Iiiiiiiiiiii
                                                               ,  II6  KI  ..  @








                                            C 0 1-1



              3   Alaban, a Regional fli@(,Iiccil Pror r,-n
                                                  .1
              4                      ccorim@ndal!on                                 2.7
                        Motion for n
              5                                                                    3 2
                                         (lical Proqram
                  Arl-lan,3as r,(;-@rional
                        t!otion for Rccc-,iTii-i-.n(3ation                          43
                  Di-Stat-o  Regional           Progr,@ri                          '51
                        notion for   reco,-mciiclattoii
                  Colo'rado-l-j'yominG Be@-ion 1,1@dical Program                    69

              .10
                         14otloh for  Becommendai-,:Lon
                  Georgia Regional.llcdical P@o@-rain                               co
              12
                         Motion for recot-ni,,icn(lni;.Ioti
                   I,'lorida,R,-,Lonal 1,lcdical ri:,o,-,r in ii,
               14        ibtion for recotiiinen,,I,,.ition
                   In(liana ll(,,UIonal Dledi.c@il Ivkc)

                          Motion  for
               17  I-,Iisconsin Rc(;ional 1!1---clical Prorram                        ci
                          Motion for recommenrlatl-on

                   l@ano,-ta Regional @lic(lic"ll

               20
                          Motion for fccomin--,ti(l.,itioti                         1113

               21
                    Inter-l,lotititain Ileriotial.      Progrcim
                           Motion for recotii,,@i,2t-ifl@ition

               2:t
                    l,lichigan aegional

                24
                           I-loti.on for recotii,: ti,

                25
                                       (icon'.tnii,!(.1 oil lic@, PO.["C)

          let; co, INC.








                                      C 0 N T B N T.8

                                                                                    PA Gri


                 3
                    kliSI3 is t) ipp IRcgion.al I,,IoLlical P:roGram

                 4
                           Motion for   recorninendation                            192

                 5
                    Illinois Regional lied.ALcal Prot;ram                           :L93-A
                           I-lotion for rocomtncn(lation                            23.5

                 7
                    Louisiana Itogional Ilo(lical Pro,,-ram                         217
                 8
                           14ot ton ror recoinmenclation                            22-f


                 10






                 12


                 13


                 14









                 1 7









                 20


                 2 1


                 2'--)


                 2.1











       @i I, rfive     II     u@





                                                                        4


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


               2
                                    LISS:  Let me take this opportunity to call,
               3  Panel "A" to order and welcome you here to this particular

               4-
                  work group.
                          '@l'think you should know that as we get into  our
               6  procedures for the next day or so that I will have at my right

               7
                  and at my left two operations Branch chiefs, Mr. Lee Van
               8  Winkle, who is the operations-Chief for the  South-Central
               9  operations Branch of-the Division of operations and Devel
                                                                          OP-
               10 ment, and Mr. Mike Posta, who is the operations Branch Chief
               11 for the Mid-Continent operations Branch,
               12.         I think the panel should know that we had expected,
               13 as Dr.@'Pahl mentioned, Mrs. Silsbee to have chaired this-panel
               14 and it's due-to her illness that I've been asked, just in the
               15 last few hours, to chair the panel.
               16        @-"Dr. Pahl and 1, as he mentioned, have been looking
                  at other things over the last eighteen months and especially
                  these matters having to do with OMB questions, with answering
                  questions from the Devartment dealing with the congressional
               20 relations, all the questions coming from the Congress having
               21 to do with the phase-out and the status of the program, the
               9.) inter-agency aspects of operating the program, and both of us
                  have left all but entirely the operational aspect of operating
               2:1
                  the division to Judy, who has, I might say, served with great
               24
                  distinction.



      ]tLpoxllNa co, INC.
     ssachusetts Avenue, N.E.





                                                                         5


                            When the annals of RMP are written, she will  truly

               2
                  be one of the strong people of RMP, a great person,   great

               3
                  lady, a prodigious worker, and a good friend to all of us.

               .4           Hopefully she will be here while these  proceedings
                                                                      I.
               5  are underway, but Mike and Lee will provide me with  ateral

               6  support, and at the same time we will have support f Om

               7  members of the ODerations Staff and also a representative from

               8  the Orants Management Staff in the person of Mr. Lar3  Pu  en.

               9            1 think the committee is well-aware of the fact

               10 that we are operating under a court order and I will onlv say

               11 one additional thing-.  Dr. Endicott said that thingslare a
               12@ mess; I agree.  I will only add my word of wisdom, i@ you can
             .131 call it that, and that isi we have lived in a chaotic  commu-
               14 nity over the past few months and this, in a way,  culminates

                  some of the trials that we have undergone by reviewing the
               15

                  applications from the regions that came in on May  lst  their

                  application for funding beginning July 1, 174.
               17

                            I think, as we get underway, you should know we will

                  be operating under the Mission Statement that we all know  so

                  well.  We are operating under no restrictions as relates to
               20
                  the program activities of the RMPS.
               21
                            And mavbe I at this time should call upon Lee
               22
                  Van Winkle to just set forth in highlight fashion some of the
               2:1
                  review guide procedures that we'll be utilizing.
               24
                            Lee, won't you



  HOOVER KLFURTING CO, INC.
  320 Massachusetts Avenue, N.E.
       n I, nnnn)I





                                                                          6

               I             MR.'VAN WINKLE:  I just primarily want to call your
               2   attention to the review guides that you have, and I know that
               3   Dr. Pahl said it earlier, but I think it should be repeated.

               -4
                   that I think this group has to focus on the over-all program
               5   of the Region and the proposal as submitted rather than on a
               6   technical review of the individual projects, and we do have

               7
                   the criteria listed.

               8                                                      to mention
                             I think the only other thing that I want
               9  at.all is the review sheet that you find attached  in there.
               10  We will expect the two reviewers to fill.that out and we'll

               11  collect those as we go along.

               12.           DR. MILLER:  When do you want them?

               .13
                             MR. VAN WINKLE:  Sir?

               14            DR. MILLER:  When do you want them?
               15            MR. VAN WINKLE:.  we'll give you time to ccmplete

                   them
               17            MR. CHAMBLISS:  At the end of each review as we sit

               18  here.
                             DR. MILLER:  As we ;it here?
               20            MR. VAN WINKLE:  Yes.  Before we go to the next
               21  application, we would like you to fill it out    in talking
               22  with Miss Leventhal -- and pick it up at that time.
               2;1           DR. SLATER: I want  to  ha.ve some time-to rewrite MY
               24  commentary on those, so I'll get it back to you during this
                   session, but it won't be immediately after my oration.
               25


  HOOVER RLPUKTING CO, INC.
  320 Massachusetts Avenue, N.E.





                                                                         7


                            MR. CHAMBLISS:  Thank vou, Lee.

               2
                            I should mention that, as you have probably  noted

               3  in some of the background materials, that the focus of the

               4
                  review will, by and large, touch on about eight elements.

               5
                            The first is program leadership; second,, program

               6  staff; third, regiona 1 advisory group; four, past performance

               7  and accomplishments of the region; five, the region's objec-
               8  tives and priorities; six, the proposal; seven, feasibility;

               9  and eight, and finally, CHP relationship.

               10           I think one additional item of procedure may be in

               ii  order here, and it's a further elaboration on the focus  for

               12. review. Dr. Pahl mentioned that the policy issues would

               13 -simply be flagged and we would not necessarily attempt to
               14 resolve them here; that the target amount should be the
               15 principal benchmark for a backdrop for the review.

                            Lee has mentioned that the two reviewers will review

               17 and the second reviewer will simply add additional comments or

               38 observat ions.
                            We hope to follow the exception principle if we are
               20 really going to get through in our appointed time.
               21           We also will have Staff comments as necessary  and
               9.) required and for each of the regions under review the  Staff
                  person handling that particular region will be at the head
               2;t

                  table here.
               24
                            After that, a brief discussion, and we will attempt
               2;-)


  HOOVER REFURTING CO, INC.
  320 Massachusetts Avenue, N.E.




               1   to clarify any items or matters that need to be clarified,
               2                                                      endation
                   looking forward to the presenter,giving us  a  recom
               3   and the rationale for his recommendation, ending  up with a
               4   motion on that particular recommendation, and from there wee
               5   will ask each reviewer to complete the rating sheet as we've

               6   touched on.
               7             There are applications at the back table, complete
                   applications on the back table, for each of the reviewers who
                                                                        1
               9   will need them, and we would simply ask you as a final matter
               10  of procedure,, kindlv speak into the microphone so th t our

               11  recorder can get all of the deta ls.
               12@           Are there any questions at this moment before we

                   begin to proceed?
               13

               14            Dr. Vaun?
               15            DR. VAUN:  I've heard Lee refer a couple of times to
                   the fact that we're not geing to.do a technical review, if I
               17  understand what he's saying.  However, I'd like to know how
                   weire going to reach a judgment about funding levels unless we
               38
                   address some of the technical aspects of the programs.
               20            On the basis of the guidelines submitted, namely,
                   leadershipt past performance, it's going to be very difficult
               21
               22  to arrive at a funding level.
               2:3           Lee, how do you want us to work this magic if we're
                   not going to look at the projects?
               24
                             MR. VAN WINKLE:  Well, I think that you do have to


  HOOVER KLFUKTING CO, NC.
  320 Massachusetts Avenue, N.E.
  Washington, D.C. 20002




                                                                          9

                   look at the projects because that's a part of the total pro-
               2   posal that came in, and if what you see in here is not

               3
                   related to the goals and objectives of that region, then I
               -4  think you have real cause for concern, and certainly  if  there
               5   are items included in here that are strictly against policy
               6   of the Regional Medical Program, that also has to come out.
               7            But I think you have to look at what they've sub-
               8   mitted, the individual pieces; but as to getting into the
               9   individual technical aspects of a particular  activity,  that's

               io  what we're trying to avoid.

               11            DR. VAUN:  Okay.
               12            MR. VAN WINKLE:  The actual makeup of  that  activity
                I that you're looking at.
               .13
               14            MR. CHAMBLISS:  Let me just add one additional piece
               15  of information so that we have something of  a  framework.  The
                   panel will have a total of 28 applications to review with a
               17  requested amount of $65.5 million.  There's one continuation
                   recTuest; there are 23 continuation and new activity  requestsi
                   there are 24 additional applications expected from this set of

                   regions in July.
               20
               21            Twelve of the regions that you will be reviewing
               22  have had -- twelve of the twenty-eight     have had new coordi-
                   nators since the phase-out was announced.  There have been
               2:1
                   limited site visits.  However, there have been Staff visits to
               24
                   nineteen of the regions in question.  Two have had review
               2;-)


   HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.E.
        n (I ')Ann)




                                                                           10

               1 certifications; six have had management surveys; and twelve
               2 others have had technical assistance-visits.
               3             So there is a body of intelligence residing in the
               4   Staff as to how the regions are functioning and operating., I
               5   thought you would like to have that just as a backdrop.
               6             MR.- VAN WINKLE:  Can I add just one thing?

               7             MR. CHAMBLISS:  Yes,
               8             MR. VAN WINKLE:  Dr. Vaun,  I think what we're seek-
               9   ing here is the development of  a level of funding and not a
               10  funding level -- level of approval, if you will, not funding
               11  level, and the funding level actually will be determined some-
               12,  where within that level of approval.
                             If you come in, let's say, with a leval of approval
               .13
               14  on one program at $2 million, the actual funding level will be
                   made up to that figure, it won't exceed it, and it may be less

                   than  that.

                             DR. SLATER:  Could I
               17
               18            MR. CHAMBLISS:  Dr. Slater.
                             DR. SLATER:  May I Make a point?  I, like you,   have
                   been trying to get a grasp on this in comparison to the old
               20
               21  days and, furthermore, in the light of what Mr. Rubel is talk-
                   ing about, and I have the same concern that you have, that
               22
                   while not really examining these projects which are presented
               2:1
                   in variable detail from one region to another, I'm attempting
               24
                   to make some kind of an assessment, really, to give   you, in a
               2;-)


  HOOVER RLFUKIING co, INC.
  320 Massachusetts-Avenue, N.E.





                    sense, professional backup as to what kind of funding these

                2
                    regions should have.

                3
                              Coming through to my mind  all the time  is  the  fact
                .4  that since we're apparently going  through  such  major  changes
                5   in the next few years in which RMP will be recast in some way

                6
                    or the other that what we're here to do, really, is to just

                7
                    look for the most obvious problems or errors which you as

                8
                    Staff have to correct in order to  justify  the  expenditure  of
                9   these funds and that we're not going to varv, really, very
                10  much from the figures you have here, because the most
                11  important role we have to nlay now in  this  interim  period  is
                12! to stabilize those staffs  out there in order that one  as a
                13  grouv of people that are well-trained and indoctrinated to
                14  move ahead in some fashion in the years ahead.
                15            So I must say I don't have too much difficulty
                l(i making assessments.  I'm having to rely so much on what
                17  they've already decided to do there, that I think we're
                18  really here just to provide professional extramural moral
                    support more than anything else -- obviously, t   here  are  going
                20  to be some holes in that,  but,  generally  speaking,  that's  how

                    I read it.
                21
                               MR. CIIAI,14BLISS: I assure you we need that, too,  but
                22
                    we do need your professional judgment.
                2:t
                               DR. SLATER:  I agree.",
                24
                               MR. CHAMBLISS: And we need  your  views  and  we  would
                2;-t


   HOOVER RLFUKTING CO, INC.
   320 Massachusetts Avenue, N.E.
        r, e, nnnn,)




                                                                                                                                              12

                                    like  you  to work  on  the  exception  principle.    If  there  are
                             2      matters  that  are  exceptions  of  policy  issues,                                     then we would

                             3
                                    like  to  have  your  judgment  on  them.
                             4                        DR.  SLATER:    I'm not  trying  to be  soft,  but what'I

                             5
                                    am  concerned  about  is  that with  the  stability  of  the  staff  and

                             6
                                    the  projects  and  all  they mean  out  there  is  perhaps  the most
                             7      important  element  in  the  survival  of  the whole  pattern  of

                             8
                                    activity  that  was  started  eight  or  ten years  ago.

                             9                        MR.  CHAMBLISS:    Mr.  Thompson.

                             10                        MR.  THOMPSON:    On  the  interface with kidney,  EM
                             11     emergency medical  services,  and  PSRO,  did  the  Staff  go  through
                             12.   and  edit  any  of  these  in  any way,  identify  those projects  that
                             13     are  obviously  in  conflict  with  kidney,  emergency,  and  PSRO?
                             14                        MR.  CHAM-BLISS:    We  have  in  fact  gone  through  all  the
                             15     requested  project  activities  and  have  seen  --  attempted  to
                             i(i    determine  if  there was  a  conflict with  the  policies  of  another
                             17     program.    We  have  also  had  discussions  with  the  key  staffs  of
                             18     the  kidney  program,  the  emergency medical  services  program,
                             I!)    and they will give  us-some  assistance  in  these  reviews where

                             20     we  find  conflicts.
                             21                        A number          of  these  activities,  the  regions  have  been
                                    into      actually  before  some  of  the  legislation was  passed  --
                             22
                                    quality  assurance,  which  borders  very  closely  to  PSRO,  and  so
                             2:1
                                    on          and  those  activities  are  )5eing  continued.
                             24
                                                        However,  in  the  case  of  EMS,  you  should know that  it


     HOOVER RLPUKTING  CO,  INC.
     320 Massachusetts Avenue, N.E.
     Washington, D.C. 20002






                                                                                                                                               13

                                    is  a program decision  and  a matter  of  statute  that  the  RMPs

                             2
                                    or no  other program will  enter  into EMS  activities  so                                               as  to

                             3
                                    build  a  system  of  emergency medical  care.
                             -4                       Our  regions  have  had  facets  of  a  system  and,  theie-
                             5      fore,  with  the  understanding  that we  have  between  Em                                              and  RMP,

                             6
                                    those  activities  are  permissible  for  funding  under                                           this  set  of
                             7      applications,  so  their basis                                they  are  not  designed  to

                             8
                                    produce  total  systems.

                             9
                                                       MR.  THOMPSON:    But maybe  the  problem.-is  that  if  vou
                             10     put money  into  those  nobody will  ever  be  able  to design  a
                             11     total  system because  those  pieces  will  be  out,  you  can't pick

                             12
                                    them up-.
                             13                        MR.  CHAr4BLISS:    Well,                  at  the  local  level  the  CHP

                             14     agencies  have  been  coordinating                            to  see  how the  RMP  proposal
                             15     fits  into  the  total  need,,a@.the                           local  level,  so  there  has    een
                             i(i    a degree  of  coordination  and  cooperation  there  to make  sure
                             17     that  the  pieces  that we  support  have  some  relevance  to what

                             j8     else is going on.
                                                        MR.  THOMPSON:    But  3:  detect  something  in  the  appli-
                             20     cations  I          read,  which,  although  it  is  not  in  direct  conflict
                             21     with the PSRO organization, it is obviously addressed to the
                             22     tactic that hospitals, if they have any brains, have suddenly
                             2:@    got to realize that they've got to get their own quality
                                    assurance program, optioning (phonetic) subbing it out to a
                             24
                                    PSRO or do it themselves, and                              some of these projects are
                             2-7)


     HOOVER ELFUNTING  CO,  INC.
     320 Massachusetts Avenue, N.E.





                                                                       14

                  asking for money to let hospitals build up their own quality

              2
                  assurance programs so they can eventually do this for PSRO.

              3
                            I object to it for two reasons.  one is they should

              .4
                  have been paying attention to quality a long time ago  ail
              5                                                      1
                  of a sudden they shouldn't have discovered the wheel',.  But

                  this isn't related to PSRO

              7
                            MR. CHAMBLISS:  indeed it is.  As a matter of policy
              8   Council policy, we have stated many times that the  s could

              9
                  not become involved in PSRO development per se;. they could not

              10  use their funds for the operational aspects of a PSR9.

              11            DR. McPHEDRAN:  They could be involved in develop-


              12  ment?

              13            MR. CHAMBLISS: They could not be  involved in the

              14  actual development, but that if there were studies, data
              15  collection or peripheral,.activities related to quality
              16  assurance, that they could be involved in that using RMP funds,

                                                           -one comment.  As
              17            MR. VAN WINKLE:  I'd like to add
              18  far as the Staff comments you find in here, they have flagged
              I!) items for your attention, items that they felt were of concern
              20  that they wanted to be sure that you looked at.
              21            Now, they haven't made any recommendation on those
              221 to the committee.  Thevlve left that up to the committee.
              2:3           And in looking at the criteria that you're going
              24  through as far as leadership, RAG, and all of these items, I
                  want to assure you that the Staff have looked at all of those


  HOOVER RLPUKTING CO, INC.
  320 Massachusetts Avenue, N.E.
       n i, )nnn,)





                      items, too, and if    you see no comment, it doesn't mean that

                  2
   (sic)              they haven't looked at them and are satisfied with what they
                  3
                      see, but if you have any question, we'll be glad to have             the

                  4
                      Staff respond to it.
                  5              MR. CHAMBLISS:  Mr. Posta.

                  6
                                 MR. POSTA:  I would like to make a comment concern-
                  7   ing, for instance, EMS activities.  Many of our states are
                  8   making applications to HSA for various EMS activities.  Dead-
                  9   lines in certain areas have been April 15th.

                  10
                                 We have   other opportunities in area resear            for EMS
                      that are going to    be funded by another bureau and weihave,

                  12.
                      from a Staff standpoint, made it clear that whatever;we --
                 .13  meaning RMP, DRMP -- will be funding will be double            checked
                      with  the  other  agencies  to  avoid   duplication   in   these   ty
                  14                                                                      pe of

                  15  efforts.
                  16              MRS. WYCKOFF:     Is that what you mean when you list --
                  17  well,, four EMS projects under concerns, that you're going to
                      check them with these other to see if,they should have applied
                  18

                  i!) somewhere else?
                  20              MR.  POSTA:   Right.   And   to   see.also   if   they're
                  21  flagged whether or not the amounts of money requested in this
                  22  application  is,  in  essence,  double  that   of   what   has   been
                      approved for the first six months of the year.  So we do it

                  24  both ways.
                  2.:')           We keynote an expansion of an activity moneywise as

   HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.E.
         nf, )nnn,)





                                                                            16


                  well as

               2
                             IM. IIYCKOFF:  I see.

               3
                             MR. VAN WINKLE:  Continuations here  aren't of

               -4
                  concern in terms of  the new legislation.  Continuations  are
               5  not of concern insofar as the new legislation.  only new start-

               6
                  UPS.
               7             MR. CMMBLISS:  All right.  Are there other

               8
                  questions?   If not, I think we should begin our review and our
               9  listing shows that the first regional medical P-rogrami  to be

               10 @reviewed is Alabama.

               11            The review is by Dr. Vaun and Mrs. Salazar  and the

               12.
                  Staff person, who is already here at the head table,@is Mr.

               13 Joe Jewell.

               14            Will the.first revievier make his or her presentation?

               15


               16



               17


               38





               20


               21


               22


               2:1


               24


               25


   HOOVER RLPURIING CO, INC.
   320 Massachusetts Avenue, N.E.





                                                                              17


                                  ALABAMA REGIONAL MEDICAL PROGRAM

                2
                             MRS. SALAZAR:  Alabama has always led    this@parade

                3
                             MR:.CHAMBLISS:  Use the microphone.
                             MRS. SALAZAR:  -- of the reviews, and I'm      afraid'i
                5  fell@into that trap and I may get carried away, but       nope  noti

                6
                             The present  fundina  of the Alabama RMP is    @687,000
                7                                .1.                       .1
                   in the third vear of a triennial status, with the year ending

                8
                   April 30th, for a total of four operational years.

                9
                             The activities that  were  reported  in  the  annlication-

                10
                   are related to phase-out pursuits, rescinding    of phase-out,

                11 reactivation, retooling, in   response  to  the  off-agaio/on-again

                12: syndrome that has bedeviled  the regions all  across  the  country

                13 this past year.

                14           In view of this, the  Alabama  application,.  to  me,  is

                15 somewhat astounding from A number of standpoints.

                             First, after the phase-out orders in February of

                17 1973 only two projects were  approved  for  partial  support  and

                18 only four which were  funded  through  contracts  were  continued

                   beyond June 30, 1973.

                             Two: the  Regional  Advisory  Council  elected  to  remain
                20
                21 intact -- the RAG is called RAC there --:  it  retained  its  work-
                9.) ing committees, and,  indeed,  throughout  such  troublesome  times

                   of adversity it grew in strength and.wisdom, guiding and sup-
                2:1
                24 porting the RMP efforts throughout the region.     The RAC  has  met
                   four times, reviewed proposals, set priorities,    implemented   new
                25


   HOOVER RLPIJRTING CO, INC.
   320 Massachusetts Avenue, N.E
        n(,. ?nno?





                                                                                                        18
                           by-laws, counseling and opening avenues of communication in
                       2   their respective geographic areas of the region.

                       3
                                        Vacancies that have occurred on the staff have been

                       4
                           filled very promptly and attendance at all meetings has

                       5   averaged better than 66 percent.

                       6
                                        There is a nine-member executive board of the RAC.

                       7
                           It has met six times, average attendance at 75 percent.   The
                       8   chairman is a member         of the State Health              the State Board of

                       9   Health Department.
                       10               The third astounding feature of               this   application, to
                       11  me, has to do with the ability of the region to seek and
                       12. obtain local support for twelve out of sixteen of their con-
                    ..13   tinuation programs, tifenty-one out of the thirty new proposals
                                  1
                       14  Spoken or stated Another way,  in addition to the $2,648,000
                       15  they are requesting,  $1,1922,000                almost $2 million -- will
                       i(i be supplied by state,  local, and              other federal monies.
                       17                Or still another wav, 73 percent of this application
                           will generate other grant-related support, resulting in a
                           total of $4,500,000 for the Al!abama RMP                     is that correct,,

                       20  Joe?
                                         MR. JEWELL:   That's correct.
                       21
                       g-)               MRS. SALAZAR:   The Review Committee and the EMS Com-
                           mittee have remained active, with the latter forming the
                       2;@
                           nucleus of the State Advisory Committee to the Governor and
                       24
                           the State Board of Health.
                       2;-)


    HOOVER RLPURTING  CO,  INC.
    320 Massachusetts Ave nuej N.E.
    ... I  I@ @ @@@nn      I




                                                                          19

                            The membership of the RAC is adequately represented

               2
                   by providers and consumers from each of the 10 CHP B agencies
               3   and it includes the Director of the State CHP A Agency and a
               4   representative complement of health educators and providers,
               5   officials, and the like -- there's a mayor, too, as 1 recall.
               6            The University of Alabama in the Birmingh@   Medical

               7   Center serves as the grantee and the present Executive
               ,8  Director of the Alabama RMP is on leave of absence f om  the
               9   university at 100 percent of time.  Maximum resource support
               10  from the universitv is accorded the Regional medical Program.
               11           The present Director has had  extensive  experience
               12@ with the Alabama RMP, having served on its first Re ional
               13  Advisory Committee in 196.7.  She has been a member of various
               14  committees for about three years, has served a-, a part-time
               1;5 professional Assoc iate Director.  She has also been a member
                   of the faculty of the School of Medicine for over 25  years,
               17  and for the past twelve years as Assistant and Associate Dean
                   for Continuing Medical Education. She is active  in  medical

                   affairs throughout the state.
               20            The Deputy Director has been with the program since
               21  October 1970 and the Assistant Director for Operations has
               22  been employed by the Alabama ME? for seven years.
                             The position of Associate Director for Health Care
               2:@
                   Services, which will provide liaison with health providers
               24
                   throughout the region, is open.  Recruitment is underway.
               2,7)


  HOOVER RLPOR [ING  CO,  INC.
  320 Massachusetts Avenue, N.E.
  Washington, D.C. 20002





                                                                            20

                              This unit is pursuing PSRO efforts  and  will  provide

                2
                   an appropriate channel  for,emerging  national  health  insurance

                3
                   information.

                4
                              An Assistant Director  for  Multimedia  Activities  And
                5  an  evaluator round out the professional staff and bring the

                   total to  its approximate prephase-out status.

                7             There's a sense of optimism and enthusiasm that
                8  domes through in this  application.  It  communicates  a  feeling
                9  of confidence in the competency and   the wisdom and  the  motiva-

              10   tion of the staff.
              11              The region appears to me to be on  target  in  meeting
              12.  its goals and objectives as revised in 1971  to  meet  the  chang-

              13   ing national and local priorities.
              14              It is quite apparent that enormous  staff  energy  went
              15   into creating four of the initial six B  Agencies  in  the  state
                   and it is still wielding a great'influence   on the  @emergence-6f

              17   the other four.
                              The Director of the CHP A Agency is a  member  of  RAC
              18
                   and several members of the Area Health  Councils  are  also  RAC,
                   members.  B Agency members frequently attend RAC meetings.
              20
              21   There is excellent communication among all groups.
              g-)             The endorsement of the Alabama  Advisory  Council  for
                   CHP A Agency is quite guarded, and there are some stated
              2:3
                   reservations concerning the duplication in sponsoring
              24
                   agencies, but for the most part  these  are  fairly  superficial.
              2;-)


  HOOVER RLPORTING CO, INC.
  320 Massachusetts Avenue, N.E.
       n r I)nnn)I






                             As far back as 1967 the Alabama Regional Medical

               2
                   Program proposed in its first planning  grant  the  development

               3
                   of six community-based health education centers  to serve

               4
                   regional needs for health manpower education, service, and'
               5   continuing education for all health professionals in  the

               6
                   region.  Eleven programs are now ongoing, covering a 1 geo-
               7   graphic areas of the state, and one is emerging in the

               8
                   resource-poor southeast section.

               9
                             There is an exciting program that is-entitled

               10  "Project HELP" which emerged from a tripartite agreement among!
              -11  University of Alabama, Birmingham-Auburn, and the State Healthl
               12! Department for health education of the public.  It utilizes
              -13  the services of the Agriculture Extension Service at Auburn
               14  University and county agents and councils in  every  county  of
               15  the state. This program,will  receive  future  funding  through

               i(i state education funds.
               17            The present application,  as I said, generates a
               18  feeling of optimism in  the  reader.  Cooperative  arrangements
                   have been achieved. Staff of both CHP A  and  Bs  are  actively
               20  involved in RMP affairs.  Projects, both proposed and ongoing,
                   are timely, relevant, and appear to be viable.  They are par-
               21
               22  ticularly applicable to the region's health needs, but also in
                   line with national emphases, such as PSRO and  quality and cost'!
               2:1
                   controls of the health delivery system.  These are all spoken
               24

                   to*
               2.r)


  HOOVER RLFUKTING CO, INC.
  320 Massachusetts Avenue, N.[.





                                                                          22

                            For the July submission the region is preparing

               2
                  additional projects in neonatology and one to develop  a  rural
               3  community health task force.

               4
                            It is significant, I think, to note that the
               5                                                       1
                  Regional Advisory Council incorporates in its committee
                  structure the CHP B planning agencies.  These areawide
               7                                                       1
                  advisory bodies formulate policy and approve plans pertinent
                  to health issues,, not only project proposals from A b
               8                                                      la ama  RMP
               9  but others requesting federal and state funds that a@fect

             10   their geographical areas.
             11             From the very limited information to  be gleaned fromi

             12@  the report on the HPA-T4, I believe it's called, which  is  the

             13   Equal Employment Opportunity breakout and my previous
             14   knowledge of Alabama,, it does appear to me that the Alabama
             15   Region has made progress,.in its Equal Employment Opportunity
                  for minorities, but, I believe, still has a long way to  go  in
             17   achieving adequate representation of these minorities on their
             18   committees, particularly in the professional and clerical
             I!)  staff, as well as membership of planning groups and committees
             20   at the community level.
             21             I'll cite you one example:  the Regional Advisory
                  Council membership is fifty-eight, only four of whom are
                  blacks; the total Professional staff is sixty-three, with
             2:3
             24   eight blacks.
                            I will withhold my recommendations, Mr. Chairman,
             25


  OOVER RLFUNTING  CO,  INC.
  20 Massachusetts Avenue, N.E.
  I:%,zhi,icrfnn f) r 2nnn2i





                                                                          3


                   until the other review.
              2              MR. CHAMBLISS:  Thank you.

              3
                             I will now call upon the second reviewers, Dr* Vam.

              4
                             DR. VAUN:  I'm not going to address attention ex@en-
              5    sively to the background because I think Mrs. Salazar has

              6
                   covered that well, and in a discussion that the two of us had

              7
                   initially, we agreed that she would address the background and

              8
                   1 would talk somewhat about the projects.

              9
                             I will start exactly opposite.  I will address first

              10
                   and foremost my recommended level of funding, and then tell
              11   you how I arrived at that in analyzing the project.
              12                           ded that their requ  st  of $2,648,439
                             I have reccmmen                   e
              .13  be reduced to $2,028,389 -- this'may be  backwards, but this is
              14   my approach to this one with the background  you've gotten on

              15   Alabama.
              16             1 think they've done a good job.  I think the
              I-,  projects that they've submitted are congruent with their
              is   stated objectives, and I saw one thing that came glaringly
              I!)  through in the Alabama application, and that is that they gave
              20   me a feel for priorities, both from the CHP point of view and
              21   from the R14P point of view, and I hope this doesn't act to
              22   their detriment because it was really a splendid job and it's
                   part of the way I arrived at the reduction.
              24             Also I arrived at the reduction on the basis of
                   some experience with like projects and observations about the


  HOOVER REFOR I ING Co, INC.
  320 Massachusetts Avenue, N.E.




                                                                                                                                              24

                            1      successes  of  like  projects.
                            2                         For  the  core  operation  of  the  Multimedia  learning
                            3      skills,  the  only  reduction  in  core was  $10,000  from  that

                            4
                                   specific  aspect  of  their  project  and  not  from project  staff

                                   itself.


                            6
                                                      From  the  continuation  projects                                  and  I  really won't
                            7      go  into  the  details  unless  you want me  to                                         I  have  arrived
                            8      at  a  level  of  funding  reduction  of  $107,753.    From their
                            9      $565,005,  I  have  come  down  to  $447,252,  and  there  is  only  one
                            10     project  that  I  really  didn't  feel warranted  funding  at  all  and
                            11     that was  the  No.  82,  which  is  entitled  "Audio-Visual  Assist-
                            12!    ance  in  Educating  Hypertensives."
                            13                         I  don't       know,  I  feel  that  there's  so much  of  this
                            14     around now  that  spending  $7,000  on  it                                 in  another  area  just
                            ir)    doesn't  seem  like it was  worth  the  effort.
                                                       The  other  $100,000                 came      from  reduction  of  funding  of
                            17     several  of  the  projects.    As                        I  say,  I'd  be  delighted  to  submit,
                            18     my  recomendations  to  Staff  or  go  over  them here,  whichever

                                   you wish.
                                                       MR.  VAN WINKLE:    I  think  it will  probably  depend  on
                            20
                            21     what  the  final  recommendation  is.
                                                       DR.  VAUN:    Why  don't  I  go  through  the  rest  of  them?
                            9.)
                                                       MR.  VAN IIINKLE:    All  right.
                            2;t
                                                        DR.  VAUN:    From their"new projects,  they  submitted
                            24
                            25      $1,422f440;  I  would  recommend  a  reduction  of  $492,297  to bring

    HOOVER  REFURIING  CO,  INC.
    320 Massachusetts Avenue, N.E.
    IAI-.t.:..4.. f) I' )nnn,)





                                                                          25

                   their new application award to $930,143.
               2            I was a little concerned again, although the pro-
               3   jects are congruent with their stated objectives -- I thin%
               4   $11,000 for trophoblastic disease left me a little cool at'

               5
                   this stage of our development; immunofluorescence for renal
                   biopsies in the State of Alabama also left me a little
               7   concerned at this point; a rather sizeable sum of money for
               8   cervical cancer screening, I reduced substantially.
               9             And then the PSRO which was $151,000i and a few  odd
               10  dollars, I thought should be substantially reduced by
               11  $100,000.  I just didn't feel this was appropriate.
               12.           So you have my recommendation in the light of Mrs.
               @13 salazar's background, and  Iwonder if that couldn't set the
               14  pattern.  Don't you think it would be wasteful for both
               1.5 reviewers to spend a great deal of time presenting the back-
               i(i ground?  Couldn't we  arrive at some agreement and one person
               17  take one task and the  other person take another task and,
               18  hopefully, come together  on it?
                             MR* CHAMBLISS:  Certainly I would await the judgment
               20  of this committee on that point.  I think it will tend to

                   expedite things.
               21
                             MR. THOMPSON:  So moved.
               22
               2;3           DR. WHITE:  I take exception to it and object, in
               24  the sense that many of us have done work already -- admittedly
               2;-) scanty -- but it might be somewhat difficult for us to recast

  HOOVER RLPUftllNG CO, INC.
  320 Massachus!tts Avenue, N.E.





                                                                          25

                  ourselves in roles which we hadn't been expecting.
                2            DR. VAUN:  In the light of consultation amongst the

                3@ two reviewers

                4
                             DR. WHITE:  If time permits.

                5
                             DR. VAUN:     maybe one would have  spent  more  time

                6
                  on one thing than the other, they could agree on a  presenta-

                7
                  tion.


                8
                             DR. IIHITE:  If the two

                9            DR. SLATER:  Mr. Chairman, I think  it's quite  easy
              10  to draw up background. Anybody  can  do  that.  But I  think  if
              11  there has been a fair amount of time spent in looking at  the
              12  projects and considering them in the terms of  the  criteria you
              13  want, I think the individual reviewers have  to  go into   this.
              14  There won't be that much duplication except as  to  background

              15@ historv.  That  seems redundant.
                             MR. CHAMBLISS:  I se@'to get a sense from the com-
              17  mittee that you would prefer to hold to the original approach.
                             DR. WHITE:  I think everybody has to play his own
                  role, and  if you don't like @ way I do it, you can holler at

              20  rue.
              21             MRS. WYCKOFF: I tried to  follow  this  thing,  which

                  is quite  different
              22
                             MR. CHAMBLISS,.  You are seemingly suggesting that
              2:3
                  we have the clock before us andwe can always call tiTn@@..
              '-)4
                             All right.  Can we get a motion, then?
              25


  40OVER REFORTING CO, !NC.
  3N Massachusetts Avenue, N.E.
       nr 9nnn?




                                                                                                                                             27

                                                     DR.:VAUN:    Mrs.  Salazar  hasn't made  her  recommenda-

                            2
                                   tion yet.    She was  going  to withhold  her  recommendation.
                            3                        MRS.  SALAZAR:    I  defer  to  you  as  the  principal

                            4
                                   reviewer.
                            5                        DR.  VAUN:    Again,,  Bob,,  I'm  new to  this.    Do                                 I  make

                            6      the  motion,  or  does  somebody  else?
                            7                         MR.  CHAMBLISS:    You  can make  the motion  if  you
                            8      choose,  Doctor.    You've  already  given  us  a  level  of  funding
                            9      that you have  recommended  and  the  rationale  for  that  level,
                            10     If you will  put  that  in  the  form  of  a motion,  the  chair will

                            11     entertain  it.
                            12                        DR.  VAUN:    I  will move  that  the  request  of  the
                            .13    Alabama  Regional  Medical Prc>gram,be  reduced  from  their
                            14     requested  amount  of  $2,648,439  to  $2,028,389,                                     .
                            15                        MR.  CHAMBLISS:    There's  a motion  on  the  floor that
                                   the  recommended  level  of  funding-for  the  Alabama  Regional
                            17     medical  Program  be  placed  at  $2,020,389
                                                       DR.  VAUN:    $2rO28,389.
                            1 8
                                                       MR.  CH-A-MBLISS:    $2,0,7-8,389.
                            20                         Is  there  a  second?
                                                       MR.  TOOMEY:    I  second  it.
                            21
                                                       MR.  CHAMBLISS:    It  has  properly  been made  and

                                    seconded.
                            2:3
                                                       Is  there  any  discussion  on  the motion,  please?
                            24
                                                       Dr.  Miller.



    HOOVER REPURTING  CO,  INC.
    320 Massachusetts Avenue, N.E.
    W-@hinatnn 1) r. 2nnn2




               1             DR. MILLER:  To what extent do we need to pay atten-
               9   tion to these motions for dollar levels in terms of the
               3.  relative relationships of the various RmPs on this list?  This
               4   motion places Alabama at a level that -- does it or does it
               5   not -- it exceeds the targeted available funds item, and with-
               6   out any consideration to the probability of what the3r  state-
               7   ment was, an estimate of $1.1,million application to be sub-

               8   mitted in July-@
               9             Are you goina to count them out, almost surel_vo,
              101  from much of anything on July lst by this level at  this  time?
              11             MR. VAN WINKLE:  Dr. Miller, again, this is  just  an
              12i  approval level. That's what's  being  recommended,  an  approval
              13   level.  It does not necessarily mean that when it's actually
              14   funded that's what it's going to come out to be.
                             DR. MILLER:  Could I ask, then, another question?
              15
                   What happens if this committee ends up with an  approval  level
              17   of $114 million this time; then you decide who gets what,

                   right?
                             I.M. VAN WINK LE:  I suspect Council will

                             MR. CHAMBLISS:  Council will then make its recom-
              20
                   mendations based on the findings of this committee.
              21
                             DR. WHITE:  I think that's quite appropriate.  The
              22
              2:1  fact that someone here has seen fit to suggest that Alabama
                   deserves more would be taken into consideration even though
              24                                   e
                   they may not get that amount -- they might get more in


  HOOVER RLPURTING CO, INC.
  320 ?Aamchusetts Avenue, N.E.
  Washington, D.C. 20002




                                                                          29

                  proportion than some other region.

              2
                            MR. CHAMBLISS:  That's quite true.

              3             DR. WHITE:  It's simply a guideline.

              4             DR. SLATER:  I'm just wondering how to deal,with'

              5   this, too. I wondered how, as Dr. Vaun has, to  deal  with

              6   dollar amounts, and I guess what I'm searching for are guide-

                  lines.  I've wondered whether or not we can't- find the same
              8   problems that you have and indicate that our guidance is that
              9   within the framework of whatever cutbacks you have to make
              10  they shall not -- that they will have to redefine their distri.-

              11  bution of funds to exclude the coverage rather than try and

              12  set a dollar level at this stage of the game.
                i
              13            In other words, I'd rather find fault with the
              14  thing, with the specific project, if we get into that degree
              I-.5 of detailing, and then leave them with whatever funding level
                  is ultimately going to be made possible, but within the guide-
              17  lines that they're not to spend money on those  particular

                  aspects.

                            MR. CHA14BLISS:  Thaiais correct, Doctor.
              20            DR. SLATER:  That gets us away from dealing with odd
              21  dollars, and I don't know whether that satisfies your thinking
                            DR. VAUN:  I'm not sure I understand it.
              22
                            DR. SLATER:  Rather than assigning dollar cutbacks
              2:t
              24  as you have, identify the concerns that you have and  give
                  guidance to the Staff and the recommendation to the Council


  HOOVER REPORTING CO, INC.
  i2O Massachusetts Avenue, N.[.
  Washinzton. D,C. 2ON2





                                                                         30

               1  that within the framework of whatever dollar cutbacks --
               2  they're asking for a hundred and thirty-six -- there probably
               3  is going to be some cutback, but in whatever framework, the,

               -4
                  money they receive shall not be spent on those particular

               5  projects.  They have to define how they

               6            MR. CHAMBLISS:  Well, I think he's simply been

               7  generous in giving us the dollar amounts and where, and we

               8  will -- the Staff will certainly take that into account as

               9  this goes through the review process.

