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                                                                       E001 742















                                       T R A N S C R I P T


                                    NATIONAL ADVISORY COUNCIL


                                             August 8, 1974






                                           C 0 N T E 14 T S

                 2    opening bv Dr. Pahl                                           3

                   f  Remarks by Jr. C. 'Robert Ogden                               5
                 3

                     Ogden Resolution                                             10
                 4

                 5   Comments of flembers of   the Public:

                 6              Dr. Donald Sparkman                               13.
                 7   Response of Dr. Richard J@neway to Remarks of

                 8              Dr. Sparkman                                      20
                 9   Arthritis Report of Mr. Matthew Spear                        36

                10   Comments, by Members of  the Public:

                11              Mr. John Sergeant (Plaryland)                     48
                12              Dr. Lawrence Scherr (Nassau-Suffolk)              57
                13   Review of  Applications for Regional Medical Programs:
                                Alabama (!Irs. Gordon)                            72
                14

                                Albany (Dr. Watkins)                              74
                15 1
                16              Arkansas  (Dr. Komaroff)                          79

                                  -State (Dr. Watkins)                            83
                17              Bi

                18              California (Dr. Janeway)                          90

                19              Central New York (Mrs. Martinez)                102

                20              Central I-lyoming-  (I-Irs. Martinez)           106
                21  Block Action                                                115
                22              Arizona (Dr. Gramlich)                          120
                23              Connecticut (Tir. Hiroto)                       122
                24              Inter-i,4ountain (Dr. Komaroff)
                                Louisiana (Dr. ia,-,eway)                       132
                25




                  1  Contents (Continued)

                  2              '4,aryland (,r)r. '@-@7ammock)

                  3              ilassau-Suffolk (.Tr. I.lIlliken)                 142
                  4              South Carolina (@ir. Haber)                       1-52
                  5                                                                153
                                 Texas (I-irs. r-loraan)
                  6              Virginia (Ilr. Hiroto)                            163
                  7              Northern Pennsylvania    (Mrs. Ilartinez)


                  9


                10





                12


                13


                14


                15


                16


                17
                .18'

                19


                20


                21


                22


                23


                24


                25










                               r
                                                           T k@





                3      IIATICNA!, 7.-DJISORY
                                                             r-dr.DICAL PPO(-PPIIS




                5


                6
                                                  Conference Room G-13
                                                  Parl,:Iai-7n Puildina
                                                  5600 Fishers Lane
                                                  Rockville, Maryland 20852

                                                  Thu rsday, Puqust 8, 1974.


                             The meeting convened at 9:00 a.m., Dr. Herbert P@.
              il@- Pahl,  Acting Di-rector, nivision of Regional @ledical Proqrars,

                   ?Dresidincr.


                 1 PRESI,-'NT:


                             r.T,P-ALD GARDFLL, Acting Deput@7 Director, DPIL@P.

              i5             SARA.H J. SILSBEE, Acting Chief', Onerations and

                 1, Development, DRMP,

                             I'@ENNETH-PPUM, Executive Secretary.

                             EDITI! M. KLEIN, Boise,@Idaho.

                             DR. ITOI<E WAMOC.Y,, La Grange, Georgia.
              .Lg

                             @IARIE E. FLOOD, T@ll Paso, Texas.

                             SET,,Tl,,LL 0. IITT@LIYRN, Columbus, nl-iio.


                                                            Dn.
                                       @IP-,PTII'rrZ Salem, 0.

                             r)R. JOI,@-T B. C@'RAIIIICF!, Chc-tr(--nne, T@@"Vor).in,cr.
              ,,3

                             DR. CEORGE P. SCHREINER, T-%Tashinatorr, D. C.
              24

                 I
                 I           DR. PAUL A. HP.RER, I-lashii-igton, D. C.
              25 i                    -
                 1.
                 I                                                              .11
                 .1








                             "NT (continued):


                  2


                  3
                     i               C. POPERT C--DEII,   .1--ookane, @-7,-,shincton.

                  4                  DR:  P,@',,TIIONY L.    PO-     Bos @@cr,, 1-@lassa-, @tts.

                  5                  DR.  @,ICITI',.RD JA'@  .-',%Y, stcn-c!alc.@, -',lo i-arolina.-

                  6                  WYNONA R. COP.DO.'-4, Creat.Berd, Yansas.

                  7                         C. HIP,@.OTO,' Los Angeles,    Cali-fornia.

                  8                  I-IARIEL S. @IORGAII, All)ucTuerc,,ue,      ".exi-co.

                                     And Others.

























                 19





                 21



                 ';2





                 24






                                       COIJTF'Llr,"S

                    Opening bv Dr. I)a'I-L I

                    Remarks by 11-r. C. Robert Ocrden

                4i 11 Ogden Resolution
                                                                           10

                   Comments of I-!embers of the Public:

                6            Dr. Donald Sparkman
                                                                           13..
                   Response of Dr. Richard Janeuay  to Remarks of
                7

                8            Dr. Sparkman                                  20

                                           L,Iatthew Spear                 36
                     Arthritis Report of @!r.
                9

              10   Comments by I-!embers of.the Public:

              11             1-ir. John Sergeant (Plaryland)               Ae
                             Dr. Lawrence Scherr  (11@ssau-Su@4olk)        57
                                                   CL
              12
                   Review                               -Iedical Programs:
                            of Applications for Regional I
              13

                             @Alabama (P4@rs. Gordon)                      7 7-
              14

                             Albany (Dr. Watkins)                          74
              15

                             Arkansas  (Dr. Komaroff)                      79
              16

                             Di-State (Dr. Watkins)                        83
              17

                             California (Dr. Janeway)                     90
              18

              19             Central iTew Y-ork (Mrs. Martinez)          .102

                             Central 1-7.yoming  (,'Irs. Martinez).      110 6
              20

              21  Block Action                                           115

              22             T!.rizona (Dr. Gramlich)

              23             Connecticut (iir. Hiroto)                   122
                             Inter-Mountain (Dr. Komaroff)               128
              24

                             Louisiana (Dr. Janeway)                     132
              25






                        Contcnts  (Continued)

                    2                 n-rvland         @@,lar-.:nock)                         139
                    3               Plassau-Su'Lfolk  (-Ilr. ','.Illliken)                    1
                                                                                                 2

                    4
                                    South Carolina ('.Ir. Haber)                              15'4)

                    5
                                    T.3xas  ('Irs. ?.IorcTan)                                 153
                    6               Virginia (Ilr. Hiroto)                                    163

                    7
                                    @Torthern Pennsylvania (Mrs.         @.artinez)           16

                    8


                    9


                  10





                  12


                  13


                  14


                  15


                  16


                  17


                  18


                  19


                  20


                  21


                  22


                  23


                  24


                  25








                                                                  c
                                                         - - - - - - - - -- - -


                                                              4 1 1 'he reeti-n@T plcas=-  core  to order

                        3    I,,7e  are now all @lugged in,  UT-) aiu-          the    hea@,    table,    and    I    think

                        4    @-,e   can proceed with        this r@,eeti-ncr    of the
                                                                                                  @nal   IkciviE@ory

                             council.
                        5

                        6                    '.Ios@- of you %..,are here        @re-sterde--- :-z)--'the     meeting     of

                        7    the     ad hoc P,,',Ii) review Committee,          but   I    do   4 S._ to      JCO
                                                                                                                  .@.e   to

                             the   table   PIrs.    Gordon,    and    Dr.    1"Ial)er,    and -"r.  @.jillil:c-n.     lle
                        8
                             are very pleased that vou can re-arrange N,,our                        summer          schedules'
                        9

                             and be here with us.
                      10

                                            As   you   know,   this   will    be,    or    is    expected    to    be,    thin
                             final meeting        of the     National Ad%,-,isory                         called       to
                      12

                             disperse    the    remaining     fiscal     73     funds,     which     have     been     rel@
                      13                                                                                                -asec

                             as  a  result   of    the    court    order.    7,11    of    the    1-974    fiscal    funcl,@,l
                      15     were   obligated    prior    to    the    close    of    the-fi---cal    v=-ar,    June     30-i,1
                                            And   as   of   this    state,    we    have    an-Drox,--.-@tely    28    to
                      16
                             30 million dollars  for ma'rrinc,- our                                         this        August
                      17
                             Council meeting.  i:low, we will he -cliscussiria   more                     of    -,hat    in  II
                      18  i
                             a    few    minutes,    because    we     had     a-'rather     lencthv     open     session
                      19


                                                                                            4
                             yesterday.    And    many    of     the     topics     were     d-4scussed     with     both
                      20
                             the Council members sitting as observers,  and the review com-                                  i
                      21  1


                      22
                                              hesitate    to    go    over    all    of    the    material     again,     and:
                      23
                             perhaps    it   might    be    better    as    we    qo    into    t--=-elosed    session     tol
                      24
                             take    up some specific r)oints.  If             there      are Questions       that       bear;
                      25
                             on    the    points    we    discussed    yesterday,     but     I think    I    should    malz@,








                         cne o-@- t@,qo qe--ral com-,.en"--s.


                                                       for        bcnef it      t'-,ic three       cou, if,

                    3    not !-)s        us vcsterdav, !)ecause I +--h4--':: --t is           -talit  -Pc)r

                    4    t-rie ciav's iDroccedinas.      l'i-rst of al--   "r . -u';--el di e,      a

                    5    jresen@@atio-ri and go over ti-,e currc-nt -,al-us of

                    6    and %.@.-e did pro,,ri-de, I believe, a hand-out, di d we Tic)-"@,        Gerr-t@.

                    7    yesterday?


                    8                 lip,. BP.UM: Yes.


                    9                 DR. 1,7i@l-l@MOCK: @'4ro.


                  10
                      I               DR. P.AIIL: !Tell,   -Lt was intended to give a hand-out
                                  Can   we make sure that we get those noe,,, today.
                  i2                  @@-IR. BAU@L: All right.

                  13                  DR.  PAIIL: I,,'hich summarizes the basic eler..erts of
                         'the lIouse  bill that has been reported out bv tl-Le -Pull corrLmittcl,,c-.
                  15     I won't go into all of that now.            Because,, reall@ll,,  I
                  16 11  that  We  still  haverany  steps   4-0   go   ,jefore   @.,e   have   legislation'
                  17     and by giving you our summary         statement,     I believe, Nlou will
                  18     understand what the main features are verv quietly.
                  19                  It is a long bill, some one hundred pages.   It does
                  oo     certainly    make provisions for a transi-"icr,'-neriod, a.-id
                                                                          L-                    WC, full,-,,,
                         anl--icirate that the local regional                   Drocj-rar-,s together
                  21
                         @.,itli  these CIIP agencies and experi.-,@-.    :1           s-ar7.,i--as deli_vel.-
                    2
                  23     systems,     and llill-]3urton organizations              be  given    the    propier
                         @i.-I@@.Lt-unity to become incorporated into the        proposed      orcrani--a-i
                  2,(,

                         %'.ions.








                                         is P--ODosc-m-"4 41 s not ccrtai-nl,,7 i- na,-i-%; 1,@z a,,

                                --a the
                2   to perpetua4           program as         4 t
                                                                       those o@   @ou

                    @.@ho have been -.Lrollm,7ing the IC2LO4
                3 I                                  s  -tti on closely "ill

                4   aoDprc-c2.ate thcil-

                5             '@,.'hen T,,,e have copies of the floor bill we will

                6   to get them out to you, because I do believe that it will   be
                7   faily close to what may be passed.  And of course, the timm-
                8  table for enactment of legislation is unknown for good and
                  11 sufficient reasons.

              10              ]3ut it r,,a@,   be passed later this fall.

                              'LIIR. BARPOI-,'S: You have -ust given me a
                                                                      note sayinc:
                  ii summary of the bill is attached to the Council agenda
                                             L L.
              12  ii                                                                i
              1,3                 Bll-.UP-1@: t a  @z;@ 4-em stapled.

                              DP,. PAHL: Ohil Ithought it was-a  seperate  hand-out.,
              14
                   I-see it.  It's the next to the last item.  There is a 'ational
              15

                   Council for Health Policy established within Dll,'E','-I.  '@,79 do not
              17   know at this time what relationship such council will have
                   @vith this council, or to the other legislatively mandated
              18

              19   councils, of the constituent programs.

                                         I.,70
                             MP,. O(',DE',_q: uld it be aiDpropri---tc- for me to sTDeak
              20

                  -to this legislation at this @-)oi-n4t-
              21

                             DR. PPJIL: Yes, I believe it would be a-gooO, time.
              22
              23             @IR. OGDET.,@: In reviewing air. Pubel's-su=,ary yesterda-.,,
                   E,,@i in thinking about the matter overni-gl-it, i-7hile I have not
              @4
                  yet had an opportunity to read the summary fully it is here.
              25






                                T      greatl-17 conc--rii--d that          as @.le -,eared

                                                                                     n
                                       to@ ignore   the   role that    ,-as pla,.e
                      described seems
                 2
                                                in recen4@- vea.-s.         1 d life to
                      i',ealth care    environment
                 3

                                                                     aj- t    SC- S7@ on
                      read to this Council   and to those   prese
                 4
                                                             @iagn'usen who is  chairman.
                    i: open session  a   letter   from   Senator
                 5

                                                                                      a
                      of the .1,;ubcorim@-tte-e on Labor, Health, E(fucation and ;-.all re,
                 6  @i
                      addressed to Senator I-',S-nnedy.
                 7
                                And I am   quoting.  Dear Senatc.    -,ennedy.  It  has
                      be.-on reported to me that the proposed lea-'slative revision      of
                      the Public Health   Service Act    in         eliminates the Regiona;
                 lo
                    ;.i .,I--d4-cal Programs. And ,,iould divert the ao,,-)ropriation  that hF-s
                    ii been used for PT,!P purposes, to local             agencies, as
                 12
                      Ii-in@-rstand the  present    proposal.
                                 Planning agencies would then he expected to develop
                    :1 services in the same   manh6-f that  PdlT-l has @een doina in recent
                 15
                      @,,,,-5ars. I  am   somewhat concerned whether planning agencies are
                      t--,a-,Dpropriate  bodies   to be engaged in  @-.e development of

                      services.
                 18
                                 From m            -,ice with the ',@7as--ncrton-Alaska Regiona'"
                                        y    experie
                 19
                               Program  it  seems  to me that the development of services
                 20
                      4  this complicated undertaking
                                                           deman(fi-nc7 the skills oF pe'rsons

                      s.1,,zc-_ric-nced in the delivery o@@, care, ard contract planning dn-.
                 22
                      p@-nds almost  entirely  on the determination of health care
                 23
                      needs.
                 24
                                 By an agency and staff which can atter..@pt to match






                                                                                7


                    th-@ lo--a'L -Command for cervices against r@-sources, and

                  1 develop a cor,,.T-,.unity --onocnsu-- as to how tD r,.'.Cet t.-i-- iic-eds

                              II" seems that  few if anv planninc agencies have
                3

                4   a broa.  sp,@,ctrum of persons     t:qc Irnowl,,  ane.       c-nce

                              for the actual creation cj'- new sc-r  ..c-s. 17 c,,r does
                    n-oceE;


                    it      practical for the planning agencies    to do  so, since
                6
                7   it would create an unnecessarily large and    cumbersum   organiza,7

                    tion.


                              I would  thii-i): that a planning board should be capabl@
                9

                    of expressing the  communities will and  the  board  of  a  develops
               10

               11   ment agency should  be capable  of malring sound technical judg-

                    ments about the best way to develop services at the patient

                    level to meet the needs  outlined  by  the  Dlannina  agency.

               1/             These are two distinct activities which rcci:kire   the
               15   involvement of boards and  staff with their efforts and    differe,@t

                    slizills.  This is the way the successful @4P such as the   1,7A
               16

               17   ril ip are now working.  I am concerned that if we attc-.
                                                                                to thro,@:

                    both activities into the same  structure, one of the
               18
               19   will suffer, and it may verv  well be the quality of .@-ie  services
               20   developed in the function--.

                              The medical school  faculty, the   medical     leciali6ts:
               21 I.                                                                   r
                  lthe          aaministrators and others who    are bas-'        inter,-
               ,.2
                  lested in  the way  care is delivered at the   patient   .,,el may   I
               Z3
               404  withdraw or not be  well utilized if both   funZTtions are assigned-
                    to a planning agency.
               25







                              it is these @-).c-rsc)ns, who with         i

                   expand the preson'L-- hcal'L--h care system in -)-eparatioii  C"

                3  national health 'insurance.   The Regional  I.-,Ic@dical l,roc,--- to

                4  dat@- has involved the talents of most of those mcst

                   I'm sorr  -- oi@ those most able to develop ser\?icc-s.
                5          y

                6            T'Lic@.r-record for gaining the cooperation of all p'a,@ C,
                   of the delivery system and-improving the quality and   accessibly
                   of care is unequaled among the public health service  act pro-.

                9  grams.  It does not seem reasonable to assume that the capabil-

              10   ities @T,!P organizations are developing are transferrable to

              11   other organizations, especially where the new organizations
              12 II have few of the talent orientations of the predecessors.

                                                               'P organizations
              13             Certainly I recognize that all nl@i
              11   like planning agencies and other health programs have not been@
              15   uniformly successful throughout the nation.  But  any lacx or
              16   success is  more attributable to lack  of consistent leadership
              17   direction at the federal level than it is the fault of the p@.'P,

              18   aniDtoach.

              19            And undoubi--edly-are we going to need to make some
              20 leffort sometime in the development of heal@i care resources.
              21 'Hopefully this task can be assigned to agencies whose expertise
                 @-and experience can make the optimum contribution.  IUIP organiza-
              22
                 ;tions might need to be changed and strengthened in some
              23                                                            ,Darts

                  of the nation.
              24

              25            But in my opinion they probably represent the best







                      means of increasing tl,,c qualify    and acccssib-'-litv o-@ care for

                  2   the average citizens.

                  3              In summary, I am hopeful that the new legislation

                  4   will.          to recognize both the    ccnourr@er anc, nrovider

                  5 j; rola@@-@-jns,-iius need2d to make the health s@,stc--j,@
                    I             -      -                                     -,: P--o,,Dc-rly.

                                                                               L       -he
                  6   There should be some way the new      legislation can   .iisure 4-
                      Continuation of healt-1 services,     development   agencies    similar!
                  8   to @,IP in structure and experience, thereby not dissipate the
                  9 ii national re--ources that we have developed.

                10               It r-iicr-lit well be advantageous if the ne@,,7  legislation

                11    were to es-'%--ablish a formal mechanism to assure that the c-ffort's
                In    Of the planning agencies and     the r-@-IP a@ coordinated, i.e.
                13  1 that Rl,!Pls are in fact developing delivery system-@ to me-et
                      the,healtli needs  identified by the planning agencies, and such
                14


                                                                         ithout scrapping
                15    mechanisms could   certainly bebe established w

                16    the present programs..

                17  it          Creating  entirely  new  bureaucratic   structures   in   the'
                18    future, and in the Drocess, using what would re-zu-,,ain we have
                19  i achieved for existing R-@.'LP- systems, such as the I-lashington-
                20  jAlasl@a proaram have been highly successful.  Thank 17OU for

                21    @,oi-,:  Consideration.

                                Si,.icerel@;,, '@,7arren G. Maonusen.
                2'-)

                9-3                   I would like to -.uggest that it is      the sense
                    ,,of this CoL,,ncil that IIR lG204 as we have heard it     described,
                      is inadequate as it is noiq drafted. In t'AIat it  -ic-ails  to  r@-cog@









                                                                                             V4
                      n@    7,uf 'L @-ci-c-n4l-- l@, i--hc i-i-,Portanl.- role (-f -@decluate !7, c.  r


                   2  d    -opment el --Forts.


                   3              7md efforts which simply cannot       be  limited  to   tire

                   4  locali-@ed  geogra-,Dh--Lc areas %%rithin a state woul.Ci seem to h)c.

                   5  encompassed in the concept of the        local  health   s,@rvice   arca

                   6  within a state which the go%7ernor@would designate under             this

                   7  bill.

                   8              And further, that    this proposed 75,000 a year        t,,@@o

                   9   y@-ar limit for a Dro-ject is   grossly  inadequate  in  our   ex,,D-@r-

                 10   ience  since  it  simply  will  not   attract   meaningful   or   useful

                 11   applications.  Therefore   I   would   like   to   propose.   a   resolution

                 12   along these lines-.

                 13               Be it resolved that     the  Congress  in  adopting  IIP,   1620i4
                 14 11 or similar-legic-',-ation give- each state the statutory and '-'inanp4.

                 15   al  support  to  maintain   a   senarate   health   systems   development

                 16   agency on a state-wide basis or independent commission appointed

                 17-  LL  ct  .,L@blicly  accountable  way  and  devoted  exclusively  to   such

                 18   work,  and be it further resolved 'that      the-co,-nments    13receedin
                                                                                              9

                 19   this  resolution,  and   the-resolut-ion   itself   be   transmitted   to

                 20   the  members  of  the  House.Interstate   and   Foi:eign   Commerce   Com- I

                 21   mittee,  and  the  Senate  Labor  and  Public   Ilelfare   Committee   for

                      their consideration.


                                  DR. PAIIL:  Thank  you  tir.  Ogden.  A  motion   has   been
                 23

                      made, to have the Council adopt this resolution.  Is there
                 24
                 15   a second to this motion?









                                   'S @ior.-
                                                1 second it.


                                 Dr.
                                       P.IIL:  c o n d e d .@-s there discussion?

                  3
                                 DR.      C, C  'Ir. Oqden? @,,,Oul-e, --,ou read that resolul--
                                                                                          L--

                  4   acTain, Pic-a,,;e.

                  5                          De it r@sc:i-vcd           Congress in

                  6   ado-
                         .L),-ing iIR 16204 or ,;imilar legislation give each state. t'@=
                  7!;I statutory and financial support to maintain a separate healt
                                                                                         h
                  8   systems development agencv on a    sl@ate-@@7ide basis or indepen@e:-.-L.
                  9   commission appointed in a publicly accountable way and dev
                                                                                       oted

                10    exclusively to such work.

                                P-rd be it further resolved that the coz,-,m3nts pre-      I
                L- :!I c-oedina- this resolution, and the'resolution itself be trans-

                                                      IT
                13    mijL-.ted to the members of the kouse Interstate and Foreign Cc@-r,-
                      r,,@ierce Con-nit-L"ee, and the Senate Labor and Public Welfare
                ,.4

                15    Committee for their consideration.

                1,UZ            DR. PAITL: D4scussion?    Dr.    Schreiner?
                17              DIT.11. SCIIPEIT.JER: Yes.Ijust  wanted   to ask a question.
                18    You, would favor the dissolution   of the    regional process?
                                I-IR. OGDEN: Yes,- I am.  Because  I  think this pie e of
                19                                                                  c
                20 i  legislation is directed toward    the state-@qide activity.    I
                21    recognize that many of our regional and medical programs       flow:
                      over state boundaries but if @,.,e are to have                 -d
                                                                      an incapsula@--
                23    program which is state boundary oriented, it seems  to me that'
                      that we 'can accomodate to that through our existing R@IP's.
                24

                                DR. WAI'L@,IOC'r": Your point was a specific statement oi'.
                25








                                 nlan?


                  2                   O'@DE.N: Yc-s, at this Particular piece of      leqisla-

                      tion.
                  3

                  4                   "YAI'U-.OC.L-,: This particula-- piece of legislation

                  5   because the  @l, I-P as we have been lool,:ing at them doesn't over-

                      flo7,q into other states  and  so   forth.
                  6

                  7              @iR.  OGDEN:  That's   correct.

                                 DR. l,v7Pd-4r,.,IOCK: P,-egions, as Iunderstand it I was-
                  8

                      told them could be no larger     than  this  room,  or  they  could.be:i
                  9

                      the whole United States.      That's  what  called  a  regional   area.!
                10

                11    So we are seeing some of these things, this is some of the

                      things that I was putting to m-,, r,rd all day ycaL-erday, ,-nd
                12

                   il earlier this morning.
                13

                14               1 didn't get up and write it on a sheet of paper.

                                 NIR. OGDEN: Of course, we have some states, for

                16    example, California, where we have one -IUIP for the who--        stater

                1 7   For the state of N3w Yorl-,, i,7c have at least four.

                18               DR.      OCK: Four, that-'s right.

                                 I,!R. 01@-DL-@'4\1: And under this ne.%-i piece of legislation,

                      these four PJIP's would become one.
                20

                21               DR. WP.-a@li@IOCK: Yes.

                                 I-IR. O(-',DT-"@: ',',,Ihicl-i incidentally, is something I havei
                22
                   I  suggested  to  this  Council   previously.
                23
                24               DR. T@77L"Lt,',OCK: Well, you've been on tt longer than I

                      have
                2,5






                             DR. PAIII,: Is L'-,'acre further discussion.


                                                                           Ij
                                                  Lri-nd mysel-r
                            DR.                                        4-1
               IL

               3      Ogd@-n's i-DroT-Dosal.- I @@cnder though, if i-7,D (f, d@-fc-r a

                  vote on  it until some of us have ',-iad -iance   read  the
               4

               5  summary  of    Bill,        I, a-'-- lc-a,- iaven't had achance

                  to do  yet.
               6

                            To take action on it, because  the  basic  apprehension,
                  that a planning agency is not t,-%7pically a body constituted
                 Ito r@,3resent the providers or to  implement  service  activities.!
               9
                 II thini@, it is a very real concern, but I share
              10

                            DIZ. 1,AIIL: I am sure others perhaps have not had the
                 iioppor'L-.unity also to read this,' anc- thus, "Yith Counc,-l's sense
              12
              13 @ie %-!ill c!2@er voting on this     until later when we have
                 Thad -in opport,,initv ;Dcrhar)s folloi,7i-nc- at least the mo coffee
                                                                       rning

                 1 break.
              15
              16            I believe I would like to take the unusual step of
                 !asIZ4.@,g whether any members of the public, because I know that1
              17
                 [several people are here from Pr.,'@P's- and also Dr. Sparkman, who
              .18
                 'is the Chairman of the Steering Committee of the @-4ational
              19
              20  Coordinators, might wish to add a comment at this point in

                                                                              itv
                 ,the proceedings, and if not, there @:ill be another onportun
              21
                 !dur4ng the formal public session for any comments, on '--his
              (412

                 !i:)oint.
              23
                           Dr.'Sparkman, would you care to make  some  comments  at!
              24
                 ,!,this point? On the topic under consideration?
              2-5








                                DP,. S P         o u  an s -n e ai n cT f o rli i s r.,.o on


                    just in general.


                                Dr@.. r-;\Tl
                                      .L:  'I was thinizi.rc@ o-F cc-.=enting on the

                        vou will.        to@ic of substance o-'-      Ogden's co=enr-s.

                                DT' .   EL .   1,,7c-11,  thank yo,@ -L aopre ia'L-le tr,  e

                 6  chance oi'  appearing before ,ou again.  ,-@nd re-,3rescn+--ing t'-,-

                 7  Coordinators, and I sunport the motion as read b@,,            Ocd,:an.

                 8  I think the two important factors in the bill as I understand

                 9  it     I too, have not  seen  the  entire  bill,  although  I  1-iave

                10  seen the summary that has been distributed to you.

                11              And I have looked  with  some  care  on  13995  which  is

                 2 il it's predecessor, which i think has not     been  modified   verv

                13 l@,buk'- I think there are two important factors.

                14              one  is  the  subdivision  of  existing  state-wide  or

                15  regional r@IP's into smaller area-%,7ide regional IlAeCiical Pro-rams.

                16  I think the subdivision into multiple smaller areas it aDp.-oDri-

                17 'iate for -,)Ianning, as has b@en demonstrated by the action of

                18 !those  CIIPB or area-wide agencies   which  can   identify   health
                19 !problems in their areas and deal      %-ii-th them.
                   I                           . -
                20              But this is, i think, a totally inappropriate %,7av

                21 1      Regional i-ledica'L Programs to @@unc' -7  since  on  a  state-

                          basis vie can    acquire staff and         caliber and a
                 2

                       different kinds of    disciplines and c-,:@ll with  D-oblcms whic-
                2,3 0
                24 lwe do on a state-wide    basis with the medical H-ssociation, @,.e
                25  voluntary health association, health departments, and other-.@4se







                           deal with licilt'q as        stato--,-:i-de @-atL@ers.


                       2                       i n,  i   @-o--,!@  4ust virtually, t.@-n,,4nat   ar.

                           P,-',IP in t-,,@e areas which  I  @-T7,  -Lcam--'Lliar   with.
                                                                                           7,nc2 as a mat       r


                       4   of  fact,  in  the  blue  shcc-t  i.,,Iiich.   @'-s   one   of the! rr--pork"-s c.-

                       5   Washington J.'ealth mat-L"ers,                            sure sc.-c- oi: 1-cu a--e

                       6   familiar  with,   last   @,ic-.el-,   reiDorte,,4   that   the bill as wr4Lt,-en

                       7   would be  -the last rates fo

                       8                 I think this in effe-ct is true,  that any health

                           resource develop7ient activit,,, .ind of things PIIP is dcina,

                     10    look to me to be added as an afterthought and in a totalln,-

                     11    inadequate manner.   I would            like to mention just a counle of

                                                            I I- 4 g' .1-1 t
                           other things,  Ilerb,  if

                     13                  DR. PAIIL:  Please.


                                         DR.  SP2'@.P-Kl@-1:  Relative to the orientation

                     I--   to  regional medical program I know that some of                     you   have

                     16 ;iserved on regional advisory groups,  or other committees   or

                     17    in other,ways have been   involved with the regional medical
                     18 liprograms.   I reccanize that some @of the others of you have not,

                     19    some are na%@;.


                     23                  Some of    your Dredecessors have haid the opportunity of
                     21 ,!having to      site v4-.-its to rea-ional r,.edi--@l -Drograms,  and t,-Iose
                     2.-) I!'l have talked to         -1-e               -i-tat @L.     was a very heloL'ul
                     23 I!experience in understanding what                         do.   I   recognize      that
                     2--,' you all carefully read the            written material we           submit to     you,
                     Z5 Ithe applications for pro-rams or projects.








                                                                  '-7c  @rc-  iratc'Lul  to  ,ou  for  the                                                           s    to        ri-@vi


                                     2     all  o@@                        !)-,-it  I  the-'   t-,a+-
                                                                                                                                ."er                          u    t:-a  tc-  1   1

                                           t"'-   story  that  I  think                         -,,You  @,qc)uld  have  an               o@@ortuni-@@v            to            u.Tid,2r-:
                                     3

                                     41    stand  i'L          -,7@       -c-re  actually  had  Iiad  an                                             visit,         or          had

                                           a  little           m@-.-   contact  @.,ith  a  coordinator,
                                     5

                                                                  I        know        you        have        an         orientation         session         for         Dr.
                                     6                                                                                                                                        Pah'@

                                           and        his        staff        the        details        6-c@@,7hich        I        @on't        kno,,.,-.        But         since
                                     7

                                          I        have        thought        about        this        I        bc--latedl"r        recoc--I,-zed        that         as,         a

                                            -cun,   the  coordinators  o@L                                            have      done       a       -,?oor       job       in

                                     10   r--xoress4@ng  @Lo  what  theN                         f eel  the  way                         s   ---unc        on

                                                                 And      I   have  written                  to  Dr.   Pahl   as'@!@ina  Whether                           there         1

                                          are  sr-reno-Ehs                           would    prevent  us   from  co@7Lunica,L.4-ncr                                       f      rc-c-lNr

                                                                     d    1               not  !-lad  an  op.-ortuni-t,.7  to  ha-\7e-=   a                           res--.,
                                                     i,ou,       an

                                     A      o        ri  on      thi-sf       but  i   LL-@tend  to                                un     on              unless  yc

                                     1,5 w F,. rl    to  speak  to  it  at  the  moment.

