know that is very hard to do and the  time

                    and the nature of the advice would be very important  to  not

                    keep things in a turmoil on the basis of  chanaing  signals,

                    But,nevertheless, just to say that without any further

                    guidanceaq, to what that means may not be as helpful as we would

                    like to have it be.


                              So that if you can get the sense of that really

                    further specification of that--

                              DR. PAH L:   appreciate that,

                              Actually I have a problem with perhaps  two words in

                    here, which I think bear directly on your point.

                              If I may read the statement again, Paul,  and  then

                    show what my concern is, because this is a concern  that  Is

                    shared.by many of us in headquarters in order to try  to  be

                    most helpful to the groups we are serving.


                              The statement reads:

                              "In view of legislative developments  now  underway

                         for further evolution of RMP, in association  with  the

                         CHP and HiLL-Burton programs, in the interests of national

                         health planning, Council encourages RMP's to develop

                         organizational readiness"--

                              And here is where I would like to delete "structural

                    changes."

                             and any remaining regional relationships  which  are

                         appropriate to lead, participate in and accommodate the

                         anticipated newoperatinrr structures and  requirements.





                         The purpose of this orientation is to preserve for the

                         new formats within the states and regions the capabilities

                         and voluntary cooperative relationships which the RNP

                         experience has created."

                              The reason that I personally, although we  will  take

                    your recommendation to what it is you wish-to say  to  Council,

                                  'I have problems with having the Council encoura,@"e
                    but the  reason

                    the rerlons  to develop structural changes at this point  is  be-

                    cause that is one of the primary uncertainties and is  still  th

                    subject o  de ate.

                              Organizational readiness capability,,closer  cementing
                                                                                  CD

                    of relationships in the regions is all to the' good.  But  both

                    CHP leadership and we and Dr. MargoLis and Dr, Endicott  in  our

                    various capacities know, both privately in the office  ancl,pub-

                    licly@ have urged groups not to jump the gun into what'they

                    presume-to be the proper organizational structure,

                              So I have a feeling in reading these words about

                    organizational structural changes, this would encourage some

                    people to move perhaps faster than would be for their own

                    good.

                              In terms of keeping regions informe(; I think we  all

                    again, in our separate capacities, and with what  knowledge  we

                    have, are trying to do this.  Some groups are moving ahead.

                              For example, there has been a change of grantee in

                    Northern New England just recently, but It is not as  a  result




                                                                          Y2

                    of the last few months' thinking,  They have been doing this

                    now for a couple of years and thinking about it.

                              It has had a lot of thought.

                              Others are trying to anticipate the  exact  outcom

                    of the Legislation and are trying to be there when It happens,

                    and both Mr. Rubel and I and, as I say, our administrative

                    superiors indeed are cautious people against undue haste.

                    That was my only concern, Paul, with your statement.  But   I

                    don't want to impose my concern on what may be the committee's

                    wish to transmit.

                              .So I would like to have that point of view further

                    explored, If you will.

                              DR. TESCHAN:  I would like certainly to respond to


                    that.


                              Sometimes I think this kind of discussion, or at

                    least issue we are now talkinT about, is a liattle bit,, oh,, a

                    little -- it is distinctly unsubstantial.  It is ethereal,

                              First of all, practicalities are nobody is  really

                    going to go to a lot of trouble in any RMP to make largo

                    changes into something they know not what.

                              There are, after all, some pretty practical figures

                    and they have a limited amount of staff time for such busy worlc.

                              Moreover, I also think it is important for us to rem(@.m

                    ber that instructions or encouragement or guidance coming down

                    from Council 9,nd staff.is also paralleled by a good deal of




                                                                             73

                     information transfer between  regions  through  the  coordinator

                     organizations in HS-1.  Moreover', all the coordinators are

                     perfectly capable of reading the legislation and reading
                     the repo-rts on the committee hearings, et  cetera,'and  so  are

                     members of the RAG and some of them do.

                               So there are several routes.    I don't  think  either

                    .having it the way it is or not having   i-t the way it is is real-

                     ly going to_have any enormous impact.

                               I sympathizeviith this an d if you feel more com-

                     fortable and if the Council would then be able to be saved,

                     all kinds of minutes of backing and filling on such an unsub-

                     stantia.1 point, I would be perfectly happy with the notion for

                                                      of getting oriented toward,
                     making preparations for or sort

                     rather.than to actually put on  paper and get signed in som

                     crucial way a specific thing we know not  what  at  the  present

                     time.

                               Critical issue, it is  almost code, It is hard for me

                     to say what needed to be said.

                               DR. PAHL:  ExcelLent   statemen4 really is.