               10           MR. VAN WINKLE:  And we would like Dr. Vaun's

               11 written figures -- details.

               12I          If you have them, we'd certainly appreciate them.
              .13           DR. VAUj'q:  Maybe I'd better get clarification of
               14 that.  Does that mean that if I submit the details that this
               15 is a mandatory translation to them where they cannot spend  the

                  funds?

               17           That's what you were saying.
               18           MR. CHAMBLISS: It does not. You  have  simply,  based

                  on your professional judc
                                           jment,'indicated those areas of

                  concern, and they will be passed on through the review  process
               20

                  and finally acted upon.
               21
               22           DR. VAUN: But it will be up to.the region  to  decide
               2:3 finally?

                            MR. CHAMBLISS:  Yes.
               24
                            DR. VAUN:  Fine.
               25


  HOOVER BEFURTING CO, INC.
  320 Massachusetts Avenue, N.E.
       r)r. 2nnfl9




                                                                          31

                             DR. SLATER:  Your indication of dollar amount is

               2  simply a reflection of your ektent of concern.

               3
                             DR. VAUN:  Gut feeling.

               4
                             MR. CHAMBLISS:  Is there further discussion?

                             I'll call the question.
                             Those in favor of the motion, may I have the usual

               7  signal of  voting?

               8
                             (Ayes respond.)

               9             MR. CHAMBLISS:  And those opposed?

               10            (No response.)
               11            MR. CHAMBLISS:  The motion, then, is carried, and

               12 we have finished our first review.

               13


               14


               15






               17


               18






               20


               21


               9.)



               2:1


               24


               2;-)


  HOOVER REFUNIING CO, INC.
  320 Massachusetts Avenue, N.E.
  Washington, D.C. 20002





                                                                          32

               1                ARKANSAS REGIONAL MEDICAL PROGRAM

               2            MR. CHAMBLISS:  In our next region we have only one

               3  reviewer here at the moment.  That region is Arkansas.  And
               4  we will ask Dr. Carpenter if he will carry the  entire  load'for

               5  that region.

               6
                            Dr. Carpenter.

               7
                            DR. CARPENTER:  Thank you.

               8
                            I don't have anything like the kind of  background  on
               9  this region that Mrs. Salazar did. My view is  that  the  region

               10 has maintained the mechanism of the regional  program  adequate-
               11 ly.  The advisory committee remains intact; the review system
               12 remains intact; and that what we have is an application pre-

               13 pared by a reduced staff in an appropriately reasonable
               14 fashion, but in a depressive time which has forced them  to,  in
               IF) the first place, be responsive to a large number of federal
               16 initiatives, some of which I  don't believe were at their

               17 emotional heart.
               38           Secondly, they had to respond, obviously, very
                  rapidly and they,, in the process, were forced to give up much
               20 of the matter of pressing for very detailed  program  objectives
               21 and there's essentially nothing in the application about
               22 evaluation either of the past program or of the -- and no
                  suggested specific evaluation of most of the projects.
               2:1
                            And, so, one has -- as I  read the application, I
               2A
               2;-i have the feeling of a regional program which,is a bit at sea;

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.E.
       n r )nnn,)




                                                                         33

                1  has no real continuing thrust that can organize Arkansas in
                2  any significant way, though it does have enough thrust to
                3  contribute here and there in a kind of stopgap way, which I
                .4 think most regions are going to have to be content with.
                5           I believe that if I were in Arkansas I would spend
                6  the next year trying to document -- trying to develop a highly
                7  professional staff and document what its effect can be in

                8  terms of a detailed project plan.

                9           I have in view the  July  submission.  You can see
                10 from your computer print out here that the present funding
                11 level is $1.4 million; that -- as that somewhere, if we go
                12 through with their projected application, in July we'll be at
                   a level -- which I'm having trouble reading -- of only 15 per-
              .13
                14 cent higher than what might be expected.  on the other hand,
                15 it would be twice what they're now spending.
                1(;         And I just don't believe that they've had an oppor-
                17 tunity to organize a coherent program that's twice as large as
                18 the one they're presently involved in.
                            So my inclination weuld be to fund them at about the
                20 same level now and if the July application shows progress in
                21 terms of more detailed planning, then I think there's an
                   opportunity to provide them with what will, I suspect, be a
                   large enough amount of money for them for the next year.
                2;1
                             So I'd recommend a fu@nding level of $1,450,000.
                24
                             MR. CHAMBLISS:  At the current annualized level
                2;-)


  HOOVER REPUxiiNG CO, INC.
  320 Massachusetts Avenue, N.E.
  Washington, D.C. 20002




                                                                          34

                             MR. POSTA: Excuse Me, Doctor. That current annual-
               2   ized level projected over a year for Arkansas is $1,848,000

               3   the first column.
               4             DR. CARPENTER: My first column shows a r Llion four.

               5             MRS. WYCKOFF: So does mine.

               6             DR. WHITE: Do does mine.

               7             MR. POSTA:  I guess it's the 17th edition.,

               8             MR. CHAMBLISS:  We're working from the May 21st

               9   edition.

              10             MR. POSTA:  I'm so@ about that.
              11             MR. CHAMBLISS:  Thanks for that presentation.
              12,            1 would like to ask if Mr. Posta will provide, in
                   the absence of the second reviewer, the committee with any
              13
              14   additional information that he chooses on Arkansas.

                             Mike?
              15
                             MR. POSTA:  I hdve been associated as operations
              17   officer  to Arkansas since 1970.  The Mid-Continent Operations
              18   Branch considered Arkansas to be' one of the better programs
                   in the Mid-Continent Operations Branch, primarily because of
              20   the coordinator who has.just resigned in February.
                             I think that Dr. Ca rpenter's comments were quite
              21
                   relevant because Dr. Silverblatt has left the State of

                   Arkansas.  There is a question of leadership.
              2:3
                             However, Mr. Roger Warner has  been the evaluator
              24
                   the monitor and evaluation chief of.that particular section


  HOOVER RLPOR I ING CO, INC.
  320 Massachusetts Avenue, N.E.
  WashinRton, D.C. 20002





                                                                              35

                    and has done a good job in this regard and is serving in    an

               2
                    acting capacity now.

               3                                                          e
                              The Search  Committee is  in process of  sel cting

               4
                    another coordinator.  Mr. Warner   is one candidate.
               5              Seven of their top professional people have    been   on

               6    board for about seven years.
               7              Now, last year when  they came in -- meaning the last
               8    Council meeting in November of 173  --  the  region  responded  to
               9    the five initiatives which DRMP had sent out to all of the
               10   RMPS; that is, "We want to do more in planning;    we want to   do
               ii   more in quality care; we'd like to get something going in

               12,  kidney, EMS, and hypertension."

               -13            Most of their ap
                                               .placation -- or  their  thrust  during
               14   that period of time was in these five  areas,  and  in  this  par-
               1;5  titular application they,-have what they call an "umbrella
                    concept' within the core staff of ten particular areas where
               17   they have maintained those five  original  ones  that  we've  men-
               18   tioned and brought in position extenders more of a program
                    force, unified health planning and new legislative concepts
                    more in the area of hypertension and a couple of others that I
               20

                    can't recall.
               21
               22             Seventeen of the activities are.new;    seven  are  con-
                    tinuing.
               2:1
                              I might refer you to your  yellow  sheet  in  the  book.
               24
                    I think you all probably have  that.  It  more  or  less  reflects
               25


  HOOVER RLFUKTING CO, INC.
  320 Massachusetts Avenue, N.E.




                                                                         36

                   what Dr. Carpenter just mentioned with reference to staff.
              2    They have currently on board 16.6 full-time people.  They  do
              3@l propose 29.6 in order to do the job that they've set out.
              4             I think there's been no problems whatsoeve'r-with'the
              5    CHP A and B agencies. Arkansas was one of  the  first  regions
              6    to have acomplete blanketed state with eight CHP funded

              7    agencies.
              8             The ARMP and the CHPS,, along with what we call an

                                                                     1
              9    "Estes" (phonetic) program, the Experimental Health  Delivery
              io   System package, have been in operation in Arkansas for  about
              11   four vears.  They have been funded with about $3.4 million of

              12   EMS activities from HSA.
                            In this particular application they do have an
              .13
              14   umbrella concept since the core,staff did develop the EMS
              15   proposal that was approved by the then-HRA agency.
                                           11
                            I could go on, @u-E I think I'd better stop.
              17            MRS. WYCKOFF:  What do you mean by "an umbrella
                   concept"?  I see this in a number of these, and I wonder what

                   does that consist of?
                            MR. POSTA:  Well, within the total program staff
              20
                   budget, they have said, "We would like to administratively
              21
                   break up our entire program staff into tan areas,"  and  they
                   break out their budget accordingly, and those ten that I men-
              2:1
                   tioned in hypertension -- they have one on arthritis  that  I
              24
                   didn't mention    each of these people on staff would be


  HOOVER REPOKI ING co, INC.
  320 Massachusefts Avenue, N.E.
  WA-hin,-tnn DC-20002





                                                                           37

               1   working in these particular  activities.
               2             Within the application,  which does request $890,000
               3   in this total program staff budget,  you have about 13 percent

               4   of the over-all request in what we  used to call a develop-,
               5   mental component or, as they call it, contingency funds -- or

               6   as some of us would call water.
               7             But I might say in all fairness to  Arkansas  that
               8   that is a mechanism of funding, and I dare say that all of the
               9   applications you see -have. certain developmental component

               10  funds.listed.

                             MR. CHAMBLISS:  All right.
               11

                             I wonder, at the end of       r
               12                                    this p esentation, if
               13 'there's a motion for Arkansas, or are there further matters to
                   be discussed?  Are there further questions?
               14
               15            DR. WHITE:  Their request is for a million eight,
                      that's only $400,000 more than  they are getting  at  the

                   present  time.
               17
               18            DR. CARPENTER:  Yes, and they're going to come in
                   for some  more in July.
               20            1 think it's very hard to set the  funding  level.
                   For me, it was very difficult.  If you try to go by      you
               21
                   look at the projects and try to see which.one would amount to
               22
                   something.  I just don't have any confidence in  anything from
               2:i
                   what they've described, and I, obviously, don't  think we ought
               24
                   to make it impossible for them to  start any projects.  I think
               25


  HOOVER RtrURIING  CO,  INC.
  320 Massachusetts Avenue, N.E.





                                                                          38

                1  their core needs to be protected, which I   and, sot I sort

                2  of added a few projects to core.
                3           DR. SLATER:  The question I'm asking  is whether you
                4  feel that they need to re-present what they  have  apparently
                5  done ineffectively for the July deadline so that they in fact
                6  are going to be coming back for the total amount tha  they

                7  were shooting for?
                8           I'm not quite sure what the guidelines arelthat are
                9  associated with your suggestion for a continuation 0; funding

                10 at the present rate.
                11          DR. CARPENTER:  I was  wondering about that," too.
                12@         DR. SLATER:  Are they  just to be given the,money and
                13 then permitted to cut back where they see fit?  How does this
                14 help improve their function?
                15           1 feel the same way you do; I'm at a loss as to how

                   to react to them.
                             MR. VAN WINKLE:  It would be too late,  though,  I
                17
                   think,, to amend their July 1 proposal because their RAGs are
                   meeting at the present time on that proposal -- I think most

                   of them are, aren't they, -Mike?
                20
                21           MR. POSTA:  Yes.  They expect  about $800,000  new
                22 activities to be @ mitted in that July   1.
                             DR. CARPENTER:  Let me comment  on that.  I  think
                2:i
                   they do have RAG approval on these Projects, and I  --  it's
                24
                   obviously suggesting an enormous am ount of work in an already
                2;-)


  HOOVER RLFURIING CO, INC.
                fjr




                                                                             39

                 1  overburdened st  f, but if I was to be convinced that the
                                   af                                          y
                 2 could spend more money  effectively,  I  would  need  additional
                 3 information about their -- the goals   and the evaluation
                 4 systems for the projects that they intend, and I would think
                 5 it might be interesting to think  whether  we  want  to  suggest
                 6 that some region provide that kind of information in view of
                 7 the difficulty of the rush (phonetic).of the projects.
                 8            MR. VAN WINKLE:  All I was looking at is that
                 9 Council will be meeting and  we  cannot  relay  any  information
                 10 back to them until after Council meets and their July 1 appli-
                 ]'I cation would probably almost be in the mail to us by that time
                 12           DR. CARPENTER:  But presumably -- and this is what
                   the key issue is      in July if you are not going to do a
                 .13
                 14 project review and you are going to have only an application

                   that describes projects
                 15
                              MR. VAN WINKLE:  I/ it'll-be a full-blown map --
                 17           DR. CARPENTER: Well,  you  see,  that  gives  you  --
                 18           MR. VAN WINKLE: it'll  have  to  stand  on  its  own.
                              DR. CARPENTER:  Thea that, standing on its own,
                 20 could say, "Hey, look at all  the  progress  we've  made  since
                    last time in our project plan."
                 21
                 9.)           DR. WHITE:  May I ask a questio  n,, Mr.  Chambliss?
                               MR. CHAMBLISS:  Dr. White.
                 2:t
                               DR. WHITE: This was  a  highly  regarded  region  at
                 24
                    one time;  is that correct?
                 25


   HOOVER REFURIING CO, INC.
   320 Massachusetts Avenue, N.E.
        r) r )rtnf),)




                                                                                                                             39

                         1    overburdened staff,  but if  I was                       to be convinced that they
                         2      could spend more money effectively,  I would need additional
                         3      information  about  their -- the goals  and the evaluation
                         4      systems  for the projects  that they intend,  and I would think
                         5      it might be  interesting to think whether we want to suggest
                         6      that some region provide that kind of information in view of
                         7      the difficulty of the  rush  (phonetic).of the projects.
                         8                       MR.  VAN WINKLE:   All I was  looking  at is that
                         9      Council will be meeting and we cannot relay  any information
                         lo     back to them until  after Council meets  and their July 1  appli-
                         11     cation would probably almost be  in the mail to us by that time
                         12.                     DR.  CARPENTER:   But presumably --  and this  is what
                                the key issue  is  -- in July if you  are not going to do a
                         .13
                         14     project review and you are going to have only an application

                                that describes projects
                         15
                                                 MR.  VAN WINKLE:    It'll'be  a full-bloi-7n map --
                         17                      DR.  CARPENTER:   Well,  you see,  that gives you --
                                                 MR.  VAN WINKLE:    It'll have to stand on its  own.
                                                 DR.  CARPENTER:   Then that,  standing on its own,
                         20     could say,  'Hey,  look  at all the progress we've made  since
                                last time in our project plan."
                         21
                                                 DR."ATHITE:   May I  ask  a question,  Mr.                        Chambliss?
                         22
                                                 MR.  CHAMBLISS:    Dr.  White.
                         2:3
                                                 DR.  WHITE:   This was  a highly re                          ded region  at
                         24
                                one time;  is that correct?


      HOOVERRLPURTINGCO,INC.
     32OMasgchus@ttsAvenue,N.E.





                                                                           40

               1            MR. CHAMBLISS:  It has been a highly regarded region
               2             DR. IIHITE:  The question now, Bob, is that there has
               3   been a change of leadership and some  disassembling  of  things?
               4             DR. CARPENTER: You know, it's hard  to  tell  whether
               5   there's been a change in leadership or just, no matter how
               6   good your leadership is, this is an impossible situation, and:
               7   it might be possible to say    well, look at this -- I don't
               8   know if you can -- but as I look at the staff, they're being
               9   asked to do some very difficult things in terms of, you  know,,
               io  the details of the sickle cell project, for instance, and
               11  they're not able to do it, and I don't know whether that
               12. maybe in the past they would have gotten the.expertise they
               13  need from their voluntary groupsi  For some reason or another,
               14  they don't seem to have it now.
               15            I can't tell whether it's the leadership or the

                   time element.
               16
               17            DR. SLATER:  Your  real concern here is not, I
               38  gather, on a project basis whereby you feel that one wants to
                   cut back there, but some sense that the program isn't as
                   strong, that the staff leadership isn't as strong, and it
               20
               21  doesn't satisfy these criteria as well as you would like and,
               22  therefore, it should be generally kept at.the present    level?
                             DR. CARPENTER:  Yes; I doubt that the staff can
               2:1
                   enforce high-quality projects of the type suggested.
               24
                             DR. WliITE:  That's a reasonable concern.
               25


  HOOVER REFURTING CO,  INC.
  320 Massachusetts Avenue, N.E.




                                                                                                                  41

                         1                 MR.-POSTA:   i  feel very awkward in defending                         the
                         2    region.   I really do.   I don't think that's my role as                            Branch

                         3    Chief,  on top of that.
                         4               'DR.  SLATER:   May I speak to that?   I think it's very
                         5    important -- if the Staff have direct contact with the people
                         6    there and they have a sense of history that we certainly canot

                         7    pick up from one reading
                         8                 MR. POSTA:   I  assure you this is not the                        best
                         9    application that Arkansas has ever submitted,  and that's true
                         io   because 15 days after they got instructions,  the coordinator

                         11   had long departed.
                         12                 However,  they do have what I consider a                       good,  small
                              staff.   Arkansas has never had a big staff.   We're talking
                         .131
                         14   about a state that's  forty-ninth in the country as far as
                         15   average income is concerned,   They have limited providers.
                                             T think that             just as      an example in this particu-
                              lar application,  for the amount of other sources of support
                         17
                              which is included in your conglomerate budget,  they have state
                              funds,  local funds,  and other.federal support of  $415,000;
                         20   mainly through the RMP,  the EMS application was approved                                 and
                         2,1  plans put into the CHP A agencies were likewise approved.
                                             They,  along with the VA, were instrumental in draft-
                         22
                              ing the proposal whereby Arkansas has a state Estes program.
                         2:@
                              These folks have been working closely together.   The Univer-
                         24
                              sity personnel is involved and definitely involved with these
                         25

    HOOVER RLPUKI ING CO, INC.
    320 Mamchusetts Avenue, N.E.
             R p )nnn9





                                                                               42

                1                                      e  application,   including
                    particular projects that are in th                            the
                2   particular function, such as quality care.  They have     the
                3   nucleus of the program in the form of  a  contract  nowigoing  on
                                                                           I
                4   which has set the stage for the other  eleven  bigger  or  larger

                5   hospitals in the state to  follow  that  pattern.
                6             The hypertension program  which  was  athrus--. from
                7   us, as of last year they have .carried  the  ball with @hat and
                                                                          s@ .
    (sic)       8   have hypertensive programs going on  in  each  of the    ates.
                9             They have drastically  improved  as  far as the
                10  minority concerns their  Council  and  review  committee  have

                11  had in the past.
                12I           Their turnover of the  Regional Advisory Group    is
                    almost nil, and I feel that the  ARMP, the Arkansas RMP,    is
                13
                14  much of a stronger agency when  you look around at  the  CHP  and
                15  its  leadership  there  and,.the  E:ttes  program  --  in  particular,
                    in the EMS portion that is  being  funded  under  Estes.  They're
                i(i
                17  looking to ARMP for that  leadership and guidance to carry that
                18  program in the State of Arkansas.
                              Now, that's not to say how much money they've come

                    in and gotten for cancer -- or have received from the cancer
                20
                    program or the heart program  or others.
                21
                              Now, I'm responding only because of what was said
                22
                    earlier with the previous region,  and  you're  coming  to  a
                2:1
                    decision here.  I agree that the token figure of 140 percent
                24
                    is something to shoot for  after  the'May  1  application  is


  HOOVER REPORTING  CO,  INC.
  320 Massachusetts Avenue, N.E.





                                                                          43

                   received, and I really don't think your recommendation is  that
               2   far off, but I felt that I needed to defend this region just

               3
                   a little bit more, because we feel, at least at this@levels

               4   that they haven't done that bad a job.
               5             MR. THOMPSON:  You see, this comment is now pushing
               6   us down to looking at specific projects.  This is what worries

               7   me.

               8             MRS. WYCKOFF:  And we can't do it.  There'5 not

               9   enough information for us to do it that way.
              @io            MR. CHA14BLISS:  We do not propose to look at speci-
               11  fic projects, but simply the program and the objectives of the

               12; program at this particular state.
               13            I would say, based on the presentation from the
               14  presenter and Mr. Posta -- I would ask -- I perceive.the
               15  recommendation that Dr. Carpenter has made with regard to the
                   level of funding.  I have heard a number of items of rationale
                   as to why he arrives at that point, and I'm wondering if I
               17
                   could get a motion on the floor for your recommendation, Dr.
               18

                   Carpenter.
                             DR. CARPENTER:  Well, in view of some of the dis-
               20
               21  cussion, let me move that we  approve $1.5 rhillio'n@for Arkansas.
                             MR. CHMIBLISS:  It has been moved and seconded --
               22
                             MR. VAN WINKLE:  No second yet.
               2:1
                             MR. CliAl4BLISS:  It has been moved that the level of
               24
                   a million five be recommended for Arkansas.
               2;-)


  HOOVER RLPOKIING CO, INC.
  320 Massachusetts Avenue, N.[.





                                                                          44


                            is there a second to the motion?

               2            DR. VAUN:  Second it.

               3            MR. CHAMBLISS:  it has been seconded by Dr. Vaun..

               4
                            Is there discussion on the motion?

               5            DR. WHITE: I can sympathize with Bob  in  trying  to
               6  come up with a figure that's more than he wanted but  less  than
               7  they asked for, but I don't know how we come to  that  ration-
               8  ally. Is there some other alternative to  this?  Is  there  some
               9  way of saying they deserve to be considered for an  increase  in
               10 monies beyond that which they're currently  getting?  We  would
               11 not like to see them get more than the --'what do they  call
               12, it?   targeted funds, and preferably less.
                                           They didn't ask for the target --
               -13          MR.  THOMPSON:

               14 they only asked for 80 percent of the target.
               15           DR. CARPENTER:,.But they'll be up to 115  percent  by
                                            Al .
                  the time it's all over.
               17           MRS. WYCKOFF: They want $782,000  new.  That's  a  lot

               38 of new.

                            DR. SLATER:  May
               1!)                            I ask a question on this? On  !:he
               20 next round that we're going to be sitting on, are the  criteria
               21 going to be different than this round, or are we really  going
               22 to be looking at projects in the old way?
               2:@          MR. CHAMBLISS:  The criteria will be  the same.
                            DR. McPHEDRAN: We will not be looking  at  projects?
               24
                            MR. CHAMBLISS: We will just engage  in  the  project
               25


  HOOVER RLPURIING  CO,  INC.
  320 Massachusetts Avenue, N.E.





                                                                         45


                1 review.
                2          DR. SLATER:  Since this is on the floor, and  having
                3  known Arkansas in the past, I have to give the benefit of the

                .4
                   doubt to the staff in Arkansas under these situations'.  I
                5  think they've been through the mill and if there is a proposal
                6  that comes in that looks as if they're a little bit at sea, I
                7  don't know what else to do except say, "That's the way our
                8  country operates right now," and I'm inclined to move the
                9  money out of here so they can stay alive in their present-
                jo state of health or at least their desired state of health, and
                11 I'd like to speak in favor of giving them what they ask for.
                12.         MR. CHAMBLISS:  Any further discussion here?
                            DR. CARPENTER:  I have-obviously thought of that,
                   too, as an approach we can take.  I have-in the-back of my min
                14
                   Iguess, something which is going to surface repeatedly, and
                15
                   it might as well surface now.
                             I think that local planning efforts have been slip-
                17
                   shod and we're now moving toward a time when weire going to
                I 8
                J!) try to redo the mechanism for-local planning, and I believe
                20 that one of the messages that has to get back, one of the
                21 matters which deserves our consideration, is that you just
                   can't reward low quality planning, and I don't see that -- you
                22
                   know, for instance, as this region begins to choose who its
                2:i leaders will be in the health  plann.ing business, I think they
                2-1
                   need to choose very talented people, and I'm not anxious to


   HOOVER RLPURIING CO, INC.
   320 Ma@chusetts Avenue, N.E.







                I lead them astray.
                2          MR. CHAMBLISS:  Is there any further discussion on

                3 the motion?
                4          MRS. SALAZAR:  In an attempt to  sort of meet halfway
                5  between these two points of view, I would hope that the
                6  message that goes bac k to this region is not punitive in any
                7  way.  Certainly the staff must be having a pretty hard time
                8  with their strong leadership having disintegrated, and I think
                9  they need to be encouraged at this time rather than punished.
                10          MRS. WYCKOFF:  What about the kidney and the EMS and
                11 that sort of thing there?  Did you discount those as things
                12, that should be supplied from other sources?
                            DR. CARPENTER:  llell, frankly, I didn't.  I don't --
                13
                   it seems to me that the health planning leadership in an area
                14
                   might well invest some monies in assisting that area to  meet
                15
                   very specific goals of categorical federal programs, so  with
                17 that philosophy, then, I didn't get -- and from what I  heard
                38 about our guIidelines, I gathered that we could permit some of
                   this.  I didn't really -- I can't say I discounted those.
                            MRS. WYCKOFF:  What about this arthritis money?
                20
                            MR. THOMPSON:  That's  separate.  There.'s  a  @cial
                21
                   group of people out there (indicating).
                9
                             DR. CARPENTER:  Is that a core    I think that's
                2:i
                   part of their core activity to assist the region to develop an!,
                24
                   application for arthritis funds, and develop the regional
                25


  HOOVER RLPURI ING co, INC.
   320 Nlassachusetts Avenue, N.E.





                                                                          47

               1  system in support of that application.
               2             DR. SLATER: I wonder if there's some other alterna-

               3  tives available here.  lielve in the past been able to send
               .4 messages back.  For instance, staff guidance.  We've  been  able
               5  to lay out visits if we're concerned -- site visits  if  we're

               6  concerned about Providing allocates (phonetic) of money.  W  e

               7  have been able to Pass things  on -- for instance, hold it  over

               8  until the next round subject to review by an elite group.

               9             Are we under sufficient pressure here to respond  to
               10 this one-time allocation? It's a survival matter,  and  we  just

               11 use our best judgment here?

                             MR. CHAMBLISS:  Certainly we're called upon to  use
               12 @
               .131 our best judgment, but the region will get advice as this
               14 Whole round of review terminates, and the concerns being
                  expressed here now will be incorporated into the  advice  letter
               15
                  going to the region.
               1(;
                             DR. CARPENTER-.  Ihave a question here.  When  their
               17
                  July application comes in,  will it be a request for a  certain
                  dollar amount of supplemental'funds or will it be a reque st fot
               20 a new funding level?
                             MR. CHN-IBLISS: It will be for both. You  will  note
               21
                  in your column 'July 1 Estimate" that the  region  anticipates
                  that it will request a stun approximating $800,000.
               2:t
                             MR. THOMPSON:  Additionally.

                             MR. CHAMBLISS: That's simply a  request.  That  does
               25


   HOOVER KLPURI ING co, INC.
   .i
           Aienue, ti.E.






                                                                            48

                   not mean that that sum will be awarded, because you know    the

               2
                   over-all limitations that we have on total funding. jAll   of

               3   this will be fitted into the amount  of the  available  dollars

               .-4 that we have once the final decisions are made by --..e  court.

               5             DR. MILLER:  That $800,000 is going to be

               6   series of projects, new projects, right?

               7             MR. CHIU4BLISS:  Right.

               8             DR. MILLER:  On what basis are we going to make a

               9  decision  about awarding Arkansas  $800,000 for a bundle of new

               jo  projects?

               11            MR. CH-A-M-BLISS:  That is only an anticipated figure.

               12: That is what
               13            DR. MILLER:  I don't care whether it's $100 or
               14            DR. WHITE: It's going to be  on  the  sam6,amount  of
               15  concrete evidence that we have today-.

                             MRS. WYCKOFF:  Exactly,
               17            DR. SLATER:  It seems to me that we're going through,
               18  a problem whereby a traditional review committee  is  having  a
                   hard time learning how to operate like a council, and this is

                   in fact what we're being asked to do.  We're being given a
               20
               211 list of projects we are not able to  technically  analyze,  but
                   we're asked to look at their conherence within the framework or
               2-1
                   the history of the pro4qram and the objectives of RMP.  And it
               2:3
                   seems to me that's what the Council used to do, and it may
               24
                   well be that in the future, whatever comes out of the
               25


   HOOVER RLPURTING GO, INC.
           Au;-.niip.  N-E.





                                                                        49

               1  legislation, some other kind of-systern will have to be put
               2  together, but I would guess that we're not going to be able to
               3  operate comfortably like a traditional review committee and
               4  we are having to look much more at policy and staff security

               5  and so on.
               6            MR. CHAMBLISS:  We share your discomfiture.
               7            DR. SLATER:  I don't know how else to make these

               8  decisions.

               9            MR. CHAIMLISS:  Dr. Vaun?
               10           DR. VAUN:  As the seconder of the motion, I'd like
               11  to reaffirm my,second of the motion on the basis of the dis-
               12@ cussion I've just heard.  I don't see that this is in any way

                   a hindrance to the group.
               13
                            I think it would be dangerous to give them more
               14
                   money than the leadership can use At this point, and they have
               15
                   an opportunity to come back again, and if there's going to be
                   a total and complete presentation, if they get a few messages
               17
               38  on this round, there's no reason why the discussion can't be
                   different on the next.
                            I don't think this is a punishment or a harm to them.
               20
                   I think it's a rational decision on the basis of their leader-!
               21
                   ship at this point.
               9.)
                            MRS. WYCKOFF:  Call for the question.
               2:1
                            MR. CHAMBLISS:  I would simply ask that those in
               24
                   favor of the motion let it be known by the usual sign.
               2;-)


   HOOVER KLYUK II NG  GO,  INC.





                                                                                                                                                          co


                                                            (Ayes respond.)

                                 2                          MR. CHAMBLISS:                   Those opposed?

                                 3                          (opposed respond.)

                                 .4                         MR.  CHAMBLISS:    There  are  two  opposed,  Dr.  Slater

                                 5     and  Mr.  Thompson.

                                 6                          The motion is carried.

                                 7                          Did  you  have  further
                                 8                          MR.  PBSTA:    I  wanted  to  know what  is  the  official


                                 9     motion?
                                 10                         MR.  CHAMBLISS:    The  official  motion                                    is  tha@  it  is

                                 ii     recommended  that  the  level                           of  funding  for  the                   Arkansas
                                 12     Regional         Medical  Program  be                     placed  at  $1,500,000,  with  the
                                       concerns           expressed  by  the  members  of  the  Review  Committee
                                 13

                                 14    going  to          the  region.
                                                            DR.  CARPENTER:    Particularly  that  they  support  that
                                 15


                                       core.
                                 17                         MR.  CHAMBLISS:                   Shall  we          move  then  to  our  next

                                       region,  Bi-State?




                                 20



                                 21



                                 22



                                 2:@



                                 24



                                 25


     HOOVER RLPUR I ING  CO,  INC,
      320 M3SS3ChLISetts Avenue, N.E.





                                                             BI-STATE  REGIONAL MEDICAL PROGRAM
                                2                    MR.     CHAMBLISS:    The  reviewers  are  mr.  Toomey  and
                                3i   Dr.  McPhedran,  and  Mr.  Frank  Zizlavsky will  be  the  Staff
                                4    person  here  to  give  the  necessary  support.

                                5                     Mr.  Toomey.
                                6                     MR.  TOOMEY:    I  utilized  the  review
                                                      THE  REPORTER:    I'm  sorry,  sir,  I  can't  hear you.
                                8                      MR.  TOOI-EY:                  for  the  basis  of  this  discussion.
                                9                      In  reading  the  application  I  think  the  first  thing
                                10    that  struck  me  -- was  the  microphone  -- was  the  fact  that  the
                                11    Regional  Advisory  Group  disbanded  and  turned  over  the  respon-
                                      sibility  for  the  program to  a  15-man  executive  committee.
                                12;
                                      That  15-man  executive  committee  has  functioned.    However,  as
                                131
                                14    time went  on,  very  recently  the  program  coordinator  himself,
                                      Dr.  Stoneman,  resigned,  and  in  the  material  that was  sent  I
                                      had,  in  reading  it,  a  tremendous                          feeling  of  frustration  on  the
                                      part  of  the material  that was  written.
                                17
                                                        All  of  the  program  staff,  however,  seemed  in  terms
                                Is
                                      of  their experience  to be  an  Experienced  staff.    I  could  look
                                      the  figures  up,  but  it  seems  to me  at  the  present  time  they
                                20
                                      have  somewhere  in  the  neighborhood  of  eleven  program  staff;
                                21
                                      whereas,  their  organizational  program would  call  for  about
                                22
                                      nineteen.
                                2:1
                                                          In  looking  at  the  past  performance  and  the  accom-
                                24
                                      plishment           of  the  Bi-State  RMP,                  it  seemed  initially  in  tune
                                2


       HOOVER KLPUKIING CO.  INC.





                                                                         52

                1  with the heart disease, cancert and  stroke  programs,  although
                2  it was affiliated with both Washington University and St.
                3  Louis University and these two unive rsities  were  the  granting

              .4  agencies.
                5           Later in the program the major thrust was in emer-

                6  gency medical services.
                7           In looking at the even more.recent programs, thev
                8  have not substantially addressed the problems  of  accessibility
                9  and availability of care with the exception.of the emergency
              I,o  medical services, nor have thev addressed themselves to the
              11  needs of the minority groups, nor to  health  deliverv  systems.
              12  In fact, they are in a very, very  particularly  difficult  kind
                  of situation because they're attempting'to provide a program
              13
              14  for the rural Southern Illinois and the urban  St.  Louis  area,
                  and I'm sure that the conflicts in terms of the  needs  of  both
              15
                  these areas are expressed in terms of the variety of  programs.
              17            At the present time they are requesting EMS con-
                  tinuation grants, assistance to local planning,  including  some
              18
                  health manpower planning, quality assurance,  manpower  recruit-
              20  ment for the disadvantaged, and projects related  to cancer  and
              21  kidney disease.
                            Now, with the exception of the EMS, the projects
              22
                  that they propose do not in fact fall within a  document  which
              2:1
                  was in this proposal which was called, "The Health Needs of
              21
                  Bi-State RMP Region as Identified by Joint MIP and CHP
              25


  HOOVER KtrUXTING CO, INC.
  320 Massachusetts Avenue, r@.E.





                                                                           3


                1  Planning Conference."
                2            In February RMP and CHP met together and they
                3  selected three or four areas that they felt were necessary for
              -4   the development of programs within the Bi-State area  a need
                5  for improvement of emergency medical services -- and@that one,

                6  of course, they have worked on.
                7            Secondly, need to improve accessibility to quality

                8  health care.
                9            And the third was need to improve the availability
              io   of trained health manpower for the entire region.
              11             And the fourth was need to coordinate heal h care

              12   de livery planning.
              13             Skipping the feasibility for a moment-, as far as the
              14   funding is concerned my comment here would be that the projectc
              15   prob@lv could be accomplished, but they do not seem to be
                   compatible with the needs expressed in the joint -R-MP-CHP memo.
                             In terms of their relationship with comprehensive
              17
              18   health planning, despite the memo that is in the proposal from
                   RMP, my feeling in reading the comments from CHP -- well, I
                   noted them as being polite but restrained, and very restrain-
              20
                   ed.  I think I read into it, certainly, that there was not a
              21
                   tremendously happy relationship with that relationship.
              22
                             As for the funding -- you can read this with me
              2:1
                   I did not have it and I am interested in seeing it -- but at
              241
                   the present time the present level of spending annualized is
              25


  HOOVER RLPUKTING CO, INC.
  320 Massachusetts Aienue, N.E.






                                                                           54

                1 $870,000 -- almost $871,000.  The targeted available funds,

                2 $1,256,000.  The May 1 request which I am pres  ently discussing

                31 is $1,129,000, but there is a July 1 estimate of $410,000

              -4  which places them at a figure in excess of the targeted avdil-

                5 able.

                6            on the basis of my own review of this, reading this

                7 material, frankly -- and the feeling that  I  got  from@reading

                8 the projects and reading the comments and relationsh.'  s  with

                9 CHP, it would seem to me to be the unsuitability of -.,'le
              10  projects in terms of the direction in which   I felt -RMP was

              31  attempting to move itself.

              12.            I recommended only $800,000 in funding for this

              13  current recommendation.

              14             MR. CHAMBLISS:. Thank you.
              15             We will now call upon our second reviewer,  Dr.

                  McPhedran.

                             DR. McPHEDRAN: Mr. Toomey and I both  were  on  what
              17
              18  1 guess was the latest site visit, formal site  visit,  to  Bi-
                  State, and the program -- this regional medical program we
              20  thought at that time had had a lot  of  difficulties  with
              21  organization and there was some delay, as I  recall,  in  their
              22  getting triennial approval, and I think that was true of
                  several other regional medical programs, but we were always
              2:3
                  concerned about leadership in this program.
              24
                             They had had a great  many'problems  with-their


  HOOVER RLPURI ING CO, INC.
  19A fiq@rhij@ttt- Avenue. N.E.





                                                                                                                                                 55

                                     relationships  with  the  medical  schools  and  it  was  perhaps  a
                               2     blessing  in  disguise  when  the  medical  schools  withdrew,  but  I

                               3
                                     don't  really  think  that  the  program  leadership  appears  to  have

                               4
                                     entirely  gotten  --  once  they  got  rid  of  what was  really  an'
                               5     incubus,  that  is,  their  relationships  with  the medical
                               6     schools,  I  don't  really  think  that  they  got  any  sort  of

                               7     coherent  direction  of  their  own.

                               8                        And  I'm  surprised  to  see  that  the  Regional  Advisory
                               9     Group  seems  to  have  relinquished  its  responsibility  --  I  agree'!
                             l'o    with  Mr.  Toomey's  assessment  of  that.    I  thought  that  the

                             ii     Regional  Advisory  Group  itself  was  capable  of  providing
                             12:,   stronger  leadership  than  that.
                             13                         In  reviewing  the  projects,  I  looked  at  the  two  new
                             14     ones  sort.of  as  a  touchstone  for what  direction  they  wanted  to

                                     take  rather  than,  I  thought,  technically  reviewing  them.
                             15
                                                        I  think  that  the  RAG-or what was  left  of  the  RAG

                                     when  they  met  in  February  with  CHP,  I  think  that  they  felt
                             17
                                     that  the  rug  was  pulled  out  from  under  them when  no  new  EMS
                             18
                                     projects  could  be  begun  and what  they  have  actually-requested
                             20      in thd way  of  new projects  are  perhaps  a dim  reflection  of
                             21      what  they would  like  to  have.
                                                        Of  those  two  projects,  though,  one  of  them  does
                             22
                             2:i     address  minority  recruitment  and  it                              . has  been  such  an  important
                                     lack  in  this  program  before  that  I  think  note  should  be  made
                             24
                                     of  the  fact  that  they  seem  to  have  come  up                                  with  a  project  that,
                             25


     HOOVER RLPURIING  CO,  INC@
      12OMassachusettsAvenue,N.E.
     t'Ja@hincfnn nC, ?OnO?





                                                                         56

               I  in the bare bones that are given here, looks reasonable.
               2            The other new project, which is a study of what's
               3  happened to manpower trained in a consortium that they partly
              .4  sponsored, is something which I find myself not much in
               5  sympathy.  It seems to me that the study -- I don't see why  it
               6  requires this separate funding.
                            So that, rather than use this as a-part of  technical
               8  project review, I think that I would like to present it as a
               9  kind of example of what I think are the difficulties  that
              10  they're having in getting a program direction.
              11            Similar things could be said about some of the con-
              12  tinuation projects, but I was interested to note that  the
                  requests for quality assurance -- two of the requests  for
              14  quality assurance relate to programs in out-patient  practices,
              15  and I don't know whether,.that comes under the same kind of
                  scrutiny as PSRO in hospitals    Mr. ThOMT)son shakes his head

                  and says not -- because this is
              17
                            MR. THOMPSON:  Right now legislation restricts it.

                            DR. McPHEDRAN: The'restriction relates  only  to
              20  hospital-based activity, hospital and nursing home  activities.
              21  Well, that's what I thought, but I wanted to be sure about

                  that.
              22
                            MR. THOMPSON:  With the option, and you know damn
              2:1
                ii well they ain't going in that direction.
              24
                            DR. McPHEDRAN:  But the purpose of these projects    i


  HOOVER ELFORIING  CO,  INC.






                                                                          57

                1  for continuing support seems to me laudable, although I must
                2  say I didn't like what I saw as a technical matter in one of
                3  them. Nevertheless, I felt that their  purposes  were  laudable.

              .4             1 don't disagree with Mr. Toomey's  funding  level,

                5  because I find such difficulty in coming up with one of my

                6  own. It's very hard to know. I think that,  for  example,  the
                   request for core staff, which is about $550,000, as I  recall,
                8  for direct and indirect costs -- I assume that that's  based  on

                9  an expectation that they would have their eight plus five
              10   staff, a total of thirteen staff. Since that is  at  least  half

              11   of what we -- five-eighths of what we would be talking  about,
              12   I don't really know whether they can get along and  do  anything
              .13  worthwhile without increasing the core staff, but I'm reluc-
              14   tant to accede to the request to increase it by  that  amount
                   because I'm not really sure that they can use  the  staffing.