                                     16                          DR.   PAIIL:   I           believe  not,   ri-@ht  at  this   time,   but  we                                           ii
                                     17  v74@ll  be  discussing  this  with  some  other  matters   individually
                                     18  and      with  the  Steering  Comir,,ittm-e.

                                     IQ
                                                                 DR.   SPARRILIIAN:   P-s   an  example,   -rL  don'@@  )cno@@                                   whether
                                         all  members  of  the                       Natiorral               Advisory               Counci'l               -eceivedthis               whic

                                            3   a  report  o'L  a  Drogram  accountability  report                                                   tl-.        @,,-as       subp..Iit..;


                                                                                                                                                                                     'liar
                                             --4t  .,7as  released  about  a  month  acro.                                      ',7h 4L c h    4 S   t'          a  fam3-
                                     2

                                         document  to  vou?


                                                               MR.       BAUM:   It's  been                  mailed.
                                     2,1.
                                                               DR.       S P    il.,,7, II L@   Ilow  many  oflou  had  a                       chance         to         see         it?l








                                     D P, P       I t     :-@ailed


                                                i: I t%.,,as       ou    as soon -s -,@Te c-c-t  it.


                   3                 DR.  PA---!T,: l,lell at the time of our --.one call it


                   4    should have been received b@r you.


                   5                 !.'R.         I did  not receive it..


                   6                 DP-,.             'Tot very many.

                   7                 DR. PAIIL: T-7c- shall  make   other   copies   available    to


                   8    you.


                   9                 DR.              ;Iell, this is of no va@          Ln m3asurin

                   10   individual i@r.IP's.    But it is a measure of the E          -.-ecate-imDa

                   11   of PJIP's in helping to train health professionals and actuall-,-

                        serving pcople.  And in ir.-clementing comriuri,:., activities,
                   12

                        and while I wouldn't expec4l--     vou to read every @.@ord of it, it

                        i-s    reasonably       don--.

                   15                And  it  is  the  kind  of  thing  that  I  %.Tculd  hope   vou

                   16   had  had a   chance  to   look   at.   In   order   to   better   understand

                        what we are tr     ing to do.   I @,,,ould like to, then, after I have
                                          y                                               L.

                   18   had  a chance to talk to Dr. Pahl, follow-up with ways  in

                   19   which we may communicate.-with vou.

                   00                Without burdening you.        I know tAat you all have

                   21   more than    enough to read.  The second item I would like to

                        mention briefly is the goal of the National Advisory Council
                   '-'2

                        and  I  am  pleased  that  in  the  motion  that  Plr.  Oaden   tha+--   was
                   23
                      i seconded that you all lookina         at the policies of P-,!P that -vou
                        all, I thinl@, then beginning       to take steps to provide the








                     leadership t4-iat the national Adv4-,-,orv Co,,i.-,c4-l-  nrovia-eci

                 2       in      Pza5:-,t.

                 3                recoc,7niza that in -,rour last tT@.,o iriectinc,-s in

                     i-.,revious year things have been p-rett,,      u,,?set, f 4-rs-  as
                 4


                 5 !I a result c@L the oha@e out directed by the          -,-tra-@ion, an,4-

                 6 @l;@ then the rather abrupt release of im.1.3ounded funds so

                                       -d with a  plications.
                 7   kind o' overwhelms          T)


                 8             But I would like   to remind yoii that you are a     ve

                 9   respected group,  on  thz  health  care  !s'cene.  You  represent

                10   a -group of distinguished and dedicated people and that your

                11   %%Ford relative to regional medical programs part in hc-alt.'l care

                     is impor;@-anll-- and I tliini@ that you should ta'@-e tir-,@- to

                13   to consider health Dolicy from the stand point of the

                     Advisory Council.

                15             And I hope that you will have time to do this. ;@t

                16 i vour last meetina, as an example, two resolutions came to

                17   you from the irrational Review Commi-t"-tee, and one of them recc:n-

                18 1 intended that Cl@IP's turn to rj-IP's when appropriate for technica'-

                ig   and professional assistance regarding health carc-,chan--@.:.

                               z@-nd the second -one encouraged Pi'.@ Is and CIIP

                21,  the state and local levels to work together closel,,, to

                     x,,,ays in which better programs would be carried on regardless
                22
                23   of the exact language that is    in the legislation.  These, 1

                     thought, were both good ideas.

                               @Ir. rubel-spoke against.both, and after what I thouc@,:-
                2,5












                                                                                                     4=
                      ii @,,@as vcrv        ---,onside-z7,-4on and discussion                      0

                    2   them were re-j4 -  L@-ed.   e--,n June 20,  ii-.,-r..eclia-tc'Ll, a-@@@@3r  --c-tinc-

                    6   I wrote to      ir.   -,,b-31 a--i,--L said I was clisaupo4-nted in   4 s dis-
                                                                                             -I-


                    4   ap
                                    of          and iL@ seems to r-.s this is  incons4--Q-z@-n'L--  %.!it',

                    5   his    --Drevious             relative to on-c.-oina                      --lationc
                        bc-t,.,:e'en PIIP and CIIP.
                    6

                    7                1,7h, i cl-i I Wholeheartedly support.       A@nd i sai-,,@   a

                        I ho-e that there will be some tanc-ible evidence f--o:n him

                    9   on action relative to this Dositive relationship.                  !ye hasn't

                        res-,)onC-ed to rre, nor have I seen any evidence of %'-his action
                  10

                        on   his    part.

                                        osut),,)ort what he said at      t,L,, meeting last

                        Let re add an anecdote regarding this.   I'@t the i,ashincfl.-on-
                  13  ii

                        :',las'r@a area @,7c- have t@.-o 'particular c-,--al-its w----
                                                                                              -ve task
                  15  !i forces looking at these       kinds of alternative arranqa,@ents

                                    ip
                        bet%@ec-.ri F-',I.l and C,IP r.7i4-h the best p@o,,:)le we can @i-c! in '-oth
                  17    I'@',',P and CIIIP a,-id other health care activities in both states.

                                    I
                                    11-etincr  and  Ir, i.-ig to shc-d their vested i@.4-@--@@sts
                        Ca        as possiblet to      se:-= what  kind  of   Drogra-7i   shoul-d   emerge)
                  19

                  213 11 and las@L.1y, that in  Al-as@a,  our  coore,.inatoi,  i,,!-.o  is  no,..?  a  very:

                                                                                that she :iias about
                  21  liable young lady announced -.to me last
                      i! to get married to +-he director of t'.-Lc          @l.-tora@;-=   ac!-=.rc%,,.

                  23                I said I was all for this kind           of exnlora-L-i-on, but
                      !it seemed    to me this @..,as carrying it a little t-I far.
                  24

                                   Than,@. you,-verv @,uch.







                                     P.,@l,: Tliank -vc)u v-crv much, Dr.
                 2         have a formal open session a little later, an@ -t,-:ers

                 3   .:?rc-senk-. should fee'
                                           free to comment ur@on   t'." im a tc r s

                 4         discussed and       1,3,2a--I@man@ should ,,ou Irish -"c 7-='--

                 5   addi t-lio-.
                                 -o@,@Tents.,

                 6               ut@- we shall table th-c- motion until ti-i@-

                 7   had the @,portunity to review    the summers,.


                                                                                 --u'd
                 8              DR. JANEIIAY: At some  time in the  agenc:,ar
                 9   li'@-e to respond to Dr. Sparkman's comments    about       7aliber-
                10   a@Lions of the  Council  relative  to  the  resolutions.

                11
                                DR. PAIIL: Perhaps this .night !De an
                12   th@n, Dr.  Janoway.    our agenda is flexi,,Dle th-'-s r--rn--ra,

                13   and perhaps this would be a good time.


                                                                                    ul:d
                14             DR. JTNET-@@.Y:  I would lil:e Dr. S@arl@.-ia-@i,
                15   not li'r@e the impression to ao  unanswered,  that  thc-
                16   did not deliberate appropriatel@r upon the substanc.:n       t'@-le
                17   resolution brought by   the Technical Review Co,-rinittzn-
                181  particularly that the   ,,@,ording of it is such that it 4@z)l-es
                19   a necessary conflict between CIIP and P21P.

                '7@3           The concern of-the Council, or a@ lea,-,t         sense
                21 I! of it as I recall it, was that there was some con--.---    over,

                                                                             4
                     the plann4-na in control function being a,,-:ialgamat   -   o
                     same agencv. The imDiicition is there, i..-e felt,   and    t--.4-nk,
                2-3
                     quite corr-or_-l                                          4t WOUI-I
                4                @-y that the advisory council for r,.,"P
                2,r) @be inadvi@@able for this Council to be rpai-,ing  d4-ctat-,--ial







                                      from F;.n  a(',-\7crs:lrN. 1-1; 0 s4L ',--ion            a c 1,


                                                                      0 c
                        0     an


                                                            to r@assure           tha@ there ,.,,as


                        adequate d-Ls--us-,ion, at least in th-c                  C)


                                        hi  -     1
                    5   are around           ta,-


                                     DP. PL@IL: Thank vou.         is   there   further   discuss@'-CTI'


                        on   this    point?

                    8                If not,    I would    liable  to  return  to  my  brief  re,-orl,--

                    9   to you.   There are      several    points and items of business we

                        should consider this morning..  First, I would lil@e to,

                        t
                         he      indulgence of the Council members who were here yesterday:

                        to   repeat    very bri@-fly for    the benefit of those who                not

                  13    here       yesterday, our      current status with respect to t,,.@ an-al-@ca-

                        tions   that    the Council :led considered list time.


                  15                 Let me ta'j,.e this opportunity to do t',-Iis,         beca,-,se  we

                  16    have rc3Dresentatives       from bo4l--h of those regions here this

                        r.-,orning, and they will I)c- speaking with us, vcr@, shortl,,,@.

                  19  11 And- in order to provide the TDro-D           background and understanding

                  19  11 I   believe   it   is necessarv- 'or me to repeat these          remar'r@s   of

                        yesterday.
                  20


                  21                 As you will -recall, at our last C@,unci-1

                                                                                   -o spe-ci'4c    a,-, -o 1 i r-:.- -
                      ;i t@.1- - the  recorumendations made with rega:,.
                  22

                        ti-c-.s -- the applications from Maryland and. Nassau-Suf-'olk

                        @-.1@re of the following natu--c:   that is, that-funds shoul-d not

                      :1 be av7ardcd for thoss Darticular appi4cations and also that the





                                 two                   in                   s'@iould be                        in  cLn  or,-I,2rly

                                 f ashio,,-i

                          3                       -7he  reco,,.=.cnfations                  accc-z)t.@d           the  (d4-,4-cc+--or
                          4      and                 on     ou-- @.- o.   D  ii-.,Dlcm@-rtinc,     these    in    c,-oo--'     fai-th
                                iihc!n    it    @,!as     called to       r attention  that  againt               it@;  a re@-ul.+--,
                          5
                                 I  am afraid,  of  a dismal  ignorance                     of  the  la@NT,  that i,7e  v.,,ere
                          C,
                                not  able,  as  a matter of  'act,  to implement what                               had been        @het
                          7  ii

                                Council  recommendation.

                                                 And    the    second      part      of      tJiat,      the      orderly      termination
                                of the  tqo orograms,  that  is,  we  had only the  opportunity  to
                        10
                                iriplen,,en-L"  +--he   first     Dart     of     the      recommendations      and      that      is
                        J')  ii no.-  to T,,rovide       funds     for       those       specific       applications       that       were
                                reviewed  at  that  time.

                                                In fact        h a t  @,ias   the   case.   14o    awards    @@,,erc    r,,,,ade    a
                                                                                                                                    t
                               the    June     Council     to     either     the      @,7assau-Suffoll,,      or      the      Plar@,landi
                               programs.   I-'Lo,%rever,  we          were  in error  in believing                              \7cur
                               recommendation  could              be  implemented  and when i.!e  i-ioria  advised
                        17
                               of  this  error by our             office      O--P  7e-neral counsel, @..,e  immediately  7@
                        18
                             i got  in  touch with  the  reGic)ns,                 and pointed out            that       there       ha&'i
                        19
                              been  an error,  on  our part,  and                    that what we v7ished  to  do was
                        20
                              inform thcm that thc-v did have                      a right,  and  we  hope  they  i,,,ould'
                        21
                             i'-@xercise  that   right,           to  resubmit  applications  for  ti-,,=  ravie@,7
                              by the  review committee -yesterday, and by this Council.
                        2-3
                                               The  reason that  that action %,7as  takEn N.:as  that                             the
                        24   1
                             i
                             it                                                                                                          t
                              applications in question, the applications that @,@e reviewed                                              I
                        25

                                                                                                                                         I
                             I                                                                                                           i
                             I
                 i           i
                 I
                 l@







                                 b@)'-h  time  June   Cou   c4l   a-rid                    u@idc-r c          rali   on;
                                    L-                    n                                          ois 4-d2


                            a;-- -Eiis CD,--ncil    +-c-chTiical      C
                                                                                             to C:.:4stin@


                       3                   The     budget      period 'Lo-@ all-               mee@ical        programs@

                                                       -ir@7 1   1974,  @lir-uqh June 30,                   and
                       4    c-@tc-.nds  from r-ebruL


                                                -ions        reviewed a-- ti-ie last Council.      T,-,@ t i ii C, , as
                       5             ar-jpli-a4.

                       6    @.7ell   as   the   ones    before    vou toda@,, technically are           su@@)@,lc-ments,

                       7    to 3.@ist4-rg, --i@.iards.

                                           Th,3refore     it is    not    appropriate    for    thc-    council     te i

                         i  ffiake a recommendation beyond funding for the   sr.)@cific applic@4-
                       9

                     10     tions    in question.          leaving gotten over that psychological

                     11     hurdle     and      shocked      everyone we as a headquarters staff,  togethe--

                            with  k--Iie staffs of the two          regions in question try to worl-,
                     12

                     13     effectively     within      the      time constraints   that    werc    on    all    o.L


                     14  i  US.

                     15                    And we extended the deadline fro,-,.              July 1 to      July     9

                     16     to those t@,.'o specific         regions to amend,  to          reviffe and     to

                            amplify those applications.   And our staff                     rret ir-,-th the staff

                     18     of   the   two   regions   and   you   mav   i-magine   that    there    @,7c-re    both

                     19     several trips involved, and many telephone calls,  and as a

                            result of this we         believe    that    the     region@     in     question     under-!

                            f--tand   fullv   the    concerns    that    the    review    coriinittce    and    the-
                     21

                            Council. had and half_ s,@oll-:en to        'L--hosc concerns in             application

                                           Also,    we    have    made    two,.made    know    to    these     regions i
                     23

                            t'i,.-- fact that during the open session both the review committee
                     24
               i
               I         I  and the     Council    there    was    the    opportunity    to    sneak     on     behalf i
               i
                                                                                                                       I
                         I                                                                                             I
                                                                                                                       I
                                                                                                                       I







                    of


                2                          cl',-@t tc @-iia open session this mo
                                                                   F        ri-i i ng,
                            have statements from representatives of bc)4-'
                                                                        Ltl eglolls
                    Now, apart from t@liaj- ricitter I -,'ill indicate to .1@e Council
                4

                5   you will recall at the June meet ing you approved rig
                6   dollars recommended for approval.

                              82 millions of dollars.  We actually made a%,7ards of'i
                7
                    84 millions of dollars, and the reason we did not implement
                8
                9   fully your recommendations was because it was felt to be b
                                                                                etter
                    management to reserve the different, four million dollars,
               10
                    so that we would have a total of 28 millions of dollars for
               11
                    su,,)iDort O' the recommendations at this meeting, because we hae
               12
                 i@ anticipated at that      to !love ar)F-royimatc-ly 43 million
               13

                    dollars in requests.

                             And    felt we needed the 28
               15                                          million in order to
                    provide appropriate
               16                       implementation of the recommendations frorri
                    this Council.
               17                 As a result of the actions  just taken that I
               18   rc@cited with @laryland, and I-lassaix-suffo-l.k, those two applica-
               19   tions have increased the requested figure so -h'
                                                                      the review
                    committee Yesterd'av had in tho 53
               20                                     a Plications before it,
               21   a total request of 46 million dollars.
                             Our total dollars tha   are available f-o- support of
               Ct
               42
                    l,'Igional I-.'Ledical Projrams included not only the 28 milli
               23                                                           on
                 Idollars, but some unexdended balances of approximately one   and
               2,4z
               25   ahalf to no more than two million dollars, from prior budget









                              So that the tota'@ i-..onic-s t-,ia+-
                                                                  z, v.@- an

                3  know exactly as i,,,c.re-ceivc- t.                 i4-Ur-@S
                                                    report and ex end


                A
                       s @,7!a I-, t',Ic total amount that we @.:ill- have fo'L 1-c,,.: i n c-,

                5  Counci'L ii@ctinq for suT)porL-0 T',Igio.-ial :-2di cal r--@-c-r;-!:Is

                6  'De approximately 29 .5 million dollars, to 30 million
                7             The committee acted @,,esterday in our clc)secl's@ss'cn,
                5  So we will be  going over the specific recorijrendations. "t"e
                0  have a point,  however, which does  require vour cons4@,,--rat4--
               10  T-.nd as I discuss what the point is, I ":ould lilze L-o pass
                 ij
               11  statement out to you.

               12            And indicate to you @,,,hFd4-- Our @roblem is; ,L-id-2-
                   court orCcr @.7hicil was signed and thus the litiaat4 on is
                   f4-vc ni-11-Lors of dollars i,7ere, given to defendants, i@
                         for purposes other  t,-ian the direct-sunport o@ regio@='
               16  medical programs.

                             T,-ils was the negotiation tha4L- occurred during t'--
                   s@-ttlement, and those purposes were described verv comple@="-r
               19  by             @llow, the          in the court order is
                   if .14'r. Rubel and staff are unable to oblig@te the five
               21  dollars within 90 days, 00 days from             a o@ '-he
                                                                  in.
                   court order, the remaining @u-ds of that five n,.ill4cn then
                 -ireverts to the support of the regional medical programs.
               2-3

                            Thus, we may be  faced in late Octo@r with the
               24
                 I ity gf distributing a very small or medium size, or all--hou@-'-
                   unlikely a large size sum to the regional medical Drograms.










                                  @4-
                                        million @c)llc--rc,     1-7c


                           c          ":a                aining,
                                          @ollars                  b@caus@- obvic)uslv


                         @r- at      --rest on the part of tl,c a(firninisL-,--ation to uti

                         L-- 'to     cis,. c @LfccL'-@--vely .for @-hc-           they N-,@c@re used
                     4

                     5              --,i_ati ons.

                                       But we do not wish to        call    h -Ls Couhci-IL ba--,':

                         it  be   required   for   us   to   distribute   the   small   sum.   TL-;us,
                     7

                         @ia have drafted a stak@-ement which.perhaps I can explai.-i t@, -@z-Ou
                     8

                         rather -I"-!,cin qo over the formalities, which would,  I thi,-.'P-,,
                     9

                         a--co@-.odal--e the situation very
                   10

                                       And  not require your further attention on matters

                         @-Y,)-.-ich I believe are not of sufLieic-nt 1-Tnr)ortance to have anc4L--'-@-A a -
                   12

                                       ,,ihat  we  will  propose  to  do  N@7iL-h  the  close  to   30

                         million   dollars   that   we   have   available,   is   --'Lter   this    meet@--a
                   14
                   15    firsl-- pay u-- to   100   percent   of   your    recommendations,    for    e=c.-I

                         6f  the PPI-I's.


                                       Should there still be funds available to us after
                   17

                         we  have Awarded 100 percent levefs of your recommendations
                   13

                         tod,--v          ld   then   return    to your recommended levels foll-winc
                                  we wou


                   20    at the June council meeting.            Because I     just    indicated    to  ,,ou

                         'L-,iat'- although you recommended      that we su-,)I-)ort progra-,-@L s  at a
                   21

                                                                                           million,    So
                      I':'to@.al level of 88 m4-'Llion, we       reduced that to 84

                         we would then tal-,e any remaining          funds and pay a'ppropria6.@

                         amounts, up to the June council recomlmended lmvels.
                   24
                                       In  the  event,  and  these  are  a  lot  of  if's,   but   L--'--.is
                   25






                            is  t','il- way this                 m-,ist  v       tliinq.-:,     o-,.i'rd t,',,crc still

                            ':)e     monies available,      @'i t"-@cr 'rori,  i-71-ia+-   now

                            to    us     or what may bccor,,2 available            Jt--O us  in  Octo!Dc-r,  cs a

                            rc-,-zult@-  of -Lh,-  situation I      11 Five                        to vou %.,,ith the

                            fivc-- million dollars,  %,Ic would             t@-ien i@r'o'
                                                                                        pozed      to maize    a     distri-i
                        6 libuti-on by formula,,  and the             formula     is  given a',--   L@he bottom

                        7
                            of tills page,  a-rid it would           merely    state    that    i,,?o would take

                                  actual    award    that    we    made,     from     this     August council meeting,

                          !I and 4@-lic actual award
                                                            riade  following the June council meeting,

                      I'd ;I and fi.-,iCL out @@,7hat percent of those two aA,,ards are of ti-,
                                                                                                                e      total.

                      11  i'ia@qaLrds made  at-the June and            August council meetings

                                           An  d app@7     that     narcentage     to      whatever      remaining      funds
                                I,,a-v.D.      d distribute       t-- 1- i o s efunds to each region.             f eel
                          @,,i h a t t'i I -,.- sis equ4-table and  in     keeping with voilr recornmenda+--.i-ons
                                                                                       and
                        5 !!of  the    June     and     August     council rLectings/have        been unusual,  in
                      16
                          it]-iat ai.1 programs, basically hav@- bcen                  revie@..-ed,            simultaneously
                      17 i, rather than at quarL--erlv periods of the year.
                      '18                    Sec ondly,     the     competiti8n,      the      applications      have      coma
                      I,,-, in under     a       competitive       system, whcrcas     during     the     earlier      iDarti
                          lof 1971 we were         making.  distribution on a formula basis, which
                      20

                      ni  !perpetuated rar-          standings of regions  for 1972.   so what we

                          '.Loel   -Ls at  th.-@    -:7 t two   council    meetings,    this    one     and     the     Jun@.

                              uncil meetina
                                                     arc    our    best    indication     of     the     latest     consider'

                          ation of merit of-each region
                      24

                      25                  Therefore    the    formula    that    @,!.e    have    devised     we     believe!








                                     fair.

                                                                cateC,,.  I ho@)@  I       vc madn  it cl!zar,
                                               t  I

                            an d     ,-.7ou"Ld lil@e -to-.,I--ve either a discussion or                    endorsement,


                                             @c)uld
                                                       like to consider it la'                  dis-ussion or

                            @,,C           r- of -3ith@r this ,-)roT-)osal or                         -4cn because
                                                                                       a

                                                   'l   meeting   ends   we   still   @-,av   be    faced    with    a,
                            on---3 this counc3-


                       7    distribution of -funds.

                       8                   And I do not have          that    authority          unless      reconv.-n@c-.

                                                                                                              r cyanc-ra'-
                       9  1 2'@-L" sorc- utur-- date,  so I would                   to oL-'-- n i t  r-

                     10     discussion or        clarification    if    I    have    not    made     it      ar.

                                           )@ll. T-7AIlliOCI',.-   -hat's   only   a   minor   sum   of money,  'Lou

                     12     say aboul-     'Lour million       dollars.    or     a     million     and a half     dollars

                            is that correct?   First            you will talre the sum we allocated for

                            eighty    eighty r,,.illion dollars,

                                         DR.  P@,IIL    T-7-11,   let   me   try,    firs-    I    will    use the fun--s
                     15

                            -'@at          a%@ailable     to us  to -@a,, up to            ,O percent        of what


                     17     w,-t  recommend todav.


                     18                    DP,. @-T Tll OCI@    D
                                                  @A- @-I


                                           DP,.  Pl,,.IiL:  T,Lie  funds remaining          %.@,ill their return

                     @o     your June      council    recommendations    and     pay     @p     to     11)0     percent

                            oi@ those recori.@TLendat--ions.  lj'  funds  still ra,-iain,.either @.,haL--

                                     -e currently available,  to us this  sui@-.-ner,  or                 any      that
                                  ha%,


                         1: May become available to us in October,  I @.,ould then                          employ
                     24     the  formula that I have given which would re@esent                             a percen4@-a@-c--

                            dat'-c-rrLin@-d for c-acl-i region bE,,sed on the June and August Counc@@l
                     25









                           a@..,ar(as.


                                          .,.ttual awards to                region,  @.,i-iici-I -,,ill ,)e at

                        3 il@00,,zrcc-nt   Juiic-    and    August    Council    rocomiTLcnOcc.1    levels    and    ap
                                                                                                                      pl-@


                        4  that   to   @.,hatekyc.-l--   balance rc-n,,P-ins


                        5                 DL-1.                  @.,ould 14-',.e  to i-,.ov,-   iat@-  the,@-  be  @-n-
                        G @dorsc-d,      or approved        that
                        7                 I.IP,.   OGDEN:    Can I ask a question?


                                          D r,. P71.11L:    Yes.


                                          I.,@R. OGDEN:  I am unclear as to what this  five million!

                          !:ivould be      used for   ardtha manner in which             tha-"    will    be    done.

                                          DR.   PPTIL:  I can speak more fully to                the second part
                     i,@, !;tl-ien to the fi---st         point.

                                          IIIP,. OGDMIT:  I   think   it   is   the   first    point    that    I    am

                           more  inJL-.-crc-st!--.d  in.


                     15                   DR.   PAII'U:  I  can   cet you material for the  first po- nt

                     16   !Let me speak       to     the second     point,  however,  Itr.  Ogden.   The

                     17   ;negotiations       on     the settlement of this litigation have                      been

                                                                                                                      e,
                     IE.  !:conduct-ad         Primarily on behalf of        the defendants by,  of              cours'

                        i-, Iliour     office of c anc-ral counsel      and   the person of         air.  Fubel.

                                          And   to the purposes,         needs,  and challenges that               will!
                     21   !,,@be    r-epr    -@nted    by    having    five    millions    of    dollars    available

                          Ito the      Ministration    thus    have    been    our    i-,ost    and    un@c-r     his

                          'direct personal consideration.
                     23
                                          He handed to us, yesterday,  a rather- lengthy statement
                          .?which frankly -rL had not seen until yesterday,  because it is a





                                 activit--@,7 \.,,ithin this b@i 11. E)o that the best Ican

                      do  is refc)7 vou  -L"o             docurcnt 4--hFt I I,,-avc-, tli,-I@- I

                    11 to get I.-Ir. Pi-@hcl to s,@2aj"-, to it rorc directly, because we
                  3

                      rea'LlN, do not ha%,c  in f o rr-L,-it i on I)-:ayond @,iii,)t he distribul-d
                  4


                  5

                                        the manner in wli-lici-i, @-he money will bc sD@nt
                  6
                      I understand is ful'L@:, IL--hrough contract process. 7md the     purpose-:
                  7

                      generally designed to look to%iard the new legislation and to

                      have organized, defined, cleared, and publish- those kinds
                  9
                    li of studies which are    concerned with health planning method-
                      oligies, evaluation studies,      and to development of manuals
                    I and procedures   which will be    of assistance to the oruanization?s
                  12
                  @3i .,7hich we ex,@-ect to be developing and supporting as a      result    i



                                 I am  not sure that that savs much more or even as           1
                  15
                  I6  well  as  what  he  said  yesterday,  but  Icannot amplif,,!- that.     I

                                 DR. SCIIREITY-,.',T-,: It's 1-@inCt of antici,,)atorv -- as I
                  17
                .18   got it.
                                 DI',. PAIIL: It's kind'of anticipatory        let's go off
                  19
                      the record for a moment    please.
                  20

                                 (Discussion        the r-
                  21

                                                  -@-i go         -he rc--co    gain.    @.7oul@
                      b@ happy if I,,Iir. Bell were here          to try ai-!,-.: get him to
                      coT,@- and speak to this point. It is kind of imT)orant, but it
                  24
                    !hFs been quite r)eriolieral to my activities.        Unless there is










                                              r@@ @on         ti  oo4 nt is

                  I L@-hinli: it is the        r2soonsib4li@v o@ t, is Counci-",  to
                3

                A   c,,Dprov(-- the c-:,:pc-nditurc -Lor l@."@P money and this 4-.-  @L-ivc  million

                                 T
                    dollars     of          2,i-id I t'@-, n'- U-,I'Less we ir-.,ltD):ovc- the rannc-

                  i and pur,@ose of= 1-@tr. j-',ubel's c.-.-T3cnditures the irc)yic-.y r,--v n o
                6

                    be appropriately spsnt.

                8             DP. PAITIL: Yes, u-ell that does bear on ho@.7 the money
                    is spent.  It is the   responsibility    of    this    Council    to    approvcL

                    all grant funds.
                10

                              il!R. OGDEiN7: UnleL-s say to lir. Rubel's resolution
                    thz,,t voi-i '.,lave the au,@ ori4-Y t                           t
                                         h        o  expend  that   money   and   @@e   delc-giic
                    to ?ou the ri@,h4L- to  sf)c-nd  i-,"-  in  the  iTianner  in  i,!hich  you  sTD-nd.i
                    -'t, lic%@7 ou  choose  to  spend   it,   and   th@-,-l   I   question   whether   he!
                    is spending it under authority.
                15

                              I,!R. HIPIl,"O: Isn't this the result of tl- cou@-order,

               .17  Bob,   ra'.her than

                              111',. P7,@IIL.- It's the resu2t of the court order but
                18
                    I am in a verv poor nosition to-take issue i,7ith'llr. Ogden.
                19

                0             IIP. IIIROTO: Ol,,al,-.

                  I!          DR. PAT'L: '@,hat I @,:,ould say,  is +-hat PLv under-
                21

                    standing that an expenditure of gran-  '@'unds must come before,
                f:2
                  i; and be recommended for approval bv this council,. but contrac@
                2
                    fuels,  -and I Oon't !:no,,,., iihat -- ...,hc-tlier it is custoni or 1-ai,7
                24
                       '@ly, bul- certai.-,ilv. to the best of my kno, lady no contract
                    f ran,






                           ii   f  es  a                     to CL)i-,i@.              is
                                          r     rc-qui r-ci


                                                      u-'Ircd to co.-a befc-rc.         c-,:: b,-,
                                                   c,7


                         3      counc2.1.


                                                Ina in  La
                         4                                   c     hav@- no@      @ceri        so          as  -,One as


                                 vc- m             d o       s      s
                                                                             -d  in  cont--acl.-  I                            c-


                                   must     no-"- cor@:ia
                                                                                ;De-L3-ev,-a it   %..,oulc,        s        cr


                                7
                                ou   to    ha@ic- a bcttsr und@-r,@l-anding-


                                                !-TZ.'  OGDFL-,T:  '@-7as  it dc-sicinaLtc-d in the  court or-:="-


                                as  contract  funds?