                               DR. TESCHAN:  But what is meant by structural changes

                     specifically is the not ion there are structures in some of the

                     regions, either the way staff is put together or t  he  way  RAG

                     Is built, or the  way the relationships  actually  work  between

                     them,, or who the grantee is or how that whole business works,

                     under the August  1972 policy, which effectively for many of




                                                                             714

                     the prime movers of health affairs in states and regions vitia.-,(

                     the'significance and possible impacts of RMP.

                               If RMP and RAG finds that Is the case, that particu-

                     lar corner of that statement was to  open  the  possibility  that

                     if there are serious -- if any part of that  is  a  serious  ball

                     end chain to the image and function of an R14P.in:.,' a,region, thiE;

                     would be a good time to get that out and to get it settled and

                     to move on its own merits, quite aside from what the fut.ure

                     might be.

                               DR. PAHL:  Sure.


                               DR. TESCH-AN:  It is to encourage those changes,

                     t@C y up.the ship, plug the leaks, get the thing ready for sea.

                     Because we are going to be in highe4  heavier  water  for  awhile

                     than we are right now.

                               So I think we really  ought to get  underway  with  It.

                               DR. PAHL:  To be specific--

                               DR. SCHERLIS:  He would like to have his statement


                     launched, I gather.

                               (Laughter)

                               DR. PAHL:  To be specific, we have had a spate of

                     inquiries in &olng into not-for-profit grantee structures.
                                  C>

                     That is all we have been trying to pull the bit of brake on for

                     their good as well as for what we believe to be sensible

                     reasons, but certainly not internal rearrangements, and the

                     kind of structural changes you are talking about.




                                                                         75

                              DR. SCHERLIS:  You would not be adverse to removing

                    those administrative covers -- what are you talking  about?


                    What kind of structural


                              DR. PAHL: We are heavily involved with it.,  more

                    people are involved.


                              It is their insistent demand we are here to serve.

                              DR. TESCHAN: My feeling on that, if in the region

                    thereis serious problem with a structural situation --

                              DR. PAHL:  Specific.

                              DR. TESCHAN:  -- let Lis,say, for example,, a nonprofit

                    corporation mode would be bet,ter for very good  independent

                    region reasons: then let's go now for a nonprofit-- for
                    its intrinsic merits in th@ regions not for something down the

                    road.


                              DR. PAHL:  That we are doing. I think we have a sen3E

                    and I think it is a very excellent statement.

                              DR. TESCHAN:  We can take those words out if that


                    part of It is understood.

                              DR. PAHL:  Is there further CiscQssion?


                              Dr. Hess.

                              DR. HESS.-  Yes,  On the second statement, again I wa-

                    looking at the practical application of that, and if your

                    Intent was that that would be applied in this next upcoming

                    two reviews, that being the case, I don't know that there

                    would be information to be able to apply that criterion to




                                                                            76

                     knowi4aether or not each (b).agency had submitted its criteria

                     and priorities, and so on,,to the RMP'S. I don't  see  how  that

                     is implenientable during the next-- these immediate two

                     reviews -Ln the next month or so.


                               DR. TESC@N:    I don't think that should bother our

                     deliberations,  I think  it is the resolve of our group and if

                     Council backs It,, which is really the question, then I think

                     we can deal with CHP comments on somewhat more  official  grounds

                     within the RMP review process than we felt really comfortable  Li

                     doing up to now.

                               I have been concerned, but reassured by the  last  two

                     days. I was.concerned when I came here that we  would  be  worry-

                     ing. We would be unduly influenced by insubstantial grounds  f:>:

                     negative comments from CHP.  We have not been to.

                              What this will do as I see it, the purpose  is  really

                     not to influence us so much if we already agreed to It, but

                     I would hope it would strengthen Herb's hands and that of

                     his staff in conducting their business with their counter-

                     parts in these new a.6 hoc subcommittees. And  will  also  influ-

                     ente the regions In how.they deal in the future,, regions at thL.9

                     point, seeing'the ascendancy of CHP, may be increasingly en-

                     dowed as to how to seek    I think this puts it on a simple

                     professional basis.

                              DR. HESS:  My only concern is for these immediate

                     applications.






                              DR. TESCHAN: WouLdn't i-i-orry about it.

                              DR. HESS:     it seems,to me a little bit too tight

                    to apply.

                              MR. BARRUIS: Without respect to the recommendations

                    the fact of the matter is our panel, panel B, concluded that

                    all we can do would be to exai-aine the r-,MP's share in this rela-


                    tionship.

                              DR. PAHL: Surely.

                              MR. BARRUIS:  They had done what they were supposed

                    to doo  We had no way of measuring the other-- I think that

                    is a factor in the recommendation to the Council involved.


                              DR. PAHL:  Yes.  This picture certainly will be

                    presented to them, so that they can view this In its proper

                    perspective.