                             And Mr. Zizlavsky has been there recently, I  think,
              17   on technical matters., and maybe he could address himself  to

                   that question.
                             MR. CHAMBLISS:  Mr.oZee, will you fill in there?
              20             I-lR. ZIZLAVSKY: There's about three or four  areas
              21   I'd like to comment on,Iand I might as well comment on the
                 I program staff area right now.
              2
                             That $550,000 figure for program staff is really
                   gobbled up by indirect costs from these two universities.
              ,)4
                   That's Point 1.



  HOOVER RTFURI ING co, INC.
              ii. E.





                                                                         5 8

               1            These five additional staff    four of these staff

               2   are secretaries. They may be a little heavy in the secre-
               3   tarial area   in the secretarial-clerical area by having
               .4  seven secretaries for eight or nine professionals, so that may

               5   be a little too much.
               6            The basic other program staff request is for a

               7   deputy coordinator and what they would call a programs opera-
               8   tion -- regional outreach person.  I think these two are

               9   legitimate requests.
               10           A comment about the RAG responsibility and the
               ii  decrease from 75 members down to 15 members.  Going back into
               12. our history, not to drag this out, but May 1973 was aof go/no
                   go" type of month.  Everybody was down.  The results from
               14  RMPS came out in terms of recommendation for funding on  the
               15  phase-out plans.  Bi-State's Program -- final recommendations
                   for Phase-out on this program were pretty skimp
                                                                 y.
               17           By June 30th they probably had five or six total
                   staff on board.  I'm not asking for any sympathy from the
                   reviewers, but it was at this'time in may that the  Regional
                   Advisory Group thought RMP was really going under, and  this
               20
               21  was the main area where they delegated their  responsibility
                   to the executive committee.
               22
                             Subsequently they have come back and they are start-ii
               2:3
               24  ing to build right now in terms of increasing the RAG.  They
                   had not made that decision yet because of the future problem
               25


  HOOVER RLPUH I ING CO, INC.
   .l2DfA2ssachusettsAvenue.N.E.






                                                                        59

                  in terms of health resource planning.  why put types of
              2   people on Regional Advisory Groups which might not be the

              3   future type of people?
              -4            Mr. Toomey is correct that in several areas they,
              5   have not addressed accessibility and availability.  rhey hav
              6   improved in the area of minority representation.  Du ing the
              7   phase-in period they have been able to hire one minority
              8   person on program staff and they're leaning heavily On this
              9   person to really get into the St. Louis area, Which really  in
              10  the past they have not done.an effective job.
              11            I would have to go along with the recommendation for
              12  $800,000 considering the factor that the July request is a
                  $410,000 request.  They are under review for 31 projects
              13
              14  presently, which there isn't any  information  in  this.applica-

              15  tion.
              16            My best estimates in talking to  the  program  involve
              17  that they decrease the 31 projects down to 24 projects, and
              18  this is the $410,000 estimate coming up.
                            MR. TOOMEY:  May I ask Zee a question?
                            Was my feeling right about  the  relationship  between
              20
                  the CHP agencies and the RMP agencies?  I got a   elinc
              21                                                  fe      of

                  some conflict.
              22
              2:1           MR. ZIZLAVSKY: The only area  of  conflict  is  dealingi
                                                 e                              I
                I in the area of EMS. There was a subtle  arrangement  that  when  i
              24
                l@ the EMS activities started up and the eight contracts were
              25


  HOOVER RLPOK I ING CO,  INC





                                                                         60

               1   awarded from HSMA (phonetic) at the time, the St. Louis area
               2   came in with a rather large contract. Simultaneously it  was
               3   submitted to MT and we recommended a $200,000 recommendation

              @4
                   and they finally received $100,000, and they were one leg up

               5
                   on EMS planning for the St. Louis surrounding area.
                            This present project director, Dr. Wheeler, also

               7
                   has almost a million dollar project request in to the Kansas
               8   City Pegional office,-, which is their respective regional

               9
                   office, for new EMS legislation.  We had a phone call yesterda@
              10   from the regional office, and so we're on top of this situ-

              11   ation.
              12,           In getting very specific, the ARCH, which is the
              .13  Alliance for Regional Comprehensive Planning, in the St. Louis
              14   area is an eight-county CH P B agency, they wanted to get into
              115  the area of EMS planning,, but the RMP was funded in this area
                   for planning.  The National Advisory Council limited their
              17   activities to planning and training and there was an agreement
                   between the RMP and the CHP that the RMP do the work.
                            The conflict now coihes out in this application
             .20   because no signals were given from the Kansas City  Regional
              21   Office.  RMP can no longer get into this activity..  These are
              22   new monies.
                             I think you're going to see that this is just a
              2:@
              24   symptom of what's happening nationally.  Hopefully, we'll
              217) keep our -- we're on top of it, though.

  HOOVERRtrURf I riG CO,INC,
  320 fhassac@,usettsAventic, N.E.








                            MR. CHAMBLISS: Dr. Vaun.

               2            DR. VAUN: Could you elaborate just a bit on this

               3                                                       e
                 ,large amount of money that's being gobbled up indir ctly  by

               .4 the two universities -- just a little bit?

               5            MR. ZIZLAVSKY: Well, maybe  "gobbled  up"  w.

               6  strong.

               7            MR. THOMPSON:  Ripped off?

               8            MR. ZIZLAVSKY:  Pardon?

                            DR. VAUN:  "Ripped off,' he said.

               10           MR. ZIZLAVSKY:  As you casually look at th  indirect

               11 cost s rates established for St.  Louis  and  Washington Univer-

               12 sity, you have something like 80  percent rate for Washington

                  University and 68 percent for St. Louis University.
              .13

                            I attended their March -- no, their April   1974
               14

                  Regional Advisory Group meeting when they were discussing
               1.5

                  their money problems,  and everybody was concerned how to get
               i(i
               17 more money, and I suggested to them  that one of the areas they

                  might consider was to reduce their indirect costs rates as
               18
                  some of the Regional Medical Programs  have  done,  and
               J!)
               20           MRS. WYCKOFF:  They  haven't  don.e it nationally, then,
                  by putting a ceiling; it's all negotiated?
               21
                            MR. ZIZLAVSKY:  It's all negotiated, yeah.  Larry
               22
                  Pullen may want to comment on the technicalities of how these-@
               2,'3

                  i-don't know---
               24
                            MR. CHMIBLISS:  Well,  suffice it to say that it is a



   HOOVERKLPURTIRIGCO,INC,
  320N,IassachusettsAvenue,N.E. 1;





                                                                           52
                    negotiated rate and there would be very little that we could

                2
                    do at this point.  I simply bring that to the attention of the

                3
                    committee.
                .4           MR. THOMPSON:  Most universities have off  campus,

                5   rates
                6            MR. CHAMBLISS:  Mr. Thompson makes the point that
                7   most universities have off-campus rates.  That's nowhere near
                8   this.  Some do, yes -- most do, but in the case of this rate,
                9   it has been negotiated and we would be at a loss to  a e a

                10  change  there.
                11             The chair would entertain a motion on Bi-State.
                12             MR. TOOMEY:  I'll so move.
                13             DR. McPHEDRAN:  I second Mr. Toomey's motion
                14  assume it  was the
                               MR. CHAMBLISS:  It has been moved and seconded that
                15
                    the recommended level for Bi-State be $800,000.
                i(i
                17            Is there discussion?
                              DR. WHITE:  Could I ask -- this is the ceiling now,
                    $800,000.  Suppose the staff comes to looking at this whole,
                    thing and they devise some kind of formula whereby everybody
                20
                    gets X percent of what they ask for or what we said they
                21
                22  should get?  These people may end up with substantially less
                    money than they have this year.  is this what you want?
                2.'l
                              MRS. WYCKOFF:  What d6es  this do to the continuation!,
                24
                    projects that are listed at $500,000 there?  Are some of


   HOOVER REFORI ING CO, INC.
   320     Avenue, N.E.





                                                                           63

                   those capable of being terminated or phased out?

                2
                             MR. ZIZLAVSKY:  There's a total of 17  projects.
                3  Fifteen are continuations.  There are only two  new projects.

                4            MRS. WYCKOFF:  What about the fifteen?  Are mostof

                5  those


                6
                             MR. ZIZLAVSKY:  I'm trying to get -- in  t -is  of
                7  being continually supported by outside sources of   funding?
                8            MRS. WYCKOFF:  I wondered if thev could  be@shifted

                9  over to something else quickly, you know, if thev're dependent

              10  on continuations
              11             MR. VAN WINKLE:  Your staff and continuations come

              12   up to over a million.
              13             DR. McPHEDRAN:  I'd like to say something  that, in a
              14   way, is in response to what Dr. White said.  We had  an  in-
              15   formal conversation earlier in which we were  talking  about
                   what happens when this $115 million is to be distributed on
              17   relatively short notice and after so much phas@-out has
                   occurred, and of the two possibilities -- one, that it might
                   not all be used and, two,, that it might all be used but used

                   in a way that would not necessarily reflect favorably on DR-MP
              20
                   or the Regional Medical Programs -- I guess  that-I would
              21
                   really rather see the former.
                             I think I'd rather have us be in that position, so
              2;3
                   that's why, I guess, I favor these  low funding levels, because
              24
                   1 don't really feel that this program, this Bi-State Regional


  1'.DOVER REPURI ING CO, INC.
  320 tilassactiusetts Avei)ue, N.E.





                                                                           64

                1  Medical Progkam, can usefully employ a whole lot of money, and

                2  1 think I'd rather see some of it just not distributed.  1

                3  can hardly imagine that that will happen, but if I had to

               .4  choose, I think that's the way I'd choose to do it,  so  that's

                5  why I think I support Mr. Toomey.

                6            MR. TOOMEY:  I'm like Dr. Slater.  It's a little  bit

                7  difficult to be precise and to be totally objective about

                8  these things.

                9            As Dr. McPhedran said, we visited there     I  guess

               10  it was two years ago -- and in the course of two years there's

               11  much that slips your mind, but I'm certainly reminded  of  the

               12. fact that Southern Illinois, in the rural sections,  has  some
               .13 11 very, verv great needs and also great opportunities  for  some
               14  good planning because Southern Illinois University  is  tremen-
               15  dously interested in what goes on in those  rural  communities.

                             This is covered by Bi-State RMP, and there was

                   rather an impassioned -- I guess in a sense an impassioned
               17
                   discussion by one of the Southern Illinois  representatives  at

                   the meeting that we attended,'Pand I don't see anything  really

                   that relates to the rural needs of Southern Illinois.
               20
                             And then there is little or no doubt that in  both
               21
                   East St. Louis and St.-Louis that there are major  -roblems  of
                                                                      p
               22
                   planning and health delivery, concerns related to  accessibil- i

                   ity, availability, sponsorship of progr@s, and I   had the feel'
               24
                   ing both at that time and now  in this presentation that the


  [IOOVER HERUNIING  CO,  INC.
  320 Massachusetts Avenue, N.E.




                                                                            65

                1  staff was just not focused in to see what could be done,   even

                2  to study and to analyze and review and work toward those

                3 areas, and it may be, having been  there  and  having  undergone

                4  the kind of disillusionment, in a sense, that you would    feel

                5  and it's within this very subjective kind  of  feeling  that  I

                6  made the motion,

                7            A VOICE:  Call for the question.

                8            MR. CHA.MBLISS: I heard that the  question  ia8  been


                9  called.

               10            Is there further discussion?

               11            MRS. WYCKOFF:  This means it's less than they're

               12; getting now; is that correct?
               13            MR. CHAMBLISS:  The  recommendation is that  Bi-State
               14  be funded at the level of $800,000.
               15            DR. SLATER:  May I ask a question?  Would you recom-
                   mend that they be phased dut?  Ilm'wondering why we're setting
               17  $800,000.  What we're saying is
                             MR. T0014EY: I don't think they ought  to  be  phased

                   out.  I think that Bi-State as an organization should be
               20  divided into at least two parts.  It would mean the construc-
               21  tion of another unit, but I think that, as'far as-I'm concern-
                   ed, this would make sense.
               22
                             DR. SLATER:  Then I think some   kind of rationale for'
               2:1
                   this that's constructive in the,sense --   in the sense that youi

                   just put it --'if you go back with a  budget  cut  superimposed
               25


  HOOVER RLPURTING CO, INC.
  320 Ma@chusEtts AvenLe, N.E.
  Viaship.7ton, D.C. 20002





                                      on  top  of  a phased-out  program  that's  already  existing
                              2                        MR.  CHA14BLISS:    Staff will  take  note                                of  the  rational

                              3       and  the  concerns  that  you've  expressed  here.

                              -4
                                                        I'll  call  the  Question,  then.    Those                               in  favor,          let

                              5     it  be  known  by  the  usual  sign.

                                                        (Ayes  respond.)

                              7                         MR.  CHAMBLISS:                 And  those  opposed?

                              8                          (No  response.)
                              9                         MR.  CRAMBLISS:                 Then  the  motion  is  carried
                              10                        I  would  simply              ask  --  wetre  reaching  the  dinner
                              11      hour          the  lunch  hour,  rather  --  I  will  ask  before                                    we  break     i
                              12.    for  lunch  that  those  reviewers  take  just  a moment  to'complete
                              13      their      review  sheets,  and we'd  appreciate  it.
                              14                        And  then  I'd  like  to  get  a  consensus  from  the  com-

                                                                                                                                          of  1:00.
                              15      mittee  as  to when we  should  return.    It  is  now  ten
                                      I  would  say  --  I  would  suggest  if  we  could  be  back  by  1:30,
                              17      it would  give  this  committee  a  chance  to move  forward.
                                                         I  would  simply  let  you  know  that we  have  accomplish-i,
                                      ed  one  fourth  of  today's  workloadl  and  I  would  certainly  sqg-
                              20      gest  that  you  return  so  that we  may  complete  the  twelve
                                      regions  that we've  set  aside  for  this  day's  work.'
                              21
                                                         I  would  now  say  that  lunch  is  now  being  served.
                              22
                              2:3                         (Whereupon,  at  12:50  p.  m.,  the  committee  recessed,
                              24      to-resume          at  1,:30  p.  m.  of  the  same  day.)

                              2;-)


     ,qOOVER RLPOKIlliG CO,  INC.




                                                                                     67
  ID-PI4-5/22      1                       AFTERNOON SESSION                   1:35 P.M.
                   2              MR. CHAMBLISS:  If we could reconvene the Panel,
                   3  I would like to put you on notice about some adjustments that

                   4  we would like to make.
                   5              The first adjustment that we would call to your
                   6  attention   is that we have a new Recorder; Miss McClure is
                   7  no   longer with us and Mr. Dillingham is now our official

                   8  Recorder.
                   9              Secondly, I would have you note that Doctor White
                      has  to  be away from the Review Committee for an hour or so,
                   10
                      and he has asked if we would move        Georgia up just-below
                   11
                      Colorado-Wyoming, and that would       give him an opportunity to
                   12.
                      go away and return later on in the afternoon.  His co-reviewer
                   13
                      has been notified.
                   14
                   15             I would like you to note also that we would like
                      to move Wisconsin up in '@tp.place,of Iowa, and hopefully we
                   16
                      would be able to get Wisconsin tod       ay.
                   17
                                  MR. THOMPSON:  We don't have to stop, do we,in case
                   18
                      we go beyond that target?
                   19
                                  MR. CHANIBLISS:  Oh, no; we can go as long as the
                   20
                      Committee wishes, and I would encourage the Committee to have
                   21
                      a late dinner if it so wishes.
                   2---)
                                  DOCTOR SLATER:  Do you think there is         any possibili-
                   23
                      ty of finishing by later tomorrow afternoon?
                   24                                       e
                                  MR. CHAMBLISS:  We would endeavor to  do  so, and

                   25

   HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.[.
      @n, D.C. 20002
   tVashins





                                                                                68
   WHD-2        1   with your help, we can.


                2             I have a sense of where the Committee would

                311  to go in terms of the timeframe and the workload.  Are there

                4   other suggestions here?

                5             MR. TOOMEY:  Let's  finish  by  tomorrow  afternoon.

                6             DOCTOR SLATER:  That means getting the whole group

                7   together again by what -- 3:307

                8             MR. CHAMBLISS: I would like  you  to  note  that  on

                    Friday the two panels must reassemble.

                              DOCTOR SLATER:  We are suggesting that for 3:30
              10


                    tomorrow afternoon.

              12.             MR. CHABMLISS:  We will have to see how the other
              13    panel is moving.
              14              @iR. THOMPSON:  I can't be here Friday myself.
              15              MR. CHAMBLISS: There  has  to  be  some  coalescence

                    of the various recommendations from,the two panels, some

              17    coordination.
              18              I would then call next for review the application
                    of Colorado-Wyoming, and please note  that  Doctor  White  and

                    Mrs. Wyckoff are the reviewers, and Miss Mary Murphy is the
              20
                    staff person.
              21
                              Doctor White?
              22


              23


              24


              25

  iOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  ,Vashington, B.C.20002
  ,7n7l rArI.AF@RA




                                                                           69
  iqHD-3       1                   REGIONAL MEDICAL PROGRAM REVIEW


               2                           COLORADO-WYOMING

               3 1           DOCTOR WHITE: As a preamble,  I  might  mention  that

   k           4   I am a lumper rather than a sorter, so I have  looked  at  this

               5   in a rather global manner, rather than looking at projects.

               6             I have the.fortunate perspective of having made

               7   two site visits to Colorado-Wyoming in the past, and know SOME-

               8   thing about it from personal experience.

               9             I know Doctor Nicholas, who is the   present  coordin-

               10  ator of the Region.  Tom was Chairman of the   RAG for a  couple
               11  of years, and then decided to take on the job   of  coordinating

                   the program, and has done a commendable and worthy job.
               12,
               13            Tom is a fellow who has been known around the Region
                   for many years; in addition to his talents as  a  physician,  he
               14
                   runs a ski-resort, a small private  plane  enterprises  because
               15
                   he practiced in Buffalo,"Wy.oming  and this  required  commuting
               17  by airplane in order to go anywhere.
                             So he is well-regarded,  well-known,  and  ambitious,
               18
                   an energetic, relatively young man.  He is active in the area,
                   he is knowledgeable in the area and he is accepted in the
               20


                   area.
               21
                             The staff, according to the proposal presented to us
               22
                   at the present time, has been retained,  in  large  part.  This
               23
                   Region remained optimistic,.e.ven through the period  of  trial
               24
                   and tribulation. Most of them remained on  the  staff;  some  of

               25

   HOOVER  REPORTING  CO,  INC.
   320 Massachusetts Avenue, N.[. i
   Washington, D.C. 20002
   (202) 546-6666




                                                                            70

    WD-4       1    the names I recognize as having  been  there  two  or  more  years
               2    ago, and they are planning to,add even one    or two  more  to  the

               3    staff to deal with  this  Health  Resources  Planning  and  Develop

               4    ment, which seems to be the direction that they're told to

               5    go in conjunction with the Hill-Burton, CHP and others.
               6               There is an  adequate  description  in  the  application
               7    as presented, in which they  describe  the  Staff  and  the  indi-
               8    vidual qualifications, and so   far as I can  tell,  all  seem  to
               9    have the appropriate backgrounds, experiences and degrees.
               10   @d I believe there has been Washington staff visits out there
                 -  to assure that they have good management practices, and follou
               11
                    the guidelines'that have been laid down.
               12.
                               The Regional Advisory Group has continued to be very
               13
                    active. It has completed,  in  this  period  of  time,  a  review
               14
               15   of all past funded projects, since 1968.  Now, I've       forgotten
                    exactly how  many  of  thesepro]ects  there  were  altogethek;  I

                    think more than 20 -- obviously more than 20.
               17
               18              18 of these  are  now  self-sufficient,  either  being
                    run by someo ne else or generating  their  own  support,  and  six
               19
                    they feel will become self-sufficient when RMP expires.
               20
                               The Regional Advisory Group has been expanded in
               21
                    numbers to deal with the geographic dispersion that is
               22
                    required in Colorad-Wyoming, in  the  sense  that  they  can't  get
               23
                    together easily, and also expanded    to deal  with  certain  new
               24
                    objectives.  They have brought on talents'which have to do wit,i
               25

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



                                                                       71
  HD-5        1   developing health resources and things of that sort.

              2              They have continued to meet quaterly, as  scheduled,

              3   and almost every individual member of the  Regional  Advisory

              4   Group is said to have participated in other  committee  func-

              5   tions, and to have made site visits, particularly in reference

              6   to this review of past projects.

              7              It has reconsidered its goals, and has  determined

              8   that the Regional Medical Program of Colorado-Wyoming is a

              9   viable one and will continue, in some form or  another,  even

              10  after funding subsides.

              11             Its past performance, I think, is excellent, as

              12. witnessed by the fact that a significant number of  its  pro-

                  jibcts undertaken in the past are now self-sufficient and  con-
              13
              14  tinuing.  It has become an accepted and utili--zed resource;
                  for example, it was designated by the Governor of  the  State

                  to be that agency which weeuld undertake planning for the
              17  Emergency Medical Services for the State of Colorado,  and  I
              18  think in Wyoming as well. And it will  continue  to  function
              19  in this regard.
              20             It has --, in our past visits, and both Mrs. Wyckoff
                  and myself have been there -- I think we have  recognized  that
              21
              22  their goals and objectives are consonant  with those laid  down
                  by the office here in Washington.
              23
              24             So far as I can tjell,,without looking at the projects
                  in great detail, and basing my judgment  on the fact that I
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washiflgton, D.C. 20002
  (202)546-6666




                                                                       72
  ,IHD-6      1   trust these people, I believe that what they are proposing  to

              2   do this year will indeed be feasible within a year's time,  in

              3   large part, and will have some hope of continuing under.some-'

              4   one elsels aegis at the termination of the support f

              5   Washington.

              6             The activities proposed consist of seven  activities
              7   addressed to the problems of availability, accessabi@lity of

              8   care; one addresses the need for more primary care "ypes of

              9   individuals, and it is worthy of,note that the Regional

             .10  Medical Program in both Wyoming and Colorado was  instrumental
              11  in getting legislation passed to permit utilization pf  these

                  other professionals in rendering health care.
              12.

                            It-has two new and one old objective, which  served
              13
              14  the rqgionalizationalization concept; this is important,to
              15  this area because this is such a widespread  geographic  area,
                  with dispersed populatiohcpnters and very  sparse  population

              17  centers as well.
                            The only -- there were.some proposals which I was
              18
                  not sure were appropriate under the material that we  received

                  from Washington. They are proposing a Bone  Pathology  Center,
              20
                  which I assume has to do with cancer in large part, and it
              21
                  seems to me I read something -- and Mike, you can correct  me
              22
                  on this -- that some of these things were'to be taken over  by
              23
                  the National Cancer Institute, were'they not, in some way  or
              9@4
                  another?
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.C.
  Washington, D.C. 20002
  (202)546-6666




                                                                           73
   WHD-7         I            It also wants to continue a Cancer Registry,      which

                 2  I think is more appropriately under the support of the      Cancer

                 3  Institute, and radiation time-sharing studies.

                 4            Even in the past I had some concern    'L..L i cL L. F-hey   were

                 5  emphasizing  pediatric  dialysis  centers'inordinately,at  the

                 6  expense of certain other activities,  and  they  are  prop  ing

                 7  even now to establish a pediatric  nephrology  center,  to  the

                 8  tune of $83,510.

                 9            I don't believe their EMS activities confl    ct  w  th

               .10  the policy, in the sense that  they  are  continuations,  more  or

                    less, of what was going oh in the past, and   they  wil  not   be
                 11
                 12. operational programs, but mainly  development and pla   ning.
                 13           So far as I can tell from the letters of endorsement,
                    their,relationships with  Comprehensive  Health  Planning  are
                 14
                 15 amicable, and indeed, they dovetail very closely in some  of
                    the more remote areas; G@a
                                               ,nd Junction is one which  comes  to
                 16
                    mind, for example.
                 17
                              The letters were generally supportive, neither
                 18
                    vindictive nor overly filled with praise,  but  I  think  they
                 19
                    indicate that there is  a  good  relationship  between  Comprehen-
                 20
                    sive Health Planning and the Regional Medical Program and that
                 21
                    in all probability, there will be joint development of program4
                 22
                    for these health resources facilities.
                 23
                              The other comment I would'have   is that  the  whole
                 24
                    tenor of the application is one  of  reasonable  optimism  --  not
                 25

   HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.[.
   Washington, D.C. 20002
   (202) 546-6666




                                                                        74
  fHD-8         1 that Regional Medical Programs in its present form will   be

                2 continued, ad infinitum, but that they have at  least  estab-

                31 lished that they have a viable role in the State  of  Colorado

                4 and that the State Health  Department, the schools     whateve

                5 other funding agencies come along, vdl utilize  this  talent

                6 that is already there and not let it disband and dis@erse and

                7 be lost.

                8           I did not come to any firm figure in termsiof

                9 recommending support.  I have a certain undasy feeling of dis-

              .10 quietude in the sense;that I find  it difficult"to really under-
                11 stand how any Regional, no-matter how good it is, ca@ ask for
                12. a highly substantial increase in its sums, and in su h  short
                  period of time adequately reviewed their pertinence  to  their
                13


                  needs.
                14
                            Now, I can't say that for sure, because I  did  not

                  look at each of their projects in great detail, but  just  on

                  that general principle, I would  think.that, and it would  be
                17
                18 my recommendation, that Colorador-Wyoming be considered  for
                  the targeted amount, and I say that in terms of what  I  just
                19
                20 discussed and in terms of knowing that they are going  to  be
                  coming in in July asking for another  quarter-million  dollars
                21
                  and that in all probability they are not going to  get  what
                22
                  they asked for in any event.
                23
                            That would be my recommendation, that they-be
                24
                  allowed up to $1,587,,644, which is the targeted available funds
                25

  HOOVER REPORTING  CO,  INC.
  320 MassachusettsAvenue, N.[.
  Washington, D.C. 20002
  (202) 546-6666





                                                                           75
  EID-9        i    seen, with the option that they can apply for more,in July,

               2    which they expressed an intent to do.

               31              MR. CHAMBLISS:  Thanks for your recommendation,

               4    Doctor White.

               5               We will now call  upon  Mrs.  Wyckoff.

               6               MRS. WYCKOFF:  I made a very long report, and

               7    Doctor white has said most of it, so I don't want to take up

               8    more of your time with this.

               9               I feel that the characteristics of    this Region,.

               10   which is a very far-flung one, which       it  is the same dis-

                    tance from St. Louis to Washington as it is across     this
             .12,   Region -- that is quite a large Region, and their interest in
                    regionalizatioh and in reaching out,  and in their use of
               13
                    things such as the Emergency Medical  Services, and their
               14
               15   attempts to strengthen the services to this extremely rura
                                              1.
                    area, are very worthwhile-and very well-designed.

                               DOCTOR WHITE:  Doctor Nicholas is a real mountain-
               17
                    man, who understands  the  mountain   psychology.
               18
                               MR. CHAMBLISS:  He  is  from  Buffalo.
               19
                               MRS. WHYCKOFF:  He  knows how to work with this Board
               20
                    and he has kept their enthuasiasm up.  I think they are very
               21
                    fortunate in getting a man who not only was a rural person
               22
                    who understood the difficulties in the rural districts, but
               23
                    he also came into Washington,onbusiness,     he was sent on site
               24
                    visits by the RMP and learned a great deal about the whole
               25

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




  WHD10         I   complex works, so that he is a sophisticated man, and yet

                2   he is a man who has knowledge of the small rural community       s
                                                                             I

                3   mind.

                4              1 think he has done a very    successful job  in that

                5   Region, through a traumatic experience, and I believe they
                6   have done the best we could possibly expect from thJm.

                7              I agree with Doctor White's recommendatio  for the
                8   funding, and I would urge that we give them what the,y.ask for
                9   at this time, even though I think perhaps the question he
                10  raised about the  cancer  projects  may  have  some--vali'ity  and
                11  that those possibly can be transferred.

                               I would like to turn in this long-winded       itten
                12.
                                                                            7
                13  affair so  that it does not take up your time, but     it has com-
                    ments,on   anumber  of  the  projects.  Is  that  acceptable?
                14
                15             MR. CHAMBLISS: I  am  sure  the  staff  would  be  most
                    appreciative of your no@'e@,. and  they  will  take  into  account

                    your concernst '4rs. Wyckoff.
                17
                18             MRS. WYCKOFF: I have,some grave q!itstions in here
                19  about the  relationship of CHP and  RMP  in  terms  of  their
                    funding, and the agency that is going to pass judgment on
                20
                    the agency that funds it  now  and-how  you  work  out  these
                21
                    relationships in a  satisfactory  way,  but  I  assume  that  with
                22
                    the new legislation, all this may become'academic.
                23
                               So I would like to second'Doctor White's motion,that
                24
                    it be funded at the,requested amount.  I thi& they are capable,
                25

   HOOVER REPORTING CO, INC.
   320 MassachusettsAvenue, N.[.
   Washinoon, D.C. 20002
   (202)546-6666





                                                                          77
  WHD-11       1   of spending the money

               2              DOCTOR WHITE:  I suggested the targeted amount.

               3              MRS. WYCKOFF:  The targeted amount.

               4              MR. CHMIBLISS:  The matter before the Committee now

               5   is simply  a suggestion, and I would certainly ente.L,-ain a

               6   motion.

               7              MRS. WYCKOFF:  All  right.  I'll make a motion to

               8   that effect.

               9              DOCTOR WHITE:  I'll second that.

               10             MR. CHAMBLISS:  It has been so moved":

                                   "That the level of funding for Colora  do-Wyoming

                        RMP be set  at $1,587,644, which is the equivale t of
               12.

                        the targeted amount for that   Region."
               13
                              The Committee has expressed its concerns with regard
               14

                   to the cancer activities and
               15
               1(;            DOCTOR WHITE:  lpianey.
               17             MR. CHAB@ISS:  And the kidney activities as embraced

                   in the motion.
               18
               19             That has been properly moved and seconded.  Is

                   there discussion?
               20
                              In the absence of discussion, I'll call the question.
               21

                   All those in favor?
               22
                              (Chorus of "Aye,
               23
                              Those opposed?
               24
                              VOICE:  No.
               25

  HOOVER REPORTING CO, INC.
  320 Mamchusetts Avenue, N.[.
  Viastiington, D.C. 20002
  (7(L?l 546-fi666




                                                                         78
   WHD-12      1              MR. C@IBLISS:  The motion is carried, with one

               2   negative vote in the person of  Doctor Miller..

               311            it is so ordered.

               4


               5


               6



               7



               8


               9


               10






               12.


               13


               14


               15






               17


               18


               19


               20


               21


               22


               23


               24


               25

   HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.C.
   Washington, D.c.20002
   (202)546-6666




                                                                            79
   :WHD-13     1               MR. CHAMBLISS:  I  would  simply  like  alert  the

               2    Committee to stand guard for some momentary changes in the

               3    order here.
               4              -I have pointed out one, that Doctor White     will h'ave

               5    to leave, and we will take Georgia next so as to permit his

               6    temporary departure from the Committee, and then I would call

               7    to your attention the fact that our staff support for Illinoi.,,

               8    Mr s. Kyttle, has to be out of the roomi and I might say that

               9    she is one of the persons who has transferred from  RMP.      She

               10   has to be out of the room momentarily also, and she will

               11   return around 4:00.

               12.             We would then substitute   Indiana in place of
               13   Illinois.    We would make a change   in Inter-Mountain and Iowa,

                    and pick up at Kansas, Louisiana, and move down from that
               14
               15   point, so there are a few changes that I would ask the

                    Committee to take cognizance of.

                               We will now call upon   Doctor White again,  and
               17
               18   Doctor:Carpenter for a review of the application of  the
                    Georgia Regional Medical Program, and they will be supported
               19
                    by Mr. Jewell, from staff.
               20


               21


               22


               2.3


               24


               25

   HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.[.
   Washington, D.C. 20002
   i2n2)




                                                                              8o
    WHD-14                           REGIONAL  MEDICAL  PROGRAM   REVIEW


                2                                 GEORGIA


                3,1            DOCTOR IQHITE:   I'll  follow  the  same  general  format,

                4   but in reality, comments    are very  akin  to  those  made  previous-

                5   ly and only the names need changing, in a sense.
                6              Georgia is in a triennial status.  It's     been    awarded

                7   that in the past in recognition of its quality; again I have

                8   the advantage of  having  made  two  previous  site  visits  to  that

                9   Region, and have  come  to  know  J.  Gordon  Barrow professionally

               .10  reasonably well during those two visits.
                11             I ftnk one  can  say,  without  too  many reservations,
                    that Doctor Barrow   is one  of  the  better  Regional  Coo  dinators.
                12.
                13  He is the original   and only  one  in  this  particular  area;  event
                    prior,to his activities in the Regional Medical Program, he
                14
                15  was very active in similar sorts of activities in the State

                    of Georgia.
                               He  has  the   appropriate accent,  and  is   well-accepted
                17
                18  by one and all  in  that  area,  and. he has  done  acommendable
                1!) job  in  establishing  a  very  close relationship  with  the   Georgia
                    Medical Association -- or Society; I've forgotten which it's
                20
                    called -- so that they are the sponsoring fiscal agency.
                21
                               There has  never  been  this  conflict  of  interest  which
                22
                    seems to have arisen in certain regions between established
                2t3
                    medical  organizations  and  the  medical   programs.
                2,4                                     e
                               He has indeed cemented relationship, both in Atlanta@
                25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washington,D.C.20002
  (202)546-6666





                                                                      81
  WHD-15       I    and clearly out in the regions of Georgia.

               2              At least on my previous  site  visits,  it was my

               3    feeling that the people in   that area  who  attended the  visits,

               4    have come to recognize  that  the Regional Medical  ..,gram  of

               5    Georgia was indeed a resource upon which a wide variety of
               6    people could call for help, ranging from  patients  t@  health

               7    professionals.

               8              The taff, again, consists of thirteen ke  and

               9    stable people who have been there an average of five years

               10   and three months, and again, are  well-qualified  in  erms  of
               11   their backgrounds and degrees for positions  that  they  hold.
               12.            They are organized well into administrate e and
                    operational groups with defined responsibilities  and  areas  of
               13

                    operation.
               14
               15             The  Regional  Advisory Group has continued to be
               1(;  active; it meets regularly'..  In their words, it did not wither,.
               17   it developed alternate plans, not just for  the  phase-out,  but
               18   for its continuation beyond the-time when support would
                    wither. It even conducted  a  "retreat"  which  was apparently
               19
               20   well-attended by most of the members  of  the.Regional  Advisory
                    Group, in which they examined  the  alternative  pl ans for
               21
                    survival with or without Washington's support.
               22
                              Again, it is  clear  that'the  individual members  of
               23
                    the Regional Advisory Group  ilot,only  participate in the
               24
                    deliberations 'of the meetings, but participate  in terms of
               25

   HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.[.
   Washington, D.C.20002
   1909) MA-EgEp.





   WHD-16       I   serving on  committees,  making  site  visits  and  interchanging

                2   with Comprehensive Health Programs throughout  the state.
                3              Its past  performance  has  sometimes  been  misunder-
                4   stood.  It also has this regionalization, or "umbrel@la"       sort
                5   of concept, and in the  past  we  have  kind  of  thought  t  times
                6   that they were continuing   an old activity  under  a  new  name,
                7   but in reality they were cont   inuing a new  activity  under  an

                8   old name, is what it amounted to.
                9              And they have gone  out  and  they  have  used  community
                10  hospitals as a source or a center from which to spre         out,
                    creating a net of educational    care  facilities,   inves   gation
                    and the like, and the only  question  I  saw  in  the  whlole  appli
                12.
                    calkn was whether or not they should broaden out and@no longer
                13
                14  use )qst -hospitals as a  center,  a  focal  point,  but  perhaps
                15  that .there are other kinds  of  health  agencies  that  could  also
                    serve this function as a'elA., but  that was a comment.
                               They have indeed establi  shed   well-defined   catchment
                17
                    areas and regions  which  subserve.  their  projects  and  programs
                18
                    and activities, and by virtue  of  this  they  also  have  a  close
                1!)
                    relationship with the area Comprehensive Health Planning
                20
                    agencies.
                21
                               It  has  an  Emergency.Medical  Services  project  which
                22
                    is largely  that  concerned  with  planning  And  coordination.  Its
                    continuation by others at the present time is not clearly
                24
                    specified.  There is no hard    money, or  firm  commitment  by  any
                25

   HOOVER REPORTING Co, INC.
   320 Mamchusetts Avenue, N.[.
   WashiDgto,.i. D.C.20002




                                                                          83
   WHD-17      I    other agency or organization which indicates that it will con--

                    tinue, but@.p resumably something might arise on the scene.
               2

               3              Its objectives and priorities have  been  well  speci-

               4    fied in the past, and are unchanged at the  present  time;  they

               5    still have to do with availability and accessibility and

               6    development of new types of manpower and  utilization  and  net-

               7    works of specialized services.

               8              It also is undertaking a fairly extensive program

               9    for planning and developing health resources, and,I guess
               10   this raises a question in.my mind,  particularly  after  hearing

                    Doctor Paul's comments this morning, that alt  hougb the.se

                    Regions have been encouraged to  do this   what is@going to
               12.
                    happen if they expend a lot of money, a lot of time  and  a  lot
               13
                    of effort meeting, getting together, saying "This  is  what  the
               14
               15   health resources facility should be for the State of Georgia,"
                    and in the meantime Congress is passing a law which is dia-
               17   metrically opposed to this sort of thing?
                              Is this something that we  should  attend  to?  Should
               18
                    we say: ,No, let's not be doing that until we see, when the
               19
                    dust settles, where we're going to go." Or should we hope
               20
                    that by virtue of their doing something now  they'll  have  some
               21
                    future influence on Congress?  I don't know.
               22
                              Their relationship with Comprehensive   Health
               23
                    Planning, I believe to be good.  They  exchange  memberships  on
               ?,4
                    the respective committees and Regional Advisory Groups and
               25

   HOOVER REPORTiliG CO, INC.
   320 MaMchusetts Avenue, N.[.
   Vi@ilito;l. D.C@ 2WU
   (202) 546-6666





                                                                      84
  WHD18       1   boards; they have funded one another for certain types  of

              2   activities, there are certain adequate letters of  support

              3.  from the Comprehensive Health Planning agencies,  without

                          adverse comment.
              4   serious

              5             I think it is important to notice also that  they

              6   have not @- even though they were told they might  expect

              7   140 percent, they have not chosen to ask for it, and  they

              8   have also indicated that they felt they would not be asking

              9   for any money in July.

              10            They have given considered thought to what it is

              11  they would like to do and they want to get underway at  ..ie
                  present time, and it is going to take less money than  they
              12

                  thought they may possibly be awarded.
              13
              14            It seems to me this does reflect some thinking, some.
                  merit.  This is a Region  of merit, a Region of past perform-

                  ance, and I would feel they.are entitled to what they

                  requested, or any fair proportion thereof that is  finally
              17

                  evolved.
              18
                            MR  CHAMBLISS: All right; our next  reviewer  for
              19
                  Georgia is Doctor Carpenter.
              20
                            DOCTOR CARPENTER: Well, it is always  a  pleasure
              21.
                  to follow Phil, because he makes it so easy.
              22
                            I would just -- this application was an  enormous
              23
                  relief to me.  I thought in.s.ome areas that maybe I was wrong
              24
                  about Regional Medical Programs, and I found that if I was, at
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washingtoii, D.C. 20002
  (2021546-6666




                                                                       85
  WHD19       1    least Gordon Barrow in Georgia agreed with me.

              2              So I can hardly say enough good things about the

                I
              3    Region.

              4              You know, for instance, they don't charge indirect

              5    cost rates, except on a few    I don't know:76-46 -@  less

              6    than $100'.000 in the total program of nearly three_lus
              7    million dollars -- less than $100,000 of indirect cjsts.

              8              They have their own goals; they are leading  the

              9    development of the health-care system in Georgia, I believe,
              10   as much as any organization I have ever seen 1"ead in such a
                   complex environment as the state, among its health  are pro-

              12.  viders and interested consumers.

                             They have their own goals and they are  pursuing
              13
                   them actively, but they take full advantage of Federal prior-
              14
                   ities, and move in new areas with amazing speed.
              15
                             They have responded to the minority problem very
              17   well; there are -- there are a large percentage of minority
                   people, particularly in the projects.  They
              18
              1!)            I am tempted to read two paragraphs out of the pro-
                   jects, because they contrast so much with the Arkansas descrip-
              20
                   tions and some of the other ones I have seen -- not really
              21
                   trying to single out Arkansas, but to make the point  that
              22
                   these people do have specific goals, they do indicate in their
              23
                   project descriptions their understanding of the pitfalls in
              24
                   developing.  You know, no matter what you try to do, t ere arei
                                                                                 i
              25

  HOOVER REPORTING CO, INC.
  320 tAassachusetts Avenue@ N.[.
  Washington, D.C. 20002
  l')n')l rar.tgrr,





                                                                          86
    WHD20      1   always problemst and they indicate, I believe, that they are

               2   aware of the importance of the problems.

               3              And I could go on and on, but I would agree with

               4   Phills funding recommendation, and I would make a motion then

               5   that we approve support of the level requested.

               6              DOCTOR WHITE:  I'll second that.


               7              MR. CHAMBLISS:  There is a motion that:

               8                   "That the funding level  for the Georgia

                        Regional Medical Program be set at $3,629,757, which

               10       is the total amount requested by the Region.11

               11             MR. VAN WINKLE:  And you tight note that they donl.t

               ,2,  propose to come in July 1.