                       10                       DR.  Pi@7-L:  I  -"urn -0 my             quasi-la@vyers.

                                                    @GAFr,@IL.   I.-@    both    I-a@.-2    a    little    in-Fori-,a-ion.    T


                                 4
                                th@nl,-.      one of the things  the  co,,ar,+--      order did              to        ralease

                                imi:)oi-,nc-i-_d founds  ai-id          funds  th--n w--re  allocated to us.


                                L..,e ar.-@-n,,irt.-                                             v fil7c i-,i
                                                nt to    t--  cour-  cl-d;=r 4-   es  @..,.a-

                                o        released  Founded funds  to                  us,     andmakes     it      availa'--!-e  i

                         6      to ninc,,    Can contracts -ha@  TTII.'2                                                     4 S
                                                                   k-              an O.- tha t' s      a L--  r:-= a 1


                                                                                                                             s
                       17       "-o,                               mill@Lon  less  to        allocate to our
                                    ti-icn,     -via have  i: 1 vc-

                       18                           OGE:@@@ll",  If -"hat is,the  case  and it goes  in                   t:i a

                       19       route,  then mv qucstion  is  out -c-F               order.


                                                I.IP,.  GARDELL:  Yes.


                       21.                      Dil.    PP-'IL:    Is    it    Ectuallv    smelled    ou'    as    contrac+-,@


                                                                   rinhat's  ri-cht@-.  Tl-ie-\r don't have  to


                                made  as   contracts.   Thc,7 are .iot made  availabl@--.-L-o us  to all-ocl@,
                       23


                                to our          Is.


                                                    OGDET-@l:  O,@a@),.








                                           P '..T7L Dr
                                      D @7              Sch@ainer?


                                      DR.                1          t h r,         o n               c -z'-. z-;


                     3
                        practical "Lc-:,asible @.,Ia@,- of tal---ina care o@L the ovcrage .      It

                     4  rally @,ould be meaningless to           '.tlav-2 a council i,@,,eel--ing

                     5  lDurposc-.    '.r don'4-. rea-,-!@, c@a an,! reason @or sn@nding  -n,-

                     6  on

                     7                        'tha motior,.

                     5                DR.  PATTL: All in -cavor of the proposcd resoluticn?-

                     9  relative to the- --Fcrr,-u'La for    distributing

                                      'IRS. l,LFT@@7: I,,e        get a second.

                   11                       ilOPIC-Il-lll.,,r: Yes i,.,e did. I seconded it.


                   12                 DR. PI-.II        sorr,r,  i-LL-'has  :-neen  moved  and   secon--d.

                   13   All in favor, D'Lcase say aye.


                                      VOICES-:


                                      DR. PZ%ML:  0-posed.

                   IE;                (r. or(@- s,) -o n s'e


                   17                 DR.         T'@=motio:i is carried.

                   18                     OGD'@",!T: As a mat+--er--of ed-L@@orial co:--Tpent, should

                   19   the   bottom   line   read   -- June?

                                      IIR. GPF",DELT
                   20                                 The words will be dated in %ugust.

                         4
                   2 1    Lll b-- effc.:cti,,,,^@ L@c-,DterL-@er 1. You're 'D@-ing t@-rri-b-i'y

                                             T
                                      DR.   @IL:  t".ll         "7o,,.! that %-To have gotten

                          next Granted to move over 'L-.o the arthritis, but I see              t  a
                   2.3
                      i both Dr.'Graml.ich and N'r. Spear just left the- room.              So, ,Lr,-'L--st
                   24

                   25   I  i-7o',ild  just  likc  to  have  the  minutes  of  the  last   meeting   --on-,

                                                                                                         I
                      !I                       -                                                         i
                      I                       -
                                                                                                         I
                      'i







                              @-idcrcd.


                      2                  T


                      3
                           h,,-d an                      read             oc-r",ar)s we could

                           -IC-ion    ci-i


                                              O(',DPil: IJT,hese @,av
                      5                                             CTI 't        mailc-d ou--

                      6    no       reason not   to suggest a mot--'Lon that they be a,@proved.

                      7                  TIF,. @IAI-11,IOCK: Second


                      8                  DR. PATIL: The motion has been made to accept                 t,e

                      9   minutes       as submitted.   Anv discussion

                    10                   ('@'io response.)

                                         DP,. @PAUL: All   in f a%,or of the motion.>

                                         VOICES: Aye.
                    12


                                         D@@.  P70IL:   O!Dposed?

                                         (.@To response.)

                    15                   DR. PAIIL: The    motion is carr4@e,d.

                    16                   IL,.IPS. I.-!Or.,GAN': As a matter of fact, it @.:ould be -'Llleaal

                    .17   and     still  is part of the minutes.

                                         DR. PAIIL. @-V-,e walk a @-iSht ro-I)e here.        I..7e will
                       'i in   just   a  morient, having a renc>rt       fro,-.. ;"@r. I-latt Spear  to  !--ring
                    19

                    2.01  you   up   to  date  on  tlic-   status of the arthritis proaram.
                    2 1  @;ou Still -"-ccall, at the       1 a,-; t'- council r-.=-eting, "Latt,  T

                                  Dllst  about      g--ttinqtdvou at this poin-
                    22



                    24                   DP,. PI,174L:  If that is su--@ici@nt.       As you recall at
                                      Council meeting, i,ou did listen to a presentation
                         the,'Las-
                                                             z
              ii!   25
 k                     I
              i        I
              i        t
              i        I
              @i       I                                                                                       i
              l@       I                                                                                       I
              ii       ii





                          bo-'--Ia Dr. G@aml  cl-i anO,- Ilir. S].)eci'r rc-', ati@,c- to t:,- -iot-

                     2    prc)grz:m.

                                       Prid th@   active 4- i i7  considerations and -,--mal

                                                         ad hoc   Ar4l-hril-is Rev.4.c-w Cor,-j-  -.e;
                     4    recor-Liiienda4L-. is o


                     5    subsc-ciuc-:nt to                      have macic-           and   7

                     6    like   to call on          --Ipz-=ar to d!-=scribe tli@-, current  status

                          t',Ae i,-)roaram, an(9 our activities since the last Council'

                          meeting.

                     9











                    13








                    Jr


                    17








                    (lo












                   24






                                               It  @@:ill be juf-,t as c7,lvcnien4-,

                      lust  rc--aD4@tti-lats  so           ir-, on 4-h-@

                          --eccivcd in 1974  -an a.n@L,Iro,7jria4-- -- f-"c r@-n alloca--cn =ar-

                          .@d 4 and a half    milli-on dollz,,rs for t,         lo   ii  c-c a
                   4


                             arl--Iiriti.E7, c--n'L-c-r.


                                  @-"!@cn the requ@st for  applications @@:c-nt out @,:c re ce',
                                                                                 mi -I i.L,cn
                   7  a-.o-L)lic,--tions from 43 regions, totalling almost 16

                      dollars.    So it was a highly competitive situation iii

                              Polic,---s were  established  which  too],.  out  of

                      'ho@@- Izinds of- activities which did not seem  JL-.c,,  bc

                      did -iolt-- scem to directly )Dear on pati-@nt sc-- vices and t-=

                  12                of things for L@atig-=nt@. and the extension c-l-c care

                      t o p a   t s .


                                 in       outco-    then, a@- recommended by           ad '-c@=

                    ;j arthritis r e v -,q committee and the Counci:l at it's "Last s=-ss-@on

                  i@  31 c,,f    PIIP applications for Dilot arthritis funds i-.ere

                  @7  ap@,)ro@?-cd.  The a,, proval exceedee.1, @ic! earmarked ful-,Cis sf-.-.@

                      sma-L.L amount.


                                 I shouldn't say small-ai-ount, that's edi+--or@-al. B@-

                   0           t of almost a lial4c a million dollar.--,.  1,7ith2 the a:D:Dro-
                      ,n amoun


                      val of      Counc4-l               or app--oved, tanded to

                          allocation o:"       fun-" to all ,)f the rrc,-rcl-7:, t,
                                                   L

                    i,i@qik--hin the earira--"@ed amounts available to the programs.

                                 .7,nl that is 27 of those appr,)vc-d p@grairs, an,4

                      rc-i-ia-Lning four @..,ho were aoproved, but for which there @.,7er- not






                                                                 earr-,al--!@-@c.1  Eunds,,   are  -@eincT

                                   2       c'-
                                                                                                                                               the      a@o,-,n--
                                   3       program                 pT.) r o v c cl          4@-hc-  Council.
                                   4                                                                     to  this                         t-a@-  a  rr%c-,'oia
                                   5       is  Or  4 S  I-lot  a_
                                                                          Z?l
                                                                            _)rCVC(3  f
                                                                                             0      -cE,,-rmarked  'z'-n@-3  Or  -13  Or                    is  not
                                          @-:-).Prov@-d  for  the  utilization  of  discr@4L--4-o.,ia",@7  fund                                                ,as  issu=----
                                                                                                                                                          s
                                   7      on  Liune  29.               Thc.   1,@,tter  also  requested  that  eaci.1  of
                                                                                                                                                                 ie
                                   8      receiving  approvals                        for  pilot  arthritis  ac4, --i%ritv  resnon,l  4,11-
                                          vjritino  as  to  its  acceptance  of  the  award,                                                           an    a,..7ard      is
                                   9
                                lt,3      involved,   and  or  in  all  cas@is  the  conditions  of  the                                                     aiiard,
                                ii       @,jliich  k,,Ls  the  statement  embodied  in  the  aD@-rova'Ls  as  to                                                      the
                                          :finds  c,@c  acti,%ri@ic-,s  @hat  sh@-uld  be  und@-r+-aken.
                                13                             And  t'@,i LzL  1-@l,ri-iits  of  the  --Funds  that  could  !-)e  expende--z
                                14                             activi4i--4-,---s.     Tcdall  l@e  have  acceptances  21  of  those
                                15       Il-',!@P's  and      we  are  waiting  for  an                         additional  ten.     -o  round  it
                                16      up.     Eig.1-it         of  those  have  been  contacted  as  of  yesterday,   and
                                .17     they  arc,  -,-,,orking  as  rapid!-x;,    as  thc-v  can  to  cTeL@  their  accen-

                                        ance     s  in.

                                                              As  you  can  iirag4-nc-,   gG-ing  from  a  request                                       of  sixtee--i
                                       million  to'somethirg  in                             the  order  of  less  than  five                              millions
                                2i     soTr@e  drastic  cu4--@-  i,,,erc  made-,   and  some  restructuring                                                o f a C 4L-. i
                                         i-"hn  t'-i--  aiD,,Drova"Ls  h,@F,  been  nc-cessar,,?,   and  thos-   cl
                                2

                                       1-ing        negotiated.
                                23

                                2'z                          It  appears  at  this  moment,   that  cnlv  one  or  two  oz
                                       the  31-approved  regions  may  turn  down  the  funds.     One  apparent',-.-






                          is liavincT sor-,,:2         -ty   in dec-'Ld-Ln       t t'@@


                                     c  -n 0


                                             the  re%7i-i.., co@-arittee and       Council     both


                                                                                          recommend
                     4    two    other actiors,   both at -Eric sar:te -L-i.-.e ,

                     5    1--herc be some centralized fu-Llo,..,,-up                         n
                                                                                    @,iv-sic.    o@

                     61   FIegional 11'@-adical Programs.     The major,,oart      of that I t hi  n'%-

                     7    the T-,osL-1 ir.,.-crl-ant asTDect .4-sadesire   t',' I a L-, there be a -ret.-.od

                     8    and    an    aonroach     to     coordinating like    kinds    of    prourams    that

                          .@-ieverth.eless are dispersed the 31 Pd-,!Pls.

                                      T 7
                   10                     are  also  in  the  advice   letter   of   Jt,-ne   29   as'r:e--7

                     I    h      P   sto  give it some thou-ht,  and to give           US  the @@isd=

                          of @Lhei-r c.-:Perience and thoughts.   However,  they         did not h=---e

                          the full  information needed b,,        then to a--ve a proper reso@s@

                          in our estimation.


                   15                 An d @,;e are   presently   preparing   a    letter    to    follo,@,-

                   16     --.'Liat- uD and (Tive them   more    concrete    information    such    as    %,;ho

                   17         the ball    players, who aot                      and for ,.!hat kincas

                   18     o-c iyurL:)o--cs and what   are   the   na4L,.Ure   of   the   programs   that

                   19     hLivc   bec-%n   anproved   for   fi,-ndirgr-

                                      And  ust in     conclusion, to these remarks,  let me

                          --,-ad @ou the draft r@-rL@-  of 4L-lie letL--er that r-ur@,or-L".s to

                           e aoD--oved programs.             --i@.nhasis of +--he a@)proved Dilo@
                     2

                          procrams   is    the    c>:tens4@on    of    present    knowledge    in    arthritis
                   23  i;

                   24  ii @iaanosis,  L@-rcati,@-,nt and    care    to    coordinated    services     @.jhch
                   2,,    demonstrated improved      patient acess to care,  and extension O.--






                                   professional  servicc-s  through                        n a n cl c- u i  1     a     n


                                   f    c. c,  ni   i-l@z,@--cn@r-il,


                                                     @r-l-,r4 tis     c---n--s  wil.1       be  established            in       r-,20ical


                                   centers,           co,,Pj-lunity                    aT-.              cormunitN,  heal--h

                                   f a c 1      c-  s    Lducat.4-o.-,i,-.1  proc7ra--.,.,      7-i                  an,,.,

                          6        visi@@ing mu'L@-@L-discij?14-narv                tear-.s            ir.Crc-   as'e   tl)--    arl.--,.ritis

                          7   i.   hc-indii-i-ic-i   capabilities   0'7                            and  oriva4-@--  !,)hvs4-ci-ans

                                   and      wi-il eauir)     larger nurJDers  of medical                  and hcalth             o3rsoiin-c-1.

                              ii   -as  Support  services  in  hospital  clinics  and                                inc--cased


                                        L
                          .0  ii
                                   )at,-,-it  care                be   i.ncr,3asc-d t'li@-ouah  the                                of


                                   pat-@ent  traini@-i,7,  ac4l--ivities.

                                                    Seminars  and i-:orksho,3s                       be    cc..,-iduc-L"ed    at     many

                                   sites  For       4-r.,@rov@-d  utilization  o@-  co nml-,,,iity  r,,-sourcc@-  L70--

                                   arj-l-r4 - 4     services,  inclu,!-'ng                      care,  gu-,7,a-;ce  and  s
                                      L-,                                                                                          urvei@-

                                   lc-nca.      Ex,,-s4.-4-rg health  c2eTDartr.-ont personnel  and  facilities,                             I

                          ,C       and       h@-aL!th   groups,    such as       the        @,-isi-ing        I',urses        Association

                          17       loc.,-.,!  zcunc4-l-s          aganc:,,  a,-.d  operating  community

                          .18      proqra,-.s  are  cooperating  and                 C-ar@nstrations   of  a@@prov--zd

                          l@       arthr4-is  health  care                                     Several  modest  studies


                          20       to      c@.,avalop criteria  for         qualitiative  carc              through              provided

                                   P:2,--"'orr-.ance  sjt--E,,ndards  are  b;@ing  convicted,  Crew

                                   survc@     -Ls  niaiine6  in  one  region.

                          23                        Pnd  an  enl7)lovee,  a-,jloycr educatici-in-'i. ,?ro-r--LI will

                                       "@v,@loped     in.     c     -1c@-rt     @@,,ith     bett--r      orga@-ii@,ad      occu77,ptional
                          24

                          2-5      hea'Ltli  services.            Z\-notlier  region  %,,,ill  investigate  the  utili-ZE.%-






                    o f so! ar 7crl-.      E: u r,,,@or t I-,aticn t r -Cs tor a4-on0-c-


                    a c tv


                              7@ nu.--@er- of programs arc 4.7ocuEi-ng on the pro!D-i-e-'s

                    of lo@.@ inco@-,,e arouDs, rural grouses, and others zre -r-ocucz4-,-

                 5     -LI-ic- C,,,Lv-:alopri-erLt of car-@ 3.n        d@

                 6  inner-city rosidcnts. Pc-dia,tri-c artlil--il--i-s sc-rvic Li wil@- I-,,a

                 7  de,,,-elo.0,@-d in a vari-c-@L.@, of,sc-tti-ngs, and one T,))7()CI-a.-'t SC-c

                 8  stratina i.rLi-,orovc-d services to the geriatric  poi?i2lat4@r-lr,.

                 9            Localities which presently have little  or  nor

                    tological resources are being supported by                 c,--

                11. the expansion-of -,,cd-@cal, il,e@.7 medical irist-Ltu-c4.cri

                    cLoabiliti-es.


                              Across the country, chapters of It--he ai-@-hri4-- -L Z:,

                    f ounea-6-io-i are       program, coord2 nat 4
                                                               @on to

                    a,-id increased nu@LIic-rs of volunteer @,7o irers in c;u-T-)orti,--
                                                            r

               1-6  services.  P-nd ip---reased agcn-',- referrals tc) lo,,:al -erV4r@-3,=

                14 and resources.


                18            That completes mv report, Dr. Pahl,  un  s s-,!,.cre

                ig  are questions.


                20            DR. PIIIIL-. Thar@k you very much, .@'llatt. Dr, Fir--tbc-r?

                21            DR.IIABT"R: I-,hat is,   is -It--hcit -@,)roarari w

                    geriatric services?


                              I-IR. SPEAP: In         Univ@-rs4-@--v of- -r'4-chigari.

                                             you, Matt.   Dr.
                 .4 III

                                               I i-nd-icatc-Ci to ,,,nu,  1

                    to i,,ou 4-'or.not h    cn able to g@t @,;ith yot:. a li--"--4--1b4 Z
                                    .V4ric b@





                                                                              4 1

                                     to the  road construction %.,,Ii,ch e@elayed Tntr
                    this morning due

                    getting  here.
                2

                              I wondered, however', if you have a statement to
                3

                    make generally or i think to add and the information
                4
                    I did pass  to you I thought I would like to make an explanatic
                5

                    and  statement to council, rather than a formal resolution.
                6
                    But perhaps you would like'to make some comments, as a result'@
                7

                8             I would have-a great deal, Dr. Pahl, except to say
                    -that this is a great example of the flexibility of the PILP
                9

                    process, in the administrative organization that is able to
              10

                    accept the task, early on, accomplish it rapidly,- and apparent :1,
              11

                    bring it to reasponably successful solution.

              13             Matt's report is superb and I have nothing to add

                    to it.

                             DR. PAIIL: Thank you.  Let me just take one or  two
              15
              16    minutes, and indicate to you.  IN7e are -.attempting, should
              17    there be further funding coming to us this year than anything
              18    we have spoken about to date, or@will there be special arthritic
                    funds made available to this pr-o'gram we would attempt to engace
              19
                    in those activities,which'the committe e recommended to you,
              20
                    and you endorse  that is to provide centralized audio-visual
              21

                    resources, the development of certain training films, vioeo-
              22

                    tapes and so forth.
              23
                            But this requires a reasonable investment, and we
              24
                    do not have the dollars at the moment. We do intend as llr.'
              25






                  I  Spear indicated to try to uull               the existir,!7, approved!

                     activities into a cohesive    procram throu,7,li the good o.4ficcs
                  2

                  3  of !lr.  Spear.

                  4              1.@nd beyond minimal funds needed for some conflict

                     meetings,   and so forth, I believe @-7e can accomplish that.
                  5
                  6  So .-7e do hope to be 'able to report'baclz to .you at some future'i
                     time  that  the program is not an assemblaac- of disjointed
                  7

                  8  projects but  does represent a total national program.

                                17ow, facing us yesterday and today there are
                  9                                                               a

                10   limited number of arthritis applications in the July 1       RMP

                11   applications. I believe five regions saw fit to include

                jn   arthritis requests in the current applications.  I-..@ich is to

                13   say that most regions clearly understood that the pilot

                     arthritis program was related to the fiscal 74 @r-undina and
                14

                15   the activities of the specially established ad hoc arthritis

                     review committee which met for one time and was disbanded.
                16

                17              Thus, we have a situation in tihichI aoministrativel
                -18  and indicate.to those regions    that basically their applications
                19   have been submitted inappropriately, although I' think in

                20   some cases there have been honest misunderstandings, so that

                ')j  perhaps this news would   not be taken lightly.
                  r             I feel : ?.t, however, it is important to-reopen
                22
                23   with you very bri----Ily the fact that we believe the pilot
                     arthritis center program was established and is no longer
                24
                     open. That  is,  regions should not be permitted to spend
                25




                                                                           43

                I  currently available funds or %@:hatever -LcunOs core to them

                211 in t-ie year, -- the distribution we havc- been discussing
                311 this morning to support additional activities.
                4            T,.e are timing to build a national cohesive proar,-,rpi
                5  -and as a result of that I have 'prepared a statement i7hic'L-!

                   I would like to read to you, and if you feel you need to studl:-
                6

                7  it we can distribute it. !rhe timing is perfect, Ken,  thank

                8  you.

                9            But I believe it would provide you with the  sense

                   of what I believe is necessary in order to be fair to all
              10

              11   regional medical programs and to try to build a cohesive pro-

              1.2  gram from those activities that were reviewed  and  approved

                   bN7 the Technical Board of Experts.
              13

              1.4            The statement that I would like therefore, for you

              15   to read to you and ask for your endorsement is the following

              16   the underlying authority for the 1974 initiative in arthritis

              17   was  pilot in scope and intent.  i@d heterogeneous activities

              .18  beyond this.level would not be appropriate employment of

              19   current grant funds.

              20             The full development and delivery of services  for
                   arthritis is an enormous undertaking, and requires a continuing
              21

                   well organized attack such as could be initiated under presenr-l-
              ^2

                   pending legislation.
              23
              24            Thus,.while Council is fully aware- of the urgent
              Z5   needs in the arthritis field, it does not consider expenditures






                    for arthritis, other than for a,@DDrovals and recc:-.@nendat-1c.,,-.E@

                    made at the June council meeting to be a.@,Dropri,!te in
                 2
                    present environment,.
                 3

                 4             And the allocation or  expenditure  b@,  individual

                    regional medical programs of funds for arthritis in addition
                 5
                    to approvals provided at the June  13-14,  1974  Council  meeting;;
                 6
                 7  are not approved.  The  Council  will  entertain  approval  of
                    additional thrusts in arthritis in the event of appropriate-_
                 8

                    authority and new grant or other funds become available ro
                 9
               10   the IUIP s .

                               Dr. Gramlich'?


                               DR. GR2VILICH:
                                              I heard there-core in the  periodizatioxi
               12

                    process at  the June meeting there were four applications
               13   that were approved by not funded. Those were outside the
               14
               15   scope of this

                              DR.PAHL: Those four are outside and'they ha-%re been
               16

                    gven specific permission following that Council discussion
               17,
               18   to.utilize their funds to support-.,  Because  those   aDnlicationa
                    went to and through the  review process by the arthritis  review
               19

                    committee.
               20 1                                              s
                              This Dertains  only to those  activities  that  were
               21
                    no-"" reviewed by that special arthritis review group.
               22
               23             DR. GPAI-I.LICII: Okay.
                              DR. PIVIL: Because regions are permitted to  rc-budget,@,
               24
                    and anybody can rebudget into  arthritis  inthe  coming  year.
               25






                    I don't know how @@,e can establish a  national @-@c.@ra-i L   c

                 2  basically leave it oDen ended.

                               The applications in  arthritis that  have  come  be'Lore,

                 4  you today  1-iav-e not been reviewed by the arthritis @anel, and

                 5  cannot be  because we have no possibi-I.,.-t@7, have no Possibility

                 6  of calling them together again.

                               'That we are saying, therefore, is  that  your  Ju..
                 7

                 8  actions, including the forn, which we did not have funds     to

                 9  pay,  but were given permission by that closes the arthritis

               10   program effort unless  special  arthritis  funds  were  made  avail7

               11   able to us, or.unless additional PJIP funds, and then it     wouldi
                                                                                       II
                    come back to this Council in full measure.
               12

               13              That is the statement, the intent of  --he  stater.--nt.'

                               DR. GRAI-IT-ICII: It seems reasonable and perfect---l-,,
               14

               15   clean to me.  I  move  that  it  is  adopted.  Unless  Council

               16   %@iishes


                               DR.           Seco.-id it.
               17

               18              DR. PAHL: It's been moved and seconded.  Is there

               -19  a discussion?

               20              DR. J@IE!@71'.Y: Isn't the intent of that also to exclude

               21   those grants  which  on  technical  grounds  were  disanoroved?


                               DP,. PZJIL: Yc-s.
               2

                               DR.           I think this will  be  clear  in  the sense
               23
               24   of it.

               25              DR. PP-TIL: This then will be incor-pora-L"ed.  This






                  i says that cnl,%, a-,)proved activit,,, -- activities in +-hc- June


                                                             4
                4   se-L. of rc-e--ings can i-,ti-l-Lze "-"P -'Ur,.-lo, disapproved activities

                3   cannot utilize them, an-,, activities cannol@- be started with

                4   currently available -or expected to     available of  the

                5   actions we have taken to date, 'his -o-nincr.

                6             DR. 1"01:AP-,OFF: Do you   off hand those  five re'gi o- s

                7
                    that we can consider that in making  -funding?

                8             DR. PAHL: The specific four regions?  'Ir. Spear?

                9             TIR. SPEAR:. Florida, @',emrihis, Mississippi, ar@@@ r'-Iri-

              lo    State.


                              DR. FLOOD: Tri-State brought up

                              DR. PPHL: There is a motion on the floor and seconded.

                    All in favor of tJe motion, please say  aye.

                              VOICDS: Aye.

              15              DR. PP.IIL: All opposed?

              16              (No response.)

              17              DR. PAIIL: Ilotion carried. L@.at concludes the formal
              -13 11 business, except for, I think th6 very  important  public
              19    session, and I would like to ask Council whether you would
              20    like a brief break and then bring some coffee back to the

                    4-
              21    L-able and have your onen meeting with the representatives,

                    or whether vou would like to continue on, and then have a

              23    break@


              24              DR. I-IILLIKEN: Coffee now.


              25              DR. P7'"IIL: All right. I think that is  fair  to our





                                                                                4 7


                 1  visitors too.


                                   Oon't we try to  reconvene in, oh, ten or twelve

                 3  minutes, as soon as--we can bring some coffee or doughnuts

                 4  back to the table.   And then we will be refreshed for hearing

                 5  from our guests.

                 6            (T,-7hereupon, a short recess was taken.)

                 7            DR. PAIIL: I-lay we -come to order please? Now that we

                 8  have had  achance to get some  refreshment,  I  would  think  we

                 9  are in better position to consider the remarks of our guests.

               10   I would like to welcome both Mr. Bacon and Mr. Sargeant from

               11   the Maryland PIIP.

               12             Mrs. I-IcCarthy, Dr. Scherl, Mr. Prasad, from Nassau-

               13   Suffolk t@-IP, and of course, Dr. Sparkman  has  already  spoken

                    with us this morning.
               14

               15             If there are other guests, I  dd  not  have  their  names
               16   here.  Ile would certainly invite you to participate in the ope@
               17.!session.   I have been asked  because  of  other  commitments  to
               18   if we'could call on Mr. Sargeant,'from  the  Maryland  RRIP  first,

               19   and I would do so now.

               20             And I would ask to  have  you  identify  yourself,  if
                    you will, for the record.   And give us  your  statement,  or  sub-
               21
                  .;Init a statement, and then following  any  discussion  will  you
                  I
               23 lplease -- we'll hear also   from Mr. Bacon.  If  you  care  to  spea
               24   and then if that is satisfactory, we will com@ to Dr. Scherl,
                    and others from the Nassau-Suffolk PD@IP.
               25





                             IIP,. SAPGE2\-P','T.- Than'x,l you. T do 1-ia%,c- a 12.00 arpoint-'

                 2 iment -in Baltimore, and that is what you got wli@n  you  try  to

                 3 schedule things so tight.

                 4           I am a member of the Executive Committee of t,Lie i@giona

                 5 -Advisory Group and the Maryland P@-gional 1-ledical Program. Lilz,--

                 6 you I am a volunteer and give my, time for       towards   hopefully

                 7 operating an. efficient and.effective regional medical program.1

                 8           I do have a  statement  which  has  been  distributed  to

                 9 iyou, but in the interest of your time,  I  am  going  to  summarize
                   I -
               10  :it if I can. lihen v7e.receiv:-nd the news referr,-md to earlier

               11  !this morning in--IL4aryland i,7e did discuss it  at  some;  length,

               12  ;and felt it important  that  perhapsepeople  coming  from  all  over
                   lithe country are not ascdgnizant of the city  of  Ba!4-.iirore,  and
               13

               14  i,tne state of Maryland, as they might  be,  and  we  felt  it  would
               15  @be important that you understand our case; and our philosophies,,,
               16  @and therefore that is part of the reason  that  I  n-,n  here  today.

               17            The gentleman from  VA  is  probably  close  to  ilaryland

                   so understands the geographic situation perhaps better tha
               18                                                                 n

               19  irl.,Co@'t Ot vou and I am sure Dr. Schreiner does, from  Ilashington.

                   @Maryland has a fairly large population but our Regional @L-ledicall
               20

                   ;population only serves about three  million  of  ti-lat  Po-.ulation1
               21

                   @,@"h,at is made un of 2.7 million, in 11-iryland.
               1"2

                             And 300,000 in  Yorlc,  Pennsylvania.  I-'.  think  it  was
               23
               24  referred to earlier this morning,  that regiorul medical programs-

                   .do cross state boundaries and ours indeed does.       As   all   of
               25






                 I   the Regional Progra--is we have been involved in changing      Drior-

                 2   i-,ies, and i change in --he effectiveness of -@undinc,, and so


                 3   forth.


                 4              So we have  been somewhat pc-r;7!exed at times, and      i

                 5   somewhat harried at   times in order to get in our aDolica--Li ons  i

                 6   for money.  And I am   sure that you  have experienced   the   same

                 7   situation that we have.

                 8              Now, of the three million people that  i..Te  serve  in-

                 9   -Ehe'.'Iaryland Regional 'I'@--dical Program aoproximatel,, two

               10    million of that total is included in the     metropolitan Baltimore

               11    area.  That comprises the five standing     counties as well as
               12    Baltimore 'City itself  which is a separate and distinct politt@cz
               13    subdivision, not part of a county.

                                And in western I-larvland there are a:,),@_Drcximat-@lv
               14


                                                              -ater,ent which was
               15    300,000.   These figures  are on the s4@

               16    given to vou, I am rounding it off; on t.n.e Eastern Shore of

               17-   !.,Iaryland, v7hich I guess is referred to as Chesapea),,e country,

               18    there are approximately 250,000, and in the southern part

                     of Ilaryland is 115,000. -
               19

               20               Then we have  an additional 300,0,00    in York,, Pennsyl-

               21 !II vania. Interestingly enoucrh,-of  the  -)o--ulation,  and  that  is

                     @@,io million in the Baltimore area, 7z-).G Fercent  of  that  pop-
                 2i  '-
                           arc-
                     ulation/in the low income area, in fact, 25.6 percent of        the
               23 1

               24    people in metropolitan Baltimore city alone a-re Medicaid

               25    recipients.