                              DR. HEUSTIS:  I would like to call for question on

                    the motion, as editorially amendedo without having you read It

                    again,

                              DR. PAHL:  Without reading, all those in favor of th(@

                    two motions, the first one as amended,, please signify by

                    saying .11 aye.

                              DR. PAHL: Opposed?

                              (No response.)

                              DR. PAHL:  Motion is carried andrecommendations will


                    be transmitted to Council.


                              DR. SCHERLIS:  May I state it be carried unanimously,




                                                                          7b

                    just for mntter-of recorCi

                              DR. PAH L: Carried  unanimously,

                              You might be Interested in hearing the  arthritis  groi


                    status report.

                              I am happy to  report they probably feel if they  were

                    panel C, they have the  tougher problem.  They are working

                    very hard.  Dr, Roger @son from Nebraska is  serving  as  chair-
                    man of that group.  Welhave a very fine ad hoc group with Y3

                    applications requesting I believe it is$16 million with  $4.2  m,

                    lion earmarked for the support of these pilot  arthritis  center3

                              The group yesterday spent the better part of  the  day

                    discussing -- this is a brand new concept.,not only program,

                    for us: but brand new concept as to what are the  elements  whici

                    should be in a center and how to give vari ous weighting to


                    these elements.

                              (Discussion off the record.)

                              DR. PAHL:  The arthritis panel is struggling with

                    $16 million in requests, with $4 million available and they

                    spent the better part of yesterday trying to develop the

                    element and important features of centers,  And they  scanned

                    through the applications in a descriptive fashion, one  by  one,

                    and about last night the time that you broke up I  believe  they

                    did also and came back to work at eight o'clock this morning  an(

                    are working today, possibly tonight, and possibly into  tomorro@i

                    morning.  Because they feel it is also important not just to




                                                                          79
                    spend @4.2 million as you feel  it is not just to  distribute

                    funds, impounded funds, but  to get something more out of

                    thiso,to get more than the sum  of the parts.

                              I am very pl eased to say they are very much aware of

                    it, and therefore I have a request to make of our own staff tc

                    stay around this afternoon and do their  post-committee  work

                    in the officeso because some of the people that you have seen

                    departing in the-last half hour or so here are being requested

                    to go into that room and tell that ad hoc Arthritis Committee

                    the capabilities of the region for managing what is a special

                    arthritis program.

                              So we are not trying to divorce this activity out of

                    the RMP activity,

                              I told Dr. Mason we couldn't be holding the Arthritis
                    Committee at a better time for having a full survey of 53
                    regions with as much Information as we can accommodate  right

                    now*


                              So I thought you would like that status report  and

                    soimhow those difficult decisions will be made.

                             Before closing, I would like to reiterate Mr. Barrow@l,

                    comment s f rom my ow n pol n t of vi ew, and I know f rom Bob s poi ni-I

                    of view on our own staff efforts.

                             We have been carrying two activities of arthritis an([
                    RMP applications simultaneously.  You do recognize, because

                    you have been with us for a much longer period of time, the




                                                                          bO


                    kind of' work and quality of work that has come out and you

                    have duly acknowledged tha.t for-which I am very appreciative.

                              The Arthritis Committee prior to the end of yes-

                    terday @,lso expressed itsappreciation for the quality of the

                    staff work, clone by agroup who I had never seen, who had

                    never seen ar hri is applica ion, had to read textbooks,

                    listen to experts,, do homework, and do staff work for that


                    committee.


                             .I think my very real personal impression &s I come

                    away from thes e two and three days of meetings is that I have

                    never been associated with a program that has risen really

                    to the need that they have, and done so in such a high  qualit@

                    fashion.


                              Many of them have been holding two jobs over the mortt

                    of May in older to get these materials for you, and so I'

                    personally thank them.  I know both Bob and Mr, Peterson,

                    chairinc, the other paneL@ do, and it is very nice to record that

                    and I am sure the Council will appreciate all of the work.

                             But in addition to that, I would also like to thank

                    you. It has been a very difficult job on your part to have

                    been away from the many changes that have taken place and  then

                    to come back and with the kind of short time and the  extremely

                    heavy workload, to do the kind of decision making that you have.

                              I think this morning's session has been  particularly

                    gratifying to me to be able to discuss some of these points,




                                                                         8 I

                   and issueso because we do feel a real respoiisibil@, ty not
                   for winding down a program, but for moving into title new phase

                   and maintaining the strength and Improving it where we can.

                             So again we thank you very much and we will look

                   forward to seeing, hopefully, all of you in July, and wish you

                   well on your return trips.

                             Meeting is adjourned.

                             Thank you;
                            ,(Whereupon, at 12:00 o'clock, tibon, the meeting

                       was adjourned.)