                              MR. CRAMBLISS:  Now that you have heard the motion,
               13
               14  is there discussion?  Mr. Thompson?
               15             MR. THOMPSON:  Some people may not know that they
                   have had probably the most'successful EMCRO programi which was
               17  an Experimental Medical Care Review organization, and they
               18  have been designated, I think so far, as the only statewide
                   PSRO, which also indicates the kinds of togetherness that
               20  somehow this state manages to put together.
                              MR. CHAMBLISS:  All right; further discussion on
               21.
                   Georgia?
               22
                              Then I'll call the question.  All those in favor of
               23
                   the motion, please say "Aye..Il
               24
                              (Chorus of "Aye.")
               25

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



                                                                      87
  qHD21       1              And those opposed?

              2              (No response)

              3i             There is no opposition, and I would simply say to

              4   the staff, as they convey to the Council, the observations

              5   -- the recommendation made about the Region in  addition  to

              6   the level of funding support recommended.

              7              I would ask Doctor White, in that he will be  leav-
              8   ing shortly, if he would be kind enough to prepare the  review
              9   sheets, and we would very much appreciate that, and you  like-

              10  wise, Doctor Carpenter.  Thank you.

                             DOCTOR WHITE:                ose: do  ou want these
              11                           The question ar        y
                  signed?  Should they be signed?
              12,
                             MR. CHAMBLISS: We have no aversion to them  being
              13
              14  signed; it is not required, but if you like. We can  be  much,
                  more specific in our observations.
              15
                             DOCTOR WHITE: You know it comes from  one  of  two


                  people anyway.
              17


              18


              19


              20


              21


              22


              23


              24


              25

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



                                                                         88
  WHD-22       1             MR. CHMIBLISS:  I would indulge the Committee and

               2   Doctor White for one further observation here, and that is

               31  that Doctor White is also scheduled to review today the appli-

               4   cation for Louisiana.


               5             Would you be disposed at the moment to continue,

               6   Doctor?   -or would your time not permit?

               7             I only call upon you on that momentarily.  It is

               8   not required, however.

               9             DOCTOR WHITE:    Well, my hesitancy reflects the

              10   fact that I don't see Doctor Perry here.

                             MR. VAN WINKLE:  Doctor Perry will not be on the


                   Panel.
              12,

                             DOCTOR WHITE:  Therefore, I am the  only person who
              13
              14   is going to have any say-so about Louisiana, I guess.

                             MR. CL@IBLISS:   You will have support from staff,
              15
                   however, in the person ok Mr. Zivlavsky.

                             DOCTOR WHITE:  It would make me more comfortable to
              17

                   do it at a later time.
              18
                             MR. CHAMBLISS:  Indeed so;  no problem.at all.
              19
                             I would then call the attention of the Committee to
              20
                   the application from  the Indiana Regional Medical Program.
              21.
                   The reviewers there are Doctor Slater and Doctor Thompson.
              22
                             I have skipped Florida.  I waAd     if the Committee
              23
                   will indulge my mistake, I will change that and revert back to
              24
                   Florida, and then come to Louisiana.  I wo@ld thereupon call
              25
                                                                         lw
  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washingtofi, D.C. 20002
  (202)546-6666




    WHD23       1  upon Doctor @liller, who will be supported by Mr. Van Winkle,

                2  from staff.




                4


                5



                6



                7



                8


                9


                10


                11


                12.


                13


                14


                15






                17


                18


                19


                20


                21


                22


                23


                24


                25

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




                                                                                   90
   IHD-24        1                     REGIONAL MEDICAL PROGRAM REVIEW


                 2                                FLORIDA
                 31               DOCTOR MILLER:  I probably have a little bit differl

                 4    ent point about many of these things than many other members

                 5    of this Committee, having directed a Regional Medical Program

                 6    for seven years, and I tend to be a little critical, which I

                 7    hope you'll bear with me, and I won't feel offended if  you

                 8    vote down my views.more liberally than I make judgments.

                 9                Florida, our Regional Medical Program has been an

                 10   outstanding RMP; for a long time       it has the second  highest

                      current level of annualized funding, according to our list,

                      under California.
                 12

                                  It is an ambitious RMP; it has always has an ambi-
                 13
                      tious,program.  It is well organized, with good leadership,
                 14
                 15   good program staff, excellent Regional Advisory Group, excell-
                      ent past performance and"acpomplishments -- I could go           on and
                      give details of these things, but there is not much  point.
                 17
                 18   They are all very good.
                                  Their objectives and priorities are not quite  so
                 19
                 20   succinctly specified or controlled, but nevertheless do addrest
                      the program activities, address all the key issues that  we
                 21

                      focus on.
                 22
                                  I dan't find anything really wrong with any component
                 23
                      of their application, which.i.s large, for three million dollar
                 24
                      the staff's only question for Reviewers' attention was  the
                 25

   HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.[.
   Washington, D.C. 20002
   (202)546-6666




                                                                     gi
   WHD-25     1    MAST program, which is an EMS component, but staff didi'l.it

              2    feel that there was any problem here.
              3              So the proposal, the operational  activities  and  all
              4    are   indeed congruent with the Region's explicit priorities
              5    and suggested areas of emphasis, and they  get  along  well  with

              6    CHP, and the CHP relationships are good.

              7              So then you get down to the problem which I
              8    addressed in all of these five'that I reviewed in detail,

              9    under a couple of basic principles.

              10             The first one was that virtually all  the  RMP's
              11   should be given complete support for their  core  staff  and-for
              12.  continuation of program activities that  they  have  gotten

                   started and that have been going all right.
              13
                             But then   provided the budgets are not doubled
              14

                   or tripled, that is.
              15
                             But-then the pr@blem-of. new projects and  the  feasi-
              17   bility of getting them completed in a successful way, with a
                   meaningful impact, with recognition as an RMP activity  in
              18
              19   one year, seems to me to be quite a big question.
              20             The staff did not summarize, in the Florida  program
                   here the answer to the ques tion:
              21
                                  "Are continuation projects budgets raised too
              22
                        much for the next year, out of proportion to what they
              2tl
                        have been this present
                                               year?"
              24
                   And I would like to ask staff if that is true, because  a
              25

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




                                                                          92
  WHD-26        1  number of these projects have rather  large  budgets,  nuch  the

                2  same, however, as you have just   reviewed in the Georgia

                3  program, with rather tremendous   individual budgets for some

                4  of the program activities.

                5             And in Florida, in the Florida RMP,  the  numbers  of

                6     lost my page here, but there are something like -- 35

                I  projects, of which 25 are new, I believe.  22 are new, and not

                8  previously funded#, and if one goes into  those  projects,  there

                9  are a number of them that  are  certainly  very  questionable-as
                10 to whether they can be  successfully  and  very  conscientiously
                11 completed in one year, activities that   would be worth  the
                12. rather large budget requested.
                              The bilingual communications system of    translation
                13
                14 from tnqlish to Spanish, of $121,000, without any    real indica-
                   tion that it is going to be continued by anybody else.

                              A number of the@e.  Visitor assessment   of  visitor's

                   needs for health care of visitors   to Florida, with a budget
                17
                   of $139,000, a Flori da perinatal program, which is an obviously
                18
                I!) needed thing, but with a budqgt of $212,000 and no real indica-
                   tion exactly as to whether they would  be  continued,  except  to
                20
                   say that efforts would be initiated to try to find    out if they
                21
                   can be continued.  One would hope so, for $212,000.
                22
                              Improving health care  assessment  quality  assurance,
                23
                   which is an excellent plan,.  in  community  hospitals.  Anybody
                24
                   who has worked in  one of those things, in those endeavors,
                25

  HOOVER REPORTING  CO,  INC.
  320 Massachusetts Aver,@e. N.C.
  Washiiigton, D.C. 2u@, 2





                                                                           93
  WHD-27       1    which we did-, knows that there is a very  limited  amount  you
               2    can accomplish in one twelve-month period  and  a  budget  of

               3    $212,000.
               4              A program to start  a  midwifery  project,  which  is

               5    obviously very much needed in many  places  in  this  country

               6    but it  is one mid-wife with a budget of $87,000.

                              An Indian health care program for acute critical

               8    illness.in Indians; we started developing  one  of  those  in

               9    Minnesota, figuring it would take at least three years to,get

               10   it  going.
               11             So, I find myself being critical of dealing     out
                    rather tremendous amounts of money, even to what I regard as
               12,

                                                                ctivities like this
                    one of the best RMP's in the country, to a
               13
               14   that have relatively high budgets and, I think, somewhat
                    questionable potential for comparable achievement.
               15
                              Now, if the RMP@was likely to be funded for another
                    three-year period, every one of   these things would  be  good,
               17
               18   and they would be ahead.  We'll-come  to  Missouri  later,  and
                    I think the situation is similar there.  They would be ahead
               19
                    .of the game, because they would have.started things, moved
               20
                    very rapidly in their very large endeavors, and    then moved
               21
                    right ahead then with some critical key  issues  and  have  a
               22
                    year's head start on a lot of other  programs  that  then  will
               23
                    start three-year projects of such things.
                                                     e
               24
                              So in terms of that, obviously one should okay
               25

  HOOVER REPORTING CO, INC.
  320 itawchusetts Avenue, N.C.
  Washington, D.C. 20002
     CAE rcc!c




                                                                        94

  WHD,-2 8    1    their funding.
              2              They also plan to come in for another application

              3    in July, for another one and a half  million dollars.

              4              So they're not modest.  They are good, but not
              5    modest.   Applying for a total of four and a  half  million.

              6              I fail to be able to differentiate the  charge  to

              7    us of reviewing these things without considering  these  cost-
              8    benefit aspects of particularly new-project activities,  and
              9    consequently -- well, my first-recon'unendation after studying
              10   all this was that they be cut by a million and a half.
              11             I guess, in view of what has gone on  this  morning,
              12,  I would say that was an unusual recommendation, and therefore
                   1 would -- well, I would like to hear  Staff's reactions,
              13
                   since the other Review Committee member is not here.
              14
              15             MR. VAN WINKLE:  In terms of the continuing support,
                   Doctor Miller, I can only go on their past record,  which  has

                   been excellent.  That has been one of their main objectives
              17
              18   in their cost-sharing of funds, 'and I just noticed the  one
                   statement in here that since July of  171,$3.7 million  have
              20   been invested by the Florida RMP, and that was augmented then
                   by $5.2 million of other funds that they were able  to  drum
              21
                   up, and then after completion of the FRMP support,  they  con-
              22
                   tinued a number of those projects with other funding in the
              2.3
                   amount Of another one and a half million.
              24
                             So they have had a very good record of continuation
              25

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




                                                                         95
  WHD-29       1   after their phase-out.

               2             Now, I noticed, too, some  of  @e  large  increases
               311; in budgets, and did check this out, Doctor  Miller,  and  parti-

               4   cularly on their continuations; their  budgets  were  jumping

               5   very  high.

               6             DOCTOR MILLER:  Oh, yes; maybe twofold.

               7             MR. VAN WINKLE: And what I found  out  is  that  we

               8   were comparing against four-month budget;  the  previous  budget

               9   that you were looking at was only for  a  four-month  period.

              10             DOCTOR MILLER:  I did not have the previous

              11   they ate not in here, the previous budgets.
              12,            MR. VAN WINKLE: No, but I went  back  to  check,  an
                   it looked like a horrible jump, but then when   I  annualized
              13
              14   that 'against this, and as an example, I just pulled  one  out
              15   here.
                             They had started-out only in two  counties,  and  it
              16
              17   was a pilot study; they now are moving out into  all  67  count-

                   ies of the state.
              18
                             The one on the next page, for example,  was  a  pre-
              19
                   test pilot program in three hospitals.  They  are  now  moving
              20
              21   that computerized system that they  developed  into.a  state-
              22   wide program now.
                             And as I went through each of these,  I  found  that

                   you know, that type of justification. The  one  on  the  commun-
              24
                   ity organ-donor program, that started only in  Dade  County;  it
              25

  HOOVER REPORTIliG CO, INC.
  320 Massachusetts Avenue, N.[.
  @V"@ington, D.C. 2@
  f?A? I c2r-Ap.;sl




                                                                              96
  4HD-30        1    is now moving out into four surrounding counties around Dade,

                2    and it will increase the capability.

                3              And I think one other thing I would like to mention

                4    about Florida, along with the other good things you say, is

                5    that they also do not have an indirect cost rating.

                6              DOCTOR  MILLER:  No.  They  are   a   separate   corpora-

                7    tion which has its costs all direct.

                8              MR. VAN WINKLE:  I   am not sure what other -- I

                     really can't say anything as   to the-continuations,, other   than

                10   the fact that their past record    has been excellent.

                11             DOCTOR SLATER:  May I    ask  a question which bears

                12   on the indirect versus direct charges?

                               Are the direct usually less than the indirect
                13
                14   charges being made by universities or other institutions?

                15             MR. CHAMBLISS:  Yes, they are.
                               DOCTOR  SLATER:   @Considerably   less?
                17             We seem  to  be  very  concerned  about the indirect
                18   costs that are  charged  to  the  program.  I  am just trying to
                19   get a fix on the  difference  in  amounts,  or  apercentages let's

                20   say.
                               MR. VA N WINKLE':  Well,-let's  assume  that  you  had  a
                21
                     two-million dollar grant to   a program.  You might have anotherl
                22
                23   80 percent of that  added on  to that, that  we  have  to  put  out
                     in terms of indirect costs.
                24
                               DOCTOR  SLATER:  Right,  but  if  you  build  the  direct
                25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washington, D.C. 20002
  (202) 546-6666




                                                                          97
                                                                uld that
  ID-31            costs into the two million dollars, what wo            total

               2   package come to?

               3              DOCTOR MILLER:  I can  answer  that  partly.

               4              It depends a lot on how the big institution hand es
               5   its accounting for indirect  costs.  If  the  big  insti  union,
               6   now, like a big university     we ran through  this  inj
               7   Minnesota, because a part of ours was a university component
               8   and may have indirect costs      now, if the universit  figures

               9   its indirect costs across the board, with all depar  ents,

               10  which includes all laboratories and research units and so
               11  forth, and they got all the costs of all those research units
               12. built into the total indirect cost rate, then a    desk@operation
                                                                         II
                   like RIAP is charged an exorbitant amount  of  indirect@@costs.
               13
               14             If however they have two levels -- and they fre-
               15  quently do -- and toy cost-account indirect costs on the basis
                   of the kind of work we ar@ doing, then it is  --  it  may  not,
               17  depending on how efficient the big  organization  is  --  their
               18  indirect costs may not come out.any bigger than  if  you  do  a
               l@) direct cost.
               20             MR. VAN IIINKLE:  Doctor Miller, you were talking
                   about this Region looking ahead, and  that  is  precisely  what
               21
               22  they are doing during  phase-out.  They  did  not  stop.
                              They said:  "No way are'we phas  ing out;" they never
               23
                   at any time believed they Were going to phase-out and they
               24
                   continued their program, and when the June 15th turnaround
               25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washington, D.C. 20002
  (202) 546-6666





                                                                           98
   WHD-32      I   came, they were way down the road.  That  is  precisely  the  way

               2   they are going to look at it right now.

               311            DOCTOR MILLER: I  expect that is precisely  what  the
                                                                                  y


               4   are working on right now.

               5              MR. VAN WINKLE:   They intend to be whatever organize-

               6   tion that  is that responds  to the new legislation.  That is
               7   their intent, whether it has,anything to do  with  thils  appli-
               8   cation or not -- but I do know that is their intent.@

               9              MR. CHA14BLISS:  I might simply suggest to  oc or

               10  Slater, if I may, that as we move from the world of  ounda-
               11  tions to the world of institutions,  this  issue  will  ecome  a

                   very keen one, about indirect costs.
               12,
               13             DOCTOR SLATER:  I'm sure it is.

                              MR. CHAMBLISS:  It is one that has  been  rather  per-
               14

                   plexing for many of us.
               15
                              DOCTOR SLATER: Foundation spending   is  very  simple,

               17  by simply  saying:
               18                  "We never-pay anybody .more than 15  percent,  if
                        that; we  can't  do  it."

                              MR.  CHAMBLISS:   Iwonder if the Reviewer, Doctor
               20
                   Miller, is now  --  are  there further questions?  I would enter-
               21
                   tain -- I would like to have  a recommendation, and I see
               22
                   Doctor Vaunts hand.
               23
                              Doctor Vaun, did yQu have a question?
               24
                              DOCTOR VAUN:  Yes.  Winnie,you  raised  the  question
               25

   HOOVER REPORTING CO, INC@
   320 Massachusetts Avenue, N.[.
   Washington, D.C. 20002
   (202)546-6666




                                                                        98 .-A
  WliD-33     I    about the possibility of these projects after a year, or the

              2    possibility of accomplishing the objectives and goals within

              3    a year.

              4              I wonder, if in the stage of transition now,  that

              5    is a legitimate question?  Not considering Florida's past

              6    performance, but I wonder if that is a real question on  our

              7    part in this panel? I would just like some  reaction  to  that.

              8              To me, it sounds like  you are questioning the

              9    whole management ability of that program when you ask that
              10   question. In other words,.if they didn't  think  that  there
              11   was either a reasonable chance of follow-through  with  funding

                   from other sources, or a reasonable chance that they would
              12.
                   accomplish their objectives, than how can you say in one
              13
              14   breath that it is a reasonably well-managed program, and yet
              15   you have sizable questions about the money?
                             DOCTOR MILLER-" When RMP's first started, the  RMP
              16
              17   was a source of "soft gold" from the Federal  Government.  I
                   went through this, in the process of getting people  to  change
              18
                   because these are the kinds of budgets we had in all our

                   applications.  They were huge.
              20
                             Now, it is quite obvious -- if you haven't heard@it,
              21@
                   but it has been expressed very widely -- RMP is now  another
              22
                   source of soft gold for one year, only. All  the  frozen  money
              23
                   has been released, and P14P now has'more money in one year thar
              24
                   they had before.
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washington, D.C. 20002
  (202)546-6666




                                                                           99
  D-34          1             Now, I don't -- maybe you don't      I'm not sure
                2  that it is politically desirable to try to react against

                .3 that at this circumstance.
                4             MR. VAN WINKLE:  Doctor Miller, I am familiar with
                5  the review process.  I have been at some of their meetings,

                6  and it is probably one of the toughest groups I have ever

                7  encountered.
                8             As I mentioned to you this morning,'  at  the  last  RAG
                9  meeting I attended, they  became  so  personal  I  almost  wondered
                10 if there was going to   be  a little bloodshed.
                11            Staff are involved with the development.of that pro-
                   gram  from Day One, and long before many of those proposals
                12,
                   ever come to the first  committee  in  the  review  process,  Staff
                13
                   has already been at work on their budgets.
                14
                15            They have two different review groups that have a
                   go at those, and again, @o
                                               'p.can get reductions in any one or
                1(;
                17 all three of those three  review  groups.  I  sat  through  one  on
                   a Saturday, and then on the Sunday I thought all the slashes
                18
                19 had been made, and then went to    the Council meeting on a
                                                   0
                   Sunday and found out that it was not resolved at all.
                20
                              DOCTOR MILLER:  Yes.  The letter says that it had
                21,
                   over 100 projects applications that they reviewed.
                9-2
                              DOCTOR CARPENTER:  How many did,they accept?
                23
                              DOCTOR MILLER:  35.
                24
                              MR. THOMPSON:  May we arrive at some kind of money
                25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washington, D C. 20002
  (202) 546-666@6





                                                                       I-- iuu


  RIID@35     I    here ?

              2                                                      n a moti
                             MR. CHAMBLISS:  The Chair would entertai         on


              3    based on the presentation.

              4              MR. THOMPSON:  I'm not going to let him o'..  te

              5       off the hook; he hasn't made a recommendation.

              6              DOCTOR MILLER:  All right.

              7              They are planning on coming in with a million and

              8    a half-more application.  Their target total is $3.' million,

              9    they are applying for three million now.  Their current fund-

              10   ing level is $2.3 million.

                             I would  recomme.nd a funding level of $2.71million.

                             MR. CHAMBLISS:  The  r.ecommendation is a funding
              12,
              13   level of $2.7 million  for Florida.  Is that in the form of a

              14   motion, Doctor?
              15             DOCTOR MILLER:  If you wish.
                             MR. CHA@IBLISS: /And is, there a second?
              17             MR. THOMPSON:  I will second it.
              18             MR. CIIAMBLISS:  It has been moved and seconded:
                                  "That the funding level for Florida be estab-
              20        lished at $2.7 million."
              21.            Is there any discussion?
                             (No response.)
              2.)
              23             If there is no discussion, are you ready fcr the
                   question?   Those in favor?
              24
                             (Chorus of "Aye.')
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.C.
  Washington, D.c.20002
  (202) 546-6666






                                                                                                                                           101

    WHD-36                                             Opppsed?

                            2                           (No  response)

                            3                          The  motion  is  carried,  and                       it  is  so  recommended,                    att

                                    $2.7  million.

                            5                          I  would  say  that  the  Committee  is  moving  a  ong

                            6      rather  well,  and  that  we  will  go  to  the  next  Regiona    Review,

                            7      and  that  is  Indiana.


                            8


                            9



                            10






                            12.


                            13


                            14









                            17


                            18






                            20


                            21


                            9.?



                            2.3


                            24


                            25

    HOOVER  REPORTING  CO,  INC.
     320 Massachusetts Avenue, N.[.






                                                                             102
  WHD-37         1                REGIONAL MEDICAL PROGRAM REVIEW

                 2                          INDIANA

                 3             MR. CIWIBLISS:  Indiana will be presented  by

                 4  Doctor Slater and Mr. Thpmpson,    supported by Mr. Jewell.

                 5             DOCTOR.SLATER:  All right, sir, I'll begin with

                 6  Indiana.

                 7             The budget request,  as you have seen on Line 43
                 8  of the print-out there, they   are annualized now at $1,057,000,

                 9  and they are requesting $1,221,000 against a t4rgete  -un
                 10 of $1  430,000, so they are considering about 84 to 8  percent
               .11  of what they are targeted for,  but  coming  back  in  July  for
                    another $400,000, which would bring them up to     aboutl,112 per-
                 12,

                    cent of their current.
                 13
                 14            I looked. at the proposal and tried to sort.it out
                 15 in the sense of the guidelines that you gave us#, and let me
                    introduce this by saying that  I  found  it  very  difficult  to

                    come to grips with what they are doing.
                 17
                               When I looked at  the  specific  projects  that  they
                 18
                    have been involved in in  the'past,  and  what  they  have  been
                 19
                    able to accomplish, I am impressed that something is going on
                 20
                    out there, and I do believe they can't write a proposal very
                 21
                    well, or write a report.  I found repetition and lack of
                 22
                    clarity, and so I think that I am    going to reflect that.
                 23
                               I would say that this is a traditional type of @AP
                 24
                    program in contrast to the   one I'll'report on later in Illinois.
                 25

   HOOVER REPORTING CO, INC.
   320 Niassachusetts Avenue, N.[.
   ... .. . - @ @ll,@@f






                                                                         103
  WHD-38       1              Program leadership is satisfactory.

               2              Program staff -- every one of the current staff

               3,!  have been in RMP for over four years and they  have  experience.

               4              The non-medical professional people, with  the  excep-

               5   tion of the Dean, who has been associated with the school and

               6   the.program support for some time, are now instituting them-

               7   selves to the level of 33, with good representation in

               8   Indianapolis and the,regional areas.

               9              At the 37 level, they had 30 people from Indianapolis

               10  and seven  from the regions.  They are now going to try, in

               11  their new  level of 33, develop a better balance for minority

               12. and geographic representation.
               13             They have the usual types of committee      Executive,

                   Review, Evaluation and so on, which I thought was'satisfac-
               14

               15  tory.
               16             They outlined that they have two major  thrusts;  they
               17  attempt to develop guidelines on.standards and criteria on two.__

                   main types of activity.
               18
                              One, the identification of hospitals to provide'
               19
               20  better capability there, with particular reference to sta e
               21  emergency medical services, and secondly, they are interested
                   in enhancing a whole series of specific programs  which  have  to
               22
                   do with quality of medical care, access and the like.
               23
                              These  are identified as renal dialysis, kidney-
               24
                   transplant, radiation therapy, angiography and the like.
               25

  HOOVER REPORTING CO,  INC@
               fl rI






                                                                          lo4
  WHD-39                      Now, as far as past performance is concerned,
               2    they describe themselves as really spearheading reqionaliza-
               .ill tion and improved cost-effectiveness by acting as coordina-
               4    tors, planners and developers, and I wrote a quut-= nere:
               5                   "They are interested in more quality of health
               6         care available  to more people at less costs

                    That, I thought, was a nice, general "motherhood" statement.
               7
               8              Within that framework they really have been working
                    closely with CHP, and have been attempting to.-exteni sub-
               9
               10   regional P14P development-that is tied in with the elisting B
                    agency development in Indiana.
               12.            Examples of what they have done in the E,,.t, very
                    briefly, are that they have developed a data base to reveal
               13
               14   health deficits. I am not quite sure what that means, becaus(
                    there wasn't enough inf6r
                                              'pation.
               15
               16             They have organized sub-regional CHP- provider-
                    consumer-groups in six areas, five or more on the Board.
               17
                              They have promoted programs to meet these above
               18
                    needs.  For instance, physician-extender and continuing educa-
               19
                    ti on programs, they have been involved in legislation on
               20
                    statewide emergency medical services, a couple of neighborhood
               21,
                    health centers in the urban areas, state'stroke-therapy
               22
                    services, consultation  in organized coronary-care units       I
               23
                    could go on.
               24
                              All of the above, with the exception of a little bit-,
               25

  IIOOVER REPORTING CO, INC.
               Nr






                                                                                    105
                                                                              initiat
  qHD-40             of continuing R-MP  staff and money input, have been             ed

                2    and are on"going   and phased over to other support.      They   are

                3    not totally  independent;  where  the  line  is  drawn,  Iam   not

                4    sure, but they have made  a  major  effort  to  act  as  a  Catalyst

                5    and move  programs  they  started  out  onto  other  fundi    lines.

                6               At  the  moment,  they  also  have  some  limite  demon-

                7    strations;  hypertension  screening  and  care  programs  'n   dis-
                8    advanta.ged urban  areas.  They  are  looking  at  what  they  call
                9    the "assurance  of  quality  of  care."  I  wish  they  had  just

                10   said they were setting up.-a perinatal upgrading program,

               -11   instead of all   the generalizations.
                12.             They  have  a  kidney  disease  program  which  includes
                     immunologic studies.  This  is  a  hope  to  define  ways  by  which
                13         1
                     you  can  prevent  organ  rejection.  I  was  concerned,about   this
                14
                     because I think it should be funded by -- it is a basic
                15
                     science study and should    be funded  by some other method.
                16
                                Now,  the  objectives  and  priorities  --  after  all
                17
                18   these years of  effort  they  had  a  mail  poll  recently  among
                19   25 RAG  members  and  65  non-RAG  members,  and  they  carefully
                     itemized what they came up with, and honestly, it is what you
                20
                     put together as a first-run ten years ago.
                21.
                                Continuing medical education, needs of      under-served
                22
                     areas, emergency medical services, -hypertension,        innovative
                23
                     health-care strategy -- it's all over the map.  But it's
                24
                     traditional, in the  sense  of  what  many  RMP's  consider  to  be
                25

  HOOVER REPORTING CO, INC.
  320 taassachusetts Avenue, N.[.





                                                                         lo6

                                                                        edical car
  WHD-41        1   the umbrella approach of improving the quality of m
                2            At the moment they are moving ahead   with the hope
                3   of having two major thrusts.  They described  this a  expansio
                4   of the program staff -- and I need some help  from S aff on
                5   that if John hasn't got a better understanding of it@ -- and

                6   regionalization.
                7            Within that framework they then present a,proposal
                8   which moves along lines that include emergency medi al ser-
                9   vices, for which they already were able to achieve 1974 legis

                    lation, which on
                10                  ly provided them $75,000 for the s  te, so
              -11   they are asking for another $95,000 to enhance that  rogram
                12. until they can get better funding from the state.
                              They are also wanting to have help for health-,.
                13
                    resources planning in cooperation with the six CHP exksting
                14
                15  B agencies.
                              On page 25,  they  outliIne, in three or four lines
                17  each, 13 new activities for which they have planned a July
                18  application, which amounts  to  $400,0100.
                19            In the present proposal they are asking for $616,000
                    -- I believe it is -- for new program staff, and what I don't
                20
                    understand from their proposal, and maybe  the Staff person
                21
                    here knows, is whether or not the $616,000 of new money for
                22
                    program staff is to program that $400,000 of 13 new projects.
                2tl
                    I don't know whether they are interrelated or not.
                24
                              The specif-A.c projects range across the board.  They
                2,5

   HOOVER REPORTING CO, INC.
   320 Ma@chusetts Avenue, N.[.
        n p )Ann)






                                                                               107
  qHD-42        1    want a kidney-transplant exchange information system --       only

                2    $3,776, and  what  this  means  really  is  to  computerize in   their
                3    Southeastern Regional Organ Procurement Program the       8,000

                4    tissue  types  scattered  among  the  population  of  people  who

                5    they can count on to contribute organs.

                6               I would gather  that  that  would  pay  for  a  computer

                7    clerk, or  something.  It is a   tremendous  program   toibuy   for

                8    $8,776.,
                9               The  second  point  was  care  for  hypertension  patients
                10   in Marion  County, which      for $141,000.  That is a specific
                11   center model they want       the y want  to  fund  the  equipment  and
                                                                             I 1
                12.  overhead on  a  center  in  which  screening,  clinical  ca re
                     screening, clinic, diagnosis and treatment, including nurse-
                13
                     practitioner follow-up of these patients, can      be  gotten   off
                14
                     the ground.  They  want  to  be  able  to  acquire  data,  study,
                     study the compliance rate of these     people in this deprived


                     area.
                17
                                They are  looking  for  the  development  of  a  statewide
                18
                19   "tele-medical"  system,  which  is   really   a   telephone-answering

                               for $41,000.
                     service
                20
                                They are looking for the development of         as   I
                21.
                     mentioned earlier -- quality assurance, which is really impro@-
                22
                     ing perinatal  infant  death,  in  Marion  County,  where  they  have
                23
                     again  inner-city  high-mortality  rate.  They  are   attempting   to
                24
                     put together six  hospitals  to  do  mortality  reviews,  with  the
                25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.E.







                                                                                  lo8
  WHD-43        I   idea of upgrading    the  performance  of  the  doctors  as  well  as

                2   patient com liance; that to     be done for $23,766.
                                 p

                3               Those are worthwhile projects -- most      of tJiem are

                4   very worthwhile.

                5               Looking at the  feasibility  of  all  of  this,  I  found

                6   it a  little  difficult  to  assess.  I  assumed  --  I  gav  it  a

                7   "satisfactory."  I can't tell on the basis of the wa  the

                8   program.is  written,  even  in  the  terms  of  past   performance.

                9               The  relationship  with  the   Comprehensive   Health
                10  Planning, I would say, is very close, insofar as the@evidence

                11  shows.

                12.             Overall assessment of    this,  I  gave  averageol:or-C-

                    minus,  largely  based  on  their  inability  to  present  it  very
                13

                    well.   Again, I come back to the     fact  that  they  are  overly
                14
                    general and euphemistic,"l@cking      specificity in  the writeup,
                15
                    but on the basis  of  what  they  have  already  done,  it  looks  as
                17  if they are capable of performing reasonably well.
                18              John Thompson and  I  looked  at  what  might  be  pulled
                    on this,  and  I  think  we  feel  the  Emergency  Medical  Services

                    is  open  to  question  with  regard  to  that  $95,000.  I  question
                20
                21  whether or not we should be funding the kidney disease immuno-
                    logical rejection studies; you mentioned the dialysis -- kidney,
                22
                    dialysis program as well.
                23
                                I need specific   information  on  what  the   $616,000
                24
                    for program staff is aimed at.  I somehow just could not decipher
                25

  HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.[.






                                                                        log
   WIID-44    1    that. So I will leave my final comment up in  the  air,  except

              2    that I do believe that despite the fact that they are only

              3    asking for 84 percent of the targeted funds, they still may
              4    be asking for too much at this time, with this type  of  appli-

              5    cation.

              6              MR. CHAMBLISS: All right. Our  next  presenter,  Mr.,


              7    Thompson.
              8              MR. THOMPSON:  I am very much in agreement with
              9    Bob's evaluation.  It  is very difficult to understand what
              10   the goals and  objectives of this particular program are,
              11   because they are stated in such general terms, you knowl

                   like regionalization -- that's a goal.
              12.
                             The nearest thing we can get -- and the  only  reason
              13
              14   I can pick this up is because it was underlined     is the
              15   development of innovative programs in health-care  delivery  to
                   -- with special emphasis on under-served geographic popula-
              16
              17   tiohs and medical areas, and on .public and professional edu-
              18   cation about health-care matters that will assure  quality  and
                                                0
                   cost-effectiveness of service.
              19
                             If those are their goals and objectives, none of
              20
                   the particular programs that we are asked to review  have  any-
              21
                   thing to do with those goals and objectives.
              22
                             The second -- I'm not quite as  obviously  optimistic
              23
                   about the relationship with CHP, because every reference to
              24
                   CHP -- and I would like to have Staff input -- is very care-
              25

  HOOVER REPORTING CO, INC.
  320 M2ssachusetts Avenue.  14.1.






                                                                               110


  IHD-45             fully phrased.

                2              For example: "Communications     have never been so goo(

                311       as they now are with CHP."
                4              Well, I have been in    areas where, if you said
                5    "hello" and somebody said "hello".back, between theitwo people
                6    communications had never been so good!      Because   before   they

                7    wouldn't even talk to each other.

                8               I can't operationalize that kind of a phrase.

                9               The staff is  over  72  percent  of  the  total  request
                10   over 72 percent of the total    request  is  for   dore-sta ff,   and
                11   the reason I  am  concerned  about  the  EMS  component  isIthat it
                12,  specifically states -- in one of the few specifics in the

                13   wliole.thing -- that, and I quote:
  0
                14                    'The general  objective  of  this  project  is  to
                          develop an areawidd'yMS system adequate for the needs
                15
                          of those counties constituting Region 7."
                     So that is obvious that they are building an EMS system, and
                17
                     whether this system  is  in  conflict  with  that  or  EME.or  not,
                18
                     I think we ought to define.
                I!)
                20              I am certainly not turned on by    .that "Dial-a-DiseasE"
                21   project which they have, where you dial in someplace, and
                     they slam on an  Ely  Lilly  cassette,  I  think,  that  tells  you
                22
                     all about the problems of the man over 40t and about --
                2t3
                                 (Discussion off the record)
                24
                                MR. THOMPSON:  But, to continue, I would rate it as
                21

   HOOVER REPORTING CO, INC.
           A.a@.a N fI I







  @IHD-46           poorly as Bob did, and certainly  not  give  them  the  amount  of

               2    money.they asked for.

               3               But on the other hand, if w(@@ @,7ant to maintain  the

               4    capacity for this outfit to do                and 72  percent  of

               5    the whole project is staff, you can't  cut  it  too  much,  so  I

               6    recommend a cut of $100,000, from what they request, to bring


               7    it  down  to

               8               DOCTOR SLATER:  To  come back on  to  that  staff,  the

               9    staff request, the  other  support  services  that  are  involved

               10   with staff, come to not  $616,000,  but  $832,000,  and  that  is
               11   really to improve the Emergency Medical Services system
               12,  development, Family Practice program development, integration
                    of Comprehensive Health Planning and IRMP activities, hospital
               13
               14   access studies.
                               A lot of this"@.s  to  do  with  data  collection  and
               15
               1(;  planning. They  see  themselves  as  the  planners  for  Indiana,
               17   as far as I can make  out,  including  the  CRMP.  The  CHP  group
                    -- excuse me, and I guess  I  need  clarification  as  to  whether
               18

                    or not this is real.
               1!)
                               ,14R. CHA14BLISS:  I would ask -- we are cognizant   of
               20
                    your recommendation in terms of the funding level, but I
               21
                    would ask, are there any inputs'as it relates to CHP for that
               22
                    state     for that Region?
               23
                                     1,MLL:  Which
                               MR. JE              question  should  I  answer  first?
               24
                               MR. CHA14BLISS:  Answer the Committee's question
               25

  HOOVER REPORTING CO, INC.




                                                                         111-A


  4111)-4 7     1  f irst.

                2            MR. JEWELL: On CIIP, Mr. Chambliss, this  is  a  con-

                3: tinuation application, and about two months ago  I  was  out

                4  there to their wedding of M4P and CHP, so  we  were  wo  dering

                5  what the children were going to look  like.  But  theyihad  the

                6  A agencies, and all their B angtncies are funded,  and  I  was

                7  surprised at the quality of men that I met up they       and

                8  -they were all men.

                9            This was a two-day meeting,  where  they  got in  a
              .10  room, in a raotel, and laid it out -- what they-,had n@t  told
                11 each other, what.they wanted to tell each other --  Sp  I  can
                   only attest to the viability of the statements in their cover
                12.                                                      1
                13 letter, that what I witnessed there on one visit  was  a  very
                   useful, viable discussion, and I am not really that much inter-
                14

                   ested in meetings..
                15

                             Doctor Slater,'o         equest for progra
                                              n. your r                m   staff,
                17 Sir, there is $616,000 that they are pulling out, and it will
                   be funded under the program-staff component, Sir.
                18
                19           It will not buy new people, and this is  for   RFP'S,
                   if you will, Sir, to address these priorities  that  they  have
                20
                   listed on the last page of the  application.  M14S,  Health-
                21
                   Resource Planning Criteria and Standards, Arthritis Study,
                22
                   Cancer Control
                2tl
                             DOCTOR SIATER:  The  13 new projects?
                24                                  -
                             MR. JEWELL:  Well,  they are contracts; yes, Sir, but
                ')5

   HOOVER REPORTING Co, INC.
   320 Massactiusetts Avenue, N.C.
   Washisi@ton, D.C. 200@32
   (202) 54o-6666




                                                                       112-11.3
  HD-48        1   that would just be funded out of the program staff component.
               21  There are -- their actual program staff request, money-wise,
               3   is about $265,000.
               4             DOCTOR SLATER:  They are only going from 9.to 18,.'
               5   so I see.  What this means, then, is that that money is to
               6   provide for contracts for people for work to be done in those

               7   13 areas. I see.

               8             MR. JEWELL:  Yes.
               9             MR. THOMPSON:  Are they going to have their contracts
               10  finished in time for July submission?
               11            MR. JEWELL:  No, sir; no, sir.
              .12,           DOCTOR SLATER:  They have another $400,000.
               13            MR. JEWELL:  This is for the next year, Mr.
               14  Thompson.  These are two separate groups.  Their other hopes
               15  and submissions for the July submission are, I think, on page
                   25.                      41.
               17            DOCTOR SLATER:  I was wrong about the program staff,
               18  John.  The program staff is to improve the contract for more
                   Emergency Medical Services, to help develop their system for
                   the Family Practice Program Development Integration of
               20
                   Comprehens ive Health Planning with the RMP.
               21.
                             That is what the $616,000 in contracts is going to
               22
                   be for; is that correct?
               2,1
                             MR. JEWELL:  Yes, sir.
               24
                             DOCTOR SLATER:  Maybe it was here, but I didn't get
               25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Aveiiue, N.[.
  Viastiingion, D.C. 20002




                                                                         114
  IIID-49       1  that originally.

                2             MR. THOIIPSON:  What are we going to recommend?

                3             DOCTOR SLATER:  Well, we will recommend $100,000
  0             4  less, and  with recommendations that  this be applied' o what

                5  the imunologic?
                6             @IR. CliAl@IBLISS:                        ecommenda-
                                                 get a  sense of your r
                7  tion; we will ask %that that be placed  in the form of  a  motion
                                                                        1
                8  momentarily, but I would s4j-niply have the Committee  note  that
                9  there  is  arepresentative here from the HEW Region  office  10,
                10 which in Indiana is a part of  that  regional  configu ation.
                11            I would simply,call upon Mr. Wally, if helwishes, tci
                12. make a statement regarding that program or regardin4  the  CHP-
                                                                        I
                   RMP relationships, and he may do so at this time.
                13
                              MR.TA7ALLY: I am not that totally  familiar with  it,
                14
                   but I know that in Region 5 we are  encouraging  a  merger.  We
                15
                                                    't was put before,
                   are encouraging a merger  or as i                    a  marriage
                17 between-RMP's and CHP's in their approach to the whole compre-
                18 hensive health program. .
                I!)           So you may find that that sort of seems  like  ambi-
                20 valence on their part, but we  are  encouraging  them.
                              I guess this is optimism on our part, that  new  legi
                21
                   lation will encompass that kind of a framewor
                22
                              DOCTOR SLATER:  It may be too late, but I would
                23
                   quietly recommend that they  get somebody else to do  the  writ-
                24
                   ing of these proposals, sharpen the focus  and  reorganize  them
                25

  HOOVER REPORTING CO, INC.
  320 Massactiusptts Avenue, N.C.
  @yasliington, D.C. 201.102
  (202)546-6666  1





                                                                       115

  W]7@l-ID-50  I  better.