                                In fact, 54 percent  of all  the people in the
                     of I-laryland, the entire population of  I-laryland @,iho -re me-di-:
                3    caid recipients rbside in  Baltimore city.  lIence, I think
                4 ii what I am tryincT to point out to vou is that many of our
                5    obligations have been centered   on Baltimore city, @.,hich has
                6    been o@ the  criticisms that we   have had.
                7              And we have tried to expand our    services in areas  1
                8    outside Baltimore, but primarily the greater part of
                9    and concentration has been toward improving  methods  of  the  @i
               10    people in Baltimore city to receive medical care.  And so,
               11   while it may seem out of proportion to the members of the
                    group, and the members of the technical advisory grou       indeed,
               12                                                            p
               13   it ]Isn't when you look uDon the geographic and the economic
                        -ribution that exists  in the state of Mar land.
                    dis4@                                          y
               4

               15              Now, we have adopted many approaches in our effort
               16   to submit  grant applications. We have  --  amongst  thoseincludel
               i7   support of planning, for IIealth I-'Ilaintenance Organizations
               18   we-have been a great deal of patient education in hypertension
               19   for the low-income black-famili-es, particularly in Baltimore
                    city.
               20

                              We have pioneered in the areas of   home health care
               21
                   @--.Lvj-L;es to neighborhood corporations and we have also assis%@-e,l
               2,-)
               23  in the training of pediatric nurse practitioners who today
                   in Maryland  are serving not only Baltimore c@ity, but they
               24
               25  are serving in the rural poverty areas as well.





                1              I v,,ould 1,3-,e to point out scme of -&-he ver@, important
                2    x:i=@c@s ol the @,IP has had cz-1 ac@i-,,i-ti-as in the health field I

                3   in the state of I.'.'.Iar-,.rland.  In Baltimore -- I can sure that
                4   those of you associated with medical schools in the city.
                      -re is al@.,,ays great rivalry bet,lqeen the medical schools
                  I T@
                5

                        is going to be the first i@:i4L-..i w hat
                6

                7             In Baltimore when we developed our mechanism for
                8   let me get the correct title here.  l,idneN, Transplantation'-
                9   Program.  l@7e were funding part of this several years ago.
                    'qe were able to bring together the state's two medical sch@Ols.,
               io
               11   the z;tate Ilealth Deparlt--,T,.ent, 'a kidney foundation, and two
                    or three of the community hospitals 1.7hich had their own  pro-
               12

               13   grams, to bring them together.

               14             So now we have one unit working in a cooperative
               15   manner to accomplish the objectives that four or five units
               16   were working towards before.  '.-%'e think that this is a very
                    positive accomplishment that has been made in the city of
               17
               18   Baltimore, particularly ,%,hen as Z-said earlier, there have al-
                    ways been rivalrv.
               19

               20            llnd I see some.smiles  on some DoQtors faces here.
                    1,7-- also back in 1969 asked for and received a grant of sll5,oob
               21
                 ill'ro,,,--i(aed off 'or a three vear closed chest cardiopulmonary
               22
                    resuccitation training program.  And this has been taken   over
               23
                    since that time by the Ileart Association of L@ieryland who has
               24
               25   trained some 13,000 individuals in the life savincT technique.





                   materials into Dutch.  L'@nd is using them in connection %..-itl-l
                2  its patient education programs in Europe.

                3            So, agai@, w3 ti-,inl-. that this is a very important
                4  for us.  14ovi, these three t-hinas that I have just mentioned

                5  to you.  We feel thev demonstrate the vital role  that  the
                61 411aryland Pegional ".iedical Program has pla@7ed in the development
                7  of new and effective methods of providing critically needed
                8  services where few if any previously existed.

                9            You have before you today,  or you will have beforel
              10   you today two projects which applied for in our July application
              11   two of them applied directly to the Western part of Maryland. i
              12  Where tliree hundred thousand of our population reside.
                                                                           hey
              13  ".LI= PcLrt Of the second application TDrogram.
              14            They involve health education in one case, health
              -15 education  for teachers and professionals.in school  system,
              16  a joint effort to educate the teachers so that we can corrunicat
              17  this information to the students, and the school system  i-n
              18  Western @laryland, which is part of the Appalachia Poverty
              19  Region. area.

              20            Over on the Eastern  shore we have, which is 250,uvv
              21  population,  we are funding a clinical cancer program  --  a
              22 -hospital discharge planningirogram and continuing educational
                  program in aeneral, in Tivert County.  fall three.of these are
              23
              24  now being continued under private enterprise and private funding
                            York, Pennsylvania which we serve, with a population:
              25





                                                                                i4

                1  with a population of 300,000, approximately we liavc-, g@L@,,en

                2  continuous attention to this area.
                3            @Nle have a@ acute intermediate and long  term  scope

                4  care program begun in 1969 with a  grant  of  $561,000.  This

                5  established a special hospital unit for the  total  care  and

                   rehab of stroke Datients. And since  the  termination  of',@-he
                6

                7  funding for that  program, in 1972, the entire program has beelt,

                8  continued, and today is serving an areas  with  a  population

                9  of 300,000.
                 I
              10             We are very proud  of  these  accomplishments.  Which

              11   we think are positive things which perhaps in the rush of all

                   the other applications and  information coming to  you  may  be
              12

              13   overlooked.

                             I would just like to make one last comment, to

              15   point out that each of the eight projects  that  we  have  pro-

              16   posed for funding which will be before  you  today,  at  least,

              17., we anticipate is aimed at achieving a specific objective spel:   ee

              18   out in the latest, I said latest-interpretation because as I

              19   have indicated earlier, there have  been  continuous  changes

                   of Federal guidelines, and that is developed cooperative
              20
              21   relationships in the improvement of care in underserved areas.

                             Developing innovative  approaches  to  medical  care.
              22 1
                   All of these projects received full review   by  the  Technical
              23
                   P-@view Committee of our Regional IIedical program b-,r the compl@,-t.-
              24                                                       .11
                   regional advisory group and by the '.'Laryland Comprehensive
              25






                                                                                    SI 5

                     11-3alth-,Plan agencv.


                 2              1 '--'-an!: you vnry much for --,,our time. I have  been

                 3   as brief a5 I couicT,.  'I'Te do have complete details on

                     material that has already been distributed. I am glad to       answe r
                 4


                 5   your questions.

                 6             DR.  PAP-L: Thank I,ou very much, !@!r. Sargeant.      Dt

                 7   Gramlich?

                 8             DR. GRAI@LICIT: Ilr. Sargeant, I am sure we all      very
                 9   m.uch appreciate vour lucid comprehensive remarks.  Play     I asY.

                10   !i your occupatioi-l?

                11             IIR. 5ARGE.AITT: I happen to be the Executivc- Director

                     of the State IL-ledical Society.
                12   11
                     I         DR. G@-ILICII: ror the state of l,@laryland?
                13


                               MR. SARGEA14T: Yes.


                15             DR. PAIIL: Dr. Wammock?

                16             DR. X,7AI-LNIOCK V,hat did you say about the medical

                17   schools competing together.  I,.Ihat?
                18             ilIR. SARGE.-WT: Ivle did geE them into a kidney transplant
                19   program.  It has been very effective  and  %.ie  have  very  active
                20   recruitment for kidney transplantation that,are --

                21             DR. W,@@%U,4@OCI": But that is the only program they  get
                     !-together on.

                23            IIR. SARG-@i@IT: They have gotten together in many
                     others. The university medical service program is working
                24
                25   verv closely with them, as is the i-ILedical Society,  lv7e have
                     a close relationship that  we  try  to  bring  them  together.  Try






                 I I  to get them to see each other's view points.            t]-iin)z COM-!

                      petition is good.    illo@-,levc-r, @@ie don't thin)-. that is en4--irel@,

                 3    bad.

                 4               DP,. Pi'fflL: Is there any other discussion or comments.

                 5    Thank you very much,     Mr. Sargeant.  We hope you make your

                 6    appointment   in   Baltimore without breaking the  speed limits..   1

                 7               Mr. Bacon, do   you have anything to add?

                 8               MR. BACOII: klo, in view of the time pressures, Dr.-

                 9   -Pahl, it has been a pleasure to be invited.  Pnd if there

                10    are questions I would stay around.  But I also want to get

                11    .'-Ir. Sargeant back to his me eting.  So  I  won't  interfere   with

                12    that.


                                 DR. PAIIL: Yes, Dr. Jane@%,ay.

                14               DR. J2UIE@@IAY: Could I ask one question of Mr. Sargeant:

                15    When you say you got them together,  does that mean in the

                16   -kidney  transplantation  and  d.ialysis,  are  being  done  in  only

                17    one  of  the   universities?


                18               MR. SARGE2U4T: We have-in Maryland, perhaps, a unique

                19    situation.  Two years ago the state legislature passed a

                20    statute which set up a I-laryland Kidney Commission.  That

                21    1--iaryland l@idnev Commission has  jurisdiction  working  with  the

                      CIIBA to designate onl  certain areas for kidney transplants
                                             y

                      and dialysis.
                23

                24               In answer  directly  to  your  question,  no.  That  does

                25    not mean that  there  is  only  one  university  in  Baltimore  doing




                                                                                7

                 I   that. Obviously there would have  to  be  some  interchange

                 2   back and forth.

                 3             There ar6 many dialysis centers.  But I thin}-, I bel4@,z

                 4   to my understanding there are onlv L@-%-,o units, two tranrT)lanta'-

                 5   tion units in the City.
                 6             DR. PAIIL:' Thani@ you ver@ much.  1-7e certainly,under-;
                 7   stand as you dash off to another appointment, perhaps.@.,7e may

                 8   now turn our attention to     I believe Dr.  Larry  Scherr,

                 9  -.from l,'.Iassau-Suffolk has astatement, and Dr. Scherr,  if  you

               10    will'identify yourself for  the record we will be  pleased  to

               11    hear from you..

               12              DR. SCIIERP,: Dr. Pahl,,members of the  Council,  I!m

               13    i)r. ia@-irence Scherr, Charman of the 1,Tassau-Suf--@olk regional

                     advisory group. ]\-nd I am a member of the  areals  medical

               -15   community.  I appreciate the fact that I can appear before

               16    you.

               17              The purTDose of my visit here is to  express  the

               .18   strong support of the regional advisory group for our progra
                                                                                    T

               19    and to answer any questions th-atlou may have. I-le  recognize

               20    very well the c'ri-@iquec of this Council and the organization'

               21    cf. our RAG group.

               2'")            And actually to that and I visited the division

               23    of the regional medical program with another member of RAG
               24    to speak with the staff, to work out means to put into effect':

               25    what  was necessarily to present this grant before you.






                      Yesterday I unfortLuiately could not be here, but ranv of

                  2
                      you did hear our coordinator, @-ir. Prasad co over the  contents

                  3   of our nrogram.

                  4              You also have a prepared state,-,ent from me and I

                  5   @@:Lll not c,
                                 o over that again.      The content of the program and
                  6   any questions referable to that I will ex-nlain -- they are

                  7   explained in that statement.

                  8              I just would like to clarify one or two points,

                  9   that are not in that statement itself.  To begin with, our

                10    r3gion, Long Island, the two counties as in @lar_vland has a

                11    corperable population of 2.6 million peonle.  The distribution

                12    of the population is in a rather hetero aeneous fashion.

                13               Ilalf being in an established suburban community,
                14    the other  in . a rural community f ast l@ecc.-iing a suburban
                15    community.  Secondly, there is a rather unique geographic
                16    Dosition  of our region.  It is penninsular in origin, and             i
                '17.1 finds itself admirably to regionalizal@-ion.
                18               Zmd it is that end that we have      developed our pro-
                -19   gram.    It is a cc-xiunity based-'regional r@-,edic,-tl program  whLr'@
                20    has been in actual operation for the past four          years  and
                21    has been recognized by the community as an       appropriate agency
                22    for the implementation of certain health ;Drocra:7,s.

                                 1,To@,7, earlier this year,  the  r-.egional-Advisorv  -@rou@
                23

                24    through iL-.'s committee had established the goals and priorities
                25    o' ambulatory care.      The  actual  development   of   delivery   ser'





                                                                                  5

                    vices and  diagnostic  services  of  preventive  care  and  t@-is

                 2  -Fortunately   confcrrqc-d to our arc-as, the goals and priori'---L=-s

                 3  of @iassau-Suffolk Com,,Drehens iVe T
                                                        Health Planning Council and

                 4  was actuall,, the start of-good effective     coo-@Dc-ration bet%.:een

                 5  the two agencies.

                 6             1-loi%7 , the grant before you is really a  revitalized.

                 7  approach for our i@lassau-Suffolk   regional medical program.

                 8  Ti-,Te are proud of the stated objective and the methods of   acl-iiev-

                 9  ing these objectives.

               10              mLo go into details it does have fourteen directing       I

               11   ambulatorycare-projects.  It has two emergency services projects

               12   which are  in  essence  ambulatory  care  projects.  And  it  has

               13   t@qo renal programs which have ambulatory care components to

               14   them.
               15              Thereby  meeting  our  goals  and  priorities.  Now,  somei

               16   of the programs, despite  the  current  limitation  on  PI.'Ps  future

               17   course do require two years for realistic completion.         Our

               18   grant contains provision for this-as well as  the  means  -r,--)r

               19   continuing staff support.

               20              That is, not only for   the monitoring those particular

               21   pro.-rams that are carried   forward, but for   monitoring   what

               22   has gone on before, what is  going  on  this  year  in  the  programs.

               23   that have been started in previous years.        And-we   believe

               24   that is a rather vital and important role.

               25               Just three other very brief items.  one is the






                1  P-IP staff. The advisory group believes thn-t our rc-wl%-, r-=cc7ani-z:

                C) staff under the direction of I-,Ir. Prasad has the str-@nc-.th and

                3  the wisdom and the@leadership to help us carry this program.

                4  Through to it's successful completion.

                5             The grant before you will, I think, not on!-, reflec@-s

                6  their dedication, but I think it reflects, their expertise in-

                7  their field, and I point out again, that their technical

                8  competence and their cooperation with regard to our area-wide@,

                9  comprehensive health planning council.

               10             Secondly the PIKG itself has corrected some of its

               11 imost of its  prior organizational difficulties.  That is,

                   the separation of t@.functions of the grantee organizations
               12

               13  from the regional advisory group itself.  The by-laws have

               14  been revised and completely conform now, to IUIP directives.

               15             And I think they have sustained a continuing interest-.,
               16 1 I;y the way, in it's,objectives by this representative co.L=,unit-,,

               17  group.  2'md we believe that it is a major and a viable- organi-.=--

               18  tion to serve the health needs, on Long Island.

               19             Secondly, a word abou-E:-Ehe grantee organizations.

               20  OUr grantee organiztion -is independently Incorporated specific

               21  ly to deal with r@1--i@p functions. I would just likd to no'Lnt
               22 @-out that in a recent fiscal audit, covering three to five

               23  months on a rather intensive basis, really on a'dailv basis,

               C)4 the grantee organization was commended for its' expert handlinc

               25 of the fiscal matters.





                                                                                  r 1

                               This, I understand,   is' 'LLnusual to have a coin-mendat4-ct)
                 211 on an e@it conference.  Filially, in ci3sinci, I @@7ould ju,-,t

                 3  like to reaffirm my.-support of our program in the support of

                 4  the regional advisory group.

                 5             lie believe that the program is well designed and

                 6  it  is well coordinated to meet the'needs of the people 'of,

                 7  Long Island.  Ile  have  asked  for  an  amount  which  exceeds slig'n4-1

                 8  two million dollars  for  this  next  period.  We  do  ask  and do
                 91 request and  do  request  that  you  favorably  consider  this, and
               10   thank -you very much.

               11              DR.PAIIL: Thank you very much,  Doctor.  I  am  sure  vou

               12   would be very responsive  to  any  questions  that  may  come  up.

                    Is there a discussion question?  ILIR. il"lilliken?
               13

               14              MP,. MILLIKE'LL: @@7ith regard to past budgets,  in  rega
               15   to the projects that you are Droposing, or recommending, i-;ithi@

               16   this, what has been built  in  to  see  that  these  projects  are

               17   inter-related  with  other  sources  of  funding.  And  what  is

               '18  the potential for their continuation in  case  the  RD'IP  money  is

               19   not available after this grant period.

               20              DR. SCIIFRR: That of course has  ali..ays  been  a  major

               21   consideration of the regional advisory Group.  Despite the

                                                 -ng, and that is to seek a %-;a,,7 to
               22 i-supposed last year of fund4

                    stimulate the project to begin    with.  find encourage the   pro3ec:t
               23
               24   office or other provider organizations  to  picj:.  up  the  program
               25   provided it is demonstrated its worthiness.

                               Now, I think that therein is the strength of our






                 1   program.  Those programs that have s4--arted have been picked un

                 2   in some asn--c@- by other organizations emergency services        b,7
                     county health departments, renal programs, bv some institution-=,

                 4 ;I and by community medicine, and by  !.'Iopc-full,,,  the  institution

                     bv T,,.!hich '@-haL- is developed, and so on.
                 5

                 6               It is our intention  from the very beginning to

                     use  the  reaional  program  as  a  stimulus  to  start  developing-
                 7

                 8   each programs, ultimately to be picked u,2 on a more permanent

                 9   basis by other means.

                10               DR. PAHL: Thank you. Is there further discussion

                11 il of  questions  of  Dr.   Scherr?

                12 it'           (.,To response.)

                                 DR.PAHL:Mr. Prasad, would you have     anything to
                13


                     add?
                14 ii

                                 !!R. PPASAD: No. I spoke yesterday.

                16               DR. PAHL: Would you use the microphone, please, if

                17 !I you car--  to  make  a  comment?

                18               @1,R. PRASAD: 140. I spoke yesterday before the Reviexr

                19   Co-,mittee, and most of the    Coun6il members who were present,

                20   and  I   have no comments to make.  Unless you have some questions

                21   to ask.

                                 DR.PAIIL: Thank you.  Iliss M.cCarthv?
                22

                                 @',IISS liCCARTHY: No. Thank you.
                23

                                 DR. PAHL: Well,  then,  if  there  is  no  further  dis-
                24
                     cussion    on Ilassau-Suffolk,  I  want to thank you for return2.n@
                2Z






                   here today, and submitting your statement throiioh Mr. Prasad

                   yesterday.

                              Are there anv rp-mbers of the p@ol, c who wish to

                   ...a!<e a statement to comment upon the proceedings so far?

                              Does the Council have anything further to discuss

                   in the open session.  Dr. Sl@arkman?

                              DR. SPAMOIAN: Can I make one more point, Herb?

                              DR. PAHL; Yes.


                              DR. SPARIL@4: I think you are all familiar  with

                   the 17ational Association R:4P, which instituted the lawsuit

                   which released the impounded  funds.  V7hen this was set up
                   it was our view that this would serve not only this lawsuit

                   purpose, but also some organization,like the American Public

                   -77iaalth Association and others to provide staff education and
              15
                   training.
              16
                              And in fact we do have such a ri..eeting planned in

                   D-anver for September 3rd, and 4th, I believe.  t%t which I

                   think a very good program has been developed.  irnich so far

                   has been oversubscribed bv the  various R.@!Ps.

                              And which will-deal with the vario,,sparts of ieu,

                   p-,-cararps:project  c-lcvelopment.  Management, and I am -.ure

                        be of considerable part, and we see that as the logical

                   extension of the National Association.

                              Actually, all of you are invited t6-attend, and

                   T-- will see that information is given to you about it.





                                                                         6 4


 n                            DR. PAHL:  Thank vo.u. Dr. Gramlich?
                2             DR. GP-A-MLICE:  Would it be ar,,propriate to ask Dr.
                3  -Sparkman to give us a one-riinute explanation of what t
                                                                           he

                4  N@M is?

                5             DR. SPARYI.IA-N:  Yes.  I had hoped that Dr. Jack.
                6  Enale from the Lakes Area Pll@'P was going to he here, sinde

                7  he is the president of the  board.

                8            This is an oraanization, Dr. Gramlich, set up
                9  aside from the steering  committee in the regular coordinating
              10   with the coordinators committee, funded bv personal and
              11   private sources cTuite aside from anv grant funds and initiated

                                          e
              12   originally around Sept'mber  of last year when it became

              13   apparent that @,7ithout the release of impounded funds the

              14   P14P future looked prettv had.

              15             But it has continued with meetings of the board
              16   the board being made up of some representatives of the
              17   coordinators, some have come from the steering committee.

              18   l,,?e thi
                         nk there is a real need for  the kind of staff training
                   that such an organizat'        rovide.
              19                         ion can p

              20             We hope that this is going to he'the ultimate
              21 1. future.  ol-viouslv we should be out of the legislative
                   I mean, the legal problem.  As Dr. Pahl has said and  as you
              22
                   know, this, I believe, has heen handled and, as  I hope, done
              23
              24   with shortly.

                             There has been question as to whether PIIP grant
              25





                                                                                        F5

 .2               1   funds could he used for this purpose.  So -far they have not
                  2   been used.  And I have snol:en vigorously to this point.  i
                      am told that legally it may be appropriate to use grant

                      funds.

                  5               Put I thin@ until we are beyond tlie legal problem,

                  6   unti.L we have clearly established      that  this  is   an   educational

                  7   activities, that these should not       be used.  So far thev     have

                  8   not neen used.


                  9               The membership  is  made  up  of  a  v7ide  variety  of

                lo    people      P,!.!P staff,  advisorv   qroup   people,   other   individuals'
                11    with i.:hoir we have worked.  There are some institutional
                12    memberships,   people   like   medical   assocations,    hospitals,

                13    volunteer  organizations  who  wish  to  join  in   that   fashion.

                14                DR. PAHL:  Dr. Haber?

                15                Thank  you,  Dr.  'ODarkman..
                16                DR. IJADER:  Dr.  1,3rarkman, T hope you  @.,,ill  indu
                                                                                        lge   i
                17    me to  the  extent that  I will Probably ask you about matters
                18    that have   concerned   me deeply for   a lona  period  of  tir-,e.
                19    ]But it  strikes  me   that with the imminent emergence of a
                20    national health insurancl- strategy, certainly the organiza-
                21    tional  and  substantive  efforts  demonstrated  by  P14-P  have  a

                      role to play, particularly in the transitional years.

                23                tlv question goes to   this  point:   If   indeed,   as
                24    this booklet indicates, there      are  some  21  mil-lion   People
                2,5   who  can  begin  to  be.beneficiaries  of   a   -national   medical





                                                                              6 6

 n3               I program, what has been done to   bring home to the reople

                  l@ the clients, if vou will     the benefits.accruinq  to  the

                3   program?

                4              It strikes me that I am unfamiliar -- much of the

                5   effort   has qone into the providers in terms of popularizing

                6   or informing.  I-That has been done or what could be done to'

                7   bring this home to the people that are the potential    natural

                8   beneficiaries?


                9              DR. SPARKT!AN:  I think not enough has been done,

               10 !I Dr. 17aber. If T understand the  intent  of  your  Question,
               11 ii one of the problems that I see as a coordinator  of an Pt.!P

               12   is that in order to function  most effectively you do some

               13   very low-key way to bring people together and wake as

                    relatively little evidence of your existence.

               15              And I find that this is the way you can get dif-

               16   ferent groups together.  And sometimes they hardly recognize

               17   that the regional medical  program  is  accomplishing  this,

               18   But in order to demonstrate to @ngress, the public and

               19   others that you are accomplishing something, this is not a

               20   very effective order of operation.

               21              And so we find ourselves caught  between these two.

                    I think that in general  regional medical programs have done     I
                    a poor job of demonstrating to beneficiaries that they have,l
               23

               24   in fact, served-a useful  purpose.  I  find  continually  as

                    move around our tivo-State region, I,Tashington-and  Alaska,
               25




                                                                                 67


 n4             I    that there are unexpected  and  surprising numbers  of  people

                2    who have been touched  in some  way bv our  regional  medical

                3    program who volunteer  the fact that  their  appreciation  and

                     their hope that something  like this  will be  continued  because,
                4

                5 1  they have been unable to find any kind of assistance to

                6    bring together activities to accomplish needs, to     respond

                7    to needs that they have.

                8              DR. HABER: I would. hazard  a  guess  that  probablv

                9    -90 to 95 per cent of the beneficiaries, while  they  may  be

               10    aware of the local clinic or  school  operation  or  outreach

                     operation, are not aware of  the fact that this is served by
               11
                  t
                  I                                                                   I
                  I  the regional medical Droqramin terms of coordinating, plan-      1
               12 1
                  ;I                                                                  I
               13    ning and executing of it.

               14 i!           And that is a critical step, it   seems -- to bring

               15    that realization home.

               16              DR. SPAMMN:  I would agree.      And I would welL-bme

                  I  ziny,thoughts here any of the members of  the  Mational  Advisorvi

               18    Council have about this. I think we  have  done  a  poor  job

               19 i  in this respect.

                               DR. PAHI,:  I think in view of the time I will close
               20

               21    this open portion of the  meeting and again thank our visitors

                  !-and guests for appearing   and speaking with  the  Council  and
               22
                     being available for discussion, and ask at this-time that all
               23 1
                     individuals in the room other than those who-are part of
               24
               25    our Council or Federal employees please leave at    this time.






   n5                            Let's  tal,,e a tiqo-minute stretch, and then .@7e   will

                  2   enter our  reiici-i of anplications.

                  3               (A sho.-t-,recess was taken.)

                  4              DR. PAIIIL:  I.!ay v.-e come to order again, please?

                  5   Will Council come  to  order,  please.  I  @.,ould  like  to  recon-

                  6   vene the Council for now the closed session and the review

                  7   of individual applications and, just as is our custom,          call

                  8   to  your  attention  the  statement  on  conflict  of  interest  and-

                  9   confidentiality of meetings which     you  v?ill  find   immediately

                      behind your agenda.

                                 AndI would like now to turn the       meeting over to

                12    Mrs. Silsbee who will guide us throuah the applications.

                13    tiost of you  were here vesterdav and     heard the discussion.

                1.@,  Ile hope that that was a mutuallv rewarding and satisfying

                '15   experience.

                16               T have heard some favorable comments from the

                17    Review Committee members.  And I certainly hope that vou found

                18    it of interest.  Let me state "f6r the      record  that  this   was  I

                I,q   an unusual proceeding and that 'it was through a comedy, a

                2,)   set  of  highly  unusual  circumstances,  but  that  the  members  of
                                                                      t
                21    the Council ..iere sittina  as  official  visitors  and  not  in  any

                   l'-way., as participants.
                  2

                23               And so  your discussion,   review   and    recommendations

                      today are  now as  Council members and mav be in support of
                24

                25    or  quite  divergent  from   whatever   discussion,   recommendations





                                                                            6 9


                    were made vesterdav.

                2             T@nd with those few comments, Judy, would you
                 i@ please lead us through?

                4             MRS. SILSBEE: There are a  counle  of  background
                5   items that I think are important here.  The  committee  did

                6   express after the meeting yesterday some concern about  the

                7   speed with which they had-to move, but they never had  a

                    choice.
                8

                              They had the Council meeting today.  And  it  may
                9

                    not have been apparent'
                                           to all, but at the  get-together  in
              11    July the individual  reviewers did talk with one another and,
              12    in most cases, where thev  were not able to, they  tried  to
                    communicate by phone.  So there was a aood deal more back-
              13

              1A       nd in terns of their deliberations  than appeared in
                    grou


              15    public in the record.

              16             The other thing is  that we put on vour desks this
              17    morning -- I.mean, in front of you    this is  supposed  to
              .18   be pink..  And this is the Staff's   yesterday as-the Commit-
              19    tee was deliberating we were trying to @.7rite these up so
              20    that you would have  something in front of vou.

              21             This is the  gist  of the recorirendations of the
                    Committee, and they are alphabetically arranaed.  Also  just
                    now we have   I feel like, yes, Virginia, there is a way of
                    doing this   we did get the transcript for yesterday
              24

                    morning's session hack in time.
              25





                                                                                  70

 n7              I              This is the first      we have been asking for this

                 2   for some  tine, but it finally care about.  That is only

                 3   those regions that-.were reviewed in the morning.  The after-

                  j;
                 4         ession is still heinq    typed. So  we  have  asked  the

                     Staff to take anart the  transcri-nts and give you the
                 5

                     verbatim transcript of those regions that we now have        the
                 6

                     transcript  available   on.-
                 7

                                With that background, I think this Tnorning    we will  ;i
                 8

                     try to go  alphabetically.
                 9


                                Dr. Schreiner?
               10

                                DR. SCHREINER:  Before you do that, I would find

                     it helpful,in perspective to    know if vou added up all these,
               12

                     what did it come to?
               13

                                IIRS. SILSBEE:  A very good  point.
                 4

                                DR. PAHL:  Well, I have the figure.

               16               MRS. MORGAN:  It was on the board.

                                MRS. SILSBEE:  I erased it from the board      this
               1 7

                     morning because it didn't seem  tg  be  a  thing  to  be  public
               1 8

                     knowledge.
               1 9

                                DR. PAHL:  The  figure  is  S26,557,154,  which   is,
               20

                     from a management point of view,    a verv nice level.  But you
               2 1
                     should not be bound to it in either an    upward or  downward
               2'-)
                     direction, particularly in view of the    action vOu took this
                     morning which gives us that kind of flexibility to  manage
               24
                     our affairs.




                                                                                71

  nS                           DR. SCITPEITTER: That           a feel for where we
                                                     gives us


                    arc.

                3              @!RS. SIL@.DEE: I am asking 1-irs. Leventhal to dis-

                4   tribute the kind of running summary    x.!e keeTD that puts toge-

                5   ther as much  information as you have at this point.  This is
                6   the summary  data on the recommendations yesterday.
                7              DR. JA14EIlAY:  Mrs. Silsbee, can I make a  gratuitous

                8   comment?


                9
                              MRS. SILSBEE:  Yes,   sir.

               10
                               DR. JAIIETIAY:  I think it is an extraordinary
               11   accomplishment-to be able to get the  transcripts  on  the  tabtl6!
               12   this morning.   You must have
                                                   had people chained to the t.?alls  I
               13 11 all night.  I don't know how  that was done.

               14             MRS. SILSBEE:  Well, this Gentleman to my right
               15   and his peers are the ones that are   respo nsible for that.
               16   But also, a push, I think, from the   Director's   office   helped'
               17             DR. PAHL:  We found that once the rumor that I
               18   relayed yesterday didn't materialize there was a    free   eveningi
               19   for everyone.

               20


               21



               nn



               23


               2,iI


               25




                                                                            7-


 n9                                           ALATIPJ.TA

                              MRS. SILSBEE: O.K. Could  we  start  with  Alabama?

                3   I think the best way to proceed today is to ask  the  primary

                4   reviewer to make whatever comments and  make  recommendations

                5   and then if the secondary reviewer has anything  different  I

                    will ask for that. -But it may not be necessary at this
                6

                    point.
                7


                              Alabama.  Mrs. Gordon?
                8

                9             @IRS. GORDON:  I was pleasantly surprised this

              10    Morning when I read the various and sundry thinas we  have

              11    received, since I wasn't here vesterdav.  I  agree  primarily
                    with the comments made yesterday,  The onlv addition  that
              12

              13    I would have is that Alabama does have a couple of their

                    projects that nearly all of the money is for equipment.

              -15   And that I do question.

              16              That is 126 and 125.

              17              MRS. c-ILSBEE:  Mr. Ogden, you were present yester-

              18    day.  Do you have anything to add?

                              MR. OGDEN:  No.  I would agree with the comments
              19

              20    that were made yesterday, particularly those which  appear
                    in the transcript from Dr. Vaun.  Project number 134  does
              21

                    indeed appear to be the sane project that appeared here in

              .3    the previous application and was rejected.