               2            MR. TIIOIVSON:  To you there were three questions.

               3            There was the CHP-IU4P; there was the program of

               .4 specifically-stated EMS programs, and  the'very  scientifically
               5  based renal programs, specifically in the project itself.
               6            NIow, I think the Staff person can answer fairly
               7  well; they are doing RFP's or,somethina, rather  than  increas-
               8  ing staff, to eyplore further programs, but we still are stucR.
               9  with the problem that there seems to be very  little  relation-
               I  ship between the goals and objectives as stated on page 19
               11 of their report, and the programs we have been asked to
                  review, which,'in fairness to them, all have  been  continuatio
               12,

               13 programs.
               14           MR. CHAI@IBLISS:  The Chair is open for a motion here...
               15 will you so move the recommendation that you just made,

                  Doctor Slater?

                            And that motion, as I gather it to be, is:
               17
               18                "That the Regional level of funding be recom-
                        mended at $1,121,159, and that due notice be given to
                       the CHP relationships, the renal aspects of  the  applica-
               20
                       tion and the EMS."
               21
                            MR. VAN WINKLE:  What about the CHP relationships?
               9
                            MR. CHAI,4BLISS: It has been moved and seconded,  and
               2.
                  is there discussion?
               24
                            MR. VAN WINKLE:  I  want to be sure of this,  because
               25

  [IOOVER REPORTING CO, INC.
  320 Massactitjs,,tts Avenue, N.[.
  @Vashingtoli, D.C. 20002




                                                                        116--
                   we are going @.o have to take the message about it to them.

                2            DOCTOR VAUN: Carrvinct through the theme of the

                II
                i@l illicit relationships, the reason I say that is that one of
                4  the ways to avoid CHP corLment is to put $600,n@00 in';a slush

                5  fund.


                6            MR. THOMPSON: Most of which is devoted to tasks

                7  that CHP ought to be looking at.

                8            MR. CHABMLISS: Is there further discuss n?


                9
                             Question? All those in favor?

                10           (Chorus of "Aye")

                11           Those opposed?

                12.          DOCTOR VAULN:  No.
                13           MR. CHA14BLISS:  Doctor Vaun is in opposition, an
                   the "A els" have it; the motion is carried and Staff will takE
                14
                15 due note of your observations, Doctor Slater, regarding the
                   over-generous non-specific writeup of the application.
                17           DOCTOR SLAITER:  Which I rated as C-minus, by any
                   elementary school standards.  I am very unhappy with this;
                18
                1!) I am very unhappy with the amount we have given them, I don t
                20 know what to cut it back to, because it is almost impossible

                   to make a judgment.
                21
                             MR. THOMPSON:  I think a critical question is
                22
                   whether the $600,000 was a dowry or a bribe.
                ,'-,3
                24           MR. CHMU3LISS:  Those are two legal phenomena, and
                                                   I?
                   the Staff will take note of them.
                25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.C.
  Washing!ort, D.C. 20002
  (202) 546-6(j6G




   WHD-52     1              DOCTOR WHITE:  I won't cast a negative vote; I will

              2    just abstain.

              3ii            MR. CHAMBLISS:  I think those of you  on the
              4    Committee who are interested in measurements would l@ike'to

              5    know that we are 66 percent through our  workload  for today,

              6    we are now 35 percent through our workload for thislpanel.

                             It is getting close to 3:00 o'clock, and those of
              8    you who would like coffee may' have a chance; those  9If you
              9    who would hot like to have coffee and would ratherl.@ave it
              10   later on today?  I am with you and we can proceed;     is left

                   to you.

             .12.            (Discussion off the record)

                             MR. CkLAbIBLISS: Would you like a break?
              13
              -14            DOCTOR SLATER:  Why don't we take a break  and bring
              15   it back to the table?
                             (Whereupon a short recess was taken.)


              17


              18


              19



              20


              21


              22


              2t3


              24


              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  W3shington, D.C. 2OW2
  (202)546-6666




                                                                          iig
  qHD-53        1             MR. CIIA14BLISS:  All right; I would like to reassemble

                2   the Committee and lay out a suggestion for you, in terms of

                3   what we might be able to do today.

                4             If we could consider the  regions in this order,
                5   think it might lay out for us a work-plan for the balance of

                6   the day:

                7             Wisconsin, coming up first.

                8             Kansas.

                9             Michigan.

                10            Mississippi.

                11            Missouri, and perhaps

                              Illinois, and
                12

                              Louisiana.
                13
                              If we could make that accomplishment today, we would
                14
                15  be well into tomorrow's work and that would mean we would have
                    completed half of our rd'gipns.
                              I hear the words "let's  go," and I am ready,   and I
                17

                    hope you are.
                18
                              I would then call upon Doctor Carpenter and    Doctor
                                                  go
                    Scherlis; I will call upon Doctor Carpenter, and Mrs.    Parks
                20
                    as his Staff support, to now begin   the presentation of the
                21
                    application from Wisconsin.
                22


                2t3


                24


                25

   HOOVER REPORTFNG  CO,  INC.
   320 Massachusetts Avenue, N.[.
   Washington, D.C. 20002
   t?n2) rAfi@fi6G6





                                                                                  120
  IHD-54          1                 REGIONAL MEDIAL PROGRiV4 REVIEW

                  2                           WISCONSIN

                  3              DOCTOR CARPENTER:  Thank you,     Mr. Chambliss.

                  4              This one is to some extent a     rerun of what we have

                  5   heard.before.  The Region has, as you have heard this morning,
                  6   lost  its  distinguished  coordinator,  and  so  we   have   a.Region
                  7   with a very illustrious past history that now, I believe,
                  8   judging  from  the  rather  poorly  written,applidation,  is   in   a
                  9   crisis of leadership, and so it is hard, first of all, to kno-o
                  10  whether -- again,,  whether  it  is  just  that  the  words  did  not
                  11  get on paper, or whether the leadership really is going to
                  12, be  a problem.
                  13             I think I have no way to judge that it       won't  be   a
                      problem, and so you can see something about where.I start.
                  14
                                 The program staff and professional staff             well,
                  15
                      it is worth noting that,they are asking for a 276 percent
                  17  increase in their funding, and the- program staff has fallen
                      to eight professionals.
                  18
                  19             The    Adviso.ry Group is not -- it has met three times
                      or so, but not accomplished anvthinq that is too clear in
                  20
                      terms  of  responding  to  the  vicissitudes  of  the  recent   past.
                  21
                                 I think past performance has been quite good.  They
                  2--.)
                      have  terminated  18  projects,  and  all  but  three  of  those  are
                  23
                      still operating in the state, in independent funding.
                  24
                                 The objectives and priorities are very vaguely
                  25

   HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.C.
   Washington, D.C. 20002
   (202)546-6666






                                                                                                         121
     WI,ID55            1    stated;  they seem to be little more than a description                         of

                        2    Federal priorities.
                        3                 Except for this         evidence of past performance,  there
                        4    is no evaluation to speak            of of what is going on no@              and the
                        5    pro3ects themselves have vague goals;  frequently there are
                        6    multiple projects in a single area,  and no evidence@of coor-

                        7    dination.
                        8                  For example,  I think there are six or seven projectc.
                        9    in the area of continuing education and the Continuing
                        10   Education Committee of the Region has not met                      for the last

                        11   year.
                        12.                I think their CHP relationships,  as far as I --could
                        13   make out, were reasonably good,  although in one instance
                        14   Comprehensive Health Planning responded with negative comments
                             of a technical nature about one of their projects,  and as I
                        15
                             read   the project description,  I must say that I believe CHP

                        17   was right.
                        18                 And the Region'did not take any note that I can see
                             of the ideas coming from the Comprehensive Health Planning

                             agency
                        20
                        21                 So I did not think there was any way this region-
                             could be considered above average,  and I was -- in other time@,,
                        22
                             you know,  this Region would not have been an average region,
                        23
                             and therefore,  the 276 percent @ncrease in funding did not
                        24
                             seem very logical.
                        25

    HOOVER REPORTING CO, INC.
    320 Massachusetts Avenue, N.[. "I
    Washington, D.C. 20002 1 ;r!





                                                                       122
  WI-ID-56     1             There were several things, many of which were brought

               2   to the attention of the Staff, on these yellow  sheets  here.
               3   You notice there are now eight full-time professionals on the!

               4   staff, and it is proposed they hire an additional  15  people

               5   in the next year to a program which will presumably phase out

               6   at the end of that time, and although in the past  there  has

               7   been a close relationship to the Governor's Office  in  this

               8   state,.nothing is made of tha't.in the present  application,
               9   and there is no reason for me to assume that those 15 people
               10  would have any kind of continuing employment, and unless' the
               11  labor market is better in Wisconsin than  it  is  in  Detroit,
                   they are in trouble, in trying to recruit  that  many  people.
               12,

                             Nor am I certain that in the course of a year, even
               13
                   if they could find them, they could get  them  organized  into
               14
               15  a constructive program.
                             The Region ha@'@l?ent $1,,400,000 on Emergency
               I(;
                   Medical Services, and -- or at  least they were awarded
               17
               18  $1,400,000 -- and I would assume they spent most  of  it,  in
               19  the last -- they have $113,000 to tun them  to  i.une  of  '74,
               20  and they are requesting essentially another million more.
                             The program is very well  described.  This particular
               21
                   project is very well described; they think, you know,   the goa@s
               22
                   have been set up for some time and  they'are  good  goals,  to
               23
                   show that there has been q,4ite a bit of thinking.
               24
                             But I guess we have the problem-now, with independent
               25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washington, D,C. 20002
  (202)546,6666





                                                                       12
  ;qHD-57       1  funding available elsewhere, whether it is appropriate for us
                2  to spend that much money in very direct -- you know, by buying

                3  telemetry equipment, in the direct development of tile EMS

                4  system.

                5           On the other hand -- well, I am not sure;'it may  oei

                6  that there is adequate staff in that area, so this  ne thing I

                7  they might do'particularly well. I can say no more about

                8  that.
                9           There are $430,000 in continuing education, projects,
              .10  plus $100,000 for a discharged-summary review@-for tl,,e hos-

                          in the state, so 't is $530,060
                11 pitals                  I              in essence for that,,
                   and that in a place where the continuing education  ommittee
                12,
                   does not meet, and where there is no particular indication
                13
                   that,,you know, it would be fine if they could say:
                14
                                  "We are going to look at the discharge summar-
                        ies and try to ide@'t@fy somethings that continuing
                17      education is needed for."
                   But there is no suggestion of any melding of -the idea of
                   quality review in continuing education that I can think of,

                   or that I can find.
                20
                21           There are a couple of research-p.rojects that snuck
                   in: development of sero-diagnostic procedures for gonorrhea
                22
                   and quantitative cytotoxic assayst and they are exciting
                23
                   projects.  The cytotoxic assay, though, they didn't even
                24
                   bother to describe it as a part of the Regional program, so
                25

  HOOVER REPORTING CO, INC.
  320 Mamchusetts Avenue, N,E.
  Washington, D.C, 20002
  f2O2') 546-6666




                                                                       124
  iD-58       1    there is another $100,000 that troubles me.

              2              There is $156,000 in mental health programs, and I
              31@                                                    we allowed!
                     they are not such bad programs, actually    are

              4    in that business?

                             MR. CIIAMBLISS:  That is an expressed concern of
              6    Staff, and we would certainly note your concern, because it

              7    does raise a substantive policy issue of funding.

              8              Your question is very germane.

                                                                      1
              9              MR. VAN WINKLE:  Those programs have traditionally

              10   been funded elsewhere.
              11             DOCTOR CARPENTER:  Well, you know, I suppose  you
              12@  can make a regionalization out of mental health as well  as
              13   out of physical health, but we will leave that forIthe policy-.

                   makers.
              14
              15             I wonder if Staff would like to comment before  I
                   guess at a -- or before,one of you all guess at a funding

                   level?
              17
              18             MR. CHAMBLISS:. Mr. Van Winkle, will you and Mrs.

                   Parks?
              20             MR. VAIN WINKLE:  I want to say one thing about El-IS.
                             This was a proposal that had been submitted to us,
              21
              22   to  a select EMS Special Review Committee; it wag  approved
                   for three years, and received two-year funding direct  from
              23
                   here, in addition to their.norinal operatig -funds.
              24
                             The reason we flagged it was not that it was any-
              25

  HOOVER REPORTING CO, INC.
  320 Ma@chusetts Avenue, N.C.
  Washington, D.C 20002
  (202)546-6666





                                                                       125
  #HD-59      1   thing new; it is a continuation, but we flagged it  because

              2   what did they get on their first award?

              3             MRS. PARKS:  I think it was about $1.6 million or


              4   something, for a two-year  period.

                            MR. VAN WINKLE: They are asking almost  as  much,

              6   for the third year as they had for the full two years,  and

              7   that seemed like a tremendous increase in funds to  us.  It


              8   looks like a doubling up in the last year.

              9             MRS. PARKS:  Well, this is why it was flagged,

              10  simply because it was a tremendous increase over what  they

              11  have gotten.

              12.           DOCTOR  CARPENTER:  What do you know about the manage-

                  ment system for the use of those funds? Is it  these  eight
              13

              14  staff,people, or do they have  now a group of people who are

                  established
              15

                            MR. VAN WINKLE:,/They are well-established, and
              17  Mike, from the Mid-Continent Branch, has visited that program,
              18  cnan EMS basis, and I think the concurrence is that this is
                  probably one of the better EMS programs that they have  run

                  into in the country.
              20
                            MR. POSTA:  Of all the supplemental funds that RMH
              21
              22  put out -- we did visit 23 projects  this past year, and they

                  wee without a doubt the top program.
              2.3
                            MR. VAN WINKLE:  But our question was -- the reason
              24
                  we brought it to you is -that that seemed like a tremendous
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.C.
  Washingtc,,i, D.C. 20002
  /')n')% 9;Ar CCCR




                                                                           126

  WHD-60       1    jump in funds, because that is about what they  had  for  a  two-

               2    year period, and now they are asking for almost that for

               3
                    the third year.

               4              MR. CHAMBLISS: I  would  like  the  Committee-to  know

               5    that we are asking for your judgment here as to -- and your

               6    recommendations about the funding.

               7              DOCTOR SLIVEER: Well, just a  minor  one,  because  it

               8    is such a small amount of money.  Mrs. Salazar and I were

               9    consulting, wondering whether that Self-Administered Sex.

               10   Therapy Program is -- violates the Federal guidelines for

               @ll  RMP'S.

               12,            MR. CHAMBLISS: That is  certainly  one  of  the  policy

               13   matters we will be handling.
               14             MR. VAN WINKLE: We  could  not  particularly  tie  that

               15   back in to their goals and objectives.
               1(;            MR. THOMPSON:   @o got the book?
               17             MR. CHAMBLISS:  That has been noted with great

                    interest; that will  be taken into consideration.

                              MR. THOMPSON:  Who is the Principal Investigator?
               19
               20             MR. VAN WINKLE:  Doctor Carpenter,   I would  like  to

                    add one thing.
               21
                              We have Staff concerns   here about the  leadership
               22
                    of the program. I think you  should  know  they  quite  recently
               23
               24   came Iin for some rebudgeting.of,some dollars  they  had,  and  up
                    to this point in time     don't believe we  have  approved  that.
               25

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




                                                                       127
  IHD-61        1           MRS. PARKS:  We have not gotten the additional


                2 information.


                3           MR. VAN WINKLE:  We have told them to go back home

                4 and further justify the information that would even allow

                5 them-to@rebudget.

                6           So we are concerned, and we think we have tried to

                7 express this.

                8           MRS. PARKS:  During the phase-out, Doctor Carpenter,

                9 they did lose just about all of their key professionals  on

                10 their staff, and of course, as you mentioned, Doctor  Hersbeck

                11 finally left, too.

                12,         At one point they were down to just about no  one

                  except the present Coordinator, and the management aspects  of
                13
                14 the program -- there was actually no one there at one point

                  to handle the program.
                15
                            They have hired Accountan-ts now, and though while it
                17 is.kind of early to really evaluate his effectiveness, he
                18 seems to be getting in there and-trying to get some of  the

                  problems straightened out.
                20          MR. VAN WINKLE:  He is one of the positive things we

                  see.
                21
                22          MRS. PARKS: Right. And the  request  for  additional
                  staff    frankly, I can not justify it because I am not  clear
                23
                  on what all of these people.will.ultimately do and it  just
                24
                  seems awfully ambitious to me.
                25

  HOOVER REPORTING CO, INC.
  320 Ma@chtisetts AvenLie, N.[.
  Wastiington, D.C. 20002
  (202)546-6666





                                                                            128
  WHD-62       1              DOCTOR SLATER: It sounds to  me  as  if  the  judgment
               2    is going to have to be made substantively, rather than in

               3    any specific objective grounds that you have.

                              What I hear is that we don't now know how the    staff

               5    will be used, and we are uncertain what -- whether  r not

               6    they can really float that much by way of programming  f t eyl

               7    have the money.

               8              I am talking about making a recommendation of

               9    $2 million.  They are at $1.73 now; that leave abou.       t  er

               10   $'500,000 to come back in for in July to get up   to the 100

                    percent.
               12,            The 276 percent is just out of the question.

                              DOCTOR CARPENTER:     Is that a motion?
               13
               14             DOCTOR SLATER:  I am just asking if that    is a  sort

                    of ballpark -- if we are both together.
                              DOCTOR CARPENTEP.:  I,couldn.'t@decide  between  $1.70

                    and $2.0.
               17
                              MR. CHAMBLISS:.  The Chair will entertain a motion
               18
               1!)  here as to the level of funding recommendation.
                              DOCTOR MILLER:  Could I ask a question first?
               20
                              MR. CHAMBLISS:  Yes, Doctor Miller.
               21
               22             DOCTOR   MILLE.R:  Is it.true, and to what extent is i@
                    true, that the current level of annualized funding, as you
               2,.3
                    have listed here, in most cases probably is the level that wa
               24
                    the highest that Region ever had in the history of the Region-?.
               25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue,  N.C.
  Washington, D.C. 20002
  (202) 546-6666







                                                                          129
   WHD-63      1              MR. CHAIIBLISS:  Is,that the case?

               2              MR. PULLEN:  Yes,  sir.

               3              DOCTOR MILLER:  I  think most of these are  just

               4   about the  top that the Regional Medical Program has   ever

               5   had.

               6              MR. PULLEN:  I think- it was more the 779.

               7              MR. CHABIBLISS: Nonetheless, in this  Region,  if  you
               8   add to it  the Emergency Medical activity, you would find it

                   a-substantively higher level -)f funding of Regional program
               9
               10  activities; I think this is :.@@@@)ut the level.
                              DOCTOR CARPENTER:  Do you have an expenditure report

                   for the July meeting?
               12,
                              lqhat am I asking for?  That would be too early  I
               13        1                                                    il
               14  guess?  Yes; sorry.
                              DOCTOR SLATER:,, Recommendation for two million


                   dollars?


                              DOCTOR CARPENTER:  Yes.
               17
               18             MR. CHAIIBLISS:  I am advised by Mr. Pullen, of our
                   Grants Management Staff,   that the expenditurereports  were  due
                   May lst, and they are in   the.process.  They are being pro-
               20
               21  cessed now, so the answer 3.s yes, we will  have  an  expenditure
                   report by July.
               22
                              DOCTOR CARPENTER:  If they are expending at the rate
               23
                   they say they.are, in July, or as they say  they  might  be,  and
               24
                   we want to push the Emergency Medic  al Program at that time, we!,
               25

  HOOVER REPORTING CO, INC.
               ti ri





                                                                                                     13c)
   :VIIID-64           I   would have another opportunity, or if we wanted to                     take    the
                       2   lid off,  then I  -would second what I understand to be a                      motioA
                       311 for tv7o million dollars.

                       4                 DOCTOR SLATER:   Two million dollars.

                       5                 MRS.   PARKS:   Two million?

                       6                 MR. CH.UIBLISS:   The motion has been properly moved


                       7   and seconded that:

                       8                        "The level of funding to be recommended for
                       9          the Wisconsin Regional Medical              Program be set @t two

                       10        million dollars,

                       11                Is there further discussion?-
                       12.               Are you ready for the question?
                       13                DOCTOR CARPENTER:   Yes,  can I add a little, or at
                       14  least,think about adding something to the record?
                                         In view of the problem of whether they can effect!r
                       15
                       1(; ively use that money for the Emergency Medical Service, would
                       17  it be practical to ask them for an interim funding report?
                       18  This one here will only@carry them into  173.                     I guess that
                       19  would be July of  173,  so if -we could have a few months more
                       20  information,  I think it might help them.
                                         MR. CHP24BLISS:   Yes, we         can request that,  and Staff
                       21

                           will do that.
                       2
                                         Is there further discussion?
                       23
                                         Call the question
                                                                .;.all those in favor?
                       24
                                          (Chorus of "Aye")
                       25

    HOOVER REPORTING CO, INC,
    320 Massachusetts Avenue, N.[.
    Washington, D.C.20002
    [7n7) -AA-666S





                                                                              131
  qHD-65        I               Opposed?

                2               (No response)

                3               The motion is  carried.


                4


                                MR. CHAMBLISS:  I would like now to turn your

                6   attention   to the Kansas Regional Medical Program.

                7               The presenters for Kansas will be Mrs. Wyckoff and

                8   Doctor.Vaun, and Staff support will be in  the person of Miss

                9   Mary Murphy.


               10






               12


               13


               14


               15






               17


               18


               19


               20


               21


               22


               23


               24


               25

  IOOVER REPORTING CO, INC.
  120 Massachusetts Avenue, N.[.
  Vashington, D.C. 20002




                                                                       132
  ,,IHD-66    1                  REGIONAL MEDICAL PROGRAM REVIEW

              2                              KANSAS

              3              MRS. WYCKOFF:  This is a modest request from Kansas
              4    I am going to follow your design that you have in the  Review
              5    Sheet, and try to construct my report along those lines.

              6              Program Leadership: the Coordinator, Doctor  Brown,
              7    has been with the Kansas P14P for several years and knows  how
              8    to work with the Kansas state' and local organizations.
              9              He understands the nature of Kansas and has its
              10   support. He has bent over backwards to get  provider  support
              11   in the early days,. and has never fully recovered from that

                   effort.
              12,
                             He has d good working RAG, which has met  regularly
              13
                   every,month.  His Executive Committee functions regularly, as
              14
              15   does his  project review committee.   They have good EMC

                   representation.
                             The program staff.  During the cut-baclc the staff
              17
              18   was reduced, and if you  w.ill look at the little yellow  sheet
              l@)  here you will see that he has, really, a very small staff  of
              20   nine professionals, two clerical.
                             MR. CHMMLISS:  If you would kindly talk just a
              21,
                   bit louder, please?
              22
                             MRS. WYCKOFF:  The remaining staff are skilled,
              23
                   having a minimum of 16 months RMP service.  They have had  to
              24
                   do dobule duty in project development and-monitor@.
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washington, D.C. 20002
  (2021 546-6666




                                                                         133
  TIID-67       1            The Health Service education directors have helped
                2   to fill the vacuum created by the loss of coordinators.

                3
                    There is a close and cooperative effort work with the CHP.
                4            There are no minority  members on the staff  as far

                5   as I can tell.
                6            The RAG.  The RAG has about three or four consumers
                7   amon.g 22 persons, and appears to have only one minor@ity mem-
                8   ber, though there are a very few on some of the
                9            The RAG is hard-working and dedicated, and has an
                10  E.kecutiVe Committee that keeps things moving in betdpen
                    Council meetings. Its Project Review Committee screLns and
                    evaluates and recommends all projects to the Council@, and
                12,
                    the Evaluation Committee monitors the projects.
                13
                14           The RAG shows itself capable of acting well under
                    the stress of the present application.  it has a liaison sub-
                15
                    committee relating to CIIP
                              However, this report  is probably the most confused
                17
                    report that I have ever read,  and if I seem confused, it is
                18
                    because I have been mired in it, trying to find what it is
                19
                20  he's trying to say.  So you will have to excuse the jer s
                    when we jump back and forth between subjects.
                21
                              I will stick, however, to the design we have here.
                22
                              The past performance has addressed substantive prob-
                23
                24  lems, in accessibility and availability, both in rural and
                    urban ghetto areas.  For example, under "Access," they have
                25

  HOOVER REPORTING CO, INC.
  320 Massuhuscits Avenue, N.[.
  Washington, D.C. 20002
  19n9) FAA.TAAR






                   the Model Cities Program,  which of course was closed down

              2    by other factors than RMP.

                             The Ottawa County health clinics, the Dart  City

              4    Indian Health Care Clinic, DeSoto Rural  Health  Clinic,  Kansas
              5    City Rural Clinic; under their efforts toward  efficilency  and

              6    quality in professional performance, they have improved the
              7                                                         1
                   Kansas Library Information system.

                             They have a rural circuit course for nurs   s that

              9    has been effective.


              10             These are examples of what they have  had;  the  cadre
              11   training for pharmacists,  and under "New Skills" tie@ have
              12.  had several courses for clinical nursing and  dermal  @systems.

              13             Under tteir "Past Efforts at Regionalization,"
              14   they have their Great Bend project. I  had  great  pleasure  in
              15   making a site visit to that onc@, and it is quite an experience,

                   I assure you, puddle-jumping across those.fields in a tiny

              17   little four-seater plane with Doctor Nicholas.

                             I realize how thorough ly rural a lot of  Kansas  is.
              18
              19             They had an extended coronary care  unit,  like  most
              20   of the @IP's of that day, and  nephrology  training.  They  have
                   been working to set up the     the core staff  has-been  working
              21
                   'to set Up four big health education service centers,  and  they
              22
                   are now coming in for a substantial amount of money for these.
              23
              24             They have helpedwith.,other Federal programs; fey

              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, ti.l.
  V4as[iington@ D.C. 20002






  41ID-69      1   have been called upon to help with the Emergency Medical

               2   Service, and they have successfully launched the big  kidney
               3   program which is quite well known throughout the center of

               4   the country.

               5             The measure of their work, I think, is seen by the

               6   fact tha t the major   the 18 major programs that have  been

               7   terminated have been continued with local support or with

               8   other support.

               9             Their Circuit-Nursing Course, their Physician

               10  Placement program, their Kansas Library project, the  Nurse-
               11  Clinician project, the basic education for medical clerks,
               12  and the formal regionalizati6n of the kidney program, and

                   method of treatment.
               13
                             Under Point No. 5, "Objectives and Priorities,"
               14
                   they say their objectives have shifted from the emphasis  on
               15
                   the information gap to direct co ncerns for the expansion  of

                   new services, Region-wide projects, or categorical disease

                   and quality assurance.
               18
               19            Much work has gone into sub-regional area develop-
                   ment of these manpower services, area education programs
               20
                   including public education.
               21
                             They have had varying degrees of success in carryinc
               22
                   out their short-term objectives in the following fields-.
               23
                             Health-care delivery, primary care:
               24
                                  1.  More effective health manpower;
               25

  HOOVER REPORTING CO, INC.
  320 faamchusetts Avenue, N.[.





                                                                        136


  qHD-70      1                    2.  Quality medical care assurance.

              2                    3.  Disease control.

              3    And it is not until you get under "Disease Control" that they

              4    mention anything to do with planning.

              5              The new proposal falls into place as congruent with

              6    the.major thrusts listed above.

              7              The 13 projects for  which they asked continuation

              8    funds  are in line with their program objectives, and they

              9    have been carefully and favorably reviewed by CIIP.

              10             Four new projects:are as follows:

              11                   Quality assurance of diabetic care: $28,500.

              12        They proposed to develop a model management system,
                        protocols for the health-care team, education, assessments
              13
              14        of patients, projects in training and utilization of the
              15        diabetic nurse-prac'@itionerl the CHP

                             The CHP comments:

                                   "The issue of funding beyond the first year

                        is not addressed, and efforts to obtain patient input
              18
                        and acceptance are not described.  However, the major
              20        outcome expected appears to be in standards   for use in
                                     and in professional education systems at
              21        peer review

                        KUMC."
              22
                             This will supplement   the juvenile diabetes project
              23
                   now  under way in Wichita, and sponsored by the Kansas Diabetes
              24
                   Association.  These fit under their Objective 3 above: qualit@
              25

  HOOVER REPORTING CO, INC.





                                                                                137

   WHD-71            improvement.

                2               The second one, the second new project that they

                31:i are asking for is primary    health care in DeSoto, a small

                4    rural community -- $26,288.

                5               The  rural  community  has  raised  $4,000  i,,  his  rural

                6    county of  a population of about $7,000 for  a  prA'JLLCL.Ly
                7    clinic  sponsored  by  the  Cedar  Valley  Medical   AssociAition. It
                8    is  now  operating  with  a  nurse-practitioner  and  a  p  rtI-time

                9     -physician.

               10               CHP okays the project but raises the      question    about
               11    the development of criteria for disposing of grant-@elated
               12    income.  This  is  one  of  their  rural  access   objectiveis.
               13               The third one is the B.erkley Health Education pro-
               14    ject,'which as I guess you know, is a 6th and 7th grade publi::
                     education program       a campaign against smoking.
               15
                                The fourth one,"the perintal mortality project
               16
                     regionalization,  is  for  $305,000  and  it  is  a  very  elaborate
               18    project, and they admit that this will take at least five
               19    years before this can become operational.
               20               The RAG says that this has special merit, and I
                     ques@n very seriously how we      are to interpret the term
               21
               22    "feasibility" when they say that with five years           that   five
                     years is the limit that they need.
               23
                                Now,  with  CHP  relationships,  I  would  say  they  are
               24
                     very good, alt  hough  they  have  not  been  funding  CHP  activities
               25

  IODVER REPORTING CO, INC.
  ;20 Massachusetts Avenue, N 1.
  Vashington, D.C. 20002






                                                                              138
  4HD-72       1     as much as some of the other RMP'S.

               2                I notice on  the  Staff  summary  that  the  concerns

               31'!  here -- No. 1, Project 70-A, Emergency Medical Training,

               4     Extension of Project  70  --  was  initiated  from  program  stff

               5     funds and is a continuation of the activity.

               6                This seems a legitimate enough program, if we are

               7     permitted  to fund this sort of thing.

               8                The second, Project No. 51,   where.the   funds   went
               9     from $24,000 -- or $48,000  in  one  year  to  $117,000  in  one
               10    year, is a pretty  big  jump,  and  Project  No..52,  which  has
               11    gone from $40,000 to $112,000 is also a pretty bi@jump.
               12               But from the little I am able to find in material,
               13    it seems as though  they  have  been  preparing  to  expand,  and
                     that they possibly  can  do  this  effectively  with  the  increased
               14
               15    funds,  since they have built a network at the junior
               16    colleges, and they have laid the groundwork     for  the   health

                     services education work.
               18               The one I raise the I* question  about,  however,  is  the
                     $305,000 perinatal project,  and  I  would  like  to  hear  from
               19
                     Doctor Vaun about it.
               20
                                IIR. CHAMBLISS:  Will you conti  nue,  Doctor   Vaun?
               21
                                DOCTOR VAUN:  I  think  the  Director  cones  through  as
               2,2
                     a very strong and good leader for the project.  I am impressed
               2,3
                     with him, I am impressed with the continuity of RAG at a
               24 1
                     very difficult time; I  am  impressed  with  the  shift  of  object-
               25

  HOOVER REPORTING CO. INC.






                                                                       139

  [D-73      1    ives, and more so with the addressing of projects to the
             2                                                       all atten-
                  rather mundane, everyday needs of people, like dent
             3    tion, and diabetes, rather than tribioplastic tissue@.

             4              I am tremendously impressed with the scope  of

             5    their projects relating to real health care needs.

             6              I am further impressed with the continuati n of

             7    fundings on projects that have been terminated.  The,

             8    a good track record with that.   I would hate to doc-c them
             9    anything, but as 14rs. Wyckoff has identified, I thinlc they@
             lo   are overly ambitious in their perinatal projects, and  I
             11   don't see coming through any special contribution on@ the part
             12   of the hospitals.
             13             I think their faculty is terribly fat, with two
             14   part-time neonatologists; I didn't know there were  that
                  many in any one state, lee alone-that they' were going to be
             15
             .16  faculty, and -- you know, again addressing themselves to the
                  development of their own intramural audio-visual aids -- this
             18   just leaves me a little cold.
             19             So I would recommend zubject to Mrs. Wyckoff's
                  modification, a $100,000 reduction from their request.  The.
             20
                  request'was $1,733,'380; 1 would recommend $1,633,380.
             21
                            I,oo it with tongue in cheek, because it would
             22
             2,.l appear that these people came in with a very  reasonable
             24   request.  They didn't ask for the @loon, like some of the pro-
                  grams have, and I hate to dock them anything, in view of the
             25






                                                                                                   14o
   flID-74                 fact that they are not even up tb what target might be, but
                   2                                          said,  is overly ambitious, does not
                           I think the project, as I
                           address certain items that I think are terribly important.
                   4                    So I think I am going to recommend that they be

                   5       docked $100,000.
                   6                    MR. VAN WINKLE:,-And do you want a message to get

                   7       on that particular project?
                   8                    DOCTOR VAUN:   I think something should be said
                   9       about it in light of what Mrs. Wyckoff commented                   about.
                   10                   MRS. WYCKOFF:   They are only asking for 77 percent
                   11      of their   target, and when they get -- if they get the whole
                   12      $300,000   that they are asking for in July,  they,              -will only
                           get 91 percent of their target.
                   13
                   14                   So theirs is a very modest request, actually.   I am
                   15      sorry that they have put so many,eggs in one basket.
                                        DOCTOR SLATER:   Question.   If there are funds left
                           over after these two rounds,  is@it possible for these Regions
                   18      to come in again for further supplementary funding?
                   19                   l@. CHAMBLISS:   No,  there will not be,               Doctor

                           Slater.
                   20
                                        DOCTOR SLATER:   This is the end of the                1-ine, even
                   21
                           if there is money left over?
                   22
                                        MR. CHAMBLISS:   They will not have a new opportunity
                   23                                                 d,
                           to apply.   The July 1 application date is'the final  date as
                   24
                           things stand at.the moment.
                   25


   t4nnvFR RFPI)RTING  CO-  INC.







                                                                       141
  ;IHD-75                     MRS. WYCKOFF:  I would like to ask about this

              2    indirect cost information that is in this project.  It ranges

              3    from 55 percent down to 8 percent, and I wondered if.-- if

              4    it is perinatal, what would affect this?

              5               MR. CHAMBLISS:  I wonder if  our Grants Management

              6    man would speak to that?,-I do recall Kansas having perhaps

              7    one of the very low indirect cost rates, sometime ago.
              8               MR. VAN WINKLE:  This is different institutions.,

              9    is  it  not?
              10              MRS. WYCKOFF:  Yes, it is their whole list.
              .11             MR. CHA14BLISS':  Staff is checking that how.
              12              MR. VAN WINKLE:  It is just the vary3ng rates,
                   would'guess, between whatever institutions receiving the
              13
              14   funds--
                              MRS. WYCKOFF:  t.hopet.we  are talking about the
              15

                   right   one.
              @16
                              MR. CHA14BLISS:  I would simply ask one question of

                   the reviewers.  Are there any comments to be made with regard
              18
                   to CHP-Pl4P relationships-in this Region?
              19
                              MR. VAUN:  I think Mrs. Wyckoff mentioned that.
              20
              21   From the report they appeared good.
                              MRS. WYCKOFF:  Yes, their  relationships are good.
              22
                   I do think they need a little prodding on the affirmative
              23
                   action program.
              24
                              They have a very small staff, but I think they
              25


  LinnticD  DrDnoyimi-  in  ikir




                                                                        142

  fD-76            should  pay attention  to it on their Board -- on their RAG.

              2
                             So, with that as,a suggestion, I would like  to  move

              3    approval of the

              4              DOCTOR VAUN: $100,000  reduction  in  their  request.

              5              MR. CHMBLISS:  Is that in the form of a motion?

              6
                             MRS. IIYCKOFF:  $100,000.

              7              DOCTOR VAUN:  $1,633,380.00.

              8              MR. CHAMBLISS: All tight; that is a moti  n,  I  take

              9    it?  Has it been seconded?
              10             DOCTOR VAUN: I will second it for Mrs. Wy koff.
              11             MR. CHAMBLISS:  It has been moved and seconded; is

              12   there discussion?
              13             MISS MURPHY:  I would like to make an addition.
                             'MR. CHA@IBLISS:  We would like to have further  input
              14
              15   from.the Staff.  Miss Murphy?
                             MISS MURPHY:  I@would like to add that they did hav(@
              16
                   a minority professional on the staff, and with the phase-out
              18   she left them.  I think-that improbably what has actually
              19   happened.in a lot of areas.
              20             DOCTOR MILLER: In response to a  question  by  Doctor
                   Slater, it is fair to say     to tell the Committee that the
              21
                   Pd4P-DR@IP staff does intend to award all the funds that are
              22
              23   available, if the Review Committees approve that  much and
                   the National Council approves it.
              24
                             MR. CHAMBLISS:  Yes,. they do indeed.
              25

  HOOVER REPORTING CO, INC.
  320 Ma@chusetts Avenue, N.[.
  W@ington, D.C. 20OU






                                                                                       143
  WliD-77                           DOCTOR MILLER:  The intent is to award all the

                 2     money requested now -- between now and the next period.

                                    MR. CHAMBLISS:   If it     is properly reviewed-and

                 4     recommended, yes, we will.

                 5                  DOCTOR SLATER:  Well, the question came up- this.

                 6     morning, on whether we might like to recommend withholding,

                 7     rather than give it away to the progra         ms.
                 8                  DOCTOR MILLER:  We might, but if we do          it will-just

                 9     be on expended funds; it will not be awarded any            other way.
                 10                 MR. CHAI,4BLISS:  All those in favor of the motion?

                .11                 (Chorus of "Aye"),

                 12                 Those opposed?
                                    The "Ayels" have it, the motion is carried, with
                 13

                       a recommended level at $1,633,380.
                 14


                 15








                 18


                 19


                 20


                 21


                 22


                 2t3


                 24


                 25





                                                                              144

  4HD-78       I               MR. CHA14BLISS:  Shall we now draw our attention

               2    to reviewing the application from the Michigan Regional

               3    Medical Program?

               4               M. TOOMEY:  Did you rule on this Inter-Mountain?

               5               MR. CHMIBLISS:  The Inter-Mountain Region will be

               6    reviewed  in lieu of Wisconsin in our final session.  That is

               7    how we got Wisconsin early oh, and Iowa was also one that

               8    we were holding over, and I thought I would review them in

               9    that Order, until Doctor White returns.

               10              MR. TOOMEY:  Unless there are other reasons, I am
               11   here, Mrs. Salazar is here and Mis    s Murphy is here; why don't

               12   you get rid of Inter-Mountain?
                               MR. CHAMBLISS:  All right.  All the parties are
               13
               14   here, and Inter-Mountain will be presented by Mr. Toomey and
                    Mrs. Salazar, with Miss Murphy as the Staff person.
               15








               18


               19


               20


               21


               22


               23


               24


               25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.E.
        n r' )nnrt,)





                                                                                                                                                          14
     .iD-79                   1                                         REGIONAL  ML?DICAL  PROGRAM  REVIEW

                              2                                                       INTER-MOUNTAIN  REGION

                                                               MR.  TOOMEY:     Once  again,   back  se
                              3!i                                                                                                  veral years ago,

                                                                                                                               r-Mountain Medical
                              4           I had the            opportunity  to  visit  the   Inte
                              5           Program prior to awards, prior to Doctor Stuart's becoming
                              6           Coordinator.  I think it was Mr. Hagman who was the Coordina-

                                              ' back then when I visited.
                              7           tor

                              8                                The implication, in                         'my-opinion
                                                               DOCTOR SLATER:  Would you speak up, sir?
                              9
                              10                               MR. TOOMEY:                  Program leadership is satisfacto                                      ry,
                              11          from  all         appearances.     I  have  not.met  Doctor  Stuart,.but  I-
                                          understand tha               t he is rather a contrast to the former program
                              12
                              13          coordinator.
                                                               The former program coordinator had some eifficult-
                              14
                              15          ies with the administration  of the University of Utah, and
                                          apparently from the mater&fal in.the application, Doctor Stuart
                                          has been able to overcome those problems, and their relation-
                              -@17
                              18          ships were on a very satisfactory                                          basis.
                                                               The program staff seems                             adequate in size; their
                                          capability seems to be sufficient.  When I was there a year
                              20
                                          and a half -- two years ago,  they had                                               some trouble with the
                              21
                              22          evaluation progr@ and apparently that                                                program still exists,
                                          because one of the positions are still                                               vacant, and the
                              23
                                          Deputy Director of the program,is in charge of the evaluation
                              24
                                          at the moment.
                              25

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



                                                                          146

  IHD-80      1              Their Regional Advisory Group, as far as I see,

              2    both in the application and from my personal  contact,  is
                i  sather outstanding.  They are interested, they meet@         ly
              3                                                           regular

              4    as a matter of fact, they had five meetings that were listed

              5    over the past year. Their  Executive  Committee  meets@--  has

              6    met.at least three times,

              7              The past performance and accomplishments of the

              8    Inter-Mountain P-14P seem to be adequate.  Their relat on
              9    -with the Comprehensive Health Planning agency in the area,

              10   they cover, which incidentally covers Utah, Montana -- or
              11   parts of Montana, Colorado, 'N7yoming and Nevada, and @they
              12   have programs that have been extended into each of I  t@ese
              13   areas.
                             they have established as their obje-- tives and
              14
              15   priorities.programs related to rural health care needs, to
                   strengthen -- the strengthening of the local health planning-),
                   to -.quality assurance -- projects related to  quality  assur-
                   ance in primary health care, and .the Emergencv Medical
              18

                   Services.
              19
                             Their proposals seem to conform at  the  present  to
              20
                   these major thr sts that I ju st mentioned.'
                                  u
              21
                             I think however, that it is important to note that
              22
                   there are 11 programs for  which they are requesting continua-
              23
                   tion funding, and that there are 38 new programs for which
              24
                      that they are proposing in this present application.
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  W2@hinortnn 1) r 20002







                                                                                                                                                       '7
                                                                                                                                                   141

                                                           Because of the 11 and 38 -- that's 49 projects
                             2          it seems as though they have in fact bitten off rather much
                             3          to do, and because of this they have requested considerable

                             4          sums of money, and if you will look at line 15, the Inter-
                             5          Mountain  section,  their  current  level  of  spending,  F,nnualized,
                             6          is  $1,878,000.    Their  targeted  available  funds  are    3,597,000.
                             7                             Their  May  1  request  is  for  $3,849,000,  which  is  106
                             8          percent  of-the  targeted  available  funds,  and  the  total  of
                             9          the  July  1  estimate  is  another  half-million  dollars,   which
                             10         would  bring  them  up  to  $4,349,000,  or  120  percent                                                 f  the
                             11         targeted  available  funds.
                             12                             In  terms  of  the              yellow  sheet  that  you  havo  in  your
                                        booklet,   there  is  --  the                      very  last  line,   I  believe,                        the  Inter-
                             -13
                                        Mountain  Regional  Medical  Program  is  considered  a  good  pro-
                             14
                             15         gram,  but          it  is  felt  that  the  Region  is                           over-funded.
                                                            I  might  say  I  @ea'rd  this  from                          several  sources,
                             16
                                        from  people  who  have  been  acquainted  with  the  program,  but  I
                                        have  to  say,  in  defense  of  what                            has  been  done,  that  it  has
                             18
                                        been  a  very  aggressive,  a  very  viable,  a  very  concerned  pro
                             19
                                        gram,  and  it  would  seem  to                        me  that  on  the  record  of  their
                             20
                                        past  accomplishments,  they  would  probably'rate  as  certainly
                             21
                                        a  good  to  excellent  program.
                             22
                                                             I  would  agree,  on  this  premise,   that  they  should
                             23
                                        pe@ps  have  a  greater  consideration  given  to  the  amount  of
                             24
                                        money  that  they  are  requesting,  more  on  the  basis  of  the  fact
                             25

    HOOVER  REPORTING  CO,  INC.
     32OMassachusettsAvenue,N.C.
               nfl I)nnn)





                                                                                  148

  ;HD=82             that they are requesting three -- and almost four times as

                2    many programs -- to be put into,operation as what they
                311  currently have in operation, and from that basis it          Would
                4    seem to me questionable as to whether the total amolt            of

                5    dollars should be provided.

                6                They  have  done  one  other   thing,   apparentl   within

                7    the  past  year,  the  implications  of  which  I  am   reall   unable

                8    to  evaluate  at  the  moment,  but  because  of  the   intere st  in

                9    RAG  and  apparently  because  of  the  extreme  --  what  I  would

                lo   consider to be their     concern  that  they  continue  with  an   on-
                11   going  operation,  to  pick  up  the  main  threads  of  an  @iP  pro-
                12   gram and develop a new organization called the "Heal"-h
                                                                                  7
                     Development Services Corporation," and this was not          in exist-
                13
                14   ence i'ihen I was in Salt Lake City, previously.
                                 I did  not  have  the  opportunity  to  talk  with  the
                15
                     staff  about  this, but it deL-med,-from very quickly reading
                     this paper,   which  is  an  attachment  in  your  booklet,  that   it
                18   seems    they have created an organization structure which would
                     allow for the work of the Regional Medical Program, to be
                1.1)
                20   carried on, to secure funding from numbers of sources, and
                     to provide for -- really through the sale of their services.,
                21.
                22   to provide for the'continued development of many         of the n6ede@
                     programs in those areas.-
                23
                                 This sort of Health Development and Services
                24
                     Corporation, which is a separate organization, has come back,
                25

  HOOVER REPORTING CO, INC.
  32OMassachusettsAvenue,N.C.
  W;ishingion- D-C. 20002





                                                                                            14c
  IIID-83          I     now, to I@IP-and requested funds' for some of the projects
                   2     that IP14P has approved in the amount of           almost $405,000.
                   3i                So IRMP will be funding an organization which was
                   4     created by IRMP to pick up the threads of the work of
                   5     Regional Medical Programs in carrying it on, and it is a
                   6     voluntary non-profit organization, and I don't mean then at
                   7     all to imply that there is a thing wrong with it.                  I just
                   8     think it is a very in novative and aggressive kind of move
                   9     on the part of the people in that area to provide for them-

                   10    selves a mechanism to continue their work.
                                     The other thing to which I would           call your atten-
                   12    tion is the extent to which IRMP is               and  you will find
                   13    this, again, in your yellow sheets               they  are providing
                   14    assistance to the Idaho Comprehensive Ilealth Planning agency,
                         the Utah agency, the Montana agency, the Western Colorado A
                   15
                         agency, comprehensive health planning, and in Nevada the
                         Comprehensive Ilealth Planning A agency, so that these plannin;
                   17
                         agencies in the state, which make up a part of the Inter-
                   18
                         Mountain section, are being specifically funded out of the
                   19
                         RMP funds, and I haven't added it up but it makes rather a
                   20

                         substantial sum of money.
                   21@
                   29,                In addition to which they have          a number of projects
                         related to the development of Hluence in the hospitals to
                   2,3
                         act,-l presume, in a more efficient and effective manner.
                   2,4
                         Management consulting services, management engineering, and
                   25

  HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.[.





                                                                       150

  WIID-s84         multi-hospital in-service training, and several others.
              2              I would just comment in general on the fact  that
              3!i  personally I am not sure that it is the responsibility of
              4    the Regional Medical Programs to specifically focus on  the
              5    development of the hospitals to enhance their  capabilities
              6    from a management standpoint.   This is the question that I

              7    do have.
              8              -I don't have any question about their sup  t t at
                  -the A agencies, particular.fy in fact -- in light of the fact
              9
              10   that it is one of the areas in which the IRMP says -:hey are
              11   interest, to strengthen local health planning.
              12             I don't know whether strengthening the A  gency can
                   be construed as local health planning, but I     attempting
              -13
              14   to give consideration to planning needs in that area
                             In net, when I look at the record they have, when
                   I have the remembrance of my visdt with'the group in Salt Lake
                   City -- their leadership, particularly, from the Regional
              18   Advisory Group,  and the fact that their objectives and their
              19   priorities are in line with those that they have selected --
                   or, let me put it this way: their project is pretty much in
              20
                   line with their objectives and priorities that they have
              21
                   selected, and it seems to me that we have a good to excellent
              22
                   Regional Medical Program which shows good strength, innovative
              23
                   ability, a desire to continue the work, to enhance the
              24
                   planning, to provide for better services in the area, and it
              25

  HOOVER REPORTING CO, INC.
   32OMassachusettsAvenue.N.E.





                                                                          151

  IHD-85           is only that I have some doubts as to some of  the  projects.

              2              That is one facet, and I have some doubts as to the
                                                                       s@
                   capabilities to initiate, desirably, 38 new project     so that]

                   I would change the recommendation    change the fund@ng that

              5    they have requested, and I don't    now, Mrs.  Salazar,  you

              6    want me to say what I think it should be,  the  neighborhood

              7    in which I think that funding should be?

              8              MRS. SALAZAR:  Yes.

              9              MR. T0014EY:  I think it should be reduced somewhere
              10   in the neighborhood  o.f two and a half million dollart,
                                                                            as
                   opposed to the request they have, which is  $3.8  mill@on.
                             MR. CIIM4BLISS:  All right.  Will -- Mrs.  S@lazar,
              12.
              13   will you make your presentation?.
                             1,4RS. SALAZAR:  I have nothing to add.  Some.of the

                   concerns that I have had about the application  have  been
              15
              16   explained.by Yx. Toomey, who has-been in the  Region  since-I
                   have.  Ilis last visit pre-dates my numerous visits.
              -17
                             I do have one question that perhaps  Staff  could
              18
              19   address themselves to, which deals with the  Region's  past
              20   history and mechanization, dealing with hardware.
                             That was one of the old  problems that-we used to-
              21
                   discuss.
              22
                             Secondly, in reading the last site  visit  report,
              23
                   which took place in January, I believe, of this  year,  there
              24
                   were some very serious issues raised as to  minority  groups
              25

  HOOVER REPORTING CO, INC.
  320 'Aamchusetts Avenue, N.[.





                                                                           152

  WHD-86            participating in RAG's or Executive Committee, and staff.
               2    And this, too, is an old program that has been with us for a

               311  long time.

               4              MR. TOOMEY:  I did not have   time to read Mdry's

               5    report on the last site visit.
                              MRS. SALAZAR:  The third thing that I might ask is

               7    what will be the interface to assure-that  there  will  not  be

               8    duplication of funds going into the new  corporation  and  irto

               9    the Inter-Mountain Region Medical  Program?  How  do  they  do-

               10   ordinate the efforts? Are  they  two  free-standing,  and  how

               11   do they relate?
               12             MR. CHAMBLISS: If you  raise  a  question  about  the
                    corporation, I think the Committee might be interested in
               13
               14   something of a  report that our Grants  Management  branch  has
                    developed on the corporation,  and-I would ask Mr. Pullen
               15
                    if he would express those concerns to the Committee, please?
               .17            MR. PULLEN:  These are some of the concerns
               18   expressed by the Grants Management  Branch  about  the  Health
                    Services -- Health DevelopmeiTt and Services  proposed  by  the
               19

                    Inter-Ilountain RMP.
               20
                               It does not appear to have the  final  approval  of
               21
                    the grantee to organize a  staff.  Such  a  corporation,  with
               22
                    P,14P employees.  We are not aware of the use of RMP employees
               23
                    solely to staff an affiliated organization, as proposed, and
               24
                    we seriously question the proposal,of the corporation as bein
               25

  HOOVER REPORTING CO, INC.
   32OMassachusettsAvenue,N.E.





                                                                        15 -01

  WIID-87          necessary to fulfill IRMP requirements. The  proposal  appears

               2   to be broader in program and geographic scope than the  RMP.
               3 -                                                              I
                             Since it exceeds that of the IRMP-BMS Alaska Project,

               4   I do not think it is appropriate for the developmental costs

               5   through employee support to be charged totally to the grant.

                             As previously advised, the RDIP does not charge any

                   organizational costs for this corporation to the grant  funds.

               8   It is understood that this organization is designed to  assume

                   all of the normal functions of the RMP program staff  after,

             10    termination of grant support.

             11              If the corporation is determined to be a free-stand--

             12,   ing organization, then the incorporating costs should be

                   spread among the various supporting agencies, not solely  to
             13

                   the I@.
             14

             15              A statement from the grantee will be required to

                   indicate that the development of-such an organization with it,.:

                   grant funds is in keeping with the grantee policy, particular-

             18    ly considering the broad scope proposed.
             19              This proposal would seem to be a mechanism to  by-
             20    pass the changing of an RMP from a university to a free-stand-
             21    ing organization which the coordinators have  been,discouraged
                  @from finalizing prior to passage of legislation.
             29

                             It could well be that if we are able to approve
             23
             24    this technique, other RMP's may,,elect to go the same route
                   with grant funds in anticipation of,passage of new legislation.
             25

  iOOVER REPORTING CO, INC.
  @20 Massachusetts Avenue, N.C.
  Vashin,Rton, D.C. 20002







                                                                             154
                                                I think that  may  answer  some  of
  D-88                         MR. C@MBLISS:
               2     your questions. It  does  express  some  concern  emanating  from

                     the Staff regarding the corporation.

               4               We admit that  it  does  have  innovative  features,

               5     but whether there is a bit of  prematurity  here  at  the  moment

               6     will be left for your judgment.

               7               Mr. Posta would add further comments.

               8               MR. TOOMEY: I don't  know  enough  about  it,  becua-se
               9     you know, I didn't get a chance to  read  this  until  just  this

               10    morning.

                               MR. POSTA:  This, I might say, Mr. Toomey, is
               11
               12    relatively new as far  as  the  other  administrative  problem
               13    issue that we have had to do business  with  for  the  last  two

               14    weeks.
               15              First of all, we have   heard from  the  Region,  too,
                     which -- which assures us that  this  is  a  separate  entity,

                     as of July 1, the same as the  Health  Department  or  AID  or
                     any other institution.  I think our concern as    far as IRIV
               18
                     is concerned is how much RI@IP or grant funds have gone into
               19
               20    this particular corporation since  its  birth  in  January  of
                     this year, through a charter with  the  Secretary  of  State  of
               21

                     Utah.
               22
                               The grantee has   worked with  the  Attorney  General;
               23
               24    they do not think there  is  any  hanky-panky  going  on.  The
                     grantee has written a letter to the RMP giving their views
               25







                                                                              155
  gHD-89       1     on this particular corporation, and they defiitely will

               2                                                   nd to th
                    .dichotomize those costs going to the RMP a            is particu-,
               3     lar corpora@n, which to date have     amounted to  abou  $18,000.
               4     That is the latest on the corporation as of this morning.

               5     We just got this $13,000 figure this morning.

               6                MRS. WYCKOFF:  How do they:.from the Healtl-Set

               7     corporations that have been formed all over the country that

               8     are non-profit and separate and funded by RMP?

               9                MR. POSTA:  I wish I could tell you; I carlt.

               10               I do know that our original -- I should say from
               -11   the Mid-Continent operations concern all along has      @oen: who

               12    are on the Board of Directors?
               -13              Are these folks a part of the IRMP?  And if they
               14    are, this  might be a conflict of interest, and they woul

                     have to make this  decision.
               15
               1(;              This is what we are still working on, but I think
                     it is a legal corporation the same as any other corporation
               18    asking for a charter in most of your states.
               19               14R. TOOMEY:   As I understand it, there is an
                     overlapping of the Board membership between RAG and the
               20
                     Board of the Health Services Development Corporation, and
               21
                     there are employees of IRMP who are on the Board      of this new
               22
                     corporation, employees.
               23
               24               MR. POSTA:  Well, the Coordinator, possibly         or
                     probably.
               25

  HOOVER REPORTING CO, INC.
  32O Massachusetts Avenue, ti.l.




                                                                         156


                                                                        would
  ID-90                      MR. TOOMEY: Well, in there  it  said  there

               2   be minority representation.from the employees.
               3.            But the other thing it seems it  is  going to do is
               4   to essentially really act as a broker.  it  will  go Jut  and
               5   develop programs and then it will come back and      mpt  to

               6   convince IR,%IP to fund those programs; am I not righ ?

               7             Between the money that is,going through t at organ-

               8   ization and the fact that there are 38 new applications,
               9   and there are questions,about a number of them, I f@lt that

               10  two and a half million which is,  I believe     they are

                   annualized now, .out of that $1,800,000, so this re  xesents
                                                                      p
               12@ an increase over their annualization, but it is a  million-
              -13  three under what they are requesting.
               14            MR. CHA.MBLISS:  Yes.
                             The first presenter, Mr. Toomey, came up with a
               15
                   recommendation, but as I re,call,-that has not been placed in

                   the form of a motion.
               18            MRS. SALAZAR:  I would be glad to second, but I
                   prefer to withhold A second until I.-hear some other comments
               19
               20  on the other points that I raised.
                             %IR. TOOMEY:  You see, the point    I think the th-inc
               21,
               22  that worries both of us right now is the  .fact  that so  many
                   people -- well, a number -- two or three  people  -- have made
               23

                   the comment:
               24
                                   "This is an organization which already had
               25

  HOOVER REPORTING CO, INC.
   32OMassachusettsAve-nue,N.E.




                                                                        157

  'IHD-91      1        already-had a million-eight and seems to be overfunded,"

               2   and so now they come back in and their request just  about

               3   doubles that, and you reduce it by a million-three and  I

               4   think the question still is: is it overfunded, and  I'don't

               5   know how to answer that.

               6             MRS. IVYCKOFF: Are any of these  project  numbers

               7   money that goes into this organization?  We can't tell from

               8   this which ones they are.

               9             MRS. SALAZAR:  Some project staff'will be function-
               10  ing in this new organization, as I understand it on page 14,

               11  but -they would gradually phase out as this  thing becomes a

              .12  free-standing agency.
               13            But this is the part that bothers me, as to who is
               14  looking at that during that interim period when IRMP.is-, over.-

                   lapping this organization.
                             MR. POSTA:  As f-understood that             the

                   Executive Committee of the Regional Advisory Group  is  the
               18  watchdog organization of this new corporation.
               19            So far as Mr. Toomey has mationed, $18,000
                             MR. TOO,%LEY:  And the projects that tey talk about,
               20
                   the ones that are meaningful -- medical  consultation  for
               21
               22  rural communities, that's a 99; rural  medical  technology
                   systems, medical ccoultations, $40,000.   Rural medical tech-
               23
                   nology systems, which is Number,104, is  for $115,000.
               24


               25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.C.
  ViashiriL,ton- D.C. 20002






                1            Rural quality assuranc e, No. 105, is for $126,000.
   WHD-92

                2            And rural medical practice and management, $114,000.
                31
                if That is No. 106.

                4            The other one is modeling the Utah Health Care

                5  system, which is only $7,100.

                6            That is a level of about two and a half million;

                7  why don't I cut that back to two?

                8            I move that we allocate two million dollars to the

                9  Inter-Mountain Region Medical Program.

                10           MR. CHAIIBLISS:  There is a motion on the floor that

                11 the Inter-Mountain Regional Medical Program be set ata level

                12. of two million dollars.

                             Is there a second?
                13

                             MRS. SALAZAR:  This is across the board, Mr. Toomey
                14

                15 that you are talking about?
                             MRS. WYCKOFF:  Now they are at one million-eight,

                   so this -- it raises them $200,000.
                18           DOCTOR MILLER:  They are at $1.88 million.
                19           DOCTOR SLATER:  $200,000 instead of two million.
                20           DOCTOR MILLER@.  It raises them $120,000, so you
                   essentially are holding them to the same level of-current
                21@

                   funding-
                22
                             MR. CHAMBLISS:  Is there a second on the motion?
                23
                             DOCTOR,VAUN: I have a"question, but I don't have
                24

                   a second.
                25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.




                                                                                              159

   [iD-93                              MR. CHMIBLISS:   All right; maybe the motion will

                   2     die for want of a second.
                   3!'                 MR. THOMPSON:   I     will   second the motion, just to g


                   4     it on.

                   5                   MR. CHIOIBLISS:   The motion has been          made end secon-


                   6     ded that    the:
                   7                         "That the level of funding for Inter-,Mountain

                   8            Region be set at two million dollars."

                   9                   Is there discussion?          Doctor Vaun?
                   10                  DOCTOR VAUii:   I still have not heard an a swer to
                   11    Mrz. Salazar's question.   All I have is hearsay that they
                   12    are over-funded.   I mean, does anybody have any evidence that
                                                                                              1
                   13    they have a Swiss bank account or that their projects are

                         lousy?  One or the other?
                   14
                   15                  otherwise, this is hearsay and I don't think we
                         should use that to reall@cut the'program fairly substantial
                   16
                         amounts of  money.   Their performance has been good,   I think,
                   18    that is what we have to  go on,'and not the hearsay that they
                   19    are overfunded.
                   20                  MR. POSTA:   Doctor Vaun, could I respond to that,

                         please?
                   21
                                       DOCTOR VALTN:   Somebody had better, I think.
                   22
                                       MR. POSTA:   I think that the Council took a fall
                   23
                         site visit to Inter-Mountain this last go-round, and was
                   24
                         concerned primarily because of the turf problems that existed
                   25

   HOOVER REPORTING CO, INC.
   320 Massachusetts Avenue, N.C.
   Washinzton, D.C. 20002





                                                                         160
  gHD-94            in Mountain States Regional Medical Programs, the Inter-
              2     Mountain Regional Medical Programs, and Colorado-Wyoming,
                    and I wanted to be careful not to say that this problem is

              @4      has been solely Inter-Mountain's.
              5              But Inter-Mountain has had more turf problems that
              6       than all Regions in the country put together.   They are

              7     even in Alaska now, doing an EMS project.
              8              But that is to their    you can pat  them on the
              9     back with one hand, but other people,  particularly  Mountain
              10    States -- Colorado-llyoming and the like, don't  particularly

              11    care for-it.
              12             So  I think that what I am saying  is as  straight-
              13    forward as possible, that there are some people that feel
              14    that this Region has got too much money and they are getting
              15    in everybody's way in the surrounding territories.
                             Now, what we di@'demand in this  particular  applica-
                    tion is to have the inter-Regional Coordinators  group,  which
                    is composed of the three Coordinators of those three  RMP'S,
              18
              19    together with the Coordinators, get together and take a look
                    at everything that has been accomplished, and everything  that
              20
                    is requested, and everything contemplated on being  rebudgeted
              21
              22       they actually met on May 9th and have submitted a letter
                    signed off by six people, that all but ten  activities  have
              23
                    been approved by all three Coordinators and RAG Chairmen.
              24
                              They will meet again, and have mentioned two dates
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  W@thinpfnn f)(: 9nno9




                                                                       161

              1    that the                                      '@s will  be
  ID-;95                  y will be meeting together final dollar

              2    distributed among the three Regional Medical Programs.

              3              But I think, to zero int Jesse, on your question
              4    concerning why do we think this is overfunding, it is coming

                                                     with your group.
                   from several different discussions

              6              MR. TH OIIPSON: viell, if y u have  hard  evidence
                                                     0

              7    you know, when they say Inter-Mountain  --  that's  between

              8    any two mountains you can fin d.

                             MR. TOOMEY: You take a look  at  the  support  of

              10   the Nevada A agency, and I think they have only touched a
              11   little bit of Nevada, and here they are  funding  A  agents

              12   for the whole darned state.
                             MRS. WYCKOFF:  I just don't understand the policy
              13
              14 of funding  A agencies and then turning around and asking for
              15   their approval.  There is something corrupt about that.  They

                   wouldn't dare not approve.
                             MR. CHAMBLISS:  Is there any further discussion?
              18   Miss Murphy, I think Jesse had a question about the minori-
                   ties, and we have always brought that up, and it seems every
              19
              20   time we get a few on the staff
                             MISS MURPHY:  Then the phase-out came, and we lost
              21
                   several Orientals, but the day after our site visit,  the
              29,
              23   G-reat White Father brought some Indian into the Inter-MountaiiL
                   Regional Program from the Arizopa area, and thay hired him
              2,4

                   on the spot.
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Averiue, N.[.
  @Vashington, D.C. 20002





                                                                           162
  KHD-96                       So-they hired him on the spot, and he is responsible

               2     for all the Indian components  that  are  in  the  projects.  But
                     they still insj& that they have their quota of minority com- i
               4     pared to the number of minorities in the Inter-@lountain

               5     Region.
               6               About hardware,  I  went  through  rapidly;  I  counted

               7     about $173,000 for all the projects.. I don't have    anything

               8     else-to compare to.

               9               MRS. WYCKOFF:  Are there W-4P  projects  where  we  are

               10    assisting the state legislatures with   information  on an

               11    organized basis?
              .12              MR. CH@IBLISS:  That is a   policy issue;  we have

                                                                e have discouraged
               13    discouraged this before, Mrs. Wyckoff.  W
               14    this before, in this Region, I might add.
               15              MRS. WYCKOFF:  There   is a great increase in the

                     amount of money for-that   -Eoo.
               16
                               MISS MURPHY:   We discussed that at the site   visit
               -@17
               18    and CHP had asked for that program, and their concern    in   the
               19    comments was that they had nco-- elicited the people that would
               20    attend, so they had turned the program, the seminar, completely
                     over to CHP, and I think it was 110  or  one  of  those  Regions,
               21,
                     and they are going to run it.
               22
               23              They are going to select   the people  right  up  there

                     themselves.
               24
                               MR. CHAMBLISS:  It simply still has some connotations.
               25

  HOOVER  REPORTING  CO,   INC.
  320 Mamchusetts Avenue,  N.C.
        nf, innn)i




                                                                        163

  qllD-97     1    though, that we might question, especially in dealing with

              2    the-legislature.

              3              MR. THOMPSON:  Your primary purpose is to set up

              4    HMO'S; to find out if the state legislature  prevents  commun-
              5    ity sponsored practices, then you have to go to the  state  to

              6    carry out your main objective.

              7              MR. CHAt4BLISS: We would agree there, but the  ques-

              8    tion is, who should do it?


              9              MR. THOMPSON:  IUIP.

              10             MISS MURPHY:  RMP is the only one with the money;

              11   the CHP doesn't have the money.
              12             DOCTOR MILLER: Maybe I  missed  something  here,  ut
              13   perhaps somebody could go over it again.
              14             What is the purpose of this  new  organization?  Was
              15   this new corporation formed to replace RMP when it finally
                   dies out, or to be the fu@ure coordinator of  CHP-RMP,  Hill-
              -17  Burton and so forth, if that evolves?  or is it  a  foundation
              18   PSRO approach, or -- I didn't quite get what the  purpose  of

                   it is.
              19
              20             MR. CHAMBLISS: Would you  enlighten  the  Committee

                   on that?
              21.
                             MISS MURPHY: I think possibly it  is  your  certain
              22
                   your second comment.  I th@- they will be ahead as  ar as
              23
                   the unified health plan is concerned.
              24
              25             DOCTOR MILLER:  Do they have some articles of

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





                                                                       164
  RIID-98     1    incorporation or by-laws that would really tell what they

              2    are, supposed to do?

              3              MISS MURPHY: We don't have the by-laws,  but  they

              4    are Incorporated, and there is the whole document.

              5              DOCTOR MILLER: One of the things you  are  telling

              6    us from the Staff standpoint is that one of the things you

              7    oug ht to figure out is how they are going to react to  the

              8    future legislation, which has not yet been written, which is

              9    a favorite story of yours, and in the past, too, I think.

              10             But anyway,  how do you put all these programs
              11   together at the local level? If that is what this is,  we
              12   ought to give them a bonus instead of cutting down their
              13   funds.  Because that is one of the goals.
                             MISS MURPHY:  When they formed this corporation,
              14
              15   they did it with the understanding they could go to places
                   like Robert Wood Johnson dnd try,to get funding that they

                   could not get through the University, because it is a  state
              18   university, because that is part of the psychology.
              19             MRS. SALAZAR: I guess one of the problems  that  I
                   have with this is the fact that they did not move away  from
              20
                   the university immediately.
              21.
                             MISS MURPHY: Ti@ is my complaint.  They  want  the
              22
                   best ofboth worlds.
              23
                             DOCTOR SLATER:  The new organization is tied to the
              2,4
                   university, too?
              25

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



                                                                                                                                                165
    '.D- 9 9                 1                            MR.  CIIAI-,  LISS:             Does  this  discussion,  Mrs.  Salazar,

                             2       begin  to  clear  up  some  of  your  questions  regarding  the  cor-

                             3       poration?

                             4                            Shall  I  call  for  the  question?

                             5                            DOCTOR  MC  PHEDRAN:    Before  you  do,  I  would    like  to

                             6       ask  Mrs.         Salazar,  now  do  you  agree  with  Mr.  Toomey's  funding

                             7       recommendations

                             8                            MR.  CHAMBLISS:    All  right;  and  Mr.  Toomey's@recom-
                             9       mendation            is  that  the  Region  be  funded  at  a  level  of  two

                                     million  dollars.
                           10

                                                          MR.  VAN  WINKLE:    That  has  been  seconded.

                                                          MR.'CHAMBLISS:    That  has  been  seconded.    Those  in
                           12

                                     favor,  may  I  have  the  usual  sign?
                           13

                                                          (Chorus  of  "Aye")
                           14
                           15                             Those  opposed?
                           16                             (No  response.)
                                                          The  "Ayels"  have  it.

                                                          Now,  may  I  call,  please,   just  a  short  break  for  the
                           18
                                     convenience  of  our  Recorder?    Just                                a  couple  of  minutes,
                           19
                           20        please.
                                                          (Whereupon  a  short  recess  was  taken.)
                           21


                           22


                           23


                           24


                           25

    OOVER REPORTING  CO,  INC.
    ?O Massachusetts Avenue, N.[.
    'ashington, D.C. 20002





                                                                       166

  VIHD-100    1                REGIONAL MEDICAL PROGRAM REFIEW

              2                      MICHIGAN REGION

              3!             MR. Cl@,IBLISS:  We would like to resumer after a
              4    momentary break; we will begin with Michigan, and as we begi@;

              5    with Michigan, we would like the record to show th"k. Doctor
              6    Carpenter has in fact absented himself while this Region is

              7    under review.
              8@             The presenters here, Mr. Toomey and Doctor White,

              9    supported by Mrs. Parks.

              10             Will you proceed?
             .11             MR. TOOMEY:  I am of the opinion  that the Michigan
                   program was -- I am not of the opinion; I know -- i@ was
              12
                   difficult to read, difficult to,understand,.and I have feel-
             -13
                   ings of inadequacy in talking very much@about it,@, because
              14
                   I think that the proposal has a number of inadequacies.
              15
                             Program leadership was difficult to determine for
                   the kind and quality of program leadership; as a matter of
                   fact, I am not even sure at the present time who  is the
              18
              19   program coordinator.
                             In a listing of staff, it listed Doctor Tupper, an
              20
                   in all of the signatures it had Doctor Graham-Welk as the
              21
              22   individual, and -.so I have some concern -- not concern, but
              23   I just don't know.
              24             TheIprogram staff; they have 12 people, four cleri-
                   cal, five professional and three in management.
              25

  HOOVER REPORTING CO, INC.
  320 Mamchusetts Avenue, N.[.




                                                                           167

  WHD-101                     The question you had on the review shseet is    the

               2   adequacy of the program staff to manage and monitor the
               3   operation of projects, undertake such  activities  as  @il'l  con-

               4   tribute to local CHP plan development and related efforts,

               5   and my one note here is that I found it difficult to find

               6   an answer to that question.

               7              The Regional Advisory Group seems to  meet  Dnly  as

               8   needed, and it was difficult to  determine  their  part.;.cipation

               9   except on a project review Committee basis.

             10               The question related to past  performance  a  d  accom-
             11    pli8hments; these items do   not a pear to be or have  @een
                                                     p

             12    consonant with the recent program thrusts, except for

                           y Medical Services, and more recently, today        and
             13    Emergenc

             14    this f did not know -- hypertension was encouraged because

             15    -- and a good thing it was, because the program is        seems

             16    to have more than its share'of  hypertension  projects  in  it.

                              Objectives and priorities at the present time relat(@
             18    to cancer, kidney, Emergency Services, hypertension, nursing

                   homes, health manpower and development, and the proposal is,
             20    as written, it seems to me, to be questionable in terms of

                   its appropriateness.
             21
                              The funds they are requesting     $3,77'7,000, of
             9-2
                   which $1,675,000, is a  continuation  project,  and  $1,755,000
             23
             24    for new projects; they have an estimated July request of
             25    $800,000, and Michigan's target  figure  is  $2,000,000  --  their

   @OVERREPORTINGCO,INC.
  0 Massachusetts Avenue, N.[.
  ishingion,D.C.20002





                                                                        168

  iD-102      1   targeted available funds, is $2,969,000     approximately

              2   -three million dollars, and their request at the momErt would

              3   total, -as I said, $3,077,000 and when you add  the  $800,000

              4   that they anticipate, it goes to better than four and  a  half
                                   p

              5   million dollars, which is 154 percent of the  targeted  avail-

              6   able funds.


              7             I think there are problems related.to the Emergency

              8   1-tedical Services; they are permanently requesting $750,000

              9   increase in the funds for Emergency medical services, to pro-

             10   vide a continuation of linkages  and relationships between

             11   the Michigan RI,4P and the non-RMP programs.

             .12            I think overall, probably I would say that I was

                  disappointed.  I was disappointed in what seemed to be a
             13

             14   lack of program leadership; I was disappointed in  the  infor-
             15   mation I could get out of it from the Regional Advisory Group.

                  I had disappointments as I attempted to review the  past  per-

                  formcmce and accomplishments and I felt --they were @-not consoli-

             18   ant with the objectives and the priorities, and I  felt  that
             19   their request for funds was vc-fy much out of line.
             20             14R. CHAMBLISS:  All right.   Shall we turn to  the

                  second reviewer, Doctor White?
             21
                            DOCTOR WHITE: I share Mr. Toomey's  views,  to  some
             22
             23   extent.
                            It was difficult to fe'rret out from this  proposal
             24
                  who, if anyone, was leading the organization at  the  present
             25

  )OVER REPORTING CO, INC.
  10 Massachusetts Avenue, N.[.
  n,zhinufnn 1) f. 9nnA2






                                                                            169
  KHD-103      I    time.


               2              As he mentioned, Doctor Tupper was indicated on --

               311  in the narrative; in one of the budget pages it    stated  this

               4    was a TBA slot; either Doctor  Tupper  was  being  magnanimous

               5    and loaning his services, or there was indeed  a  lack  of  an

               6    executive director.

               7              They have  a bit of  a  confusing  relationship,  in
               8    that they have what  they call an Executive  Director  who  is'

               9       whose responsibilities are the  overall  direction  of  the
              10    program, and then they have a  Program  Coordinator,  which  I

                    feel fills the more traditional role of   the @IP Director.

              12              I am not quite sure that both   are necessary, but on

                    the other hand, I seem to recall that Michigan got good grade;
              13
                    in the past.  It was a fairly well-regarded Region at one
              14

                    time, at least, and I don't know what  has  happened  in  this
                    transition, but obviousl  '/there is some question as to  whethej7
              16                             y
                    or not leadership is :adequate, at the present time.

                              And also, I share Mr. toomey's concern as to
              18
                    whether or not the Regional Advisory  Group,  although  it  has

                    cotinued to meet quarterly at full strength, has participated
              20
                    at the same degree of enthusiasm  and the same critical atti-
              21
                    tude as it has in the past.
              22
                              It does state, however, that the Regional Advisory
              23
                    Graup is meeting; the members of@it meet with the Comprehensi%e
              24
                    Health Planning and Ifill-Burton personnel  to  develop  health
              25

  !OOVER REPORTING CO, INC.
  20 Massachusetts Avenue, N.[.
  lashinvton. D.C@ 20002





                                                                       170

  ID-104           services resource, and I raise the question again,  as  Doctor

              2    Miller did a i.-,,Drient or so ago: is --his an appropriate thing?

                   Are these people something which will come to naught, by
              4    virtue of the fact that they can't get the Congress i@o do   it

              5    anyway?

              6              They do seem to have appropriate  Regional  Advisory
              7    Group representatives on Review and other Committees,, and  on
              8    paper, at leastil it would indic ate that they have a good,,

              9    thorough review process. I question that for  some@rig  that

              10   I will bring up later.
              11             Their past performance I did not evaluate @ell;  I
              12,  could not tell exactly from their narrative how mariy@of these
                   have been picked up by others and how many were  continuing.
              13
              14             Some of them seemed relevant, and I based that
              15   assumption on the fact  that they were previously given eval-
                   uations of good management and good hypothesis; therefore,

                   one would assume that their continuing projects, haviV  been
              -17
              18   approved under the old set-up were reasonable ones.
                             Their new ones, however, raised the question  in  my
              19
              20   mind as to whether people haven't been too critical.  They
                   have something like 40 projects, in 6ne guise or-another,
              21
                   and Idon't really get the idea from reading this  that  they
              22
                   have spent a great deal of time in developing these or in
              2t3
                I giving them adequate review, even though they  riuy  have  gone
              24
                   through the holes that are appropriate. I wonder  if  some  of
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Wa,zhin,tr.n 1) r 20007







                                                                            171
  ,,THD-105   1     them weren't'just kind of hanging there in  the  wings  and

              2     have never even been given a great deal  of  attention  in  the

              3@    past, and now they say:

              4                    "Boy, we'd better get   these done  while  we've

              5          got the chance."

              6               Many of their projects  presumably  could  be  accom-

              7     plished in short-term, but one at least  has  a  short-term  --
              8     two-year time schedule, which  obviously  precludes  its  being
              9     accomplished in a single year.  This  is  another  example, I

              10    think, that they have not looked at critically.

              11              They do have a relationsh ip  with  Comprehensive

              12,   Health Planning, and are participating  in  this  blanket  sort

              13    of of agency that is to take over.
              14              They indicate that,they  have  d  meeting  scheduled
              15    in July, at which fey will come to  some  further  concrete

                    conclusions about this.

                              Some of the titles of the  projects  also  raised
              18    the question in my mind as to  relevance  to  Regional  Medical
                    Programs.   Some of them seemtd naive -- or  I  am,  and  that
              19
                    is possible; some of them  seemed  clinically  oriented,  like
              20
                    their clinical research projects, in  a  sense,  rather  than
              21
                    educational demonstration projects.
              22
                              I question, for example,  what  is  their  "buddy?"
              23
                    They have something here called  11 a "buddl  system,"  for  the
              2,4
                    role of supporting a buddy in hypertension control.      I don't
              25

  HOOVER REPORTING CO, INC.




                                                                             172

  IHD-106      1     know if this simply is something like   Alcoholics  Anonymous   --
               2     -you call and say: "I'm having an attacl@; I need your help."
               3 i              They have a great deal  of  emphasis  on  hypertension;
               4     they have  one which I can't think really can be accomplished
               5     in  a year's time.  I'm not sure really one can evaluate
               6     hypertension in a variable population and come to any valid
               7     conclusions in a year's time; you  can't  even  collect  the  data

               8     in a yearis time.
               9                A comprehensive relaxing therapy.  Well, this smack3

               10    of accupuncture.
               11               Well  these are the questions I have   in my mind.
               12               Number 1, their leadership is unclear.
               13               Number 2, how critical were they in evaluating what

               14    is going. on?
               15               No. 3, 40 projects seem an impossibility., Some
                     of them are obviously an @impossibility by their own statements,
                     and I think that their request for funding is ludicrous in
               18    terms of the amount of activity'they could really undertake
                     in a year's time and get something out of it.
               20               As Mr. Toomey mentioned, they are asking for
               21,   $3,700,000, they are targeted for $2,900,000; they are
               22    currently $1,400,000, and they want to come in for $800,000

                     in July.
               23
               24               If you gave them two,million now, you would be
                     doing them a favor, and  anything  they  get  in  July  presumably
               25

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




                                                                            17-

  WHD-107      I    could be critically appraised.
               2              MR. TOOZ@IEY:  The 40 projects  they  have  lis!ted  as
               311                                                                d
                    "Review and Comments' by CHP  agencies,  the  projects  entitle

               4    "Action taken" -- they are  all  asterisked  as  statewide pro-
               5    jects that referred to the Councils  of  the  B  agencies, but
               6    there were four of the 40 projects that were endorsed by
               7    these CHP agencies. The other  36  are  either  "no  action
               8    taken," "pending" or     no action  or  pending.  They  ha d four

               9   -endorsements.

              10              DOCTOR WHITE:  I think   Mr. Toomey pointed out,  and
              .11   Mrs. Parks certainly did a creditable job in   bringing   this
              12,   to our attention, this expansion of funding   for some  of  the
                    operating projects, the doubling of the budgets for some
              -13

                    things that seemed hardly valid.
              14
              15              I guess  the one exception I might  take  is,  if
                    .indeed they have  acommitment,  which they say they have,
                    from state agency  in Michigan,  to continue the  EMS  service

                    at the end of one  more year.
              18
                              MRS. PARKS:  Right.    This is what I understand.
              19
              20              DOCTOR WHITE: Then perhaps it is a valid investiga-

                    tion.
              21
                              MR. VAN,WINKLE:  Doctor White, on the    matter of
              22
                    the Coordinator, this was a very strong   program  under Doctor
              23
                    Hustice, and then there was an interim   period  before  Doctor
              2
               ,4
                    Tupper came aboard, and the  program  slipped  very  badly.
              25

  HOOVER REPORTING CO, INC.
  320[AassachusettsAvenue,N.I.
  l.'@a@%hinvton. D.C- 20002




                                                                          174

  WIID-108        Doctor Tupper turned  that program all the way around and

              2   brought it right back up to the top.

              3 1            Tupper left; he's li,,Lng in Grand Rapid.,-,, -',ght now,

              4   and if you know the geography, that is some distan(:,"-,;from
              5   where this is located.  He  is on a full-time job, and  I  think

              6   he is lending his name to this, and I think it is a    riva e

              7   commitment on his part to give it some guidance.

              8              MRS. PARKS:  He is available?


              9              MR. VAN WINKLE: He is available by  phone  and  by
              10  request, but Doctor Graham-Welke was a former  staff  i@ember
              11  whom they brought in who 'in fact is running the program from

              12, day to day, and Doctor Tupper has very little input    t  the
              13  present time, very little.input, and I think your criticisms

              14  were well justified.
              15             DOCTOR MILLER: Could I ask  a  question,  bot h with
              16  regard to  this EMS businesA@, because there is some confusion

                  in  my  mind certdnly, about the limitations on EMS.
              18             Now, here is one; we said -- our  directions  said
              19  that a program in ITNID can continue a previously started EMS
              20    hat can not mount a statewide EMS system.
                             Well, here is one that has gone from $36.,OOO a  year
              21
              22  to $750,000 and it is obviously developing a statewide system,
                  or trying to in one year.
              23
                             Is this directly opposed to the principle, or  is  it
              24                                   1
                  not?  Because we have some others that are coming up where the,,,
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N,I.
  Viashingtoii, D.G. 20002
  (207)




                                                                       175

  @IIID-109   1    obviously got a statewide EMS system.