              24              And it is unlikely -- I felt in reading the material

                    that was sent to me -- that it could be completed in a
              -5





                                                                             73


  nlO
                    reasonable period of time.  And some of their other projects

                    perhaps are not terribly feasible within the periodof one
                3   year.
                4             The matter of the equipment doesn't bother me that
                5   much.  And I would agree @.7ith the allocation made bv the
                6   Review Committee yesterday.
                7             Mrs. Gordon, do'you have anv other feeling   on

                8   that?

                9
                              IIRS. GORDON:  No.  I would agree with the alloca-
              10    tion.
              11              MRS.' SILSBEE:  Could I have a motion, -please?
              12              MR. OGDEN:  If Mrs. Go@don will move it, I will

              13    second  it.

              14 i            !-IRS. GORDON:  All right.
              15              MRS. SILSBEE:  The motion has'been made and
              16    seconded that the Review Committee recommendationof a
              ,17   funding level for the Alabama application for $680,000 oe
              18    approved.

              19              Discussion?

              20              (No response.)

              21              MRS. SILSBEE:  All  in favor?

                              VOICES:  Aye.

              23              I-IRS. SILSJ3FE: Opposed?

              24              (No response.)

              25              MRS. SILSBEE:  The motion is carried.





                                                                                   74


  nll
                                                   ALBANY


                 2              !,IRS. SILSREE:  The  next  reaion  is  Albanv.  Dr.

                     Watkins  is  the  primarv
                 3                             reviewer.

                 4              DR. WATKINS:  Albany has a hisk-.orv as a superior

                     region.   In the may  funding  which  Council.  recommended  in
                 5

                     June it almost got 100 per cent of the recruest.  In        other
                 6

                     words, it was 1 million    66.hundred  thousand,  and  thev   got
                 7

                 8   1  million   12,thousand.

                     -          They are asking this   time for 541,437. ?.Iilr.  Barrows!
                 9

                                             Pased on  Albanv's superiority and
                     recommended 487,000.

                     community involvement
                                               I make a motion  that  they  get  487,000,1

                     which was recommended   'yesterday  by  the   Review   Committee.

               13              -IIRS. SILSBEE:, Dr. Haber?

               11               DR. HABER:   I have nothing to add, except that I

               15    would ask  Dr. Watkins  if we could amend his motion to make

               16    it $500,000, $13,000 more than he has suggested.

                                MR. MILLIKEN:  For what reason?


               18               DR. HABER:  I think that these projects,are      well.

               19    conceived.   I think that the   one  I  am  particularly  interested!

               20    in is the  one commented on  in  terms  of  evaluation  of  the

               21 i'l meaicaid screening program.  I think that     there  seemed   to

                     be some dispa2itv  between  some  of  the  reviewers  about  what

                  ii the level of funding should be.
               23

                                Since both of them  are  a  little  bit  below  what
               24
                     they asked, I think we can be slightly more      aenerous   and give,






  12            1   then some more.

                2             DIRS. SILSBRE:  Does thatconstitute ci second, Dr.
                311 IT aber?

                4             DR. HADER:  Yes, it does, if Dr. 1,7atkins will

                5   accept  it.

                6             DR. 1,7ATKIN'S:  I accept it.
                7             MRS. SILSBEE:  The motion has been made and seconded
                8   that the Albany application be approved at  a  $500,000  level.

                9   Additional comments?

              lo              Dr. Milliken -- I mean, lir. I-Iilliken?
                              MR..MiLLIKEN:.  I  am concerned about the   precedent
                    for the future applications.
              13              MRS. SILSBEE: Could you  use  a  microphone,  please,

              14    sir?

              '15             MR. MILLIKEN:  I am a little concerned about the     I
              16    precedent of this amendment for consideration  for  the  forth-
              17    coming applications.  I think if we  could use specifics the
              .18   Dr. gave in terms of a specific project that the increase
              19    be allocated specifically to that for the reasons that he
              20    gave rather than -leaving it to the judgment of heaven, thev
              21    might st)end it on projects that this Council and the
                    Committee feel were not worthy.
              22

                             And I notice a departure from our usual routine.
                    I am not against it.  But I believe there ought to be more
              24

                    specific instructions.





                                                                            76


  nl3
                             MRS. SILSPFT':  Mrs. @lorgan?

               2             MRS. MORGMT:   Can we give  specific instructions

               3   to the regions as to how they are to  spend the money?

               4             MRS. SILSBEE:  TA7e can strongly recommend that the

               5   basis of the funding decision was based on that aspect.

               6             DR. PAHL:  We can give advice, but we do not  really!
               7   earmark it for one specific project.  And in that sense,
               8   in adding additional funds we would just have to rely upon
               9   whether they chose to follow our advice or not.  So your

              10   reasons should he very well spelled out.

              11             But we can't guarantee the results.  We do our best

              12   to transmit that advice.


              13             DR. GPAMLICH:  Dr. Pahl, Mr. Milliken's remarks
              14 1 have crvstalized a crowing concern that has wormed its way
              15   into my mind.  This sounds a little bit like -- I want to

              16   apologize and make it very brief.
              .17.           The mechanism that is used is illustrated by this
              18   particular request, especially wh7ere yesterday you will
              19   recall that one reviewer-said, let's make it this figure,,
              20   the second" reviewer said., let's make that, and they said,

              21   well, let's just split it.

                             And I like the approach that Dr. Haber has suggested,
              22

              23   that they be more specific.  And this points up 'to me the

              24   urgency of the problem which is only existing-in this parti-
              2.5  cular session, --because if this is the last session it will





                                                                                 77


   nl4           1   never be up again.


                 2             But here is a situation in which the whole str,-c-,-,re


                 3   is a reverse pyramid. The  primary  reviewer,  who  is  the  oniv

                 4   one who has really had the time and  the  ability  to  go  over

                 5   the grant request in detail is the one who starts at the

                 6   bottom of the apex of the pyramid  on  which  the  total  funding

                 7   process is accomplished.

                 8             The secondary reviewer.says,  well,  yes,  I  think

                 9   it is probably all right, or mavbe we ought  to  do  this  or

               10    that.   But then the Review  Committee  accepts  that,  and  if

               11    we accept it,7in  turn,  the  Review  Committee's  recommendation

               12    ex pro facto without any really terious consideration we

               13    are just compounding that pyramid, on which some very

               14    important decisions at the regional  level  might  well  take

               15    place.

               16              So my plea is simply that I think yesterday's

               17    review session,  which  wasinteresting,  very  interesting,  wa
                                                                                   s

               18    probably unique in that it  was  pressured  timewise,  and  rav

               19    have reached the right decision      probably in most instances

               20    it dj)d.


               21              But'I would agree.  I think the   Council should

                     subject that to ample scrutiny before accepting it.
               22

               23              MRS. SILSBEE:  The motion has been made and

               24    seconded that the  Albany  application  be  appmved  at  S500,000

               25    with advice to the region about  the  one  project  involving





                                                                           7q


  nl6           1                             ARKANSAS


                2             MRS. SILSBEE:  We will go to Arkansas.

                3             I'm sorry, I can't remember which ones came up,

                4  so if you  all will point this out it would be most helpful.

                5             Dr. Komaroff is the primary reviewer of the

                6  Arkansas application.

                7             DR. KOMAROFF:  The June Council rated this region

                8  as average.  Its'funding level on  the basis of the June

                9  Council recommendation is currently 1.425 million.  They seek'

              10   a supplement of $816,000.


                              The main concern of the June Council centered


                   around the stability of the core staff and the uncertainty,-
              12

              13   about a new coordinator to replace Dr. Silverbladt.

              14 1 According to Mr. Posta and the Staff of DPIIP, that problem isi

              15   being resolved.

              16              Virtually all the vacant staff positions have  been
              17-1 filled. And the current acting coordinator  very  likelv  will
              18   become the permanent coordinators.  The project proposals in

              19   this supplement are somewhat disappointing to me.  And I

              20   think Dr. Carpenter's review yesterday summarizes  my  imnres-

              21   sions.

                              The application ,-consists of a great variety of
              22

                   unrelated projects.  Many seem  designed to further the  coals
              23

                   of a single institution within  the region rather than to
              24

                   accomplish regionalization.  I  agree with that.  There are
              25






  nIS           1             1 think there are similar prototype fc)r'this kind

                2   of  a  rape crisis center around the countrv,that apparently

                3   are   guite effective. But the concern I have is whether IUIP

                4   funds under Section 900 .of the law reallv allow for this
                511 kind of a categorical activity'to be supported.

                6             It is not noncategorical; it is categorical.  And
                7   it does not fall, in my estimation, within the language of

                8   the law.


                9             DR. PAHL:. It is also discriminatory.

              10              MR. KOMAROFF:  I suppose rape can be.  I would, to

              11    make these recommendations tangible, agree with the level of

                                                            I
              12    $400,000 the Review Committee recommended yesterday, but
                    with two restrictions:  one, that there be no dollars expended
              13

              14    for the rape project and, second, thatno more than 930,000
              15    be expended for the digestive disease proposal.

              16              DR. 'P7AMIOCK:  Which would be for education?

              17              DR. KOTMROFF:  Yes.

              '18             DR. PAHL:  Dr. Komaro:tf, I think we would feel

              19    comfortable with that recommendation as a program.

              20              MRS. SILSBEE:..Dr. Janeway?

              21              DR. JANE!IAY:  Dr. Komaroff and I have discussed

                    this nrior to the meeting.  I concur with the technical
              2

              23    review and with Dr. Komaroff's comments, and second the

                    proposal.
              24

              25              MRS. SILSBEE:  A motion has been made and seconded






                                                                          82

  nl9          1   that the Arkansas anr)lication be arproved at a S400,000
               2   level, with the following conditions:  that no dollars be

                   expended for the rave review project and that no more than
               3

               4   $30,000 be expended for the digestive diseases activity.

                             DR. JANEV7AY:  That is component 104.
               5

               6             MRS. SILSBEE:  Component 104.

               7             Ts there further-discussion?

               8             (No response.)

               9             MRS. SILSBEE:  All in favor?


              10             VOICES:  Ave.

              11             MRS. SILSBEE:  Opposed?

              12             (No response.)

              13             MRS. SILO-BEE:  That motion is carried.


              14


              15


              16


              17


              18


              19


              20


              21


              22


              23


              24


              25





                                                                                  83

  n2O                                             BI-STATE

                                MRS. SILSBEE:     The next application to be reviewed

                 3   is Bi-State.  The principal reviev?er there is @Ir.  illiken.

                 4              Mr. Milliken,  'Dr. T,7atkins was here yesterday and
                 5   'you weren't.  I don't know whether that

                 6              MR. @TILLIKEN:  I will defer to him.

                 7              MRS. SILSBEE:  Dr. Watkins?

                 8              DR. @7ATKINS:  Yes. The Pi-State request was for
                 9   -$472,458, and the recommended funding level was for S275,000.
               10    And I agree with  the  Review  Committee.  I  think  that  this
               11    Bi-State critique,  the  projects  compared  to  May-June  were

               12    sort of around the same level  --  in  other  words,  the  save
                     level of prioritization and  so  forth  --  except  that  since
               13

               14    time is running out it is possible that they might have madded

               15    a little to  get  the  $472.

               16               So what we are  asking is that this be reduced to a

               17    more feasible figure for   them at 5275
                                                              000.  There was,a

               18    recommendation by two reviewers of 270 to 300 thousand.  And

                     I think one  reviewer  even  suggested  335  thousand.  But  we
               -19

               20    are suggesting that it be 275 thousand.

               21               I-!RS. SILSBEE:  Mr. Milliken

               22               MR. @!TLLIKEN:  I would like  to  in  general  agree
               23    with that. However,  in  looking  at  the  manv  projects  that
                     were recommended be dropped, there was one, n-umber 59,
               24
               25    evaluation and placement of long-term care patients.  I don't





                                                                          8 4


 n2l            1  know the qualitv of this program.

                2            However, generally there are two great needs in
                3  the country which @ould show a need for developing and

                4  continuing such projects.  One relates to cost containment

                5  for health care, and the other to get resources in place for

                6  the impending national health insurance.

                7            And based on this, and if this is    I would have

                8  to rely on Staff -- if this is a program that can be a

                9  quality program and.make contributions to those two needs,

              lo   I woul@d recommend that we add $30,000 specifically -earmarked

              -11  for funding of number 59.

              12             MRS. MORGAN:  I don't see where 59 was deleted,

              13   anyway.


              14             MR. HIROTO:  It wasn't.


              '15            MRS. lORGAN:  We've got 57, 58., then we go to 60.

              16             MR. MILLIKEN:  Oh, really?  The list I have

              17   indicates@,--

              .18            DR. WATKINS:  Let me see if I can -- the regional

              19   office made comments on 60, 57,-'59 and 64, which were

              20   favorable.  And it would he an additional $60,000.  The

              21   question is:  Are we in agreement with this?  If -vou are

                   in agreement I will addthe $30,000.
              22

                             MR. MILLIKEN:  Right.
              23

                             MRS. SILSBEE:  O.K.  Mrs. Flood?
              24

                             MRS. FLOOD:  The Review Committee's comments that
              25





                                                                                 P5

 n22             1   are listed on the pink   sheet says that brief mention is made
                 2   of Dr. Felix's arrival   as the new coordinator.  Fo%,7ever,
                 3   little discussion was givento  his  new  role  in  plans  or  the
                 4   role he might  play  in  the  development  of  this  application.
                 5              Being a little bit familiar with the past history
                 6   of the Bi-State program,, I think that the pox.!er   that a  man'

                 7   of Dr. Felix's personality and capability might     have in

                 8   making the  program  develop  into  something  stronger  even  in

                 9   this last phase is something we shouldn't overlook.

               10               Now, I would agree that at first alance some of

               11    these projects do not appear   to  be  of  the  most  outstanding
               12    quality.  But I would think that Dr. Felix has the capability

               13    of holding neutral  ground  in  a  particular  area  wheke  there

               14    is quite a bit of universit-v medical school discussion, and
               15    there is impingement on Bi-State by the Illinois P14P and
               16    there has been inactivity at times by the @iissouri PMP.
               17.              I would like to ask if the gentlemen might consider!,
               18    in' light of the cut that  was  given  at  the  June  Council,  an
               '19   additional $100,000 to fund the Bi-State program at S375,000
               20    rather  than  $275,000,  with  your  specific  recommendation  of

               21    that project being included, that 59, but with no comment

               22    made about the rest of this money -- that is, $60,000 or           I

               23    $70,000.

               24              That might be of value to Dr. Felix to accomplish

               25    something, coordination in another area.





                                                                          86

 n23           1             MR. MILLIKEN:  You feel that he needs additional

               2   staff, do you?
               3             MRS. FL06D:  No,I don't think he needs necessarily
               4   additional staff.   I think he needs a little discretionary
               5   capability there, to be responsive to these things in the
                         so
               6   region/that he doesn't have the stigma of being related

               7   the universities in that area.

               8             1 think he needs a little more discretion so he

               9   -can be more able than the previous coordinator to relate to

              10   needs,in that region.

              11             DR.:WATKINS:  Well, if we were to review and we

                   were to add, I would suggest that it he based on what we
              12

              13   just mentioned, the regional office comments.  And those

              14   comments were an additional 60, not 100.  So I would want

              .15  to have a reason for adding to the 275, and the reason would

              16   be ,strongly in favor of the regional comments which were

              17   the projects just mentioned, 59, 64, 60 and  57.

              18            That was the group eliminated by the reviewers.
              19   That is a group that is worth 6-0,000.  So it would give me

                   a better feeling if I said 60 rather than 100.
              20

              21            MRS. FLOOD:  Well, I would accept the 60.

                            MR. MILLIKEN:  TThat bothers me -- I am not against
              22
                   adding another 40-000.  We have the money.  But-I think we
              23                   r
              24   need a more tangible, specific advice for so-doingp in line
              25   with my earlier comment.





                                                                           87

  n24          1             1 think it puts us in a verv bad light to add

               2   additional amounts without a very specific cause

               3             DR. 1-7A.TKIIIS:  Can we have Staff comment on this?

               4             MRS. SILSBEE:  Mr. Posta?

               5             t!R. POSTA:  I think the vurnose of %.rhat Mrs. Flood
               6   picked up in the green sheet was primarily instigated by
               7   Staff.  It was something that was not said rather than what
               8   was said. Dr. Felix did come in and talk to Dr.  Pahl  and

               9   the proper staff here at DRM-P.

              10
                             He did respond with a three-page letter  stating
              11   some of his goals, what he would like to do during the next
              12   year-in the St. Louis area.  As we know, he does have a

              13   terrific reputation. And to date -- he has been  on  board

              14   since July lst -@ has aotten together with exrerimental

              15   health delivery service system there in St. Louis as  well
              16   as with ARCH program and the CITP agency.
              17             And one of his primary goals is to utilize the
              .18  institutions already set up and -et at the same timeto
                                                   y
              -19  pursue some of his goals-in primary care and in  manpower.
              20   Now, the other point that was mentioned in the rink  sheet
              21   you have before you was the role that Dr. Felix has played
                   in establishing and preparing this Particular  application
              22

              23            And when we asked him that, the answer  was  com-
              24   pletely negative:  He did not have a role irr-prevaring this
              25   particular application.  So it is our strategy at least to





  n25           1   present this to you with expectations that perhaps Dr.
                2   Felix would have more latitude in getting into those areas
                3   that he particular has a special talent for.
                              MRS. SILSBEE:  But for Council's consideration,
                4

                5   they  have the application in front of them.  This is sort
                6   of the horns of a dilemma.  And in terms of the advice that.
                7   we would give to the region, as I heard the discussion, is
                8   thatcertain of your activities we think are first rate#,
                9   some of the others we don't think are good.  But we really
              10    think that you ought to scrap the whole thing and look at
              11    your priorities all over again and put your faith in Dr.
              12    Felix.

                             Now, this could be translated in some way or
              13

                    another, but it does create a problem.
              14

              15             MR. HIROTO:  Is there a motion?

              16             MRS. SILSBEE:  No, there isn't.

              17             DR. WATKINS:  1-7e move $335,000.

              18             MR. MILLIKEN:  I second it.
              19             MRS. SILSBEE: -The motion has been made and seconded,
              20   that the Bi-State application,'be approved ht the level of
              21   $335,000.

                             Is there further discussion?
              22

              23             (No response.)

                            MRS. SILSBEE:  In favor?
              24

                            VOICES:    Aye.
              2,5





                                                                          89

  n26           I            MRS. SILSBFE:  Opposed?

                2            DR. JANEWAY:  170.

                3.           MRS. SILSBEE:  Let the record show there was one

                4  in opposition.

                5            The motion is carried.

                6            MR. HIROTO:  Am I to leave?

                7            DR. JANETIAY:  Yes.

                8


                9


              10


              11


              12





              14


              15


              16


              17


              18


              19


              20


              21


              22


              23


              24


              25






  n27            1                             CALIFORNIA

                 2             MRS. SILSBEE:   The next application to be reviewed

                 3   is from California-.'  And  Mr. Firoto is out of the room.

                 4   Dr. Janeway is primary reviewer.

                 5             DR. JANEWAY:  As noted in the May-June review,
                 6   the program was above average and continues, in my onin-@on,
                 7   to be above average to superior.  The May-June request    i..,as
                 8   on the order of $8,170,000, with a  DPMP  funding  decision  of-

                 9   almost 7 million dollars     even somewhat below the

               10    Committee recommendation.

               11              The current request is for $5,592,000.  It is rlv
               12    opinion in reviewing,this -- and'I  concur  with  the  technical
               13    review committee -- that the request is overly ambitious
               14    for the time frame of accomplishment.  And the amount can
               15    be effectively reduced to an amount of 3'million dollars.
               16              I would express onlv one administrative concern:
               17.   Although there seems to be a reasonably good relationship
               18    between the T;LNIP activity and the various CI'P'agencies, there
               19    are some areas of clearly unresolved conflict.  And I thin-.
               20    that with what T see as.somei@yhat more dispersion  of  activity
               21    in this State tending to get back to the way it was before
                  'reorganization, that the coordinator should he cautioned
               22

                     in this regard.
               23

                              The recommendation for funding is -at   the level of
               24

               25    3 million dollars.  And I so move.




                                                                           91

 n28           I             MRS. SILSBEE:  Mr. Ogden?

                                                             Janeway on the
               2             .IR. OGDEN: I disagree with Dr.

               3   level of funding. _.And I would like to spend a few moments

                   on this particular application  inasmuch as I think it is
               4

                   the largest before us today.
               5

               6             Those of you who were here yesterday and listened

                   to the discussion will recognize that Dr. Heustis, who was
               7

               8   the primary reviewer yesterday, recommended this be funded
                   in full, $5,592,000.  Dr. liirschboeck, who was the secondary
               9

                   reviewer, suggested it be reduced to 2 million dollars.
              10

                             After considerable discussion among the people
              11

              12   around the Review Committee table about the projects and a

                   group of other things, the final decision came down to a bit
              13
                   of dickering.  Now, at the risk of going over things that
              14

              15   you Jigtened to yesterday, there was a show of hands on how

                   many would prefer 3 million.
              16


              17.            Dr. Heustis said, how about 4 or 5?

              18            Then Mrs. Silsbee said-; well the motion has been
              19   made at 2million, how many in favor.  That was voted down.

              20   That motion was defeated..

                            And Mr. Barrows said, well, then I will move it a-t
              21

                   3 million.  And they finally got an acceptance at 3 million
              22
                   without any discussion of whether.these were valizble projects'
                                                                                01
              23
                   whether the P14P.was being cut too far or particulardiscussioni'
              24
                   with respect to the quality of the this program.
              25





                                                                             92
  n29           I             Now, you don't have available to you, I don't think,
                2   the yellow printout sheets on this.  Do you have this in
                3   your books? if you would look for a moment with  me  at  the
                4   yellow printout sheets on the California  Regional  Medical
                5   Program, there are some things here that I think are of

                6   considerable interest to us.

                7            MR. MILLIKEN: These are numbered.  1-7hich  one  do

                8   you want to look at?

                9            MR. OGDEN: Let's begin with  the  cover  sheet  for
              10    just a moment. There are 83 projects here; 61  of  them  are
                    new, and 22 ar e requests for continued support   1.3 million;
              12    of continued support.

              13             And if you look at the next page, you will see that.
                    program staff, which includes existing projects as  well  as-
              14 i
              15    continued projects, is 1.6 million. Now, if vou add  uo  the
              16    continued support and proaram staff, you are at 2.9.million,
              17    which is the 3 million dollars that we are talking about.
              18             Admittedly program staff may  be  possibly-reduced
                    in the event they do nothing on new rrojects.  But the 3
              19
              20    million, I -suggest, may-only continue the,projects that-thev
                    have and cover programs. That does not cover  new  projects.
              21
                    In looking across, I see that there may be some cutback  on
              22
                    program staff if there are no new projects.
              23

              24            DR. JANEWAY: May I make a  point  of  clarification?
                    It was my impression, as I was primary  reviewer,  that  none
              25





                                                                                  93

 n3O                 of this was for program staff.     That was all  funded  in  the

                 2   May-June application.


                 3              MRS. SILSBEE:  Is that not correct,    Mr.   Russell?


                 4              MR. RUSSELL:  That is correct.


                                DR. JAI@TET,,IAY: That 1.6 million has alreadv  been
                 5


                 6   funded,


                 7              MR. OGDEN:   All right.  If  vou come  down  to  the

                 8   request for September.of 174,to June    of '75 which  is  in  the-

                 9   third column, that is.under the heading of five in here,

               lo    vou Will begin to see  the  programs  that  they  are  proposing

                     are those to which they propose to add some additional

               12    funds.


               13               These include a series   of  kidnev  programs,  some

               14 i  of which were funded at very  small  amounts  in  the  iulv  174

               15    to June of 175 request and  for  which  they  are  now  reauestina

               16    additional funds.


               17               And when you come over, core several pages alone,

               18    don't you have a printout, now   b@ginning on  page  7  you  beain

               19    to pick up new projects which they are talking about beginning
               20    with about 147T.  And you   will find some t,hat are added to.

               21    But beginning on page 8 they are all new projects that they
                  I-'are talking about funding for  the  period  of  September  174  to
               22

                     June of 175.
               23

                                Now, I find some  of  these  to  be  of-considerable
               24
                     intexest and also of value.  There are projects here concerning
               25





                                                                             94

  n3l               the health care neto7ork in the Imperial Valley which   involves
                21
                    migrant workers.  There is an American Indian clinic   aware-
                3   ness project here.
                4             There are upgrading of free clinics, ambulatory
                5   care facilities -- a whole series of things that I feel
                6   were simply ignored in the discussions yesterday.  And I
                7   came awav from yesterday's discussion somewhat dismayed  with  i
                8   the manner in which the California application was handled.
                9             I recognize that this is a big program and it is     i
              10    an expensive program. It is a lot  of  money.  But  my  reaction
              11    to it is that the cut from 5.5 million, nearly 5.6 million
              12    to 3 million was done almost on a bargaining basis, without
              13    much consideration of the actuality of the needs of this

              14    pro-gram.
              15             And I think or feel that we should add back money
              16    into this application.  I haven't totaled up the requests
              17    that appear on pages 8, 9 and 10 at all.  But I would sug-
              18    gest@t:hat if we added back upwards of a half million  dollars,!
              19    maybe--even a million, we.would be finding money well spent    I
              20    in a superior program that has always had  Exceptional  manage-'
              21    ment and has done a great deal of good in what is now the.

              22    largest State in this nation.

              23             MR. TIAIIMOCK:  You would take it back to 5 million?  I

              24    Is that what you are saying?

              25             MR. OGDEN:  I would take it back at least to 4.





                                                                            95
   n32                        DR. JANETQAY:         respond to that.  Perhaps I
                                            Let.me
                2   am speaking not as a member of  the National Advisory Council

                                       I
                    and a little bit too much from a technical standpoint.  But
                3
                    if you are going to put 1.5 million dollars into a hyperten-
                4

                5   sion screening program in 10 months, you had better be
                6   pretty well prepared as a physician population to have  some
                7   reasonable idea as to what you are going to do  with  the

                    people who you identify.
                8

                             And that is where my comments saying that they are
                9
                    being overly ambitious:  if there are indeed 23 unidentified
              10
                    hypertensives-in the United States, and probably more than
              11
              12    that, you can set uiD programs which build up people's expec-
                    stations to a level which you cannot possibly meet within the
              13
                    limits of the delivery system or within the cost barriers
              14
              15    that would be imposed by defining that population.
                             I think it is an admirable program.  And I am not
              16

              17    making a comment there. I am just saying that as  to  the
              18    quality of it I think it is overambitious.  And that was my.
              19    interpretation of the technical-review that was also given.
                    I would agree that on the.surface there would appear to have
              20
                    been some bargaining as to the level of funding, at the
              21
                  -outset of which one would get the impression that it was not
              22
                    being done on the merits of the proposal.
              23
              24             But I thnk ultimately that it was and  that  the
                    technical expectation was the one that cast the   deciding
              25





                                                                             9 6

  n33           1   factor.  And I would say that I agree with your comments to

                2   a point, but I certainly agree with the  recommendations  of

                3   the Review Committee.

                4             That is just too much money. It would  not  be  as

                5   well spent in that as it would  if it were distributed  dif-

                6   ferently throughout the regions.

                7             @IRS. SILSBEE:  Dr., Gramlich?

                8             DR. GRAMLICH: Dr. Janeway raises  a  criticism  of
                9   a million dollars for a hypertension screening program.  And
              10    I would observe that the same Review  Committee  recommended
              11    a million dollars for a hypertension screening  program  and
              12    treatment program in the State of Mississippi.
              13              DR. JANETA7AY:  They cut is by $840,000 specifically.,

              14              DR. GP-V.ILICH:  Yes, but from a 2 million dollar

              15    level, leavin- them with a million dollars.
              16              DR. JANETIAY:  The incidence of hypertension in
              17    the State of Mississippi or Prevalence, whatever you want
              18    to use, based upon the racial distribution and the character-
              '19   istics of people living in tha@ area, I think you will find

              .20
                    a striking difference from California.

                              As I said, I don't want to aet into b
              21                                                    eing a
                    technical reviewer on this, but when vou have a very high
              22

              23    percentage black population,and in the entire Southeastern
              24    United States, if you look at the prevalence-of hypertension,

              25    coronary, arterial disease -- you are dealing with a different





                                                                             97

   n34          I   type of population and a different health care need.

                2             PIR. OGDFII:  Let me make one brief comment here.

                3   I think since the time we started the Regional Medical
                4   Programs in 1966, we have witnessed  in  Pmerica@probably  the
                5   greatest migration of -people in historv. And  I  speak  about
                6   the migrati on of the black p&oples of this countrv from

                7   the South to the north and-the West.

                8             V7e may not all be aware of this, but as recently
                9   as probably 1946, right after the war, some 77 per cent of
               10   the black population in this country lived in  the  South  and
               11   was thought of as the rural Southern problem.  Today 65    per

               12   cent of the black people in this country live  in  the  north.
               13   and the West and are really thought of as  an  urban  problem.
               1411           The black population in this nation has settled
               15   in California, New York State, Michigan, New Jersey.  And
               16   I think we sometimes are not aware of these things that have
               17   been affecting our regional medical programs.

                              And I would suggest that if hypertension exists
               18

               19   in Mississippi it also exists in California.  There is a

               20   tremendous black population in California., And it  has  been.

               21   a very rapidly growing population.

               22             Dick, nav I just comment, too, then I will close
               23   this off: Many of these projects I asked you  to  look  at  on
               24   pages 8, 9 and-10 of this computer printout are not hyper-
               25   tension projects; these are projects spread among a great






   n35              many other things.

                2
                              I plead no particular case for California.  I am

                3   not from California. But I simply feel that this  is  a  t)ro-

                4   gram that deserves better consideration than  it received

                5   yesterday.

                6
                              MRS. SILSBEE:  Dr. Schreiner?

                7             DR. SCHREINER: -1 justuant to point  out  that  both

                8   the reviewers have made some excellent specific Points.  I

                9   'do think, however, we should put in perspective that 7 million
               10   dollars plus 3 or something over that is roughly  10  per  cent

               11   of the entire'nation's RMP funds.

               12             1 don'tthink we should'view California as being

               13   a deprived State.

               14             MRS. SILSBEE:  Dr. Komaroff?

               15             DR. KOMAROFF: Another was to'look at  the  T)ersr)ec-

               16   tive is that California has 10 per cent of  the  population  of

               17   the country.  And we had available about 64 per cent of
               18   the funds that were requested in-this  cvcle.  3  million  -ut

               19   of a request of 5 is about 60 Per cent.

               20             So an average region  ought to gqt around 3 T-,illion.
               21   But I would think that if this  region is, in  fact,  recarded

               22   to be sunerior or above averaae that -- just  that  is  another

               23   context within which one might look at the 3 million.

               24             MRS. SILSBEE: Dr. Janeway has  made  a  motion  that

               25   the,application be approved at the 3 million dollar level.





                                                                          99
  n36              -I didn't hear a second.
                2            MR. IAIMIYOCK: I will second that motion.
                3            MRS. SILSBEE:  All right.  The motion has been
                4  made and  seconded that the California application be approved:
                5  'at the level of 3 million dollars.
                6            Is there further discussion?
                7            (No response.)
                8            MRS. SILSBEE:  All in favor say aye?
                9            VOICES:  Aye.
              10             MRS. SILSBEE:  Could you nut your hands up, please?!
              11   That is one, two, three, four, five, six, seven say aye.
              12             Nay?  Seven'.