              2              MR. Cl-IAI-IBLISS:  Will you comment, Mr. Van Winkle?

              3              MR. VAIN WINKLE:  This is a continuation project.

              4              DOCTOR MILLER:  Yeah, but a continuation from

              5    $35,000 to $750,000?  That is quite a continuation project.

              6              MR. VAN WINKLE: We are aware of this, but they  are

              7    saying that as far as it being affected by this new law  that

              8    we can have no new starts, but we can continue to fund what

              9    has been funded.

              10             But we strongly questioned this use.

              11             DOCTOR MILLER: We question whether this  can  be
              12   ripened into a full-fledged $700,000 system in one year  with

                   a    with Regional Medical Program funds.
              13

                             MR. VAN WINKLE:  There is one other
              14
                             DOCTOR MILLER: I will tell you, practically  it  is

                   ridiculous.  I have had oiYe of those things.

                             MR. V@N WINKLE: I would like to hear  from  some

                   of those physicians about this automated peritoneal  dialysis
              18


                   also.
              19
                             The kidney program is going almost totally  with
              20
                   home dialysis, using artificial kidney, and now all of a
              21
              22   sudden, we are going off, apparently, in this year with auto-
              23   mated peritoneal, and I can't very well see people walldng
                   around the street carrying a bottle in their hand, and I
              24
                   don't know if it is a part of the Michigan State Renal  Plan.
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts A,4enue, N.E.
  @Vashington, D.C. 20002
  (2021 546-6666




                                                                             176

  HD-110            There is no mention of it, and Michigan does have a  very

               2    highly sophisticated renal program      you know, a state pro-

                    gram that is supposed to cover all   of this.

               4              DOCTOR SLATER:  Presumably this has all been

               5    cleared by their professionals before it ever gets  here.

               6              DOCTOR  MILLER:  Peritoneal  dialysis?  I   didn't

               7    think they did it any more.

               8              MR. VAN WINKLE:  I didn't think so either.


               9              MR. CHAMBLISS: I  think  the  Committee  should  know


              10    thag both the EMS and the kidney  activity  will  be  commented

              11    on by the other agencies that are supporting those activities

              12    and we will have input from them.

                              DOCTOR SLATER: 'Can we.put a contingency on this
              13
                    subje@t  to clearance of the technical use of'.this-', despite
              14

              15    the fact that they have already approved it at their own -- ?

                              MR. VAN WINKLE: I  think  it  raises  two  questions.

                    If this came through their review process, and they are send-
              -17

                    ing it in saying that it has bee n technically  looked  at  and
              18

                    cleared, then I question the process.
              1.9
              20              DOCTOR WHITE: That is  right.  That  is  why  I  said
                    on paper it looks good  but obviously they have gone through
              21
                    the motions without having any enthusiasm about this.
              22
                              MRS. WYCKOFF: Don't they  still  have  to  get  an
              23
                    ad hoc panel of experts on kidney programs?
              24
                              MR. CH@IBLISS:  Are the reviewers prepared to make
              25

  DOVER REPORTING CO, INC.
  10 Massactitisetts Avenue, N.[
  ashingtoft, D.C, 20002




                                                                          177
  ilD-111     1    a recommendation on funding, in the light of the discussion

              2    that has taken place?

              311             DOCTOR MC PHEDRAN:  I just wanted to ask -- the

              4    other people that are@likely to comment on EMS going from

              5    $34,000 to $750,000; they are not likely  to  take  exception

              6    to-that.  They might have to bear the bur-den of expense

              7    otherwise.


              8               I mean, I don't think that because we  think  that

              9    that is tantamount to a new projct -- we ought to be able to

              10   say that that is tantamount to a new project,  and  we  can't

              11   imagine anything going from that low a figure  to  that  high

              12   a figure without it being a new project, so I         we

                   ought to be able to settle,it here and not leave it for some-
              13

                   body else to take care of.
              14

                              MR. CHAI@IBLISS: Then we would like your  specific
              15
              1(;  recommendations here as it,/relates to EMS.

                              MRS. WYCKOFF:  Why don't we ask Doctor Dushan
              18   to comment on -ffis thing?  He is on the panel, and he is a

                   pathologist.

                              MR. ClLkMBLISS:  Would -the Committee seek that?
              20
                              DOCTOR MILLER:  There is a jurisdictional question,
              21
                   however, that I wish you would answer for us.
              2 --@)
              2tl             We are not empowered to make technical  review
                              14R. THOMPSON:  I donlt,tliink we can; Ithink  all
              24
                   we can do is cut the,hel-1 out of them.
              25

  40OVER REPORTING CO,  INC.
  320 Massachusetts Avenue, N.[.
  3shingloii, D.C. 20002
  ,202) 546-6666




                                                                         178
  @IID li2                   DOCTOR MILL.I@"R:  Therefore, if @ve- are facing a
              2    technical question, that is beyond our jurisdiction.

                             MR. THOMPSON:  No way.

              4              DOCTOR WHITE:  I take exception.   We are not

              5    looking at the quality -- well, at the peritoneal dialysis,

              6    perhaps, but not at the EMS together.

              7              DOCTOR MILLER:  No. But about this kidney tdng,

              8    this is a technical question.

              9              DOCTOR SLATER:  Let's ask another-point.,

             10              Are they requesting funds for services, or simply

             11    planning, evaluation?  We can't provide money for dialysis,

             12    can  we?


             13              MRS. PARKS:  For. the EMS?

             14              MR. CHAMBLISS:  For the kidney.

             15              MR. VA14 WINKLE:  They are trying to determine the

             I(;   feasibility of it.

                             MR. THOMPSON:  You ought to get some kidney people

             18    to look at that.

                             MR. VAN WINKLE:  I related it back to process here.

             20              MR. CH@IBLISS:   We would simply like to have on

                   record an expression of your reservations, if there are any,
             21

                   and then Staff will proceed further on that.
             22
             23              MRS. WYCKOFF:   Couldn't we have the old process
                   we used to have, of a special Committee on Kidney, to look
             24
                   at this for us and give us a report later, or give the report
             25

  OVER REPORTING CO, INC.
  @ Massachusetts Aveiiue, N.C.
  @hington, D.C. 20002
  2) 54F,6666





    LID-113                 1         later?

                            2                            MR.  CIIAI.,IBLISS:    Yes,  we  will.    That  expertise  now

                            31
                                      resides with Doctor Goodman, and we will call- upon him  to
                            4         give us input as -- and an assessment of this particular

                            5         activity.

                            6                            DOCTOR       SLATER:       Well,        let's        leave        it        that        unless
                            7         we  approve  it,  we  don't  think  it  should  be  included  in  the

                            8         figure.

                            9                            MR.  ClgYiBLISS:    That  is  very  clear.

                            10                           MR.  TIIOl@l-PSON:    The  issue,  I  think,  is  whether  we

                            11        think  it        is  a  whole  new            project.

                            12,                          DOCTOR  MILLER:    Mister  Chairman,  could we  get  some
                            13        understanding  here  with  regard  to  future  actions  we  are
                            14        going-to        have        to        take,tomorrow,        that        a        continuation        of        an
                            15        E@%IS  project  for  Rl'iP  would  be  one  that    is  proceeding  at  not
                                      a  total  statewide  plan,  unless.it  previously  was  approved,
                            -@17      and  would  be  of  a  magnitude  of  funding  similar  to  what  it  has
                            18        done        previously,        and        that        anything        beyond        that,        moving        in
                                      or      beyond      the      jurisdiction      of      IU.IP's      in       EMS,       would       that       be
                            1!)

                            20        fair?
                                                                 CHAMBLISS:         Not          entirely;          we          have          discussed
                            21.
                            22        this,with          El-IS  and  they  feel  that  unless  there  is  a  total
                                      system  involved with  all  the  components  of  the  Emergency
                            2 ti
                            24        Medical  Systems,  that  these  act                          ivities  would  be  proper  for

                                      funding  under  ICIP.
                            25

    HOOVER REPORTING  CO,  INC.
    320 Massachusetts Avenue, N.[.
    Washingtoi), D.C. 20002
    (202)546-6666





                               But we raised another question of magnitude in
   ilF)-114

               2    terms of funding, and I think that in and of itself would

               3ii  require  interaction  between  these  two  programs,  and,a

               4    closer exarni@nation of the project, so as to take care of

               5    the concerns that you express.
               6               We will do that; we  will  call  in  Mr.  Strykier,  and

               7    I believe --  Mr.  Reardon,  and  Stryker,  and  get  their!assess-

               8    ment of this project.

               9               The level of  funding  requested  here  is  ver  high;

               @io  they have  gone, as you have indicated, from $30,000  0
               11   $700,000,  and we in fact Will bring them in    and get  their
               12.  views here, and it will  be  taken  into  account  as  this  recom-

               13   mendation goes forward.
               14              MR. VA14 WINKLE:  All we have to look   at is  a  Form
                    15 here; we don't have, you know, the original       application,
               15
                    but it certainly looks 1"l@.a full statewide comprehensive

                    EMS system.

                               MR. T0014EY:  Mister Chairman, my recommendation
               18
                    that I have here, on the presumption of the three-quarters of
               I!)
               20   a million for E24S, and the  amount  of  money  that  was  involved
                    in the hypertension, I was  going  to  recommend  two  and  a  half
               2 1
               22   million dollars  until  I  heard  this  morning  that  hypertension
               23   projects are within the province -- and I hadn't counted
                    them but I think there  were  13  or  14  hypertension  projects.
               24
                               llitli.this in mind, I would recommend funding at the
               ,),5

  HOOVER REPORTING CO, INC.
  320 Niassnhuselts  Avenue,  N.C.
  Vias@ti@gton, D.C. 20002




                                                                      181


                   level of three million dollars.

              2              I,!P,. CHAI,!B'UISS: You have heard the r'ecomme ndation.

                             Is there a motion to that effect?


              4              MR. TOOIE, Y: I so move.


              5              DOCTOR SLATER:  Seconded.

              6              MR. CHA14BLISS:  It has been moved and seconded
              7    that the level of funding for Michigan be set at  thrIee million

              8    dollars.

              9              Is there discussion?
              10             DOCTOR VAUN:  Yes.  I find that at seriou  confl4-ct
              11   with the ti,7o million dollars that was recommended b  your

              12.  reviewer.
              13             Dor'TOR MILLER:.I found a serious objection in this
              14             DOCTOR VAUN:  He recorftraended two; you recommended

              15   three.
                             DOCTOR VIHITE:  I said we'd be generous if we gave

              17   them two million dollars.
              18             MR. CHAYIBLISS:  All  right; we have something of a

                   dilemma here.
              1!)
              20             DOCTOR IIHITE:  That's all right; the motion is on

                   the  floor.
              21
              22                 VAN VIIINKLE: Was there a second?
              23             MR. CH@,IBLISS: Yes, there was a second.   All tlios

                   in favor?
              24

                             DOCTOR SLATER:  Aye.
              25

  HOOVER REPORTING CO, INC.
    assachusetts Avenue, N.[.
  320 M
  Via@@llifigton, D.C. 20OD2




                                                                         181

  WHD-115     1     level of three million dollars.

              2               MR. Cl@4BLISS:  You have heard the recommendation.

              311             Is there a motion to that effect?

              4
                              MR. TOOMEY:  I so move.


              5               DOCTOR SLATER:  Seconded.

              6               MR. CHAMBLISS:  It has been moved and seconded
              7     that the level of funding for Michigan be set at three millioi

              8     dollars.


              9               Is there discussion.?
              10              DOCTOR VAUN:  Yes.  I find that at serious conflict

              11    with the two million dollars that  was recommended by your


              .12   reviewer.
              13              DOCTOR MILLER: 'I found a serious objection in this
              14              DOCTOR VAUN:  He recommended two; you recommended

              15    three.
              1(;             DOCTOR WHITE:  I'said we'd be generous if we gave

                    them two million dollars.
              18              MR. CHAIABLISS:  All  right; we have something of a

                    dilemma here.
              19
              20              DOCTOR WHITE:  That's all right; the motion is on

                    the  floor.
              2t
                              MR. VAN WINKLE:   Was there a second?
              22
              23              MR. CHAMBLISS:   Yes, there was a second.    All thos

                    in favor?
              2,4
                              DOCTOR SLATER:  Aye.
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Wasiiiagton,-D.C.29002





                                                                        182

              1              MR. CHA14BLISS:  Opposed?
  IHD-116

              2              (Chorus of "No")

              .3             MR. CHAIABLISS:  The motion did not carry in the


              4    matter of three million dollars.


              5              That motion is lost.

              6              DOCTOR SLATER:  That is the only motion that's been


              7    lost all day.

              8              DOCTOR MILLER:  It shows we are disturbed..

              9              MR. CHAMBLISS:  The Chair is open, then, for another

              io   motion.

              11             MR. TOO@1EY:  I will go back to my original recom-

              12   mendation for $2,500,000*
              13             MR. CHA14BLISS: There-is a motion off the floor  for
              14   a level of funding for $2,500,000.  Is there a second?

                             MR. THOMPSON:  Second.
              15
                             MR. CHAMBLISS:  It has'  been moved and seconded.

                   Are you ready for the question?

                             DOCTOR V7HITE:  I would like some discussion.
              18
                             I would point,out again the various number  of  pro-
              19
              20   jects; whether they  are  mer.itorious or  n-ot is immaterial,
                   one would think. I do not believe that they  could  have  been
              21
                   given the critical appraisal they deserved within  the time-
              22
                   span that is allowable, particularly if  the leadership has
              23
                   faltered in the meantime; witho"ut infringin(,- upon a territory
              24
                   which we are not allowed to get into, I would point  out  that
              25

  HOOVER REPORTING CO, INC.
  32OMassachusettsAvenue,N.C.
  @lashinktorl, D.C. 20002




                                                                                182@


  ID-117            point out that the specific  objectives  of  the  EL@-IS  program

               2    the specific outlets they are seeking, setting of of standards
               3'.i for courses, the training of 1800     EMTA's --  I  confess  to  be
               4    unfamiliar with vqhat is involved    with that, bull-- it seems  to
                                                                               i
               5    me it  is  a  big  number  within  a  single  year.  Perhap  not.
                                                                              Si
               6                Perhaps  the  evaluation  of  this  program  as Ito its

               7    benefit  to  Michigan,  I  don't  think  you  can  evaluate !it in a

               8    yeat's time; you  can't  even  get  it  done,  so  I  don't think you

               9    -can evaluate  it,  in  a  coordinated  statewide  EMS  com onent

               10   to be assumed by the Michigan Department of Public         ealth.
               -11              Now, I will  retract  a  statement  I  made  ear lier, thai:
               12   if  the State Department  is  going  to  take  overt  perhaps  this

               .13  is  worthwhile, because as I read.this now, it      appears  to  me
               14   that perhaps the Michigan Department of Public Health is
                    going to take over responsibility for training rather than
               15

                    for the establishment of existing programs.

                                Therefore, I  doubt  that  $750,000  is  a  wise  invest-

               18   ment.
               19               DOCTOR  WHITE:  I  don't  think  we  should  settle  this
                    question without beggingthe question, I guess.
               20
                                MR. TOOI@EY:  The  funds requested   are for program
               21
                    staff  of  approximately  $350th6usdnd  and  for   the   continuation
               22
               23   projects  of  approximately  $1,675,00.0,  which  gives  you,  at
                    two  million  dollars  just  to  continue  their  project  staff,
               24
                    their  core  staff  and  their  program  staff  in  the  continuation
               25

  IIOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.C.
  @iashinoton. D@C. 20002





                                                                         184

  [iD-118     I    projects.  T hat two million dollars allows for  no  additional

              2    projects.
              31              I mention that merely as a sidelight.  If the

              4    concern is a further reduction from the two and a half to

              5    approximately two, as I said, this allows for continuation.

              6               Now, I will once again admit that their $600-700,00)

              7    -- and I did the arithmetic very quickly -- in hypertension

              8    projects -- in some of them, for  instance,  hypertension  pro-

              9    jects in the Detroit Department of Public Works, as an

              10   example, and then you mentioned, Doctor White, the   buddy

              11   system of hypertension, whatever that is.

              12              And then on top of that,  you know, I am  extremely

              13   skeptical  of the -- in the application anyway, but  I hate  to

              14   cut them down to exactly where they are      where  we are  now.

              15              DOCTOR b-IILLER:,. Question, please.

                              MR. CHM@',BLISS: Is there further discussion of  the

                   motion  on the floor? It has been  moved  and  seconded.  Shall

              18   I  caI11 the question?
                              All those in favor of setting a level at $2,500,000
              19

                   for Michigan, say "Aye."
              20
              21              (Chorus d "Aye")
              22              Those opposed?

                              (Chorus of "No")
              2.1
                              MR. VAIN' WINKLE: Almost all ought to have a show
              24

                   of  hands.
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.C.
       n r, gnnn,)




                                                                                                                                                             185

    ;IliD-119                                                    MR.   CT(IA,,,,IBLISS:     I  would  ask  for  a  show  of  hands,

                               2         please.     those  voting  "Aye,"  may  we  see  your  hands?

                               3i                                (Show  of  hands)

                                                                 MR.  CHAMBLISS:     Five  in  favor?


                               5                                 Those  opposed?

                               6                                 (Shoii  of  hands)

                               7                                 MR.   CIIA14BLISS:     The                 "Ayes"  have  it  and  the  motion

                               8         is               carried.


                               9


                              10


                              11



                              12


                              13


                              14


                              15





                              17


                              18






                              20


                              21


                              22


                              2.3


                              24


                              25

    iOOVER  REPORTING   CO,   INC.
    320 Mass3chusetts Avenue, N.[.  @i
           @ton. D.C,               I
    Nashinc         20002          1 !




                                                                         186


  IID-120                         REGIONAL MEDIAL PROGRA14 REVIEW

              2                          MISSISSIPPI REGION

                             MR. CHAMBLISS:  May we turn our attention   then  to
              4    Mississippi?  The reviewers there are Doctor Vaun aid Mr.
              5    Toomey, supported by Mr. Van Crinkle, and I should  mike  men-

              6    tion of the fact that the Committee has set as its  goal.  the
              7    review of three additional Regions this afternoon, @and

              8    there will be two left when MIssissippi is completed.

              9              DOCTOR SLATER:  What are the others, sir?


              10             MR. CHILMBLISS:  Illinois and Louisiana.

              11             DOCTOR VAUN:  First, I should be -- should @ssue
              12   a disclaimer.  My daughter happened to be looking t@rough

              .13  this; she looked at the pictures and I didn't, and she said:
                        1
              14   "Daddy, you needed a haircut for the picture."

              15             Remembering the nature of the visit, however, I am

                   sure there was no effort  on Doctor Lampert's part  to  seduce

                   me into giving him more money, and I will describe the nature
              18   of the visit, which has, I think, some bearing on the issue.

                             MR. CIIAMBLISS:  We will not consider that as a
              19

                   conflict.
              20
                             DOCTOR VAUN:   I think it was September  1972  when'
              21
                   Doctor Joe !Iess and his storm-troopers went down  to straighten
              22
                   up the Mississippi Regional Medical Program.  They were
              23
                   having a great deal of difficulty and they went down there
              24

                   to take them to task.
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N@l.
  Wn@hingtrin ri C 20002






  ID-121                     I must admit retrospectively, as I look back on

              2
                   what we did when we were there, we might have been  a  litth

              13                                                       of their
                   too critical for Mississippi not having evaluation
              4    projcts, because in the subsequent years I haven't  seen much
              5    evaluation of anything from anybody, let alone Mississippi.

              6
                             But nonetheless, fty were in trouble with leadership

              7
                   problems, and the question that kept coming across the table

              8                                                       ol'  miss
                   during the day was: it is very hard to tell  where
              9    ends and R14P be ins, and that was a serious problem and there
                                  9
              10   seemed to be a great deal of incest between  the progra mand
              11   the 01' Miss.  I am indeed pleasantly surprised to see.this

              12   summary of'projects come out these years later, because
                   whether it was us or whether something has happened down
              14   there, certainly this is a pretty good piece of work that
              15   has come out since then,,,and I am rather pleased with it.

                             I think it would suggest that there are some
              @ii  strengths there that we did not identify at that  time,  but
              18   Doctor Lampert has obviously done a pretty good job  of  his
              19   burden of sustaining staff t@-ough a pretty rough time.
              20             It would appear that the CHP relationships are
                   satisfactory.  I think that here the projects address them-
              21.
                   selves more now to the health care needs of Mississippi
              22
                   rather than to continuing this so-called  soft money for the
              23
              24   University of Mississippi when NIH  was phasing out  and other
                   aspects of that nature.
              25

  HOOVER  REPORTING  CO,  INC.
   32OMassachusettsAvenue,N.C.
       nr, )nnn,)





                                                                       18 8

  RIID-122     1             Maybe it said the General was no longer there,   but
               2   there was a retired General down there who was  running at that
               3ii tte the University of Mississippi and also seemed to'be,  to

               4   a large part, with a certain lady, running the RMP.
               5             Things have changed, and I think that  though  their
               6   request at this time is unrealistic, I think that the  @IP  of
               7   Mississippi deserves a few pats on the back.
                             I-am recommending a reduction of funding which I
               8
                   will hold until Mr. Toomey has his licks, and then t(
               9

                   we will recommend something to you.
               10
               11            MR. TOOMEY:  Well, once again I am followi @g the
                                                                         i
                   format; I felt the program leadership was strong and   viable.
               12.
                   I felt the program staff to be competent.
               13
                             RAG meets, the Executive Committee meets, the
               14
                   Planning Committee meets, the Manpower and Education Committee
               15
                   met several times, Health Systems and Public Education.

                             Their past perf ormance has been impressive; for

                   instance, I don't want to go into these, but the first stroke
               18
                   and intensive care unit, care and training, the first chronic

                   pulmonary disease unit, treatment and training program, the
               20
                   first on-going effort toward coordinating  continuing  health-
               21
                   education, the first system for coronary care and training
               22
                   and there really are a dozen of these "firsts," that indicate
               23
                   the impact of the Mississippi Region on -- the Regional Medical
               24
                   Program on the state of Mississippi,, and frankly I felt it was

               25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.





                                                                              18 9

  HD-123         1  quite impressive.
                 2             Additionally, they were extremely -- I felt
                 3i'  erceptive in establishing goals and they were quite precise
                    P
                 4  in the establishment of objectivesin order to support.the

                 5  accomplishment of those goals.
                 6             The proposals that they have are congruent and they
                 7  certainly  mesh well, generally speaking, with the proposals

                 8  that were  made.
                               I looked at the CHP comment, the state comprehensive
                 9
                    plan came with an endorsem@    of 39 out of 59 projects that
                 10
                    had been proposed.  There were four responses from comprehen-
                 12. sive health planning agencies, and the tone of these respon-
                    ses were all extremely cooperative, extremely friendly, an
                 13
                    seemingly with a good relationship between the two.
                 14
                 15            one of the items -- perhaps Doctor Vaun mentioned
                                              1.
                    this -- but we again run @nto the situation where the funds
                 1(;
                 17 for the continuation of the projects already proposed or
                    already on the boards is $1,200,000 and their proposals
                 18
                    thelfunds for their new proposals are $1,155,000, which
                 19
                    means that requests for new funds are just about as great for
                 20
                    -- as for the continuation enterprises.
                 21
                               In brief, I think that this was an extremely     well-
                 22
                    done proposal; it indicated a considerably higher degree of
                 2.3 1
                    strength than several of those that I have reviewed earlier,
                 24 11
                    and I ended up with an evaluation of this project as being in

                 25

  HOOVER REPORTING CO, INC.
  3,'-O llassachu!,etts Averue, N.C.
        D.C. 20F,2






  @HD-124          1  a good to excellent stage.
                   2              DOCTOR  WHITE:  Mrs.  Wyckoff  has   been   doing   a   techni-

                   3i cal review here and has a question to ask.
                   4              MRS. WYCKOFF:  What is "Pierre the Pelican,"?
                   5              MR.  CHAMBLISS:  That   was   a   policy   question!we   raased

                   6  too;, we wanted to know.
                   7              DOCTOR VAUN:  I thought I went through tha        t very
                   8  carefully,.and I don't remember       any pelican.
                   9              MRS. WYCKOFF:  Pierre     the Pelican is No. C-179.
                   10             There is also 137, "Solid Waste," and "Soliid Waste

                      Management Training."

                                  MR. VAN WINKLE:  it is education of illiterate
                   12.
                      mothers.  It is a pamphlet that goes out; it          is quite well
                   13
                   14 done.'
                   15             MR. CHA14BLISS:  Would    the reviewers have any recom-

                      mendations here?

                                  DOCTOR VAUN:  Our     independently arrived-at  judgments
                   18 are  reasonably close it would appear, so I would make  a  recom-
                      mendation that the Mississippi RMP be funded for $2,200,000.
                   1()
                                  MR. CF.AMBLISS:  Is that a motion?
                   20
                                  DOCTOR VAUN:  I so move.
                   21
                                  MR. CHAMBLISS:  Second?
                   22
                                  DOCTOR WHITE:  Seconded.
                   23
                                 :MR..CHAI,IBLISS:  It is.-moved and seconded      that

                   24
                      Mississippi be funded at a level of,$2,200,000.
                   25

   HOOVER REPORTING CO, INC.
   320 faassachusetts Avenue, N.[.
   @VashintrtoR. D.C. 20002





  WIID-125    1             Are there questions or discussion?

              2             DOCTOR MILLER:  Yes, I would like to ask the
              3   reviewers: did you look at the magnitude of the collective

              4   -- of the renal programs?

              5             I see two programs which total $230,000; are  they
              6   running a statewide renal program, and is that contrary to

              7   RMP principles?

              8             MR. CHAMBLISS:  No, it is not contrary.
              9             DOCTOR VAUN: But that, plus a few others,  when  I
              10  said I arriv ed at my personal evaluation
              11            MR. VAN WINKLE: I raised the question  because  of

                  the substantial increase in the costs.
              12
                            They are opening up a new unit and I think we will

                  have to flag this for  Doctor Goodman, in kidney, because  it
              14
                  is an expansion for  dialysis facilities.  We want to be very

                  sure whether they have proper clearances on this sort of

                  thing.

                            DOCTOR MILLER: How about EMS here?  It  goes  from

                  17 to 92; that is only four and a half times, it isn't 20


                  times.
              20
                            MR.  CHAMBLISS:  We don't see the magnitude there
              21
                  that you referred to  earlier on, Doctor Miller.
              22
                            DOCTOR  MILLER:  No, not quite.
              2.3
                            MR.  THOMPSON:  What happened to the turf  problems
              24
                  they were having with  Memphis for a-while?

              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N@l.






   WHD-126    1               MR. CIIAMBLISS:  There has been an agreement between

              2    the. two Regions on the overlap areas in Northern Mississippi,

              3    I believe, has there not?

              4               MR. VAN WINKLE:  Yes, including the CHP A agencies.

              5               As a matter of fact there is combined funding.

              6               MRS. WYCKOFF: There is a  beautiful  interface  and

              7    it is working very well; very nice interface -- 3oint fundingi

              8    joint- meetings, both RMP and CHP.

                              There
                                    is one CHP in Northern Mississippi  and  both

                   Mississippi RMP  and Memphis RMP have funded it and started
              10


                   it

                              MR. VAII WINKLE:  And are evaluating it.
              12
                              MISS !4URPHY: Right, and it is a very  nice  inter-
              13

                   face.,
              14
              15              MR. CHAMBLISS: Shall  I  call  the  question  then?
                   All those  in favor of the-inotion?-
              1(;
                              (Chorus of "Aye")

                              Those opposed?
              18
                              (No response)
              19
                              The motion is carried and the level is set at
              20
                   $2,200,000 for mississi
                                           ppi-
              21


              22


              2,.3


              24


              25

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




  HD-127       1                REGIONAL MEDICAL PROGRAM REVIEW

               2                         ILLINOIS REGION
               3              MR. CHAMBLISS: Shall  we  now  turn  our  attention  to

                   a review  of the Illinois Regional Medical Program?
               4
               5              Doctor Slater is here, Doctor Scherlis is not here,

               6   and
               7              We have Staff support  for  you,  Doctor  Slater,  in
                   the person of Mrs.  Kyttle,  who  is  very  knowledgeable  about
               8

                   that region.
               9
               10             DOCTOR SLATER:  I was just going to say,    Mrs.  Kyttle
               11  and I have power of veto over this group, because     we both
               12  agree that Illinois is first-class, recommend it     have   full
                   funding; I have nothing adverse to say and I am     handing   in
               13
                   my recommendation  as  good-excellent,  with  a  final  superior
               14

                   at the end.
               15
                              Do you want to @earzbout'this program?  I would like

                   to tell  you, because I think it is really good.
               17
                              You may take my light-hearted  vein  as  a  little  bit
               18
                   of.hypoglycemia.
               19
                              All right.  I think the main reason to proceed
               20
                   with this is really to  bring  into  focus  the  orientation  that
               21,
                   this particular pDgram has,    which I find  exciting after having
               22
                   listened to points of view    expressed from the various regions
               2.,3
                   today.
               24
                              The staff role      the program leadership,  as  I  can

               25

  HOOVER REPORTING CO, INC.
  320 Mamchusetts Avenue, N,E.
        nr,





  WHD-128      I    make it out, has been very strong.  Doctor Creditor has       been
               2    able to carry a very  strong  program  forward  wh ile phasing
               3:1  down.  He went from a professional    staff level of folur
               4    this has now been built up to approximately 12,  and,lhe    countil
               5    on a few more people but he does not plan on grossly'expandinc

               6    the central staff, despite a  considerable  --  a  100  nercent

               7    expansion of funding requests.

               8              During the course of the phasing down they f    elt that

               9    -there was a great deal to be learned out of the     experience
               10   they had been through,  and  joining  forces  with the CIHP,  they
              .11   actually sat down and  looked  at  the  planning  techniqIues   and
               12,  the outcomes and,developed  a  planning  model  which  waIs   built
                    on the comprehensive social approach to health care planning.
               13
                    It was for.this reascnthat they really wanted to spend a
               14
               15   couple of million.
                              They finally published-a book    which  has  just  come
               17   out, on health care development which I    think  is   worthwhile
               18   spendng a moment on, but as back-up on  this  I  can  say  that
                    the RAG had been intimately  involved  in  this  along  with  CHP,

                    and in general, the program,  against  this  kind  of  backing,
               20
                    has been organized into two   types  of  approach.
               21
                              A health process approach,  if  you  like,  which  is
               22
                    looking  at  problem-oriented  medical  records,  patient   educa-
               23
                    tion techniques, on  the  one  hand,  and  disease-oriented  pro-
               24
                    grams, improvement and specific  care,  -nodels  such  as  kidney,
               25

  HOOVER REPORTING CO, INC.
  320 Ma@chusetts Avenue, N.[.
  tv@thinainn r)(', 9nnn? I .





                                                                        l@4

  IID-129     1   cancer and hypertension, on the other.
              2             They have elected, within that framework, to put
              3;1 a great deal of emphasis on a few specific types of prominent!
              4   concerns.  Problem-oriented records, for one, and problems
              5   of hypertension for another, and thus have in-depth experience
              6   with a high investment historyin those two areas, and at  the
              7   same time they have had very good out-reach to the  disadvan-
                  taged urban areas as well as the areas in the Region of
              8
              9   Chicago, in terms of the types of RMP support for primary.care
              10  and the like, which I will mention briefly.
              11            Let me just give you an inkling in their approach
                  to planning.   They decided that rather than take the  rather
              12,
              13  global, generally-stated type of expression of goodwill  that
              14  has been really traditional to @IP's, they would take an
              15  objective approach to planning, so they sat down with the CHP
                  group and the RMP group a@ said:
              16
              17                 "Well, what are the human goals? What  are  we
                       attempting to achieve here? And within  that  framework,
              18
                       what are our objectives,"

                  Objectives being slightly more sharply defined, and then, out
              20
                  of this one comes health-care goals -- more specifically,
              21
                  health-care objectives, and then down    finally down to
              22
                  programmatic goals.
              231
                            So that, one: when this was developed with the
              24 1
                I people they had available, they were listening to consumers
              25

  HOOVER REPORTING CO, INC.
  3720 Massachusetts Avenue, N.[.
       D.C@ 200@-2





                                                                         195

  130             as representatives of CHP, and finally coming out with @ip

              2   professional providers providing an answer to the  expressed
                I
              3!! desires of the people in that Region..

              @4            A couple of examples.  At the Human Goals approach,

              5   the most broadly oriented  description, the people wanted
                                                                      I
              6   optimum functioning of the health system,  optimum  longevity

              7   of life, optimal tranquility.'

              8             Well, this is pretty general when you start  moving

              9   along to the kinds of interpretations of objectives.  The

              10  lay people said they really wanted to be able to prevent dis-
              11  ease, they wanted to be able to cure curable conditions  and
              12. treat treatable conditions.
              13            It is interesting that Creditor goes on and  says:
                                 "The interpretation of those sets of objectives
              14
                       by any group in an area realLy is dependent Upon the make-
              15
                       up of the group,  and depending on the environmental-

                       educatinal-health orientation,  socioeconomic  relation-
              18       ships, you may come out with a variety of different
              19       projects which lead to these ultimate goals."
                            So that on the basis of that CHP type  ofactivity,
              20
                  the provider looks at this, then comes down to the presentatior
              21
                  of health-care goals, which is emphasis on accessibility,
              22
                 @quality of care, effective management, optimum  cost relation-
              23
                  ships, and so on.
              24
                            Moving to
                                      another stage down the line, they take  a
              25

  HOOVER REPORTING CO, INC.
  320 Mamchusetts Avenue, N.[.
       n r )nnn,)





                                                                         19 6

  rHD131      1   more sharply-defined look at objectives, such as improving
              2   the understanding of health care;  specifically,  availability
              31  of the entry points of the system, optimal  relationships  of

              11  the system.
              5             I won't go on, except to say that when they  get  to
              6   programmatic levels, 'they have specific series  of  approaches
              7   that canbe taken within these healthcare objectives, and
              8   then they have taken a variety of programs or  projects  which
                  have been fed irto them from the Illinois area, and  categorize
              9
                  them specifically as.meeting these objectives within the frame-
              10
              11  work as a whole.
                            Now, that to my mind, is a pretty neat way of putting
              12
                  in specific terms of reference some workable  pattern,  instead
              @13
                  of five lines of such genEral statements that one wonders
              14
                  what -- whether or not the thinker is very clear when  he  is
              15
                  attempting to do it.
              17            It does provide a procedure to examine what projects
                  one is covering now, where there are gaps in the  system,  and
              18
                  it really puts into a highly analytical form some of  the  more

                  philosophical objectives that we  are groping to satisfy  all
              20
                  the time.
              21
                            So I was impressed with that,  and that is the projec"
              22
                  of the phasing back. They have taken time  to  analyze  where
              23
                  they have been and where they are going.
              2,4
                            So now, everything that is presented in  the  present

              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, t4.1.
  Washinvton@ D.C. 20002





                                                                               197


  WHD132         I  proposal is cast within those  general  frameworks,  and  all

                 2  batted out by the RAG  and  Comprehensive  Health  Planning.

                 31           Well, I guess, against  that  background,  then,  how

                 4  have  they performed?

                 5            They have had a series of  projects,  I  think,  that

                 6  there  are about ten here, which have been started up over the,

                 7  past few years and in one way   or another have  been  spun  off

                 8  and picked up fully operational by other groups.

                 9            Health care at home has been  picked  up  as  a  free-

                 10 standing enterprise by a group in the area.

                              Health  information  and  referral  is  terminating

                    because they had inflated ideas about what they could perform
                 12.

                    and they just decided to phase it out.
                 13
                              multiphasic screening  in  industry  has  been  picked
                 14
                    up by the Heart Association and shared with a variety o     f
                 15

                    industrial managements.

                              I,wonlf- go into  all of,them, except  to  say  that

                    they  have had a series of  specific projects  starte  ,  proven
                 18
                 19 and  moved on out while they used their funds catalytically
                 20 to start something else.
                 21           I was interested  then  in  a  series  of.proppsals
                    that  they put forward. I  have  not  mentioned  that  part  of
                 22
                    the specific activity -- well,  which  I  just  mentioned  in
                 23
                    passing -- part of the specific activity is to go into depth
                 24
                    on how the problem-oriented  medical  record  might  be  more
                 25

  HOOVER REPORTING CO, INC.
         ! t t slnnue, N.[.1
  320 Massachus





                                                                        19 8

  WHD133      1   effectively utilized, and then put a great deal of  funding
              2   into that in the past, a great deal having been spent in
              31!! teaching other groups and institutions how best to use  the
              4   problem-oriented record, and they have about four pages  of
              5   institutions and groups, that they have set up train;Lng and
              6   demonstration programs for, and they plan to continue  that

              7   in this next year.
              8             The other major venture, of course, has be n in
                  -Iiypertension, and they have been attempting to devel p a
              9
                  computer technique which will provide a simplified diagnostic
              10
             -11  and therapeutic protocol for that. In  fact,  relativIely simple
                  screening and input of information can orovide back @a protocol
              12,
                  which is applicable to large numbers of people in the disad-
              13
                  vantaged areas.
              14
                            I am fascinated by the fact that they figure they
              15
                  can have that computer program so that it is about ten cents
              16
                  per computer ruh after you go through the matter of data
              17
                  collection, and input.
              18
                            .So the proposals then boil down into two parts:

                  those that are going to be continued, and those that are
              20
                  going to be new.
              21
                            Problem-oriented record -- tey want to proceed

              22
                  withimplementation, as they have already  been doing, for
              23
                  $105,000.  They sent in an evaluation report, and the evalua-
              24
                  @n indicated that this was a very influential program up to

              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N,E.





                                                                            19 9



  WHD134           now.
               2              The computerized hypertension treatment, they

               3iii needed to continue to work on that,  and that is  $205',000.
               4   A group of physicians in residence   out of Champagne  Lounty
               5   are looking to  problem-oriented  record  systems  integrated

               6   into what is called the "Plato  4  Dance  Computer,"  about  which

               7   I know nothing. Apparently it  has  been  funded  be'  a  and

               8   they want to continue that into the future.

               9              They have had a Chicago  alliance  for  VD  awareness

               10  under way, and that is to be continued.
                                                                          I
               11             Peoria frozen blood programi which  is  simp@y  a
                   matter of providing frozen  blood  for  people  in  need,@undergo-
               12.
              .13  ing kidney dialysis and other  types  of  extreme  problems.
                              Now, the new programs have moved beyond the existing
               14
                   problem-oriented record to take  this  out  into  ambulatory
               15
                   care programs that they  have in the out-patient program depart-
               17  ment and elsewhere, for   the next year, and  they  provided
               18  evaluation as well as to  the  effectiveness  applied  to  ambula-
                   tory care.  $128,000.

                              And then a nice  little  touch  here.  The  Christian
               20
                   Action Ministry are concerned about access    to  care  services
               21
                   of a broad type; inner-city  health  and  social  needs.  This  is
               22
                   such matters as day-care centers that have a health     component,
               23
                   and they all interact.  Not--mu@h'    $44,000,  but   well-spent
               24
                   money, in that type of thing.
               25

  HOOVER REPORTING CO, INC.
  320 flassachusetts Avenue, N.[.
        np nanno




                                                                            2  00


  WHD135       1              They want to hold a series  of  dialysis  consumer
               2   workshops for $30,000.  Again,  I  think  avaluable  type  of

               311 patient education.

               4              And Access Chicago, a rehabilitation institute

               5   program, to take a look  across  the  city and-find.out how
               6   barriers to handicapped people can  be  decreased  and  develop

               7   this as a public monitoring system; just $12,000.
               8              And then, finally, this is  interesting  because  I
               9   would like to know about this project; an institutional cardic-
               10  vascular center.  They are asking for $100,000to help organ-,
                   ize this. This  is  against  a  background grant of $38 million
               12. to pull together  eleven  institutions  to develop  a-@ulti  --
                   or at least a consortium  of  activity  in cardiovascular   dis-
               13

               14  ease.
               15             I think that is real  original  planning.  Who  has
                   that proposal?  Does anybedy have    that?
               17             MRS. KYTTLE:  National Heart and Lung.
                              DOCTOR SLATER:  I would like to look at it sometime;
               18
                   I think this is what cities need to do more of.
               19
                              Finally, they are asking for $643,000 for statewide
               20
                   hypertension control program. That is  going  to  be  built  on
               21
                   their model, which is going ahead  from  the  present  fnnding
               22
                   because of the-action -- the present  action  that  they  are
               23
                   also funding for -- 350,000 inner-city  people  who  are  going
               24


               25

  HOOVER REPORTING CO, INC.
  3?0 f.'amchusetts Aver,@i@e, N.[.
  'i@ashinElon, D.C. 2DaO2





                                                                          2  01


  IHD-136         to be programmed into that computer and hopefully monitored.

               2             They have developed a very fine record of starting

               3  little projects and seeing that they  work,either  spinning

               4  them off or expanding them up to a  broader  application  at

               5  the state level, and clearly they are moving in the direction

               6  of hypertension.

               7            Now, looking at all of this in terms of the feasi-

               8  bility,.I would say that the feasibility of  what  they  are

               9  asking for this year in new-projects have a good chance of.

             10   flying, and if they run out of funds by the end of the year

             11   they will spin these off or re-fund them or find ways to

                  carry them out. That has been their record and it  has  been
             12.