              13
                             MRS. MORGAtl:  Maybe we should set it aside and go
              14  to
              15             MRS. SILSBEE:  Dr. Wammock?
              16
                             DR. 1,7AMMOCK:  You talk about the new projects over
              17  here.  I have just been looking at that hypertension.  And
              18
                  if you look at on page 9,1 thought I had it, California, it
              19  seems to have gotten away-.  But it looks to me that there are
              201 lots of hypertension pro@ects over here --,159C, 159D, 159E,
              211 159P, 159G, community hypertension awareness nroject, 159H,
              22 I'high blood pressure control in Berrett County, 159 -- there'sl
              23  about 10 or 15 down there that'go right on to the hyperten-
              24  sion.
              25            So I think there is a tremendous amount of money





                                                                             100

  n37           1   being put in that program there.

                2             @IRS. SILSBEE:  Well, I think that was brought out

                3   a little earlier.

                4             DR. 1,7MSIOCK:  It was brought out a little earlier.

                5   But this is in the new projects in which they are requesting

                '6  this.

                7             MR. OGDEN:  Can-I make a nee? motion that we T)ut

                8   California at 4 million dollars?.

                9             MRS. SILSBEE-.- Is there a second to that?

               10             DR. GRAMLICH:  Second.

               11             MRS. SILSBEE:  The motion has been made and seconded

               12   that California application be approved at the level of 4

               13   million dollars.

               14             Is there further discussion?

               15             MR. MILLIKEN:  I think 3 and  ii half.  Try 3 and a

               16   half.

               17             DR. JATIEWAY:  Poi-i about 3 million 640?
               18             MRS. SILSBEE:  I might-add that the Council doesn't

               19   seem to be any more deliberate-in its setting the fund levels

               20   than the Committee seemed to be yesterday.

               21             All in favor of the motion to approve the adolica-

                    tion at-4 million raise their hands?  Four.
               22


               23             Opposed?  Eight, nine.

               24             The motion is defeated.

               25             MR. ODGEN:  Dick, you want to move  it?





  n38           1             DR. JANEWAY:  I move approval of the California
                2   application at $3,640,000.
                3            MRS. FL06D: I will second that motion.
                4            MRS. SILSBEE:  $3,640,000.  The motion has been
                5  made and seconded that the California application be arnroved
                6  at the level of S3,640,000.
                7            14RS. GORDON:  I would like to ask for a short
                8  explanation of the magic mathematical formula used to arrive

                9  at that?

              10             DR. JANEWAY:  It is 65 per cent of 5.6 million.
              11             MRS.-SILSBEE:  Does that answer your question?
              12             Is there further discussion?

              13             (No response.)
              14             MRS.  SILSBEE: All in favor of the motion sav aye?
              -15           VOICES:    Aye.
              16            MRS.   SILSBEE: Onvosed?
              17             (No response.)
              18            MRS.   SILSBEE: The mot:ron is carried.
              19             I-lould someone ask Mr.-.Iiiroto to come back?

              20


              21


              22


              23


              24


              25





                                                                             102

  n39           1                         CENTRAL IIETI- YORK

                2             MRS. SILSBFE: The next application is Central

                3  New York,  and P-liss-Martinez is the primarv reviewer.
                4            MISS f!ARTINE7:  The Committee recommended a funding:,
                5  level of  $450,000.  I was not quite so generous.  I found

                6  that at least two sets of projects duplicated or extended

                7  each other in that they were tvio that were,. number 77 and

                8  78 were really building-of facilities, which I  don't  think

                9  'is feasible for one year projects.

              10             Two more were really sort of  education  projects.

              11   The end result' is that I ended up with a funding recommenda-

              12   tion of 381,372.

              13             MRS. SILSBEE:  Dr. Schreiner?

              14            --DR. SCHREINER:  Yes.  I had perhaps the advantage  1

              15   of site visiting this area.  And there a:re a number of
              16   developments from the previous time.  I agree with miss
              17   Martinez on those two particular projects.

              18             I would also like to p'oint out, however, that  in

              19   the region's own priorit-y list-they are in the low priority

              20   groups, so that they have ins ight into thq problem which she

              21   mentioned.


                             We helped them actually set up a  verv  democratic
              22

              23   method for determining the priorities in the various place's.

              24   And I think it has worked extremely well the-re.  There  are
              25   a high number of inputs, and they have a verv good  type  of





n4O            I   rating system for establishing priorities.
               2             Now, in previous sessions the kidney programs were
               3   toned down because-'they did have some problems in getting
               4   areawide agreement on a number of the projects.  I do think
               5   that they made a lot of progress in that Particular area
               6   since our last funding.
               7             And the kidney projects have been asked for at a
               8   level of 111,000.  The second area that I would give very
               9   'high priority to, and I can find in their priority list
              10   reasonably highly rated as well, are those relating to the
              11   north country,,which is an extremely desolate area.-
              12,1           Even though it is in New York State, within easy
              13   driving distance of New York City, it has one of the lowest'
              14   population densities in the United States.  And there are a
              15   number of very unique minority circumstances u@ there,
              16   including an Indian reservation which never signed a treaty
              17   with the United States and therefore doesn't come under the
              18
                   Bureau of Indian Affairs and it Is entirely-,dependent upon
              '19  this kind of activity.
              20            I can identify.about another $135,000 worth of
              21   projects relating to the north country area.  So I am afraid
              22   that my recommendation would be a little bit higher.  If I
              23   assumed the program staff figure is correct -- and I would
              24   agree it is possible it'could be cut a little-bit and put
                                      two
              25   the emphasis in these/areas    I could come up with a figure





                                                                             104


  n4l           I   of $562,000.
                2             So then I am a little far away from Miss Martinez.
                3             MRS. SIL8BEE:  Well, I don't have a motion.
                4             DR. SCHREINER:  I would like, obviously, to   move
                5   the higher figure and she would like to move the  lower figure.
                6             MRS. SILSBEE:  @7e've got three figures before  us

                7   now.

                8             MR. OGDEN:  What are those, please?
                9             MRS. SILSBEE:  But we don't have a  motion.
              10              DR. SCHREINER:  I would like to move 562.
              11              MISS @IARTINEZ:  562 ?
              12              DR. SCHREINER:  Yes.
              13              MRS. SILSBEE:  $562,000.  Is there a second?
              14              (No response.)
              15              MRS. SILSBEE:  Is there another motion?
                              MISS 1,MRTINEZ: Yes.  I would like to make a motioni
              16

              17   for 382,000.
              18              MRS. SILSBEE:  38j,0001>
              19              MISS MARTINEZ:- 82.
              20              MRS. SILSBEE: -382,000.  Is ther6 a second?
              21              (No response.)

              22              MRS. SILSBEE: Is there another motion?
              23              DR. KOMAROFF: I move the Connittee's  recomrienda-
              24  tion of S450,000.

              25              DR. JANEWAY:  Seconded.





   n42          1             MRS. SILSBEE:  The motion has been made and seconded

                2   that the Central New York, application be approved at the

                3   level of $450,000.-.


                4             Is there further discussion?


                5             (No response.)

                6             MRS. SILSBEE:  All in favor?


                7             VOICES:  Aye.

                8             MRS. SILSBEE:  Opposed?

                9             (No response.)

              lo              MRS. SILSBEE:  The motion is carried.




              12


              13


              14


              15


              16


              17


              18


              19


              20


              21


              22


              23


              24


              25





                                                                           106

   n43          1                         COLORADO/T-7YOMING

                2             MRS. SILSBEE:  The next region to be reviewed is

                3   Colorado/T-7yoming. And let the record show that Dr. Gramlich

                4   is out of the room.

                5             Miss Plartinez?

                6             MISS PIARTILTEZ: I am waiting.

                7             All right.  I believe the Committee's recommendation

                8   was for $200,000.   Again I am a little low in that I recom-
                9   inend 146,959.  1 have a comment to make on one of the projects
              10    in particular -- well, two, all right.
              11              one, number 59, seems to me to be primarily an
                                                                   a
              12    education project.  And I was wondering whether/Staff oerson

              13    could tell me if this was developed in cooperation with the

              14    educational commission of Colorado?

              15              MRS. SILSBEE:  Miss Murphy, did you hear the ques-

              -16 i  tion?


              17              MRS. MURPHY:  Yes.  I have to check.it.
              18              MRS. SILSBEE:  Could you get over to.the microphone

              19    please?

              20              MRS. MURPHY:. -I really know no mbre about the

              21    project than what is on page 15.

              22              MISS @IARTINEZ: Well, if it is the information that!

              23    I read last night, then Ijust make the observation that the
              24    educational commission or agencies in the Sti7te were not
                    consulted and that the project description was extremely
              25




                                                                           107


  n44           1   hazy in my mind.  So I have severe questions about that


                2   one.

                3             But the bne that I really object to is number  64,
                4   which is entitled, health promotion service, primarily a
                5   project to reach senior, Spanish-speaking senior  citizens,.
                6   sort of an education project. And at one point  the  comment
                7   is made that the money is 'going to be given-to the public
                8   health department to,hire nurses who will go out and try to'

                9   overcome social barriers.

              10             That doesn't explain how it is going to be do.Li=,,
              11    it doesn't explain who, you know, what criteria is  going  to
                 ii be used inthe selection of staff"to do this.  To me, this
              12

              13    is an example of a lot of poor planning that goes into  pro-
              14    jects which are supposed to reach minority people and don't.
              15             In other words, it is an emmpl@ of the use of a
              16    minority population for funding.  And I would suggest that
              17    either that project proposal be developed so that it is under:,
              18    community control and hires community persons to do the out-

              19    reach or that they be requested to not fund it.

              20             MRS. SILSBEE: Dr. Haber?

              21             DR. HABER:  I have a serious question about project
              22 I'.number 61. Could Staff enlighten us about what  is  intended
                    with the $17,000? You can't buy band-aids for S17,000.
              23

                             MRS. MURPHY:  That proposal has bed-n called into
              24
                    EMS 'for consideration.  We will not fund it until it gets
              25





   n45          1  approval.

                2            DR. HABER:  Very well.

                3            MRS. SILSBEE: It has not been  referred  to  EMS.

                4  That was one we wanted to get the Committee's views on,
                5  because it doesn't conflict with the legislation.

                6            DR. HABER: I would like to point out  that  a  burn

                7  center is an extremely expensive  operation,.reauiring  heavy

                8  staffing by very skilled people.  And I think that we sadlv-

                9  -or badly need the development of such burn centers.  But
              10   unless this is some kind of exploratory project --  I  can't
              11-  tell here -- I would say that the scope appears to  be  hope-
              12   lessly inadequate.

              13             The demands of these burn centers are  such  that

              14 i you should deploy these with the createst precision  and  in

               .15 areas where they are likelv to be well utilized, and concen-
              16   trate the rest on developing transportation svstems  to  aet
              17   people to where the burn centers  are.
              18             I don't know what this-  but S17,000 seems to  be

              19   so inadequate that it is ludicrous,  Iwould think.

              20             MRS.  SILSBEE:  Mrs.'Morgan?
                                                              t

              21             MRS. MORGAN: I don't believe Colorado  has  a  burn

              22  -center or such at the present time. They  have  applied  to

              23   the legislature and were turned down last spring  for  money

              24   to build-a burn center.

              25             This $17,000, I believe, mainly is  to take a nurse




                                                                             10 9
   n46           I   who has been working in, quote, unquote, what they call
                 2   their burn center where they treat their burn patients,
                 3   which is a $12,OOCL., add to it travel about the State, and
                 4   1 think really to urge passage of a legislature bill where
                 5   it will be taken care of by the State at,the Colorado

                 6  General.

                 7             DR. HABER:  Well, if it is preparatory or educa-

                 8  tional

                 9             MRS. MORGAN:  I think it is really a study to get
               10   information to develop one.
               11              DR..HABER:  T,7ell, O.K.  Under those circumstances

               12   1 will be  mollified.

               13              MRS. SILSBEE:  I haven't had a motion on Colorado/

               14   Wyoming.

               -15             MISS MARTINEZ:  Yes.  I would-to make a motion thatl
               16   we  fund  at the level of 146,959.
               17              MRS. SILSBEE:  Is there a second?

               18
                               DR. KOMAROFF:  Second.-
               19              MRS. SILSBEE:  A motion has been made and seconded
               20   that the Colorado/Wyoming application be approved at the
               21   level of $146,959.

               22              DR. KOMAROFF:  Including that caveat that she
               23  mentioned   about thespanish-speaking

               24              MRS. SILSBEE:  That is project 54
               25              MISS MARTINEZ:  Yes, either it be developed with    I





n48          I   number 64, unless that project can be developed to include
             2   a community control policv board and outreach workers who
             3   are from and sensitive to the needs of the particular popu-
             4   lation being served and that if s.uch conditions are met
             5   that the funding level be increased

             6             MRS. SILSBEE:  No, you have to go the other way
                 to get a motion like that.

             8             MISS MARTINEZ:  $4iooo.
             9;I           DR. KOM-AROFF:  187, 188, but restrict the $41,000'
             10  unless they do it right.
             11           miss MARTINEZ:  O.K.  Does it come out exactly

                 187?


             13           MR. HIROTO:  188.

                          MISS MARTINEZ:  All right.  Let's try this once
             15  again.  Imove that Colorado/Wvoming be funded at 188,182
             16  with the condition that project 64 is to be developed to
             17  include acommunity policy board and community outreach
             18 i@ workers sensitive to the population in question, and that
             19  if such conditions are not-met that the funding level be
             20  reduced to 146,959....

             21           MRS. SILSBEE:  You have heard the motion.  is there

                 a second?


                          DR. WAMSOCK:  Second.

                          MRS. SILSBEE:: An]( further discussion?
             24

                          (No response.)
             25





                                                                           112

 n49           1             MRS. SILSBEE:  All in favor?

               2             VOICES:  Aye.

               3             MRS. SILSBEE:  Opposed?

               4             DR. JANETQAY:  No.

               5             MRS. MORGAN:  No.

               6             MRS. SILSBEE:  Let's see.  Let's have the ayes
               7   raise their hands.

               8             O.K.  Let's have the nays raise their hands.

               9             The ayes have it.  The motion is carried.

              10             Dr. Janeway?
              11             DR. tANET,7AY:  It seems to me that there must be a
              12   reasonable balance between fulfilling all the responsibilities
              is   and carrying out the policies and statutes of the Rt.!P versus
              14   the selective identification of particular  projects.  The
              15   technical review has been done.

              16
                             And there are only two Council members who  have
              17      7uae opportunity even to read the forms 15.  1 would just
              18   hope that we don't-get'-like the fellow who went down into
              19   the swamp and he saw an alligator down there, and he  beat
              20   that alligator over the head and he killed,them.
              21             And he just kept running into more alligators and'
              22   killing alligators and forgot after he was down there with
              23   all those alligators around that somebody sent him down to
              24   clean out the swamp.

              25             DR. WAD,@IOCK: Common, Sam Ervin.





                                                                            11  3


 n5O            1             MR. PIILLIKEN: You mean he is up to his elbows  in


                2   alligators?

                3             MRS. MORGAII:  He's not quite that far.

                4             DR. JANEWAY:  I have to abridge the story a little

                5   bit.


                6             MRS. PLOOD: As a matter of comment---  and  again,

                7   as Dr. Janeway occasionally says, gratuitously -- I do think

                8   though that we have some responsibility.  If  the  technical

                9   reviewers or the Regional Advisory Group itself does not

              10    take into consideration the problems of dealing with minority;

              11    groups and using terminology such as overcome cultural

              12    barriers rather than to address cultural barriers in a


              13    manner that can be adapted to the health delivery system.

              14              And we do face the responsibility  of  questioning
              15    the development of individual projects when they are serving!

              16    a population that many times is not articulate in expressing

              17    its own needs.

              18              DR. JANEWAY: I don't-disagree with that  one  bit,

              19              MRS. SILSBEE:  Thank-you.

              20              The transcript for Arizona has arrived,  and  have
                                                             t

              21    you had a chance to look at it, Mr. Hiroto, or would you

              22    rather go ahead?  We can come back later?

              23              MR. HIROTO:  All right.  I will   take-Connecticut.

              24              MRS.-SILSBEE.:  You'll take Connecticut.  Do you

              25    have that one?





                                                                           114

  n5l                         MR. HIROTO.:  No.
               2             MRS. SILSBEE:  We have  to hold -for just a few
               3   minutes while there  is a switch    the changing of the guard
               4   here.
               5              (Whereupon, at 12:30, a luncheon recess was taken
               6   until 1:00 p.m.)

               7


               8


               9


              10


              11


              12


              13


              14


              15


              16


              17


              18


              19


              20


              21


              22


              23


              24


              25





                                                                           115

               1                      AFTFRNOON SESSION

               2              t4S. SILSBEE:  The meeting will.come to order.

               3    In the break that-we have had, I've had about three or four

               4    requests of individuals in regions who have to leave early

               5    and I'm prepared to accomodate them as much as vossible, buti
                                                                                 i
               6    weire going to have to move along.  Mr. Hiroto.

               7              MR. HIROTO:  Ms6 Chairman, would you entertain a

               8    motion that should the primary reviewer and the secondary

               9    -reviewer have no problems or difficulties with the result

              10    of the Review Committee, that we vote in block on those and

              11    go along the table and list those states that we feel  secure

              12    with and only review those or discuss those that some  people

              13    may have questions about.

              14              MS. SILSBEE:  I will entertain the motion.

              15              MR. MILLIKEN:  Second.

              16              DR. HABER:  One mechanism for accomplishing that

              17    might be if you were to read down the entire list of  remain-

              18    ing proposals and ask if objection is raised on the part of

              19    primary or secondary reviewer with the committee's  recommen-

              20    dation.  A negative answer would seem to indicate that it

              21    would then be part of a block to vote on.


              22              MS. SILSBEE:  Right.

              23              DR. 1,7ANlMOCK:  You said-you would read down the

              24    list?

              25              DR. HABER:  Yes.  There are several ways to




                                                                             11 6


                1    accomplish this, but the most expeditious wonid be for

                2    Mrs. Silsbee to read down the list and if anyone feels
                3    that he doesn't q@ along with the committee's reuort,  he

                4    so states and it is then removed for- individual  considera-

                     tion from the Block Vote.

                               MS. SILSBEE:  I think  the record should show @hat  1
                6

                7    the entire council has before them the  composite  recommenda-i

                8    tions of the review committee showing the requested level

                9    and the committee approved recommendation.  I also think

               10    that the record should show that this is in view of the

               .11   fact that you participated as observers in discussions of

               12    the committee's deliberations yesterday.

               13              I-IS. GORDOIT:  Was there any problem with the con-

               14    flict of interest?

               15              MS. SILSBEE:  Not on block action.  All right,
               16    the motion has been made and seconded that we go through
               17    this.  I'll go down the list and if anyone has anv objec-
               18    tion to the committee recommendation, we will take that

               -19   particular application out for-@discussion, otherwise there

               20    will be a motion about the block action.  All in favor.

                               MS. SILSBEE:  opposed.
               21


               22              Motion carried.

                               I will not only read the list, but I-will  read  into
               23

               24    the  record what the recommendation was as far as the funding

               25    level.







                  f:
                                MS.  SILSBEE:  Arizona    $150,000.

                                MR. ITIP@OTO: Object.
                 2

                 3              MS.  SILSBEE:  Connecticut    $750,000.

                 4              DR. GRAMLICII:  Object.

                                MS.  SILSBEE:  $600,000    Florida.
                 5

                                Greater Delaware Val-ley   $684,512.
                 6

                                Hawaii - $486,7.50.
                 7

                                Illinois - $750,000.
                 8

                                Indiana - $240,000.
                 9

               10               Intermountain

               11               DRi KOMAROFF:  Object.

               12               MS. SILSBEE:  Iowa - $173,929

                                               Kansas - $363,545
               13

               14                              Lakes Area - $150,000

                                               Louisiana
               15

               16               DR.  JANEWAY:  Object.

               17               MS.  SILSBEE:  Maryland - $650,000.

               18               DR.  WAMMOCK:  I think-we had better go over that.

               19               MS.  SILSBEE:  Memphi,s - $950,000

               20                              Metro-D.C. - $256,000

               21                              Michigan -  $500,000

                                               Mississippi - $2,000,000
               22
               23                              Missouri,-  $540,000

                                               Mountain States - $300,000
               24

               25                              Nassau/Suffolk



                1             DR. KOI,IAROFF:  I think we had better discuss that.1
                2             MS. SILSBEE:  Nebraska - $95,000
                3                           New Jersev - $1,100,000
                4                           New Yo rk Metro - $950,000
                5                           North Carolina - $120,000
                6                           Northern I.,Iew England - $600,000

                7                           Northlands - $300,000

                8                           Oklahoma.- $25OiOOO

                9                           Oregon - $148,693
              10                            Puerto Rico - $131,335
              11                            Rochester - $1,000,000
              12                            South Cdrolina

              13              MRS. GORDON: 'Objection.

              14              MS. SILSBEE:  South Dakota - $88,850
              15                            Susquehanna Valley - $500,000

              16
                                            Tennessee/Mid-South - $570,000
              17                            Tri-State - $610,000
              18              MS. SILSBEE:  We'll co-me back to Texas.  Tri-State
              19   $610,000.  Virginia - $960,860-.

              20              MS. MARTINEZ:  Object.
                                                             f
                              I-IRS. FLOOD:  They have an arthritis program.  It's!
              21

                   not essential, it's automatically taken care of.
              22

              23              MS. SILSBEE:  From the previous recommendation.

              24              Washington/Alaska - $530,000

                              West Virginia  $1,000,000
              25





                               MS.  SILSBEE:  Wester-n Pennsylvania $450,000

                               DR. HABER:  Objection.
               2

                               MS. SILSBEE:  Wisconsin - $200,000.
               3

                     We'll review Arizona, Connectucut, Intermountain, Louisiana,i
               4

               5     Maryland, Nassau-Suffolk, South Carolina, Virginia, Western I

               6     Pennsylvania with Texas.

               7               MRS. MORGAN:  I  move that we accept the Re view

               8     Committee's recommendations for funding of the regions

               9     not specified to be taken care of separately.

               10              DR. KOMAROFF:  Second.

               11              MS., SILSBEE:  Is there further discussion?

                               (No response)
               12

               13              MS. SILSBEE:  All in favor.

                                             Opposed.
               14

               15              MS. SILSBEE: Motion is carried.

               16    We'll now go to Arizona.

               17              MRS. KLEIN:  This is just a minor thing, but we

               18    had taken some this morning and-the way the motion was

               19    worded, all those other than the ones that were recently

               20    enumerated, so I think the motion should show,, except for

                     those already discussed and approved.
               21

                               MS. SILSBEE:  I think that was the consensus
               22

                     of the discussion beforehand.
               23


               24


               25                                                           %




                                                                             120


                1                          ARIZONA


                2              MS. SILSBEE:   Arizona   Dr. Gramlich.

                3              DR. GPN4LICH:   As a matter of principle, Arizona
                4    has had difficulty with  the organization, the  leadership  andi
                5    had had some other difficulties that were  technical  with  the,
               .6    DRMP and counsel said to clear-it up,  so  Arizona  cleared
                7    them up and the Technical-Review  Committee  rewarded  this
                8    function by cutting their allocation --- their  recommenda-
                9    ..tion.  The question is one of principal.  Do you reward
               10    virtue in a negative fashion or a positive fashion?
               11    There's not much question about the technical capabilities
               12    of the region to accomplish the project it had ordered.
               13    That was a minor element, but the concern on  the  part  of
               14    the technical review committee was, if you haven't been   goodi
               15    up to now, that you've changed everything we  said  you  shouldi
               16    do, so we're goina to reward you by cutting your grant.
               17             MR. HIROTO:  I,echo that.  I was going to request
               18    the council to consider changing-the amount  of  the  award
               19    to $240,000 --- $240,718 because-at least it meets the three
               20    component projects in the upper three projects that have the
               21    highest oriority.

                              DR. GRMILICH:   If that's a motion, I  second  it.
               22

                              MS. SILSBEE:   The motion has been made and
               23
               24    seconded that the Arizona application be approved atthe
               25    level of $240,718.  Is there further discussion?





                                                                             12i


                               (No resnonse)


                2              MS. SILSBEE:  All in favor.

                3                            opposed.

                4              MS. SILSBEE:  The motion is carried.


                5


                6


                7


                8


                9


               10





               12


               13


               14


               15


               16


               17


               18


               19


               20


               21


               22


               23


               24


               25





                                                                              12Z


                 1                           CONITECTICUT


                 2              MS. SILSBEE: I-le will now go to  Sonnecti-cut.

                 3   Mr. Hiroto.


                 4              MR. HIROTO: I can  appreciate  the  problem  that

                 5   probably we all face with Connecticut and that Connecticut's;

                 6   program has continued as it was designed until just the    last

                 7   10 months. The  technical  reviewers,  one  recorimended'a

                 8   a level of $250,000; the other recommended a level of

                 9   $1,400,000, which reflects, I  think,  the  difficulties  we

               10    all have in reviewing  Connecticut.  Dr.  Gramlich,  if  you

               11    have any comment that you would like to make.

               12             . DR. GRAMLICH:  Yes.  Again, these are general

                     comments  and more  philosophical  then  technical.  Here,
               13

               14    apparently and I don't know the  region  well  at  all.  I

               15    may be in error, but it appears this is an RMP  set  uo  with
               .16   a different kind of  program from the pattern throughout the

               17    rest of the States,  throughout the rest  of the nation and
               18    therefore, our last  Technical @eview Committee said,  well,,
               19    since it doesn't conform, we shouldn't give them anv money.
               20    Now, maybe this is an entirely wrong interpretation.  I

               21    would appreciate staff input on the assessment of the
                     justification for dropping the funding because of the    fact
               22
               23    of the different kind of program, one from the'other.

               24              MR. HIROTO: Dr. Gramlich, I don  @  think  that  is
                     a primary consideration. The problem seems  to  be  that  all
               25





                                                                             3
                 I  of the P14P funding or most of it has gone into the
                    institutional area, rather than into other areas and
                2
                    despite staff eff@rts to spread the program a little nore
                3
                    fully throughout the state and throughout other institutions.,
                4
                    this was not accomplished At the  last  council  meeting,    i
                5

                    council agreed to reduce funding dramatically because this
                6
                7   was the only way that Connecticut would get the  message,
                    so to speak.  They have gotten the message to a degree and

                9   .so the $750,000 level seemed reasonable to rhe review

              10    committee.

                              DR4 GRAMLICH:  Rebuttal.time.

              12              MS. SISLBEE:  Dr. Gr@.lich.

              13              DR. GRAMLICH:  To begin with the May request for
              14    funding was not large. It was something in the  order  of
              15    $,636,000 dollars.  The major request is what we have in
                    front of us now. Therefore, since the timing  again  with
              16

              17    Connecticut, was differnt, we are penalizing them even
              18    further by not killing their program by refusing to accept   I
              '19   their major funding request.

                             MS. SILSBEE:  Dr.Janeway.
              20

                             DR. JANEWAY:  It is my recollection,  Dr. Gramlich
              21
                    that one of the things that was taken into consideration  wasi
              22
              23    considerable amount of their funding was going'through into  I
              24    1976.

              25             DR. GRAMICII:  Correct.





                                                                             124


                1              DR. JANEIIAY: And the way I recall the  technical

                2    discussions, there was a general sense of that  group  that

                3    felt they should not fund projects through 176.

                4              MS. SILSBEE: There were  several  considerations,

                5    Dr. Janeway in terms of the level.  One of them was the

                6    two year funding request.  The- other was a contract that

                7    would have enabled the monitoring capacity to go bey ond

                8    June 30th, but in addition, there were the  two  university

                9  -.resources that were funded at a fairly sizable amount.

               10    Other portions of the program that would have been of  con-

               11    cern was the--third faculty. There were no funds  requested

               12    for that.  The Connecticut application in May, Dr. Gramlich

               13    was requesting support for staff plus two months of continua.-

               14    tion projects.  This amplification asks for 10 to 22 months

               15    for some activities and 10 months for others  so it is

               16    complicated by that factor.

               17             DR. GRAMLICH:  Right, but neverthelsss, if you

               18    take all the two year projects And this iscrude arithmatic-

               19    but nevertheless if you-take t'he two year projects and cut

               20    each of them in half and award them one h,alf of the two year

               21    total, you're in effect awarding them for  one  year.  They
                     still wind up with a figure $1,430,000.  The way I visualized
               22

               23    this, it was incorrect, that since Connecticut'came in  for

               24    a small grant request last May, if we cut them way down this
               25    time, we're in effect, killing their total program.





                                                                             126


                     we have---


                               MRS. GORDON:   --- it's not a matter of a new  activi
                2


                3    so much.

                4              MS. SILSBEE:  I think we may need some help here
                5    from Mr. Nash.  The two year projects, are they all new

                6    or are they continuations?

                7              MR. NASH:  I think some of them are  new.  The      i
                                                                                   i
                8    onces, I think, that concern the review committee, the      -
                9    -four projects going to Yale and Yukon are fo:e over $800,000

               10    for the two year period.

               11              MS.@ SILSBEE: Mrs. Gordon, because you were not
                     here yesterday, there was considerable discussion  with  the  I
               12

               13    committee and Dr. Pahl about the two year request.  The
               14    re gion recieved its money and has the option of putting
               15    some money away for some activities, if they feel they
               16    shoudl go longer than two years, if they can work out some
               17    kind of a contractural arrangement, so this is just a  way  of!
               18    arriving at a level and I don't-think that should,be a major
               19    worry for you.  The Regional Advisory Group will make that

               20    decision.  Mr. Milliken.

               21             MR. MILLIKEN: My understanding is  that  you  have--:1
                     my understanding is that Yale was just awarded one of the
               22
                     few large cancer centers --- ca ncer development tesearch.
               23
                     Are they going to be able to spend all of tITis with the
               24

               25    limited staff they have there?




                                                                             127


                1              DR. GRN.ILICH:  The money that goes into the

                2    Regional Medical Program aspect of this.loroqram would

                3    not --- this is their community outreach part of the

                4    university budget.  They won't --- I don't think they will

                5    have much of a problem spending money.

                               MS. SILSBEE:  They have had experience in  this.
                6

                7    The motion has been made-and seconded that the Connecticut

                     application be approved at $1,430,500.  All in favor.  Couldi
                8

                9  ..I see a show of hands? Five. Opposed -  the  opposed  have

              10     it. The motion is not carried. I  will  entertain  another

              11     motion.

              12               MR. HIROTO:  I move the review committee's

              13     recommendation of $750,000 be.approved.

              14               MS. SILSBEE:  Is there a second?

              15               MR. OGDEN:  Second.


              16               MS. SILSBEE:  The motion has been made and

              17     seconded that the Connecticut application be approved

              18     at'the level of $750,000.  Is there further discussion?

              19               (No response)

              20               MS. SILSBEE': -All in favor?


              21                              Opposed.

                                              The ayes have it.
              22


              23


              24


              25




                                                                           12 8



                                         INTERMOUNTAIN

                2             MS. SILSBEE:  The next application to be reviewed
                3   is Intermountain and the record shows that Mrs. Klein and
                4   Dr. Gramlich are out of the room.  Dr. Komaroff was the

                    reviewer.
                5

                6             DR. KOI-IAROFF:  Intermountain was rated by the
                7   June Council as an above-average region.  -They were awarded
                8   2.23 million dollars, as a result of last councils session.
                9   They now request a supplement of $481,000 for 19 new project
              10    activities.  The last council expressed several concerns
              11    which appear@--most of which appear to have been  resolved
              12    and let me summarize them briefly. There has  always  been
              13    a turf problem with the Intermountain regions, the mountain
              14    states and Colorado and Wyoming regions. This  appears  to
              15    have been resolved by some interlocking membership of  the
              16    advisory groups and frequent regular meetinas of the members
              17    of the advisory group --- of the members of each  of the three
              18    advisory groups as well as by s6me joint funding of pr@'ects
                                                                           3
              19    which have a geographical overlap with these three PI.IP's.
              20             A second concern has been the relationship of this
              21    RMP its CHPH agency and apparently, according to the-staff-
                    review and the CHP letters in the aDolication, there is now
              22
              23    a serious  review by CHP under consideration by the RAG of

              24    CHP.

              25             The third concern that the council expressed last





                                                                              2 9

                     time involved the role of the RAG in developing and  rion4tor--

                2    ing projects.  The region has developed what they call a
                3    drag advocate pro-@ram whereby individual members of the

                     RAG are responsbile for shepherding a project Droposal
                4

                     through it's passage and subsequently monitoring that
                5

                     project after it has been funded.  It seems like a worth-
                6

                     while idea.  There was a
                                              .question of conflict of interest
                7

                8    in the establishment of a health development services

                9    corporation.  Dr. Pahl mentioned yesterday that,throucrh

              10     action by the State Attorney General and through meetings     I

              11     with the RMP:staff members, this conflict of interest ques-

              12     tion has been resolved.  There was concern that council

              13     epxressed regardingthe university domination of past          I

                     projects.  In this cycle, 18 of the 19 projects were
              14

              15     sponsored by outside agencies which may have created a

              16     problem, but has solved at least the  concern  of  council

              17     from the last time. The directorship of  the  program  and
              18     th@ capabilities of the four staff are deemed  to.be  good

                     by those people who know the region best.  I have not
              -19

              20     visited there. The project proposal,  however,  seemed  to

              21     me to be exceedingly non specific and hard to evaluate.

                     They have some very uninspiring continuing education Dro-
              22

                     jects and they propose to develope their own audio visual
              23
                     materials.  Many of them give the impression of duplicating
              24

                     kinds of activities which have gone on in other  regions  with7
              25




                                                                           130

                     out giving evidence that they nlan to build on the experience

                     of others and I have the uneasy feeling that they may bs
                2

                     repeating the failures and not the successes of other such
                3

                     attempts at @IP, but it's hard to tell from-these abstracts.
                4

                              One nrooosal is to establish a workshop on drug
               ,5

                     and alcohol abuse, and I just wonder why they haven't
               .6

                     applied through the institute for drug and alcohol abuse
                7

                8    or such an activity. It seems to me on the fringe of

                9    P14P's funding mandate. Several strong projects are

               10    listed. One of the most interesting involves a computerized

               11    agency referal for extended services in which they would

               12    try to do a better job of referring patients to apparently

               13    social service agencies. I would --- I'm not concerned that

               14    the projects are over inflated as has been described by the

               '15
                     past council and the review committee yesterday. In fact,
               16-   if anything, they appear to underestimate the cost and time
               17    needed to accomplish local-objectives, but I have a feeling
               18    there is a lack of cohesion about the whole Dackage and I

               19    take issue with the committee's decision to fund them at

               20    virtually 100 percent of their recruest and would reduce

               21    the request from---reduce the award from $450,000 to
               22    $350,00.0, out of a total request of $480. I would also

               23    convey to them again, as council did at its last meeting
               24    that the project --- the corp staff, not the project staff
               25    shQuld include more minority representation, particularly




                                                                            1 3 2



               1                        LOUISIANA


               2              MS. SILSBEE: The next region to  be  reviewed  is

               3    Louisiana.  Dr. Janeway.

               4              DR. JANET-IAY:  I'm the secondary reviewer---I'm the

               5    primary reviewer. The reason why I wanted to  take  it  out


                                                                  -dvice ft
               6    ofthe block was partly to get some technical a          OM'

               7    the staffon this. I am concerned  about  the  application

               8    for $75,000.

               9              MS. SILSBEE:  Bring Dr. Gramlich and  Mrs.  Klein

              10    back in.


              11              DR.@JANEWAY: I'll hold my  comment  until  Mrs.

              12    Klein gets back. She's a lawye@ and she may  be  able  to

              13    help.

              14              (Dr. Gramlich and Mrs. Klein re-entered the

              15               hearing room.)

              16              MS. SILSBEE: Is staff ready to  listen  to  the

              17    question Dr. Janeway has. Can theycome  up  tothe  table,

              18    please.

              19              DR. JANETIAY:  My questions are technical and

              20    relates to Project C-10 in the Louisiana application which
              21    is entitled "Study of N. 0. Tax Supported  Clinics  Serving
                    Title 19 Recipients."  It's the major request in the
              22

              23    Louisiana Application and I would like to  know-whether  it

                    is appropriate that RMP funds be used to evaluate the
              24

              25    activities of the clinics supported by other tax funds.





                                                                              3 3

                1   One wonders if that shouldn't be the function of either


                2   the state, per se or the agency that provides medical

                3   funding.  It's just a question that I, myself am unable

                4   to answer it.  I don't have the knowledge.

                5             MS. SILSBEE:  Mr. Sibloski, do you have any

                6   comments?


                7             MR. SIBLOWSI:  Not really.   It's a hard one to

                8   swallow.

                9             DR. JAIIEWAY:  I brought it up BECAUSE Nobody in

               10   Technical Review even mentioned it.

               11             MRS. GORDON:  As secondary reviewer, we only   ficured

               12   what  they were trying to do  wasget  an  impartial  judgement

               13   on it  and the other federal agencies weren't impartial.

               14             DR. JANETIAY:  It might pay to have Blue Cross  co.-..e;

               15   in and  do it for them.

               16             DR. GRKMLICH:  My impression of the medic-aid

               17   level is extremely low.

               18             MR. SIBLOWSKI:  'I can.-'t really respond.  I really

               19   had some concernwhen I was tal-king to Dr. Savlier as to why

               20   they decided to participate.  He was basi cally  saying  that

               21   the F.MP is in the only neutral position in the state to.

                    attack it.  Everybody else seems to be involved and it's
               22

               23   a non biased review assessment and if you  look.on  Paae  16,

                    the people all involved in this --- are involved with the
               24

               25   consulting firm of Shindell and Associates.   The   Louisiana





                                                                            1 3 4
                1    Division of Administration and Planning; the Division o-@

                2    Family Services; the Division of Health Maintenance; the
                3    Charity hospital @ystems division and it  seems  reading

                     in between the lines that many Board members  in many
                4
                     organizations, it is a non biased type of thing  where  the
                5
                6    RMP is entered in and is trying to fulfill a certain role.

                               DR. JANEIIAY:  Let me ask you --- try to explain to
                7

                8    me the comments coming out of the HPC in Lafayette, Louisiana

                9    to which is attached, at least in my copy a memorandum, the

              10     last paragraph which says, "This study is intended  to  in-

              11     fluence the manner in which HEW funds out  patient  medical

              12     services in the state and may result in increased availabilit,-

              13     of these funds." I'm only asking this  question  because  I  i

              14     don't want the people in this 14ational Advisory Council to

              15     be put in the position of approving something  which  is

              16     against statutes.  I'm not trying to hurt the Louisiana

              17     RMP.

              18               MR. POSTA: If I could make  a  brief  comment.

              19     This is not related directly -to your question, which  I

                     think is quite valid.
              20                            The last council, if you will

              21     remember, one of the reviewers specifically requested

                     to get-them more involved with the REgional Medical
              22

                     Program, more involved with bringing the  private  institu-
              23

                     tions-in and,the private sectors into the  indigent  clinic
              24
              25     or the hospital system.  I'm not saying this was developed






                                                                          at least
                    recipients and they  are going to contract this out,
                    it says in the memo here they will contract it out to
                2

                    Shindell Associatds.
                3

                              MS. SILSBEE:  He is questioning the leaality.
                4
                5             DR. JANEIIAY:  Far be it from me to question the
                    legality.  I'm questioning whe ther it is lecal.  I want
              -7    some technical input.
                8             MS. SILSBEE:  That's a better way to  put'it.  The
                    legality of counsel taking action.
                9
                              DR. PAHL: As usual, I am not  preoared,  certainly
              10

                    on the spur of the moment.  I think what we would like to
              11

                    have is your recommendation within.what the legalities are
              12
              13    and we can determine then post counsel and act  accordingly.
                    In other words, on a technical matter like this, I'm  not
              14
                    really prepared to give you an answer that has any  force
              15,

                    behlnd it.  lihat I would prefer to do is find out whether
              16

              17    it is the consensus of this committee that, if leaal,  do

              18    you recommend that we make theaward which  would  include

              19    that or if not leaal, do you recommend a fundina level which

              20    encompasses those dollars, but they could use those  dollars

              21    for other purposes, so we need your assent and we will

              22    determine the legality.

              23             DR. HABER:  I too was concerned about this project,
                    but in-a direction somewhat different from Dr. janeway.  I
              24

              25    thought this was a particularly apt use of funds, Regional





                                                                               1 37
                1    Medical Program and at a stage when winding down is in

                2    process and when one would  hope  that  funds  appropriated

                     for the project would be susceptible to a final verdict,
                3

                4    1 think that one of the purposes of the RecTional Medical

                     Program is the development  of  innovated  projects  and
                5

                6    certainly the evaluation of ongoing government mechanisms.

                7    I agree with Dr. Schreiner  assessment  that  Louisiana  is

                8    hard put in terms of development of medic-aid programs

                9    .and I think it would be very useful to get independent

               10    surveys. I think  it  is  appropriate.  I'm  not  qualified
               11    to judgethe legality-In terms of appropriateness, I think

               12    we ought to approve it though.

               13              MS. SILSBEE:  Is there a motion?

                               DR. JANEI,7AY:  In light of the discussion, I move
               14

               15    therefore that we accept  the  recommendation  from  the

               16    Technical Committee that louisiana be funded in the    amount  1
               17    of $168,680 dollars, pending review by the staff on    the

               18    le4ality and appropriateness of-C-10.

               '19             MR. HIROTO:   Second.-.

                               MS.   SILSBEE: Dr. Janeway, does that motion en-
               20

                     compass, as a  rule,  if they could not spend money on that,
               21

                     that the region   should have the money or have it taken awav.;
               22


               23              DR.   JANEWAY: NO.

               24              MS.-SILSBEE:   is there any discussion?

               25              (No response)




                                                                            13 8


                               MS. SILSBEE:'  The motion has been made and

                2    seconded that the Louisiana 'application be approved
                3    at the level of $i68,680 i-7ith the condition that the

                4    funding for the amount of money for Project C-10 be contin-

                5    gent on our staff review of the legalitv and appropriateness.

                6              All in favor.


                7              Opposed.

                8              The motion is carried.


                9


              10


              .11


              12


              13


              14


              '15


              16


              17


              18


              19


              20


              21


              22


              23


              24


              25







                1                             IIARYLAND


                2              MS. SILSBEE:  The  next application to review is
                3   Maryland.    Dr. W@ock, would you get the microphonebefore     i

                4   you   start?

                5              DR. ll@-IOCK:  I think so. I was  the  primary  judge!
                .6  in this case and at  the  May-June Council meeting, there

                7   was a request of $762,000-dollars and  this was denied and

                8   then they put in a new request for $724,000 dollars and
                9   .786 cents and at the meeting  yesterday it was approved for
              10    $756,000 dollars. I need  a  little  bit of information  here.  i
              11    The total program staff - C-0000 - is  that $336,604 correct?

              12               MS. SILSBEE:  Let me look at the sheet?

              13               MRS. FLYNN:  That was May-June.

              14               MS. SILSBEE:  Mr. Nash, could you come un to the.

              15    table please?

              16               MS. SILSBEE:  Did you hear Dr. Wammock's question?

              17               MR. NASH:  I did not.

              18               MS. SILSBEE: Dr. Wammock wants to know-what abo-.,-

              19    was it 338 --- ?

              20               DR. WAMMOCK: $336,467 was the original mroaram
              21    staff --- total program staff.  The original grant in May and  I
                    June, the request was then $762 and the new one is for Program
              22

                    Staff of $233,000 and $724,000 for July.  The Program Staff
              23

              24    of $233,000 with the approval yesterday of $-350,000 --- no,
                    $650,000 --- that's one-third for staff.
              25



                                                                           14 0


                1              MS. SILSBEE:  Dr. Wammock, ifyou will look at the

                2    printout labeled 7-74, you will see that the total request

                3    was $724,000, of which the staff is$302,961.

                4              DR. 1-72U.LMOCK:  That's right, the indirect column is

                     right,.
                5

                6             @MS. SILSBEE:  There was no money provided for
                7    staff because there was no money provided from the May
                8    application, so this is it.  The.$650,000 as I understood

                9    the committee recommendation yesterday would allow for the

              10     staff, about half for staff and about half for the activities

              11     that were proposed.  Is that right, Mr. Nash?

                              MR. LNASH:  I thin, one of the recommendationswas
              12

              13     that $250,000 for staff and $400,000 for projects.

              14              DR. tVAtU4OCK:  400 for projects and 250 for staff?

              15              MR. NASH: Yes,sir.

              16              MR. OGDEN:  I think we ought to be aware that a
              17     great deal of the activities that may go into this project
              18     is staff activities, so that you can't judge the total
              19     request for a particular project as being the total cost
              20     because some of that activity is being carried out by staff

              21     people themselves.


              22              DR. 147@L%IOCK: I recognize that.

              23              MR. OGDEN:  So,'I don't believe the action yester-
                     day of say $250,000 for staff and $400,000 for programs 'IS
              24

              25     any-sense out of line.





                                                                               4 1
                 I              DR. 1,7k".I-'40CK:  You don't think that's out of line?
                 2              MR. OGDEN:  No, I don't.  I recommend that  it be
                  I
                 3   accepted the way 'it was yesterday.
                 4             DR. 1'77L?@r4OCK: I just reopened it for the questioni
                 5   of clarification in my own mind as to which way this was
                 6   going because I wasn't quite sure. I  went  through  this-thincr
                                                                                    7
                 7   and looked at the various projects which I descri
                                                                        bed and I   1
                 8   don't know whether they're goingto be implemented or   not.
                 9   Perhaps it may do some good and perhaps it  may  not  do any
                 10  good.  I'll let the motion stand as it is as of yesterday,
                 11 but I wanted,to bring this up for clarififation in my own
                 12 mind.    I make a motion.

                 13           MR. OGDEN:  I'll second it.
                 14           MS. SILSBEE:  The motion has been made and
                 15 seconded that the committee  recommendation  of  $650,000
                 16 stand.  Dr. Watkins, did you have anything to add to that
                 17
                    as secondary reviewer?
                 18           DR. WATKINS:  No comment.
                 19           MS. SILSBEE: The motion has  been  made  and  s
                                                                            econde
                 20 that the Maryland aD                                    of
                                       -placation be approved atthe level
                 21 $650,000 dollars.  Is there any further discussion?

                 22           (No response)

                 23           MS. SILSBEE'  All in favor?

                 24                         Opposed.
                 25                         The motion is carried.




                                                                             14 2



                1                         NASSAU?SUFFOLK

                2              MS. SILSBEE:  The next region to review is
                3    Nassau/Suffolk and.the prira@, reviewer is Mr. Milliken.
                4              MR. MILLIKEN:  Was this discussed vesterdav?
                5              MS. SILSBEE:  Yes, sir.  Do you have a transcript

                    on that?
                6

                7             MR. MILLIKEN:  Yes, I do.  With the   information
                8   we had this morning, it would appear that we do have to
                9  .,change our previous decision of no funding.  I have no
               10   evidence to find fault with or change the reviei-T  committee
               11   recommendation of $900,000, although  I  personally  question
               12   if that much is necessary due to the situation therein.
               13   Maybe the second reviewer has something  to  add.  I'll  make
                    a motion later on.
               14

               15             DR. GRAMLICH:  I find this interesting.  It
               16 ' appears we're reversing our position of June and iulv.
               17  They have made a strong appeal and I guess if council has
                   no major objection to reinstating them, I would have to
               18

               '19 support that decision.  -so movb.

               20            MS. SILSBEE:  Second.

               21            MS. MORGIU4:  Second.

               22            MR. OGDEN: Could I ask  the  members  of  council---
               23            MS. SILSBEE:  Mr. Ogden, could you use the
               24  microphone.
               25            MR. OGDEN:  Look at the page concerning Nassau/





                                                                             1 4 3
                1  Suffolk.  The program staffing here of $343,000 for what
                2  they have proposed to be slightly over a  $2  million  dollar
                3  program, now if we'@e limiting this to $900,000 dollars,
                4  obviously we cannot let the entire $343,000 for  the  DrocTram
                   stay, so I think there needs to be something said if we
                5
                   accept the $900,000. 1  didn't  hear  the  review-committee,,
                6

                7  yesterday.

                8            MS. SILSBEE: They made the  point,  Mr.  Ogden,  it
                9  Kas not in the motion, but it was in the advice to the

               10  region.

               11            MR. OGDEN:  That may be in the minutes.  Idon't have

               12  that in my notes.

                             MS. SILSBEE : The pink slip says:  "Based on the
               13
               14  funding recommendations for the attending period, it was
               15  further recommended that the Nassau/Suffolk R-NIP be adjusted,
               16  -Staffing request to be proportionate to the forthcoming

                   award.
               17

               18           DR. GPA14LICH: In relationship  to  the  presentation
                   this morning, I was a little at a loss and wondered if the
               '19
               20  applicant was fully aware of the fact that this  council  felt
                   they should be in a nhase out period
               21


               22           MS. SILSBEE:  Mrs. Flood.

               23           MRS. FLOOD: May I ask if  staff.'hzis  verified  that
               24  Projects 021 and 022 of the EMS projects  are  @Dropriate  to
               25  the allowable concepts of our funding.




                                                                            1 A  4


                1            MS. SILSBEE: We have -had a return from Mr.  Reardon

                2  who is EMS Systems Chief and he doesn't see any problem with

                3  regard to their portion of the legislation and we got a

                4  telephone call this morning from the part of HRA that is

                5  administering the training part'of EMS and they also do  not

                   see any problem or conflict.  That is not to say they are
               .6

                   looking at it from any other standpoint but that.
                7

                8            MS. FLYNN:  Those two line items approximate

                   $400,000 dollars and even though we're recommending from
                9

               10  committee that their staff be brought into line  by  readjust-

               11  ment according.to the award, if they're just given an  award   i

               12  without further recommendation, other than staff  limitations,
               13  it would appear that their only endeavor would be  emergency

               14  medical services and emergency medical training.

                            MR. STOLOV: We have received the  priority  level  on
               15

               16  the projects and the equipment is below the $900,000  dollars,

               17  however, the EMS training is above it,but again, I feel it

               18  is expensive, but it was their determination where to put
               19  the money once they get this $90.0,000. They may not put  it

               2o  all into that EMS training.    The Nassau County which  is  the!

               21  more populated and richer county is way down at the  bottom  of;

               22  their priority list.

               23           MR. OGDEN:  Would you explain  to me what this

               24  $355,000 is, how-much of this would be funded out of the

               25  $900,000?





                               MR. STOLOV:  I believe Dr. Pahl mentioned vesterdal-
                 2  that we still have not developed  policy  regarding  iiha+-.haDoen-@
                    in terns of independent @'4P beyond June of    '75, so we don't
                 3  1

                 4  kno,@%, IIE';L wide if this is allowable under arants and administr=-
                    j;
                 5  tion Practicesy but I believe it    would have been a contract
                 6  lin their o-v7n'  Nassau/Suffolk M.IP Inc to carrv this  out  in  this
                 7  iscone and amount.  then the-conmittee looked at this, it did
                 8  not consider this in their funding level.  They left it out.-
                 9            MS. SILSBEE:  The Chairman suggested the $2,000,000
                    1
               10   Irequest be cut down to $900,000 and that maybe a moot issue
               11   in terms of continuing the program or putting money aside.
               12             DR. SCHREINER:  I was -primary reviewer on the

               13   1last go round.

                              MS. SILSBEE:  Accordina to the old assignment list,
               15   Mr. Milliken, you had it last year also.
               16             DR. SCHREINER:  I was hoping it would be somebody
               17   !here.  I'm very impressed as Dr. Scherer hanpens to be an
               18   jold friend of mine and I was wondering if this was in line
               19  With his $900,000 speed.

               20             DR. PAHL: Mr.  Milliken,  right,  Ilm  afraid  you're  it.
               21             MS. MORGAN:  Mr. Milliken, you were it last time.

               22             MR. MILLIKEN:  I don't recall all the details.
               23             MS. SILSBEE:  In  terms of making the assignments,
                    I try to keep them as consistent as possible.
               24

               25             MR. MILLIKEN: On  the  yellow  sheet,  the  second  yellow





                                                                              14 6

                1  sheet,  the second item CO-5,COG-5, Grantee Central Service.

                2  Could somebody explain %..,hat .-hat is?

                3            !,IS. SILSDEE:  That is what we were just discussing.

                4            MR. STOLOV:  It's an independent P2.IP, therefore
                5  according to instructions, they should close bv June of '75
                6  and they have to issue contracts  to  extend  beyond  that r)driod
                7  and they felt it would be good  use  of  Government  monev if thev
                8  continued to fund the grantee should over ride contracts be

                9  issued.

               10            DR. PAHL:  I was about to make a statement on that
               11  when we got to Dr. Schreiner's question.  We have a nolicv
               12  which comes-out of the DHEW decision not to permit staff or
               13  Ian R.?@IP to perpetuate itself beyond June '30 of '75.  To
               14  merely state that al 1 grantees, regardless of what they  wish to
               15  do in terms of contract activities may not engaae in that kind
               -16 of situation which would perpetuate the RMP or the staff beyond,
               17  June 30 of 175.  They may contract with groups to carry out
               18  activities past June 30 of '75, bu  not in such a wav to
               '19 perpetuate themselves, so-if Nassau/Suffolk, and I don't   know
               20  the details of this, if Nassau/Suffolk or some other R.IP  has
               21  ifunds in..it which, in effect, would continue to sur)Dort staff
                   Peyond that iDoint in time, then I believe we  would  take
               22
               23  hpproDriate administrative action with our office of manage-
               24  ent because we're applying a uniform rule in -accord with
               25  departmental policy.  I hope I have made that distinguishing






                                                                            14 7


                1  line rather clear.


                2            MR. @IILLIKE"q: I still go with the action  of  June

                3  and the reDort of the committee unless there is new informatic,-,

                4  or evidence that shows reconsideration should be made.

                             l@IS. SILSBEE: Would you state that motion  again
                5

                6  and into the microphone so we can all hear it.

                7            MR. MILLIKEN:  I'move the committee recommendation

                 f
                8  of a phase-out award of $9 00,000 be awarded to  this  state.

                9            MS. SILSBEE : A "phase out" award, do you want

              10   that stated in the motion?


              11             MR. MILLIKEN:  Yes, I do.


              12             MS. SILSBEE:  Is there a second to that?


              13             MR.  KOMAROFF: Point of clarification.   Would  you

              14   resolve your ambivalence?

              15             MR.  MILLIKEN: I will remove from the  motion  the

              16   "Phase out" words, but I would like staff to  be  instructed

              17   to have them  understand that this $900,000 dollars is for the
              18 ipurpose of helping conclude their efforts  and  not  continue
              19   the program as they propo7sed.

              20             DR. PAHL:  I'm-not sure I'm going to  clarify  this

              21  situation at all.  I think we  do understand that in  all  of

              Z@2 ll:these recommendations, particularly where there has been some

              23   drastic cuts from requested levels and I'm sure more  so  in

              24   the case of this region, that it will have a  very  serious

              25   impact on their program development. I think  it  would  be





                                                                              4

                1  really in error for us to characterize  this  more  than some

                2  others that we have been concerned with  here  as  phase out

                3  or terminated.  I think we really should onlv accept   the

                4  motion for a funding level recognizing that probably   what

                5  you say will cause serious dislocation from what they had

                6  anticipated.


                7            ,@IS. SILSBEE:  Would you restate your motion.

                8            MR. @IILLIKEN:  I move that council accept the
                9  -committee recommendation to fund this agency at $900,000

              10   dollars.


              ii             MS. SILSBEE:  Is there a second?

              12             MRS. MORGAN:  Second.

              13             MS. SILSBEE:   The motion has been made and seconded

              14   that the Nassau/Suffolk  application be approved at the level

              15   of $900,000.  Is there  further discussion?

              16             DR. ;I@MMOCK:  I would like to ask a question about
              17   32 family nurse practical and critical care' nursing patient
              18   family nurse, that comes to  $150,000.  Will somebody explain

              19   that to me?

              20             MR. STOLOV:  Your addition is correct on that.
              21             MS. SILSBEE:  What do you-want explained,' Dr.

              22   !"ammtock?

              23             DR. 1'7P2,U.IOCK:  Are they going to train practical

              24   nurses or what.@

              25             MS. SILBEE:  We don't know if they're going to do






                                                                        14 9
                  anythina because they have had a request of $2 million.

              2   Jerry, do you know the purpose?

              3             M. STOLOV:   They are separate projects.  One is
              4   the university base and the other is a community base.
              5   one is nurse trained - nurse practioner and the other
              6   is more of a socio emotional thing to train nurses in
              7   giving support to families who have critical illnesses.
              8   They are different projects.

              9            MS. SILSBEE:  The question is, where do they fall
             10   on the priority list?

             11            MR.  STOLOV:  I'll check that out on my paDer

             12   work.

             13            DR. GRIOILICH:  May I ask a question?  It does not
             14   relate to the subject at hand, but it does relate to the Nass4u
             15   question.  In one of the other regions, we find that the
             16   regional advisory group apparently worked very well and in
             17   Nassau/Suffolk, they apparently did not.
             18            MS. SILSBEE:  That has a long history.  I think
                  they actuallv didn't have-a c
             19                               ombined board.  There was a
             20   combined grantee and we made them have a different regional
             21   advisory group and a different council.  Thre was some overlap
             22   butthe combined grantee situation did not work out andthat was
             23   was about a year ago September or so.  We had joint staffing
             24   too, Dr. Gramlidh.

             25           MR. STOLOV:  I have on both projects my paperwork.






                                                                             I 0
                                                                             -5

                1  On both projects - familv nurse practioner which was S142,000
                2  project, it ranks n umber 11, which the critical care nursina

                3  project, Number 16.-, The dollars fall out,if  they stick to

                4  the original dollars submitted, $860,000  off  of  nrojects

                5  1 through 10 and it stops at venereal disease.  These

                6  are well below the level again.'

                7            MS. SILSBEE:  So,they  would fall out.
                8            MS. FLYNN: If I may just ask, does Project Z',I-umber-

                9  @'9, fall out.

              10             M.R. STOLOV:  Project 29 does not fall out.

              11             MS. SILSBEE:  That project---
              12             MS. FLYNN:  They left their priority and snending

              13   dollars the same?

              14             MS. SILSBEE :Yes.  There is a motion on the floor.
              15             MR. STOLOV:  Mr. Ogden raised the question, what was
              16   the title of the project.
              17             MS. FLYNN:  It's a computer analysis of whether
              18   health educational materials have  been written bv authors in
              '19  a leval that is readable-by the health care consumer.  $36,0001
              20   dollars to have a computer analyze  all  health  education

              21
                   materials so it will be  at the 4th grade  reading  level.

              22             MS. SILSBEE:   There's amotion on the  floor  to the
              23   effect that the Nassau/Suffolk  applications  be  approved at thet
              24   level of $900,000 dollars.  Is  there further  Discussion.>

              25             (No response)





                                                                               151

                 1            I-IS. SILSBEE:  All in favor say "aye".

                 2                           Opposed.

                 3                           The motion is carried.

                 4


                 5


                 6


                 7


                 8


                 9


               10


               11


               12


               13


               14


               15


               16


               17


               18


               '19


               20


               21


               22


               23


               24


               25




                                                                                                                                                                                                        1 52.

              McLane                        1                                     MRS.    SILSBT7E:      Mrs.    Flood,   we   will   convey  your

              rml                           2         concern   for  this    complete   documentation   at  v7hat   level   health

                                            3         education   materialg'need   to   be   prepared   for   consumabilit,,r

                                            4         canabilitv.

                                            5                                     As   this   discussion   went   on   before   vou   finallv

                                            6         acted,   there  was   reluctance,   but   in   terms   of   the   final   a:ction

                                            7         Nassau/Suffolk   now   has    $900,000.      I-le   will   be   glad  to  work

                                            8         with   therq   further  on   this.

                                            9


                                        lo





                                        12


                                        13


                                        14


                                        15


                                        16


                                        17


                                        18


                                        '19


                                        20


                                        21


                                        2'Q)


                                        23


                                        24


                                        25




                                                                               1 5 4


     rm3         1   very veliementlv because  thev  felt  that  the  representatives

                 2   of the 17@overnor's commission had been a Dart  of  the  --  both

                 3   the technical review and the regional advisory groun in

                 4   iihich the decision had been made, and there were none o.L

                 5   these difficulties raised,  and  thev  felt  that  the  project

                 6   had had oroper review, but  we  have  been  explained  bv  phone,

                 7   the council's  condition  took  the  consideration,  but  still

                 8   felt there had to be a resolution locally.  That has not

                 9   yet occurred.

                10             DR.  IIADER: T.,.Iell, that is unfortunate, of  course.

                11   Nonetheless I  feel, and riv contention is that the  funding

                12   review that some of the reviewers, have recommended for  this

                13   is undulv harsh. I feel  that  this  has  been  a  good  Droara-

                14   In the face of adversity thev have tried to keeo it      together.

                .,15 They have replaced their losses with  admirable  fortitude.

                16   I think that manv of the Drojects are  well  constructed  and

                17   conceived. It seems to me we are criticizing  them,  or  at

                18   least some of the reviewers are criticizing them, for a.w,-de
                19   variety, apparently, of disorganized Drojects, and yet in the@

                20   earlier criticism was that it'tended to  be  too  global  and
                                                                   t
                21   not specific enough, so we are getting them     both  ways,  and


                   'I think this unfortunate.
                22

                                Again, I feel that manv of the projects are
                Z3
                24   well constructed.  I feel that there is no point in.our

                25   perpetuating our own indecision or worse,  contrary  views,





                                                                           155


     rm4           towards them.  I thinl- they have had the endorsement on

                2  pages 104 and following  the CliP PJ,IP annual review conference.

                3  1 thinlz that they have; it seems to be indicated the ultimate

                4  phase-out of this bv modest extensions of some of these

                5  activities, and I would suggest  that instead of the  oronosed

                6  level, that they should be  funded at a level  of  a  million

                7  dollars for the supplemental request that  they  have  come -Li,

                8  which is some $473,000 less than they have requested.