                 -very successful.
             13

             14             No question about their relationship with CHP    and

                  overall, I give this a rating of superior, and I feel that I
             15
             1(;  would recommend that they @ave-all'of the funds they are

                  asking for, which is only 78 percent of the funding  tat  is

             18   allocable to them, and if there have to be any cuts  at  all

                  made, we provide them the chance to cut back where they deem

                  fit.
             20
                            I doubt if that is going to be necessary-
             21

                            MR. THOMPSON:  I guess I have one problem.  I wish
             22
                  somebody, would do what the RMP did in the early  days  when
             23
                  finally we got sick and tired 'ofegiving money to  computers
             24
                  and money to this and that, and finally somebody came in with
             25

  OOVER REPORTING CO, INC.
  20 Massachusetts Avenue, N.[.
  lashingtoti, D@C. 20002




  WHD-137      I    a big print-out out of a computer, and told us all the money

               2    was being put into computers.
               3               And I want to know how   much money  is being',put intoi

               4    the problem-oriented record.  Not only here,     which is  a
               5    $3 million grant going up there out of Research and Development,
               6    o'ut of Gerry  Rosenthal's  shop.  I  mean,  boy!  I  don't  know

               7    where all  that  money  is  going.
               8               I am  not  against  the problem-oriented record.; don't
               9    get me  wrong.  This  is  kind  of getting over-killed with money.
               10              DOCTOR SLATER:    Do you think it would  be  @,7ort'h-
               11   while for  R-MP as one of its final acts to lay on a sophistical
                                                                             I
                    ted -- a professional -visit, not just to this progra       but
               12.
                    to take a look at the financing of problem-oriented' records
               13
               14   or computer-type programs    just so as  we  go  out,of  business
               15   here and face probably a lot more money available through
                    other agencies in the fi64A., where  we  are  at  with  this?
               17              MR.  THOMPSON:  Now   we are talking about something
               18   else. What  does  it  --  what  is the take out of all  the  P.IIP

                    activities?

                               DOCTOR SLATER:  Well, you    would like to  get  a
               20
                    national fix on this; it would be interesting to have a play-
               21
                    back from the other Regions.
               22
                               MR. THOMPSON:  Computerizing th   e problem-oriented
               23
                    record?  That is a new catchword, along with        quality assur-
               24
                    ance."
               25

  HOOVER REPORTING CO, INC.
  320 Itiassachusetts Avenue, N.[.
  Washington, D.c 20002
  ('ZO2) 546-6666





                                                                           2 03


  THD-138                    MR.. CHPIIBLISS:  I do think that is a rather sub-

              2    stantive question you raised.
                             The Council did look at multiphasic screening in
              3
              4    the same way that you are looking at the computerization of
              5    records.  I don't know how we can go about getting a fix on
              6    that; we will raise your concerns,  though,  and  appreciate

                   your observations here.
              7
              8              MR. THOMPSON:  Well, you know, we went  through
              9    that cervical screening mess for, a while., 'kou,know,  that
              10   was all there, and if you read
                             DOCTOR .SLATER:  That's a horse.of a different
              11
              12   color. I think that here you are  really  providing  a  real
                   aid to differential diagnosis and the position tracking of
              .13
                   the patient; the cervical diagnosis was prefaced on incorrect
              14
                   information.
              15
                             MR. THOMPSON:   I am not.arguing about  the  validity

                   of it; I just wonder how much bucks?
              17
                             DOCTOR SLATER:  I would like  to pick up Mr.
              18
                   Thompson's concern and say th@t I feel  this program  is  work-

                   ing, is producing so well that we should not hold back on the
              20
                   funding for this, but that the larger  concern  that  is.raised
              21
                   by this type ofactivity probably will be the basis for a
              22
                   recommendation for a task review of not what  just  RMP  has
              23
                   been doing, but an overall.pictlire of the  Federal  Government

              24
                   in supporting this type of activity, and what is its-meaning,

              25

  HOOVER REPORTING CO, INC.
  320 Mamchusetts Avenue, N@l.
       n i,,nnn,)




                                                                          2 04


  WHD-139     11   what is the situation today?
              2              MR. CHAMBLISS:  Doctor Carpenter?
              3il            DOCTOR CARPENTER:  I have some questions  about  the
                                                             a piece of paper  at
              4    problem-oriented record, too.   You need
              5    a staff meeting and you have to have something on  the  paper
              6    in order to make it go, and I don't understand what the money

              7    is for.
              8              MR. THOMPSON:  They are all computerized.
                             DOCTOR CARPENTER:  What I actually want to raise
              9
              10   is the issue of $643,000 for screening program  for  hyperten-

                   sion.
              11
                             MRS. WYCKOFF:  It's a million  if you count the
              12
                   other.two projects with it.
              14             DOCTOR CARPENTER:  Okay, a million.  Thank you.
                   How many previously unrecognized hypertensives will be brought
              15
                   to treatment as a-result of'this-program, and who  will do the

                   treating?
              18             DOCTOR SLATER:  Now you are getting into project
                   detail for which there is not.information here.

                             DOCTOR CARPENTER: I am raising  a  management  ques-
              20
                   bon; I think if those questions have not been dealt  with  in
              21,
                   the application, there is something wrong with  the  Region's
              22
                   management.
              23
                             DOCTOR SLATER: I am assuning that  the  quality  of

              24
                   the review process, if it is affected by the quality  of  the
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  V.1a@hit,ainti r) r. 2nnn? i @                                                   I




                                                                          2 0 5


  WHD140       I   way this is wri
                               .  tten, can answer that question.  I can't

               2   answer it.
               31            MR. CHAIIBLISS: Do you have comments,  Mrs.  Kyttle.
               4             MRS. KYTTLE:  I don't know the preciseness-of the

               5   treatment, but I know the protocol and the thrust of the

               6   proposal, and it is an empirical thing.

               7             It mobilizes the state into  local  organizations
               8   that will specifically survey for hypertensives,  assure  that
               9   they are recognized, identify, treat it in a fashion  so  that

                   the rest of the state can get the information, so  that  the
              10
                   basic data shows in Illinois that hypertension is epidemic.

                             But no one is organized to attack the  problem,  and
              12,
                   this is not so much a treatment of the specific  patient  as
              13
              14   it is'organizing the system of care that treats  the  patient.
              15             DOCTOR CARPENTER-. What part of that budget  .'is
                   invested in personnel?

                             MRS. KYTTLE: I  can  tell you that in just a minute.
              18   $48,800 -- no, no; wait a minute. I.have the wrong one.
                             $291,000.
              19
                             MR. THOMPSON:  How  much?
              20                                         -
                             MRS. KYTTLE:  Out of $743,000     no; @xcuse  me.
              21
                             $100,000 of it is coming from other  sources,  and
              22
                   the $743,000 is the total cost, but PIIP is being asked  for
              23
                   $634,000. $291,000 is a line item for  salwies  and  wages;
              24
                   $170,000 for equipment, $28,000 for.supplies,  $15,000  for
              25

  HOOVER REPORTING CO, INC.
  320 Massachusetts Avenue, N.[.
  Washingtor,, D.C. 20002





                                                                       2015

   WfID141   I   travel, $23,000 for rent.

             2             It creates local consortia of some:- type, and
             3   there are charges listed here, and $25,000 in the other

             4   categories.

             5             MRS. WYCKOFF:  How is it related to Project 18

             6   and 32?


             7             MRS. KYTTLE:  This -.is statewide; 18  is-Mid-State
             8   and Southside.  Southside is a coo erative B that Illinois
                                                   p
             9   has used as a springboard for a lot of its activity that  it
           10    tri es out in mid and Southside, anq then comes off a later

                 timeframe as a national


                          DOCTOR SLATER:  This is not a final program, but
           13   they are estimating a million hypertensives out there; 3601-

                in this'experimental program.
           14

                          MR. THOMPSON:  My concern now -- well, two question
           15
                          One is that you s@id the control program is based
           ),7  on a computer print-out, computer diagnosis.
                          MRS. KYTTLE:  That is in a controlled population.
                          MR. THOMPSON:  Yes, I understand that, but somebody
                said that they were fooling around with some kind of a computer
           20
                program in hypertension, and would apply this computer pro-
           21,
                gram -- which again, unless I misunderstood you, is not  com-
           22
                pleted yet -- to a statewide control program.
           23
                          DOCTOR SLATER:- I think I left that impression.
           24
                         MRS. KYTTLE:  The precepts of that program will   be
           25

  ,-.R REPORTING CO, INC.
  a@ichusetts Avenue, N,E.
  iptoii, D.C. 20002                                                          1





                                                                                                                                  u I

   WHD142                   I   fed to the local boards that will be established, but to
                            21  speak     to     the     whole     future     of      the      thing,      three      things      have
                            @i!;! happened  in  Illinois  all  at  once,  that.the  Illinois                                       Regional
                            4   Medical  Program has  been waiting  for  for  a  long timel,

                            5                     They  got  a new A man;  they  could  not n.-.-                           statewide

                            6   well.with  their  former  CHP A man,  who was                             replaced  by          a

                            7   former       Board       member        of        the        Illinois        Regional        Medical!Program

                            8   Board  of  Trustees.
                            9                     The concept  ofithe key  factor  analysis  for  planning
                            10  has      been      a      philosophy      of      the      program      before      phase-out      but

                                could      not      be      moved      statewide      because      it      met      A      opposition.

                                                  It no  longer  meets A                 opposition,  and  they               are       now
                            12.

                                able  to move  it.
                            13
                            14                    They  have  a new State                Health Officer who  is                 a  formero
                                RAG member,  and  she  is  now working with  the  program  in                                        state-
                            15
                                wide  areas  that  they have qiot had  an  opportunity  to work well
                            1(;
                            17  in before,  and most  importantly  of  all  for  this  project,  we
                                are      thinking      about      now      the      state,%4ide       hypertension,       and       we
                            18
                                have     a     new     Governor     that     stood     off     from     that     --r      from      matters


                                medical.
                            20
                                                  No one,  not  the A man,  not  the  new Public  Health
                            21
                                Director,  and  not  the  existing  RMP  could  open  his  door,
                            22
                                because  he  had  other  assessments  tb'make.                            Ile     only     now     has
                            23
                                established  someone  in  his  office  to work                            with  the  Illinois
                            24 1
                                Regional Medical  Program to develop  a regional  legislative
                            25

    HOOVER REPORTING CO, INC.
    320 taassachusetts Avenue, N.[.
             D.C. 20002




                                                                        2 0 8


  1ID143          package.
              2             They got to him with the epidemic hypertension
                  figures, and he is working with them for a  legislative  pack-

              4   age that they hope will continue much of this.
              5             DOCTOR SLATER:  Let me give you  the wording on this,',

              6   John..  I think we may have it here:

              7                  "The immediate objective is to develop a
              8        state network of hypertension registries which is to
              9        evaluate quantity and quality.  CIIP B agencies would   be
                       asked to assist in components of the program, w@ich in
              10
              11       turn will mobilize regional resources to determine
                       registry input, reporting of requirements and  action  to
              12

                       be taken in terms of screening, referral,  management,
              13
              14       and consumer and professional  education.
                                 Discussion has begun  with stateceficials,
              15
                       and heart association legislation."
              17            MR. THOMPSON:  Is it against the law for CHP B
              18  agencies to run programs? They are  not  the  implementers,  if
                  that is the question that I  hear  you  stating.
              19
              20            DOCTOR SLATER:  CHP  B  agencies  will be asked to
                  assist in regional components  of  the  program, which in  turn-
              21
                  will mobilize resources and essentially determine registry
              22
                  input, and so forth.
              2 ti
                            MR. CHAMBLISS:  There  is a substantive issue  here,
              24
                  I think, and that is one of balance on the part of the R-@,IP,
              25

  IIOOVER REPORTING  CO,  INC.


       D.C




  VIIID-144    1  and is there -- and we would like your judgment  here  --  is
               2  there an overemphasis in the area of hypertension, especially,.
                  since there are 350,000 people to be screened on the'computer:

               4  set up?
               5            I simply throw that out  for  your  assessment.  of
               6  course we would like to have your views here on feasibility.
               7            DOCTOR SLATER:  My impression of this as I@read
               8  it through, and I would like to hear what Mrs. Kyttle's under-
               9  standing is, having visited there, is that they made  a   speci-
               10 fic decision programatically, sometime ago to go to  two

               11 routes.
                            one is to satisfy some of the start-up nee@s of
               12
               13 what you might call community-action  programs,  health  care
               14 access, and the like, which have been reflected in these pro-
               15 grams that have been passed on, and  are  not  free-standing.
                                     second"d
                            And the          ecision,,some of  these  mass-popula-
               17 tion approaches which are clearly associated  with  the  mechan-
               18 ical improvement of screening and information gathering, so
               I!) they can be applied to masses of individuals who are disad-
               20 vantaged, and in order to get to that  level  of  technology,
                  they need a reasonable level of hardware, as  John  was  putting
               21

                  forth.
               22
                            Now, I think the questidn'is whether  or  not  this
               2.
               3
                  is incorrect, that at the national level we have  decided  like-
               24
                  wise to go this route of kind of the task approach to cancer
               25

  IIOOVER REPORTI@,G CO, INC,




   @7l@ID145   I  originally it was heart disease, cancer, stroke, and now even
               2  more so we have oriented our efforts on a programmatic basis

                  to such things as cancer.
               3ii
               4           So I have trouble making a decision at this level
                  based on the -- that they have done the wrong thing.  I th ink
               5
                  they have taken an experimental approach as part of the
                  pluralistic way of going about it, and they are not doing it
               7
               8  to the exclusion of all other,a,ctivities.
                           They could have a lot more Christian Action Ministr@,
               9
               Jo and I think they might -- I think that would be very effect-
                  ive and I am sympathetic to that, but I say there, they decid-
                  ed to put a lot of money into this one orientation.
               12,
               13          DOCTOR VAUN: I move that Illinois  ge t their full

                  request.
               14
                           MR. CHAMBLISS:  All right.  There is  a motion on
               15
                  the floor, and will you cite the dollar level that you are

                  referring to, please?
               17
                           DOCTOR SLATER:  I suggested that they get what
               18
                  they requested -- 78 percent of what you indicated.

                           MR. VAN WINKLE:  $2,816,935.
               20
                           DOCTOR WEIITE:  I'll second.

               21
                           MR. CHAMBLISS: It has been moved  and seconded

               22
                  that Illinois be recommended for the level they have requested,

               23
                  $2,816,935.  Is there further discussion here?

               24
                           DOCTOR MC PHEDRAN:  I guess I'll go along with that,l

               25

  IIOOVER REPORTTNG CO, ING,
  3?0    Avenue, N.[.
         20002





                          ink we ought to mention we think it is going   to  be
  WlID146         but I th
              2'i difficult for them to spend that amount of  money  on  hyper-

              3@@ tension, on the liypertensionidentification in that   length

              4   of time.  I really think it is going to be hard.

              5              There are places where similar efforts  have  been

              6   tried in the past. Doctor Joe  wilburfore,  in  Atlanta,  and

              7   there are a lot of problems with it, and  the   implications

              8   that Doctor Carpenter makes are.a very important one.

              9              That is, in places where there are a largelnumber
              10  of hypertensives, Particularly in deprived people, i@ is
              11  extremely difficult to  get'them  into  effective  treatment
              12. programs, and it always seems a pity to  identify_a  lot  of then
              13  and not be able to follow up at all, and I think it    takes
              14  away from the luster of the Regional Medical Program that is
              15  engaged in an activity like that that is effectively followed

                  up.
              17             So I think -- I guess that maybe is one of the
              18  things that Doctor Carpenter is  concerned about.
                             -DOCTOR SLATER: We are more concerned  about  the
              1!)
              20  fact that they are attempting to do too much in too short a
                  period of time rather than that.
              21
                             MR. THOMPSON:  Plus the fact we have gone through
              22
                  cancer detection, we have gone thr'cu'gh multiphasic screening,
              23 1
                  we have gone through all these kinds of things where everybody
              24
                  runs around, finds a lot of pathology that nobody sees until
              2

  IIOOVER REPORTING CO, INC.
  3?0     Aveflue, N.[.




    @,I]ID147                i      the  damned  stuff  is  treated,  because  it  is  outside  the  system.!
                             211                        MRS.  KYTTLE:    Mr.  Thompson,  not  in  Illinois.    When
                                    I  followed  up  there,  Illinois  had  an  interesting  spin-off

                                    from  the  follow-up.

                             5                          It      was       referring       all       of       these       people       witn  identified

                             6      hypertension  to  doctors,  and  the  doctors  all  said:

                             7                                    "You  know,  I've              got        sicker        people        in  m@y         office

                             8      And  so  the  RAG  in  Illinois  decided  that  one  of  the                                         spin-offs

                             9      from            their next         controlled         hypertension         would         be          to educate

                          10        physicians            to  treat  mild            hypertensives.                    They      were    illing

                                    to-take            on the  referred  critical  hypertensives,                                but  they

                          12@       couldn't  get  the  mild,  even  though  they  followed  them                                              up,
                          13        they       hauled       them       right       into       the        doctor's        office        and  that     is
                          14        where,it  fell  down.
                                                        MRS.        KYTTLE:        But        you        know,         some         screening dro  ped
                          15                                                                                                                       p
                                    the  man  and  didn't  followup,  but  they  did  not.    They  followed

                          17        up;  they  re-screened.
                          18                            DOCTOR  SLATER:    It  is  very  important;  even  if  it
                          19        is       negative,       it        is        certainly        something        that        helps        the        system.
                          20                            DOCTOR  MILLER:    Dlister  Chairman,  could  I  ask  a
                                    question?
                          21
                                                        I  have  known  a  good  deal  about  the  IllirAs  progr
                          22
                                    and      to      a      great      extent      the       strength       of       the       Illinois       program       is
                          2.'j 1
                               11   directly  related  to  Doctor  and  Mrs.  Creditor.
                          24  11
                                                        Doctor  and  Mrs.              Creditor        are        both        moving        to         Urbana,
                          25

    OOVER REPORTING  CO,  INC. I
    'IO i,@ssactilsclts Avenue, N.L.
                 20002





     wiir)148              lil'    and  though  he  is  going  to  spend  25  percent  of  his  time                                               on

                           ,@!i    continuing  this  program,  the  magnitude  of  the  effort  has                                                 got

                           :1      to  be  led  by  somebody                   better        than        just         a         Creditor         on]25-per-


                                   cent  of  his  time  from                   Urbana.


                           5                           What       assurance       do       we       have       that       a        similar        competent

                           6       person  is  going  to  take  over  or                           that      he      will       be       able@to       help

                           7       recruit,  or  maybe  can  we  help  them  recruit  one?

                           8                           DOC-TOR  SLATER:                  I  apologize  for  forgetting

                           9       tion            that.

                           10                          MR.  CliAI,4BLI8S:    That.is  very  critical,  yes

                                                       DOCTOR  MILLER:                 The  two  of          them  ran  that  program.

                           12,                         MR.  CI-IAMBLISS:               Would  Staff            have  any  comments  on

                                   the  efforts  in  recruitment  there?
                           13
                           14                          MRS.  KYTTLE:    What  I  mean  --  well,  as  I  mentioned
                           15      in  my.staff  paper,  the  Board  talked  with  Dean  Bloomfield,  and

                                   I  have  talked  with  Dean  Bloomfield.

                           17                          The       Board'has       decided        that        25        percent        of        Doctor
                           18      Creditor,           which  they  think  will  also  bring  them  25  percent
                           I!)     of      Mrs.      Creditor      for       free,       is       good       enough,       and       they       would
                           20      rather  go  with  that  than  to  recruit  hastily.    They  are  recruit--
                                   ing;  they  have  a  Search  Committee.
                           2   1
                                                       Bloomfield      is      a      member      of      the      RAG;      he       is       deeply
                           22
                                   involved  in  the  problem-oriented  r'ec'ord.    That  is  how  a  lot
                           2:3 1
                                   of  it  got  going  down  in  Smithfield  or  Champagne  and  Urbana
                           2,41:
                                   in  the  first  Place.    Dean  Bloomfield  assures  the  Board,  and  me@,
                           25

    HOOVER  REPORTING  CO,  INC.
    320 t@,lassa,,tiLisetts Ave n@,e, f4.1.
    t,41stii@li@ t;),-" P,@c. 200'32





                                                                         4.Lt


  AllID149      1 that that is not going to be a skimpy 25 percent, and that
                2 it would be his assessment  that it would be the better of

                311                                  ougli December, and recruit-
                11- the two arrangements, at least thr
                .I                                                                i
                4 ment efforts are going on.
                5            They have found no one; the Board wants an M.D.
                6 and tney are simply not coming up with a successor to Doctor

                7 Creditor, and there is no assurance.
                8            MR. CHAMBLISS:  I would simply ask the Committee,
                9 is there a judgment that it wishes to express on the issue

                  of recruitment?

                             DOCTOR WliITE: I would like to agree  that  the  Board
                12, is using some sense, because I can't  imagine,knowing  what  is
                13 going to happen in July of 1975, that they  could  get  anybody
                14 who is really effective as a replacement.
                15           DOCTOR CARPENTER: There can't be  anyone  who  could
                  solve the  problem of bri@ging 66 percent of  the  hypertensives,
                17 in a population to effective treatment that wouldn't make a
                18 national contribution that would be enormous.  That will take
                  someone five  years of his life to prove that he's  a  relative
                I!)
                20 fadlure in this area, as a lot of people have done that in

                  other screening areas.
                2 1
                             Is there a Project Director here that  we have not
                22
                  heard about who is committed in the @ng run to the control of
                23
                  hypertension in a population?
                24
                             DO,"-TOR SLATER:  Doctor Kyttle   Doctor Koe.  Cat
                25

  HOOVER REPORTING CO, INC.





                                  I     you talk to that?
    @11ID150
                                  2                             MRS.   KYTTLE:     Well,   they  thought                                Fred  Coe  might
                                  ,III  have  met  this,  but  he  can't  at                                 this  time.                Can  not  be  dis-

                                  4
                                  ItI   tracted from what he is doing.
                                  5                             Doctor  Creditor  is  temporarily  listed  as  the  Project
                                  (i    Director  in  hypertension.     That  is  temporary,   and  it  is  almost
                                  7     a  cloak;  because  this  project  creates  a  State  Board,  they
                                  8     have  proposed  a  candidate,  and  I  do  not  know  who  it  is,     that
                                  9     the         Public         Health         people,         the         CHP          people,          the          Medical
                                  10    Committee  and  the  IRMP  would  proposed  to  the  Governor's
                                        office,         and         now         that         the         Governor's          office          has          gotten
                                  12.   involved,        and        this        they        look        at         as         the         possibility         of the  pro-
                                  13    ject  for  the  hypertension.  effort  being  the  continuing
                                  14    Regional  Medical  Program  Director.
                                  15                            So  they  are  approaching  it  cautiously,  because  the
                                        man  has  to  be  ratified  by  @o  many  different  interests.
                                  17                            MR.  CHPIIBLISS:     We                  have  a  call  for  the  question?
                                                                The  motion  has  been  to  recommend  a  level  of  funding
                                  18
                                  11)   for  Illihois  at  $2,816,935.
                                                                All  those  in  favor?
                                  20
                                                                (Chorus  of   "Aye")
                                  21
                                                                Those  opposed?
                                  22
                                                                (No  response)
                                  2 @3
                                                                one  in  opposition,   and                         the      "Aye's"           have           it.
                                  24
                                                                I  would  say  that  with                       regard  to             Illinois,   the
                                  25

     tiOOVER  REPORTING  CO,  ltiC.
     32c) l@las&ichtiselts Avef)tie, N.[.





                                            discussion will be noted and taken into account, as presen-

                                            ted here by the members of the Committee.
                                                                    I would call your attention to one thing, that our
                                     41 workload                 for today is still one short, interms of the number

                                     5      of  Regions   to  be  reviewed.
                                     6                              The   last  Regiaifor   today  is  Louisiana;   I  would  have
                                     7      a  hope  that  we  might  finish  by  ten  after   6:00.      Is   it  your

                                     8      pleasure   to  continue?     Let's  go.


                                     9                                                         -   -   -


                                     10






                                     12



                                     13


                                     14


                                     15






                                     17


                                     18






                                     20


                                     21


                                     2


                                     2@3


                                     24


                                     25

     @100@,'ER REPOPTI,'i@u  CO,  INC.




  1ID152        1                 REGIONAL MEDICAL PROGRAM REVIEW

                2                       LOUISIANA REGION

                             MR. CHAIIBLISS:  All-rig@t, the reviewers for

                   Louisiana are Doctor White, who will  be supported by'@ir.

                5  Zivlavski.
                6            Doctor White, will you proceed, please?
                7            DOCTOR WHITE:  I am sorry that this comes   at   the
                8  end of the day, because I have yet to make  up  my  mind  what
                9  should be done about Louisiana; as I  was  saying  earlier  to
                   Doctor Vaun, I had a feeling I was in an intensive care unit
                10
                11 and I really had a patient  who had died but  was on a,respir-
                12@ ator and I didn't quite know how to pull the plug.
                13           Yet, on second thought   perhaps there is  a feeble
                   beat going on there that I didn't detect at first   glance, and
                14
                   maybe something can be salvaged.
                15
                1(;          Well, with tha@,,as a preamble,  you can see my

                   confusion.
                17
                18           Louisiana has had a checkered career in the past.
                   It had a Regional Medical Program, but it has never been

                   awarded a triennial status.
                20
                             It was a difficult chore  to  even-get  the  concept
                21
                   accepted in the state of  Louisiana  for  many  years.  Doctor
                22
                   Zabatlyea took on the job, I forgot'when -- sometime ago; he
                23
                   had been President of the State Medical  Society,  he  was  an
                24
                   acceptable individual, and on the basis that @-y knew him and
                25

  tiOOVER REPOPTTING CO, INC.


          )C,002




  qlID153      1  on the basis t hat the thrust would be on planning initially,
               2  it got off the ground, and in reality the Regional Medical

               3
                  Program has functioned there for a number of years much like
               4  the CHP agencies were supposed to function.
               5            And on a site visit a year or two ago, this was
               6  noted, and I was asked then  that a Regional Advisory Grou p
               7  begin to become more action-oriented.  At the same time we
               8  became aware that Doctor Zabat lyea was really running this
               9  thing; the Regional Advisory Group was sort of there in name

               10 only.

                                 'Mith then took over                isory
               11           Mr.  S                    as Regional Adv'
               12, Group Chairman and turned things around, but only  at  the  time
               13 Washington was turning around, and this disillusioned them
               14 totally.  Doctor Zabatlyea resigned from his position, and I
               15 guess is now donating some amount of time, and  a  doctor  whose
               1(; name I don't recall -- a d,6ntist.-- is filling in for him.
               17           The other problem in Louisiana is -that there are
                  two systems of medical care, and the two seem not  to  be  meet-
                  ing.  Although, as I have down here, there had been some
               20 change under way when the, axe fell.
                             So the leadership is in question at the present
               21
               22 time.  This report that @ have before us was prepared by a
                  task force, signed by Doctor Zaba-El'yea but obviously not the
               23
                  product of his thinking.  It is rather disorganized, it  oes
               24
                  not follow any sequence that permits yoato see  the  program  as
               25

  40OVER REPORTITIG  CO,  INC.
  320 Nla@ichuset@,@ Aveii[ic, N.[.





  WIJ,Dl54    I   a wliole@ -
              2             The staff has been reduced considerably;  there  are
                  four and a half professional people listed with presumably,,  I

              .4  as I mentioned -- the Regional Advisory Group  began  the,turn
              5   around, but I have the feeling that now they  really  developed
                                                                                1
              6   phase-out plans and when this new concept came along they
              7   kind of even delegated this development they had  not  expected

                  to others.
              8

                            I am not sure from the narrative how often the
              J,O Regional Advisory Group has met, and as I said, I do feel
                  that probably their work has been delegated to staff  in  some

                  existing communities.
              12,
              13            The past performance of this has not been good;
              14  they have begun some outreach programs in some of the rural
              15  areas, they have begun some patient care  program  activities;
                  they are proposing other's. and --,in this present package.
                            They have participated in the  established  Emergency
              17
                  Medical Service programs in the state, the two  direct  efforts
              18
                  toward hypertension, quality assurance and  outreach  counsel-

                  ing.
              20
                            They do recognize, and I guess they have been
              21
                  atturned to this for some time, that they may not  get money
              22
                  for more than a year at a time, as they have in the  past,  so
              23
                  I guess it is nothing new to them.
              24
                            Their efforts are reasonably feasible on  a year's


  IIOOVER REPORTING CO, INC.
              N,E.
       D.C. 200,@)?




                                                                                                                          2 2 0


   ,,IIID--155                budget period.
                       2                       One plus is that the state itself                         has finally
                              reorganized its health-care delivery systems, evaluation
                       4      systems,  and has  a centralized  state  agency which will  take
                       5      on   and     direct,     presumably,     many      of      the      things      that      are      going

                       6      on   in      the      Comprehensive      Health      Planning      agencies,       many       of       the1

                       7      things  that have  been going  on  in  the  Regional Medical

                       8      Programs.
                       9                       This      was      accomplished      in      1972      when       this       consolida-
                       10     tion    was    under     way,     and     it     seems     to     be     accepted;     funded     by
                       11     the  state,  at  least partially,  and  for  that reason,  if  nothing
                              else,  I would  s         uggest      that      this      request      by      Louisiana,       even
                       12,
                       13     though we know  the  leadership  is  not good,  at  the  present  time,,
                              and     that     past     performance     has     not     been     good,     that      there      is
                       14
                       15     some merit  now  that  the  state has  begun   to move  in  the  focuse4
                              direction,  in  not cutting @he rug out  from under  them,  with
                       17     the     hope     that     at     least     some     amount     of     money     will     continue      the
                       18     emphasis      toward      this      simple       direction       of       the       health       services.
                       1!)                     That    is     the     only     justification     I     can     find     at     all
                              for  recommending  any sum of money  for  Louisiana whatsoever.
                       20
                              Some  of  their  projects  are  adequate;  a  co                      uple of  them are
                       21
                              rather     biased,     I     think     because     the     Director      at      the      moment      is
                       22
                              a     dentist.     They     have     a     couple     of      -fairly      sizable      dental      pro-
                       2 t3
                              grams,    including    a    mobile     bus     that     is     going     to     go     out     and     fix
                       24
                              teeth,  I  guess.
                       25

   IIOOVER REPORTING CO, INC.
   320 tlas,.iclitis(@tts Avenue, t@.E.




                             We have another strange one, or at least it seems

                2 funny to me; they are going to establish  a  Midway  assessment
                  Region at the Charity Hospital, and as I read  some  of  the
                41 comments, this is to move the patients out of  the  wards  into
                5 another place, because these are patients they  can't  get  rid
                6 of -- families don't want them back, they  don't  have  any,
                7 money to pay nursing care, and that is one way out.  And
                8 the Midway Assessment Region is for patients flowing the other
                9 way, that come in-through the Emergency Room  and  can't  be
                10 evaluated adequately, and they have to be placed in this area
                  and then moved into the hospital  or  someplace  eventually.
                11
                12@          But anyway -- they are at least making some efforts
                13 at bringing some services to people who are denied services

                  at the present time.
                1 4
                             Another one at the Earl K. Long Hospital      they
                15
                  indicate that there is a,-60-day waiting period for patients
                17 to be seen in the clinic, and they are asking a  modest  sum
                  of money to open up night-time clinics  and  weekend  clinics

                  so that this waiting period might be shortened, and I guess

                  that is reasonable.
                20
                             DOCTOR SLATER: Well, that  is  straight  operational
                21
                  patient-care delivery.
                22
                             DOCTOR WHITE: Well, it 'id. oing to  support  some
                                                         9
                23
                  staff work to help administer that.
                24
                             MR. THOMPSON:   You can't do that with a modest sum
                25

  HOOVER REPORTlt4G CO, INC.
  320 M,3ssacliusetts Avenue, N,E.
       D@,@. 2002
  2   6 6 G,',





  ,Tt) I57      1  of money.
                2            DOCTOR WHITE:  Well, I get through saying these
                3i things; i4l-'s a bad bag all around, and yet I don't feel that
  0             4  it should be denied survival for as long as the rest  of  them
                5  are going to survive, in the hope that one more year might

                6  see something turn around even more.
                7            They have asked for $985,000, which is only 77
                8  percent of the targeted funds, which would go to them on a

                9  formula basis.
                10           Mr. Zivlavski, maybe you have some  comments  before

                   I come  up with recommendations?
                12,          MR. ZIVLAVSKI:  There are several negative comments
                   which  you made, and I hope I can cover these comments.
                i3
                             The phase-out of the Louisiana Regional Medical
                14
                15 Program was taken very seriously by their Board of Directors;
                   as of July lst of '73, D@q;tor Zabatlyea was only part-time,
                   and a    business management was basically left to  the  Board
                17

                   staff.
                18
                if)          This was a non-profit corporation, by Louisiana
                20 law;  they have to notify the state 60    six months in advance
                   before terminating the corporation.
                21
                             At that time Doctor Zabatlyea did reduce his staff;
                22
                   he was on approximately 20-25 percent.  He remained as a part-
                2 t3
                   time coordinator.
                24
                             In late June things did change.' in September, thing@$-
                25

  HOOVER REPORTING CO, I?iC.

        c





                                                                                2 2 3

               1    looked a little bit better @%ilic-,,n $17.1 million was released
  [IDD158
               2    from the Division of Regional Medical     Programs.  The Board
               3    of Directors, instead of submitting official notice to      the
  0            4    state that they were going to terminate, kind of put       the cor-@
               5    poration in neutral gear and decided to wait.
               6               It sounds like some story, but I am     trying'to get
               7    it in the  right sequence so that you will understand.
               8               As more money was released from DRMP, Doctor
               9    -Zabatlyea had hired  several  people  to  the  program  staff;  when
               10   it became  clear that the lawsuit was won by the      Reg.Lunal
               11   Association, the Board of    Trustees again, for the corporation,
                    gave Doctor Zabatlyea another nod to go ahead and hi@re addi-
               12.

                    tional staff members
               -13
                               During this   time we made a site visit; Mt.    Posta
               14
               15   and 1, in November 1973.   1 The National Council was concerned
                    about that; we made a site visit  we discussed this with

                    Doctor Zabatlyea in February of this year.  lie indicated        that
               17
               18   he was going to resign from the     corporation; two months    ago
                    he handed in  his  resignation  and  the  grantee  would  not  accept

                    it.
               20
                               He has increasedyis  time  back  to  50  percent;  he  has
               21
                    rehired several  of  his  staff.  Several  of  the  staff  have  been
               22
                    Project Directors with the LouisianA RMP when they worked
               23
                    for the CHP agency and have joined     the staff, and what you
               24
                    see here basically are eight or nine         maybe te-ii people; I
               25

  IOOVER REPORTING CO, INC.
           Averiue@ N,E.



     @qiiDI59             think it is 8.6 tuli-tlme equivaiuiiLb.
                 2        and they ire asking for $1.25 million.
                                       Doctor Cool-,, the Deputy Director,  is 100 percent;
                 4        he did come back to fill in the gaps when Doctor Zabatlyea

                 5        was not there.
                 6                     So it has been slow;  the staff has been slow in
                 7        building up.  The present situation now is -that he is                     going
                 8        to remain 50 percent.   For how long I am not sure.
                                       I would rather not comment on anything else.
                 9
                                       MR. CHAMBLISS:   I would if I may just make'this
                 10

                          observation to the Committee.
                                       You should know that the staff has been very much
                 12.                                                                               1
                 13       concerned about this Region for some time, and that there is
                 14       a concern beyond the staff as it relates to the CIIP-Rl,.T
                          issues. in Louisiana.
                 15
                 I(;                   This has been one of the Regions that both Doctor
                          Paul  and         Rubel have began concerned about the CHP-R!,IP
                 17
                          relationships in, and I say            that only to give, perhaps,
                 18
                          Staff an opportunity to comment on those relationaps betweer

                          RMP and CHP and this Region.
                 20
                                       DOCTOR WHITE:   I should have mentioned that,  too.
                 21
                          That is apparent in the application, at least the comirtunica-
                 22
                          cations from someof the CHP agencies,  @t                  people there are
                          trying to stake out territories.   They want to be the surviv-
                 24
                          ors and not IUIP.   They impose conditions on R@IP, or try to,

                 25

   @'JER REPORTItiG CO, iNc.
            AvenLie,   ti.l.
        D.C. 2000'4'
    54 -6666





  @-11ID160 9  1  which I thought were totally unrealistic, in demanding  that

               2@@ they come and  resent their proposals for review, and they
                                p

               3';@; were going to go after technical merit of the whole thing,

               4i! as we were trying to avoid.
               5            All that sort of thing instead of trying to determine

               6     yes, this is consonant with  what we should be doing.

               7            So I guess I also got up on my hind legs on that

               8  thinking, that I have invested time and effort in RMP  and  I

               9  would rather see them,survive then CHP, and.I  shouldn't  say

               10 that.
               11           MR. ZIVLAVSKI:  I would like to add some   comments
               12. on the CHP comments.  On the yellow sheets we have two  para-
               13 graphs; one speaks to the New Orleans Health Planning Council,
               14 and the other speaks to the Northwest Louisiana  area  Health
               15 Planning Council.
                            The concern th@t,,Doctor White discussed  concerning
               17 the Ne,.7 Orleans area; they notified the Project Directors
                  the Friday evening before the CHP Monday morning meeting
               18
                  this one, their meeting on May 28th.  Doctor Cook, the Deputy

                  Director is meeting with the CHP agency, trying to resolve
               20

                  this.
               21
                            The second concern is the Northwest area,  which  is

                  madeip of eight parishes in the Northwest part of  the  state.
               2
                  There is a three-page summary from this agency;  basically  it
               24
                  is probably the most negative letter in the whole application,
               5

  HOOVER REPORTING CO, INC.

       D,C




  fID161        1. but when you read the whole lett6t- you r(-,,,lize the territory

                2  that the Northwest area takes into account.
                             They havelisted 12 projects here which they receive
                4  and they are all negative comments for these projects.   None
                5  of these 12 projects fall into the area which their CHP

                6  agency has.
                             It is a mess, in that they received a b unch of
                8  project grant activities, which they really should not have

                9  received.
                10           This will help you alleviate some of the   concerns
                   about the Northwest area.  In addition, the Deputy   Coordinator,

                   Doctor Cook, is also meeting with this group on May 27th, I.
                12,
                   believe, to get this area straightened out.
                13-
                             They were favorable in three of the arthritis
                14
                   proposals, which this group is not reviewing, and they were
                15
                   favorable in another project, which again was not in their


                   area anyway.
                18           The two projects which head into the Shreveport
                19 area were continuation projects, and these were projects
                20 Number 42 and Project Number 44.  These were continuation
                   projects in this grant request in the Shreveport CH     agency
                21
                   voted for approval for these two projects previously, and
                22
                   this is in the $71.1 million that was awarded for octobPr
                23
                   to December, so I hope we can take care of Mr. Rubells
                24
                   concerns in addressing the RAG and the CIIP areas.
                25

  HOOVER REPORTING CO, ING@
  320 Massactiusetts Ave nL@e, N.[
       D.C. 200-92





  ID162                       I think we have taken care of these major concerns.

   0 0 I? i@,4 2              MR. CIIABMLISS:  Thank you.

                              We would now entertain a recommendation, Doctor
  0            4   White.
               5              DOCTOR WHITE: Well, unless  you  would  prefer  further
               6   discussion of the CIIP issue, though I don't ]-,now that there
               7   is anything further to discuss.  There is an obvious influence-
               8   of some kind there that has to be resolved.  I don't think

                   iiis Committee can resolve it.  We have already identified-it@
               9

               10  anyway.
               11             I think that PIIP has done some good work down   there;
                   Doctor Zabatlye'a was a dedicated fellow, and I think he   has
               12.
               13  done a lot of  work the CHP should  have been doing, and  there
               14  are some things  to be completed, and I think it would be a
                   shame to  terminate it at this time, and therefore  I  would  move
               15
                   that this be approved at the requested level, at $985,212.

                              DOCTOR MILLER:  Second.

                              MR. CHAMBLISS:  It has been moved and seconded that
               18
                   the level to be recommended for Louisiana be at.$985,212.
               I!)
                              Is there discussion?
               20
                              I hear a call for the question.  All   those in  favor?
               21
                              (Chorus of "Aye")
  iD           22
                              Opposed?
               23
                              (No response)
               24
                              The "Aye's" have it; the motion is carried.  This

               25

  HOOVER REPORTING CO, INC.
  320 Massactiu3etis Avenue, N.L.
       D.Cl 200@)2




    1)163                       1     panel has  com             :plo-tcd one-half of its work.  I wish to commend
                                2     it for its patience, its stamina and its participation, and
                                ill   I would also like to say to the Staff and to our Recorder
                                4     that  we  appreciate  your  patience  and  stamina                                              also.
                                5                           (Whereupon,  at  6:10  P.M.   the  Committee  recessed

                                6                          to  8:30  A.M.  May  23,  1974)

                                7



                                8


                                9


                                10






                                12


                                13


                                14


                                15


                                1(;


                                17


                                18


                                19


                                20


                                21


                                22


                                23


                                24


                                25

     HOOVER REPORTIfiG CO,  I?iC.
     320 fiassacliusetts Avenue, N.[.
                D.C, 2OGrj2