                9            MRS. SILSBEE:   Dr. ir%omaroff?

               10            DR. KOT4AROFF: I think a series of  projects,  66

               11
                   prO3ects which are described here, can both be'vague in

               12  their individual description  and disconnected,  without  anv

               13  kind of sense of cohesiveness, and I -- well, that in fact is

               14  my feeling about reading this application. We  have  a  region
               15  that is a relatively small state in terms of its population
               16  which is already funded at a level of  two  million  dollars,
               17  and I have kind of a gut feeling that their  supplement  ought
               18  to be closer to $400,000 recommended bv committee  than  an

               19  additional million dollars, bringing our level  up  to  three

               20  million.

               21            DR. 1',OIIAROFr: I will summarize. As an  example

               22  of my edginess, I will tell you i-7hv I am edgv.  Yesterday

               23  there was a question as to whether the RAG had set any

               24  priorities among these 66 projects.  Ilow, irr-fact, there is

               25  a listing of priorities, but you will notice that the ranking





                                                                             157


     rm6        1             DR. KO!.IAROFF:  Could I move five hundred thousand?


                2             DR. @,771@-IOCK:  I se--ond that motion.


                3             j@4RS. SILSBEE:  The -.iotion has been made and

                4  seconded that South  Carolina aoolication be approved  at the

                5  level of $500,000.


                6             Is there further discussion?


                7             (No resnonse.)


                8             MRS. SILSBEE:  All in f avor?


                9             VOICES:  Aye.


               10             MRS. SILSBEE:  Onoosed?


               11             (No resoonse.)


               12             MRS. SILSBEE:  The motion is carried.


               11


               14


               15


               16


               17


               18


               19


               20


               21



               22


               23


               24


               25






     rm7        1                            TED"IIAS

                2             IIR-',. SILSBEE: If we go alphabetically, we come

                3   to Texas.

                4
                              MRS. FLOOD:  1,7e are going to Texas?

                5             @IRS. SILSBEE:  llrs. Flood is going out of the room.

                6             lias the Texas pink sheets, or white, been distri-

                7   buted?


                8             MPS. @4ORGA-N:  No.


                9             MRS. SILSBEE:  Let's distribute them.


               10             Off the  record.


               11             (Discussion  off the record.)


               12             MRS. SILSBEE:  On the record.


               13             You will recall that the Ilay-application from the

               14   Texas regional medical program included requests for funds.

               15   for a series of contacts of which the ideas were smelled out


               16   in the May at) lication, but the specifics regarding @.7h
                                 p                                         o was

               17   going to carry it out and what institution and the  amount

               18   for each contract was missing bedause that was going through

               19   their local review process at the time that it @-7as aoing

               20   through the national review Drocess.

               21             Council considered this application and decided

               22   that in general the goals and objectives of the region and

               23   the general management of the region seemed to be sufficient

               24   to enable council to delegate to the review committee which

               25   at that time had felt that it was going to meet in June or




                                                                        16Q

   rmO             review committee which will consist of on this, nlus members

                   from the  RAG.  The concern of the review committee was health
                2

                   professionals revi(@-i,7ing these r)rojects.-  If you are familiar
                3

                4  with the Texas RAG, it is Dractically all health  professionals.
                5  About 95 percent of them are Dhysicians on  the RAG, and thesei

                6  physicians are going to be the ones, and this is from the

                7  material we have received,.who will be on the review committee.

                   -here is no question in my mind but that there will be health
                8

                9  professionals reviewing these area  contracts.  They  have
              10   sent in their form, which is a six page form.  It has to be
              11   filled out-monthly on the various contracts and  sent  in; will
                   be reviewed by their committee.  I havein  mv mind  no doubt
              12

                   that these will be reviewed bv health  professionals,  and
              13

              14   I would like to move that the level from June  meeting  of

              15   one million four hundred thousand be returned to the Texas

              16   IUIP


              17             MRS. SILSBEE:  Dr.Schreiner?

              18             DR. SCHRRINER:  I am a -little bit confused about

              '19  the back and forth thing and the'old grant.  If vou could

              20   clarify that a little bit?  In other words, are you  --  I

              21   didn't hear the discussion yesterday on this T)articularone.
                 I- 'Are they proposing any additional new money?
              22

              23            MRS. SILSBEE:  No. vlbll, they are.  I was going

              24   to ask !Cars. Morgan if she would mind rewording her motion.

                   We gave them an award for two million three hundred whatever
              25





                                                                                161

   rmlo             it was, and we restricted    1.4 million dollars pending the@
                 2  satisfactory review, so   in a sense they can't spend that

                 3
                    1.4 million.

                 4             DR. SCIIREITIER: It is cal led internment.
                 5             MRS. SILSBEE:   Internment for a reason.   The action@!
                 6  of the committee yesterday would release one million dollars.i
                 7  of that. Another  four  hundred  thousand,  presumably,  would
                 8  come back here, and they would not be  allowed  to  spend  it.
                 9             MRS. MORGAII:  May I change mymotion to state
               10   that we released to Texas R-MP one million four hundred
               11   thousand dollars of impounded funds to them?
               12              DR. PAHL:  We remove all restrictions.
               13              MRS. IIORGAII:  In other words, restrictions are

               14   remved from Texas.

               15
                               DR. WPJTMOCK:  The restricted funds is what you

               16
                    meant, and not impounded.

               17
                               MRS. MORGAN:  Had this one million four hundred

               18
                    thousand dollars been,released in- June to Texas,  they  we're
               19  not planning on coming in-on thi@ cycle four, any money at
               20   all.

               21
                               DR. SCHREII-TER: So this comes out of  the  84,  not

               22  out of the 20.  Thatis what I wanted.

               23              ?IRS. IIORG2UT:  It comes out of that money.

               24              @IRS.'SILSBEE:  The money that has &Iready been

               25   awarded.





                                                                         1 6.3


    rml2                                    VIRGI:IIA


                2             MRS. SILSBEE:  :@lo,.q we go to Virginia, and Dr.

                   @latkins.
                3

                              DR. ',,7Aj'KI7.,IS: I have no problem  with  Virginia.
                4
                5  This is Virginia, and Dr. Perez has changed the face of the

                   whole program.  !4iss Martinez had a question.
                6

                              MRS. SILSBEE:  Miss Martinez?
                7

                              IIISS @IARTINEZ:  In thinking over the project
                8

                   descriptions, I notice that a great nanv  of  the  projects
                9

               10  are reallv supportive or extending grants  to CHP's for

               11  planning, for the normal planning of  ChP  programs,  whichI

                   am not sure is terribly wise, even if it is legal.  In any
               12

               13  case, I think the committee recommended nine sixty-three?

                              MRS. I-IORG@4:  It is nine sixtv-three eight sixtv
               14

                              MISS i4AR7LIIIE'"7:  And I would like to reduce that
               15

               16  sum somewhat to seven -oh-seven seven fifty-nine.   I  just
               17  went through the projects, and eliminating things like number

               18  48 which is a arant to a CIIP age@cy for a

               19             M @TZS. SILSBEE:  Miss ii-artinez, in terms of what you

               20  are recommending there,, have you, are vou aware, that a

               21  message was sent back to  the reaional medical programs
                 @-concerning the need to do  -- or to get geared up for health
               22

               23  resources planning and that this  should be done,in collaboration
               24  with the CHP agencies?

                              MISS @IARTINEZ:  No.
               25





                                                                                   6 5

      rml4,      1              I-IRS. SILSBEE: All in favor?


                 2              @"OICES:  Aye.

                 3             MRS.   SILSBEE:  Onposed?

                 4              (No response.)

                 5             MRS.   SILSBEE:  The motion is carried.


                 6


                 7


                 8


                 9


                10


                11


                12


                13


                14


                15


                16


                17


                18


                19


                20


                21


                22


                23


                24


                25





                                                                                       16 7


     rml6         1              DR. GRZU.ILICII:  May I open up one more small subject7

                  2              DR. PAHL:  T.-le have that as well as Mr. Oaden's

                  3   resolution.

                  4              DR. GR7LT-ILICII: I mean. relative  to  this  project,

                  5   specifically  !.IississiT)pi.

                  6              MPS. SILSBEE:    Yes, sir?

                  7              DR. GRAI--ILICII: There is a very strange request
                  8   and it is  kind of -- the   review committee didn't pal, an
                  9   awful lot  of  attention  to  it,  a  two  million  dollar,  roughly
                10    two  million  dollar  request  for  hypertension  screening   and
                11    treatment   prog.ram including one million dollars for salaries,l
                12    and included in that salary scale was 82 public health nurses
                13    who presumably are  already  on  deck,  so  that  the  @-T  funds
                14    as far as  I  can  determine  from  the  grant  requests,  be  used'
                15    simply to supply what is now being spent by the state health

                16
                      department.  Included also is $500,000 nlus or minus for
                17    drugs for treatment of some possible 11,000 hypertensives.

                18
                      Ilow, the review  committee's  attitude  is,  it  is  a  poor  state
                19    and they have got  lots  of  blacks  and  they  need  all  of  this, I
                20    but there was no Particular attention paid,to the construction
                21    of the budget which  included  apparent  substitution  oo  P-T-IP

                22    salaries  for  what  are  now  state  Health  department   salaries.

                23    That is one item.

                24              The  other  item  is,  if  the  treatment  to  be  applied

                25    to the suspect hypertensive or to discover hypertensive which





                                                                             168
      rml7          is to be administered to the county health officer in    each
                 2
                    county.  No@v, this poses a loroblem of practice of medicine,
                 3
                    if you will, by rl_"-IP funds. If the council feels this  is
                 4
                    appropriate, this is fine. All I want  to  do  is  bring  it
                 5
                    to the council's attention to make  sure  it  is  considered
                 6  appropriate.  This has to do with Mississippi only.
                 7            MRS. SILSBI-'E:  I's-there discussion on this ooint?
                 8
                              DR. KOIIAROFF:  Can staff enlighten us as to wheth(irt
                 9  this will supplement the  resources of the state health
               10  department, or merely supplant them?
               11             MRS. I SILSBEE:  Mr. Van Ilinkle, there are two
               12  issues here, in case vou couldn't hear.
               13             MR. VA,@4         I heard.  I was trying to hide.
               14  ",Iy answer is, no, I don't know.  I read the application.
               15  Ile did ask that they include the full, when  they  sent  in,
               16  not the center form 15.  That is all vou i..7ould have had.
               17
                   I presume that Dr. Vaun looked at it, being the -primary
               18
                   reviewers  He did not discuss tha't; however, as far as
               @19
                   practice of medicine, we have been in the habit of doing it
               20  for years on demonstration  projects.  I  doknoxq  that  thev
               21 proDosed to take these over and continue it after this first
               22 year funding.  The Government has put already a line out of
               23 its budget to suonort it, but   I do not know if these nurses
               24 are on bid, or if they intend   to hire new ones-.  I just don't
               25 know.






                                                                             1 6 9
    rml8                      P-IRS. SILSBEE:  Dr'. Komaroff?
                2
                              DR. KO,"@lA@OFF:  I  looked ' at that application
                3
                   .last night after our discussion, and I had the impression
                4   that it was an unusually well documented request, but probabl@t
                5   -that was going on was that I'@T money was offsetting certain
                6  expenditures that were part of the state department of public@,
                7  health this year,  but that the quid pro quo was that the
                8  government was going to take over the support of the program
                9  in future years, and that that seemed to me a reasonable
               10  bargain; consider the importance of this problem in that
               11  state medically.
               12            DR. GR2UiLICH:  I am satisfied.  Thank you.
               13            DR. PAHL: T-have two items of business before
               14  we adjourn.

               15


               16


               17


               18


               19


               20


               21


               22


               23


               24


               25






                     a @,all amount of difference, only r3Ol,n@@.
                  2              D   P @'.'7-L I f L'Ilcre is a di-@-'ere-ice, v.-e @,.,ill
                  3  --itlier take it out of j-dith's   salar-,,, or c,-i,.,e it to her.

                                                    -iese 4antist4
                  4              @-7e have one of  t,            @c data -ratic
                  5  aides on sale, or something, and      IL--'.-ere is voltaae fluctua+--4----
                     and during one of my afternoon tele-.oho-.e calls- I foun@-
                  6
                     J-dith sitting nol:ing these keys.      %t the same  time, doina
                  7
                     everything in lonq hand because with voltage        fluctuation
                  8
                     you don't end with the same digits'vou should.  So, I think
                  9
                     we better go back to lead nencil and naper.
                 10
                                I gather the correct fiaure      is @,27,349,054.
                 11  Another one of 'the rumors.

                                                                                        4-
                 12             1 have received information also, again, I don
                     knoi@7 whether it is a rumor or not,but @resumably it has
                 13
                     been announced out of the !,!!,iite Tiouse  tl-at, as .,ou knoi-7, -h@-
                 14                                                                      --e
                     @-iill he announcement either at 01:00 --    and now  some peonle
                 '15
                     say 8:30 - and Congressman Ford is to undergo his inauaerat4-on!
                 16
                     at 6:00 u.m. tomorrow.   I auess we           all learn as to
                 17
                     go  to  airports  whether   this is rumor or.direct.  This was
                 18
                     given to  -ie  as  a  statement.
                 19             '.he  other  item  of busi-n'ess @.,,hich I think we are
                 20  on more firm ground ab out     is to reconsider    the resolution
                 21  that !lr. Oaden introduced,    and i-l-hich @.,,e tabled until

                     -you had an opportunity to look over.
                 22
                                The su,-m-iar-v material pertinent to the resolution.
                 23
                     'Ir. Ogden, I think i.,e have distributed this to each person.
                 24
                     Perhaps,  vou would lil-,e to r@.ake some comments.
                 25
                                IIR. OGDEN: I hope that manv of vou have had an





                                                                                         172


                  1   onnortunity to loo'j- at the Tnaterial headed "Su.=,.ar,,, of   t@e

                     I.ational Health Policy Plannina and I"esources  Develo-ment
                  2

                      It@l.ct of 11)74."
                  3
                                 Dr.  l'omaroff,      is  sitting  next  to  me   here,
                  4
                      has n@-obably gone through it a     little T--.ore  carefully  than
                  5
                      many of vou and underlined the      areas and I  .,,ill  call  on
                  6   him just  in  a  few  moments  for  his  comments.  But,  in  acina
                  7   through this piece of legislation I found no iDlace where I

                  8   could find anything that fitted the function of any existing-
                  9   regional medical program, save perhaps       some  of   the   programs
                 10   v7hich are in fractions of states, such      as  some  of   those
                      perhaps in the State of l@,ew York.
                 11
                                 If  the  Governor  of  the  state  were  to  decide  the
                 12  1
                      health service area, for example, @%Tas '-"Iassau/suffolk - perhaps
                     I
                 13  1'.7assau/Suffoll- P-'-IP could become the health service systems
                 14   agency in that particular area.  But, this particular piece'
                 15  of lcaislation while it seems to encompass Fill.-Burton-almost

                 16   completely and you %.7il 1'find that comes ur) on  Pacre  5  o.-i  the

                 17   description of the health resources development            the    only

                      place that I find 'UIP perhaps even suggested is        on  Page  6
                 18

                      under Area Health Services     Development Fund.
                 '19
                              @.Zow,  remember  here-we  are  talkina  about  a  health
                 20
                      svstem  agency.  @7ow,  health  system  agency  is  a   non-.profit
                 21
                      private operation  on  a  local  or  area-'7ide  '--asis.  But,  this.
                 22  lis  a  nealth  service  area  nonulation  of  less  than  half  a
                 23   -li-llion. it is  not  permitted.  It  can  be  up  to  a-bout  two

                 24   million, as I recall lir. Rubel's comment yesterday.  But, it

                      would  encompass-the  health  service   area   would   encompass   anv
                 25





                                                                                  1 73

             4

                    standard metropolitan statistical area, v7hich is entirely

                 2
                    ,.!itli a boundr-,7 - it cin cTo over state lines, I:)ut there are

                 3
                    literally, I understand,   100's of S,'ISA's in the United

                 4
                    States.  So, that what we   are looking at here is an area

                    health services development fund    which is aoing  to  be  a
                 5  A

                 6  localized thing, and indeed  we  find  that  the  grant  that

                    can be made for the development within one of those on pace
                 7
                    2 - no single grant or   contract may exceed $75,000 be made
                 8
                    for more than two years.
                 9
                               It simply taliled about the area health services
                10  development fund.  This is why I have proposed this resolution.
                11
                    That this piece of legislation - it be suggested that this

                12  be amended to give each state the'statutory and financial

                13  support to maintain a separate health s-,rste-is development
                                                               -4

                                                      So, t.-iat at least we hava
                14  zigency on a state-i.!ide basis.
                    something similiar to the P,.!-,IP's we have today who can perform
                15
                16  a state-@@iide mission or function.  And, indeed, i,,-c could
                   leven say, goincT beyond  state  lines.  nut,  I  suspect  the
                17 1,r,incl of legislation we are seeing coming up here is-croing to
                18
                    be limited to state boundries' and national health insurance.

                19
                    may indeed have in it have some    sort of state-wide function

                20  mechanism.

                21             So, I pronose this resolution and in it, the

                    -second Part of it I have said, "The comments that proceeded
                22
                    the resoltuion and the resolution itself be transmitted to the
                23
                    members of the licuse Interstate and-TLoreicrn Commerce Committee
                24
                       and by that I meant to encompass  the  com,,,@nts  that  T made
                25
                    in the letter from Senator I'@lagnuson to Senator  ':\ennedv, which
                                                                              .A





             5                                                                 1 '1'4


                   I read to ,-ou earlier and v!hich should an-,oear  n     -ranscrin-
                 2
                   O.L the -iinutes o@-    meeting.   I can aive vou  J@- -.a L@- letter
                                                                           L


                       ?
                   if  ou would life to  ;'erox it.  I %,,ould like to ',a7,7e it baclz.
                 4  Dut, I vTill be hannv to hand it to you.

                 5            I do recommend that we  do this. I am au4L-".e
                   concerned  that the kind of legislation that i..e'sc-e co7-irg
                 6
                   out   simply does not recognize the place that re,-,ional medical i
                 7                                                                   i
                   programs have come to serve on the American scene.  And
                 8
                   certainly many of us who worked with this proaram since its
                 9
                   enception eight years aao this Sprina feel that i.-- has accompl4s:-
               10  far more than it has been given credit for and that it '.-,as
                                  7
               11  the potential to accomplish a great deal that is co4.nato
               12 The necessary in order to male national health legislation
               13  function when 4t beains to deal with the verv Co:nnl4cak--ed

                   undertaking of     delivery of services and the deli-,Terv of
               14


                   care.
               15
                              And, it seems to me that unless  the providers of
               16

                                                                      r in @ut
                  @this Station are given an opportunity to make  the,
               17
                   --hrough something like IUIP, that the success of national
               18
                   health insurance is jeopardized and I hope that we are doing
               '19
                   to be able to have the continuation of somethinglike the
               20  regional medical rrograms.

               21 1           DR. I" T L: -mhank you, very much  !.Ir.
                              There .,as a motion introduced and seconded, I thl'nk
               22 1                                                                  1
                     possibly..
               23
                              DR.           Second.
               24
                              DR. Px@l'@L: Thank you, Dr. ',,@laininock.
               25             I think there should be room for discussion by



                                                                                    176


               7

                                    J@ll:T-" Y: I would support, quite franl:ly,  tl,l
                                         A                                          c

                 2
                    separation of   the planni-na function, particularly the
                 3  strategic Planning -@unction, to use a managerial term, which

                 4  is  implied  bv  the  summary of the legislation - proposed

                 5 legislation.

                               I thin!: tl-lat to have planning  and  control  -  when
                 6
                    I  say  operational   control   the implementation mode of
                 7
                    any kind of management function in the same agency is courting
                 8
                    disaster and, although,  I  e7ould  agree  with  you,  Tony,  that
                 9
                    there has to be a responsive interrelationship, that there
                10  is so much to be gained by having the planning function
                11  separate  from  the  implementation  function.  That,   I   would

                12  certainly be prepared to support a resolution of this nature.
                13                              1-i@y do you feel it would be courting

                    disaster.  T.,re vou thinking back to experience between
                14
                    @ll-P 'and CY.P?
                15
                               DP,. j'A'IE7-7AY: ,,@70. I am thinking in  terms  of  the
                16
                    management function and there is room for      disagreement in this
                17
                    but  if you read tlnthony's book on Planning Control Systems,

                    the  possibility of  the  planner  becoming  so  involved  in  the
                19  plans that the  implementation  be-c'onLes  impossible,  or  that

                20  there is no outside regulation of it.  it p@ts too much.
                   ino@qer in one place.
                21

                               Now, there are   admittedly some managers who disagree
                22
                    with that  and sav the  planning  control  ought  to  be  in  the
                23
                    same agency, tf   you set  planninq  or  isolate  it  you  develop
                24
                    think tanks that don't,drain anywhere.
                25             But, if you  put  planning  and  control  in  the  same




                                                                              177


                  laacncy, you go to the-opposite  extreme @.!here -vou thin),, that
                 2
                  ilby creating an infinite nu@-iber of haystacks will  give  you
                 3
                      infinite   supply of needles.
                 4           11,@. EOI IA@TZORF: It cuts I-loth %.!a-vs, but the for

                 5 tl-,e reason -,7ou just cited, it seems to me that the  providers

                 6 would  more likely be attracted to.these  kinds  of  planning

                   agencies, and therefore, the doing of reasonable planning.
                 7
                   If there were some - or more  tangible  operational  components
                 8
                   that thev  could  be involved with.
                 9
                          I  think  one of the problems with CHP has  been  that
               10
                   the  providers  have found it unattractive because it was

               11
                   so abstract  and  so unrelated to subsequent tangible accomplish-
               12 iments and  if  there could be some uniting of  this  operational
               13  arm and the planning arm, so that what the operational arm

                   was doing didn't in fact thwart the rational  plans  ol  the
               14

                   region, then it would seem to me to make  more sense.
               15
                             DR. JANEl,7AY:  What I was trying tO indicate is
               16
                   that I vould hope that the planning function would not thwart
               17
                   the normal.operational arm.
               18
                             MR. OODEFI:  I think that this, perhaps, could be.
               19
                   corrected by having the  development  component@also  report
               20  to the state health planning and development aaencv, which is

               21  assumed to exist under this piece  of  legislation.  It  has

                   to come into being. But the  legislation  just  simply  doesn't
               22
                   spell out sufficiently how that development is  going  to  take
               23
                   place, except for these very local agencies.  And, I would
               24
                   like to see drafted into this piece of legislation the
               25  provision that there be a separate health systems development




                                                                            179
              10

                   it gets dissolved -- and I haven't  read  this  --  and  if   I
                2
                   read it I 'am quite sure I %..couldn't ]'-,no,..., what I was  readina.

                3
                   I may have to read it bacluz the third  or  the   fourth   tine

                4  or the fifth time, and nay not know what  I  N-7a.s  reading.

                5            !ly o@-in personal fee-li.-ticr is that I  am  probably too
                6  close to the  trees  to  see  the  --Forest,  or  the  forest  to  see

                   @-he  trees.  Or  i%@hatevcr  vou  call   it.   Forest-trees,   trees-
                   4
                7
                   forest.


                             @IR. CGDEN:  Woods.
                9
                             DR.           I thin)-, that, as !,Ir. Ogden has
               10
                   pointed  out  and  someone  else,  that  people   don't   know   about

               11
                   the acod  that  the  RI'P  has  done  and  I  think  it  is  pretty

               12  hard to cret across to people x@,hat P,"@.P is and I am sure

                   that there are a lot of pl,vsicians that do not understand
               13

                       ce-e--ation and the mechanism of the ."JIP nrogram. Some of
               14
                   them feel that it has not been worthwhile,  1--ut  I  Personally
               15
                   -Feel that it has been worthwhile and I think this resolution
               161
                   here drawn up by 'Tr. Ogden. T @7ant to congratulate  him
               17
                   for  the  foresight  and  the  merit  and  the  courage   and   the
               18
                   good common sense and judament to'draw this up and I  thiny.

               19
                   we need to support this resolution and somehow  or another

               20  get it across.

               21            How effective it -v@ill be as far as Congress  is
               22  concerned, I don't 1-@now.
                 I          ID.,". P@-TIL: Is there further discuspion.or modification'
               23
                             DR. NO!L@PO'.c"F: I i.:ould like to add some language
               24
                   that makes it clear that this health  systems  development
               25  agency will supl)ort.demonstration health services  projects.








                                                                                    1 8 0



                                I don't tlfini-, thz,,t health services is written in.

                  2
                       am not sure it is auite clear ho,..., this aaer.--y  would  be

                  3
                     different from the planninQ agencies that are in the current
                  4  bill, and secondly, I thin'lz @,:e ought to state @-'-,at this
                  5  separate agency @7ould  report  to  the  state  health  -,)lannin'
                                                                                    9

                  6  and development agency that is described in the Bill.
                  7             DR. J,-@l.',IET,,iAY: 1,7ould you read it to us?
                                DR. 1,@n,7.IAROFF:  Read the proposed lanauage?  I
                  8
                     haven't written it yet, but I will.
                  9
                                How would this he: "Resolved:  That ,-lie Congress
                10
                     in adopting  HR  16204  or  similar  legislation  aive  to  each

                     state the statutory and financial support to maintain a
                12   separate health systems  development  agency  i-.,',Lich  supports

                13   demonstration  projects  and  health   services.   This   agency
                14   i,.,ould renort to  the  state  health  planning  and  development
                     aaency, or similar independent --'I am sorry - agency
                -15
                     and be devoted exclusively to such work.  And be it further
                16

                     resolved

                                DR. I,.7,@IU-IOCK:  Dr. Komaroff, I am sorry, but   you
                18
                     are getting too wordy there.  I-'ile are going to get    lost
                19                                                   t
                     because I think the first sentence-what vou say -        the health

                20
                                                               -wide basis   --  and  I
                     svste,is development agencv on a state

                21   thin'-, health systcns development agency is very      comprehensll%"C.

                    TO  me it is.
                22   -L
                23              D.Z. T,-IAI.rR: 'light I.suggest Health &ystem developmeA-.@-
                     and, demonstration agency.
                24
                                l,'LR. OGDF,1'4: On a state-wide basis for similar
                25





                                                                            181
        12
                1   independent commissions in a publicly acccun4--able way

                2  in reporting to the state health and development agency

                3  and  devoted exclusively to such ...-ork.

                4            DR. 'L70-!!A.TIIOFF:  All right.
                5            DR. 1,7AI,llIOCK: I yield.
                             DR. PAHL:  tliay i..Te have the final @,:ording before
                6
                    we have the question?
                7
                             .'iR. OGDEN:  The t-:ay that I have this drafted
                8
                    at the moment reads "Resolved: That the, Congress in adopting

                9
                    IIR 16204 or dmil.arlegislation give to each state the statutory
               10   and financial support to maintain a senarate health systems
               11   development and demonstration agency on a state-wide
               12   basis, or similar independent commission annointed in a
               13   publicly accountable way, reporting to     state health
                    accounting and development aaenc@,, and devote--' exclusively
               14
                    to such work, and be it further, Resolved:  -.hat the
               15
                    comments preceding this resolution and the resolution
               16
                    itself be transmitted to the membcrs of the House Interstate

               17
                    and Foreign Commerce Comittee and the.Senall-e Labor

               18
                    and Public r@7elfare Committee for their consideration.

               19             DR. PAHL:  Thank you.
               20             DR. I-W-L@-IOCK:  tir. Ogden, for clarification.

                    Accountable way and reporting?
               21
                                  OGDE""': I am sorr\r.  P.npoi-nted in a publicly
               22
                    accountable way.  That lias to do with
               23
                              DR. T,@;I'L@'LOCK:  But you put another word in there.

               24
                              I'tR. OGDEN:  I-le inserted the v,-ords reporting to
               25   the'state health and planning agency."



                                                                           182


           13

                             This was Tonv's TDoint, that separate health

               2
                   systems doveloament has to report to somebody.  @,7e are
               3   going to have it report to the state health planning

                                           T-'Iouldn't that be under state, or not?
               4


                                               I (@'on't think that this
               5

                   damages the sense of what I am trying to accomplish.
               .6
                             !@@!?S. KLEI17:  llr. Chairman.
               7
                             Dr\.. PAIIL:  Yes, 'kl!rs. Klein.
               8
                             1',!RS. KLEII;:  This reporting bothersme as to whether
               9
                   i.@L. should be to the agencv or,as in Idaho, the planning

               10
                   groups report to the Governor, who is responsible for adinii.-
               11  tration of all-programs.  And, that would keep it on the
               12 Istate -- As I understand it, the purpose of that insertion
                 lis to keep it on a state-wide basis, rather than reporting
               13

                   to any  federal agency, for example. So, I i7ould like to sc-e
               14
               15  it made more general, rather than a specific title, because
               16  some states don't have that type of agency, or one that is
               17  titled that way.
                             I'IZS. LIIORI;A,T:  They v7ill have this Bill.
               18
                                 OC-,bE'@:  Under'this Bill, they will have to.

               19            DP. C@R7@.i.LICH:  in the resolve, what do vou mean

               20  by, "in the comments preceding this resolution?"

               21                OCD!717:  This was the letter from Senator

                   :agnuson.
               22
                             DR. PAHL:  Is there further discussion.by Counsel?
               23
                                          Question.
               24
                             TI@. O('jDEL:,7:  T-,ait just a moment.  On the matter

               25
                   of information.  Tony and I have decided that this should be




                                                                                       183
              1  4


                      rerortina to the state-@-.,ide health coorcii-na't4-nc -@cun@il."

                  2
                     -!Jose are  the people that have the 16 mcml--ers.

                  3
                     the i-7rong. groi-i,,) to @eporl@- to.

                  4              lqe are goina to  report  to  the  state-@.-ide  health

                  5  coordinating council.

                                 Is everybody terribly confused?  Can'@,.,e vote     onit?
                  6

                                 DR. PAHL:   I-litli '-hat change, namely, the s,--ate-@-iide
                  7
                     health coordinating    council.    iiith  no  further  discussion,   I
                  8
                     would ask the Question - all      in  favor  ofthe  resolution   as
                  9
                     last amended, please say "aye."
                 10
                                 VOICES:  Ave.
                 11              DR. PAHL:  OniDosed?

                 12             (:-'to response.)

                 13              DR. PAHL:   -Lhe motion is carried.

                                 In closing, I i.?Ould like  to  thank  @'rs.  S4-'sby
                 14                                                              L
                     and the staff very much for again going throuah an unusually
                 15
                     difficult neriod  and  specifically  say  that  I  an  not--  auite
                 16
                     certain under  "-hat  circumstances  this  council  --  @.-e  may  or,
                 17
                     may not meet again.  T,,.7e  have  not  set  a  future  meeting  date.
                 18
                     I would, however, like to thank you individually and collective'--
                 '19 as a council for your guidance      and support  throual.-Iout  a
                 20  rather  difficult  period,  -and  not  this   particular   review

                     cycle.   Since v.,e are uncertain what does 'Lace us,
                 21

                    -vou to understand that terms of appointment continue until
                 22
                     such time as we inform you otherwise because of                passaae
                 23
                     of legislation or other unforeseen circumstances.
                 24
                                 But, I do look forward, as I know the Staff does
                 25
                     to @-iorkinq with you  -again  in  some  way  as  we  enter  into





                                                                               1 84




                   our new error.

                             Unless there are further comments, I then

                 3
                   adjourn this meetind.

                 4           Than!- you.
                 5            ("Thereupon, at 3:15 p.m., the meeting was adjourned.,:

                 6


                 7


                 8


                 9


               10


               11


               12


               13


               14


               15


               16


               17


               18


               '19


               20


               21


               22


               23


               24


               25