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                                                                     @'f! N G C O'@', P -1
                                                                POT
                                               HOOV'ER RE                                LiY, INC.


                                                                              D. C.
                                                                    5,@"t6-66'0'6






  rc                   DEF-PRT14ENT OF IEALTH, EDUCATION, AND WELFARE



                           ME-ZTING OF AD HOC CONQ@ULTANTS REVMIING

                            REGIONAL MMICAL PROGRAM APPLICATIONS





                                                   Conference Room H
                                                   Parklawn Building
                                                   5600 Fi,.zhers Lane
                                                   Rockville, Maryland 20852

                                                   Wednesday, May 22, 1974

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


                  Chairrran, oresiding.


                       PA@F,L B:

                           @Mr. Kenneth Barrows, West Des Moines, Iowa

                            Dr. Joseph Hess, Detroit, Michi-an

                            Dr. -Albert Heustis, Three Rivers, Michigan

                            Dr. John Hirschboeck, Mi lwaukee, Wisconsin

                            Mr. Joseph de LaPuente

                            Dr. Charles McCall, Dallas, Texas

                            Dr. William Thurman, New Orleans, Louisiana

                            Dr. Paul Teschan, Nashville, Tennessee

                            Sister -Ann Josephine, Notre Dame, Indiana






                                         C 0 N T E N T S


                  @3.2ns:
                               Maine                                        15
                                   Motion                                   28
                                   Vote                                     34

                                   Motion                                   40
                                   Vote 40

                                   Motion                                     I
                                   Vote 42
                             -A lbany                                       49

                                   Motion
                                                                            57
                                   Vote                                     6o
                             Northern New England                           62

                                   Motion                                   7
                                   Vote                                     79
                               Connecticut                                  82
                                   Motion                                   100
                                   Vote                                     101
                             Central   New York                             103

                                   Motion                                   115
                                   Vote                                     ii6
                             Hawaii                                         ii8

                                   Motion                                   131
                                   Substitute motion                        132
                                   Vote                                     133

                             Arizona                                        135

                                   Motion                                   152
                                   V.@te                                    153

                                   Motion                                   153
                                   Motion a.,ne nd e d                      i.6 o
                                   Vote                                     i64




                   I
                                                                                2-a


                     fie,7ions.(continued):                                     EtZe

                                Gree,ter Delaware ValLey                        i66

                                      Motion                                    175
                                      Vote                                      179






















   0




                   I



   49




                                                                        3


                                          P R 0 C E E D I N G S


                                PLITERSON:  We might as well get started,

                            (Discussion off the record.)

                           14R. PFTERSON: Before we do get  down  to  individual

                  regions, I would like to mention some thinrrs going back to

                  what Herb took off on, not tryinn, to repeat, on the other hand,

                  but get down to some of what I see as the more nitty-gritty

                  details.

                           You have already heard from Herb and the review
                  guide that I hope ail of you got, the kind of things that   seems@
                  to me is almost imperative that we individually  and  collectives

                  ly sort of try and keep in mind, the necessity for  trying  to

                  keep our focus on the overall reviod and Its proposal, need

                  to try and cotich our review in terms of the criteria and factors

                  which we soecified as beino, the basis for our jud,,,ment.

                  Clearly if we try to look at very many projects, we are  in trou'icl.=
                  I think I calculated we would have two minutes per project if

                  we operated on a project basis.

                            On the other hand, there certainly are going  to  be
                  some instances where the reviewers and staff will want to single

                  out some projects. I ,7,uess primarily because they may  raise

                  policy issues or they have attracted strong negative CHP

                  comments.  So those are exceptions.

                            On the other hand, as Herb indicated to the total

                  group this morning, I think we are going to be;confronted





                                                                        4

                   in a number of instances with projects which staff has already
                   identified and perhaps others which you and in the application
                   you have looked at, there are some policy issues about which WO,
                   may not be able to resolve in our best tact at this juncture,

                   maybe simply to flag those.
                            .And certainly the time that Herb dwelt I think on tha@t
                   last table, he passed out to everyone, I guess the column C

                   we spent more time talking about than anything else.

                            That tar@et amount, while it is not a formula, while

                   it is not an assurance that the region will receive that much,

                   I think yet in many ways It is going to have to serve as the   i
                   principal benchmark or backdrop against which we Look at these
                   applications, rather than necessarily the much larger amount in!

                   some instances that is being requested.

                            But in terms of the review procedure itself, we have

                   tried to assign each application to two people.  We haven't

                   designated them as primary or secondary reviewer, and the fact
                   there is one column and another doesn't really have any oreat

                   significance  I may deviate from that certainly.

                             There are a few instances, I know you have one or
                   two, Mr. Barrows, Yihere dLie to last minute cancellations
                   Dr. James I think just called the other day and I had someone
                   call me who had their third numeral thorax within the past day

                   who isn't here, so there will be a few applications where we
                   only have a single reviewer because of last-minute canceLlciL,.Lvti,-.






                           In a few instances we have tried to get to someone

                  else.  I knoV Bil4 apparently there was a contact with you on
                  Northern New England since you had visited that region and
                  possibly Bill will be able to pinch hitter as another reviewer

                  on Northern New En-
                                    .land,
                            Generally I would propose to not have the staff
                  comments -- you do have brief summary sheets In your books,

                  not to have staff comments precede the reviewers but rather
                  to follow a--- appropriate after the two reviewers have, addressed

                  themselves to the applications.

                            I think in setting down with Dick Russell    where

                  is Dick? -- who is chief of the Western Operations Desk and

                  with Frank Nash who is chief of the Eastern Operations Desk
                  yesterday afternoon, we have singled out a couple of applica-
                  tions where we will deviate from that rule where I think in
                  the case of Hawaii, for example, there is some significant

                  background we think we probably would like to present initially,
                  perhaps also a Metro New York where we have got a different ki-n,,,'
                  of application.  But generally we will look to the reviewers
                  initially and any staff comment subsequent to that if appropriate.
                            Certainly apart from the two reviewers that will
                  be called on, on the other hand, I think we do need to permit
                  ourselves some  tirm for a brie4L.-discussion fromthe others,
                  questions and answers,, hopefully al@-red at either brin@ina spe-
                  cific information or general impressions to bear, other people




                                                                       6

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

                  issues crystalized.

                           We will ask the two reviewers in those singular

                  instances where there is only one, the reviewer, the two or

                  single reviewer to prepare the ratind- sheet which,,again,

                  I believe was sent out to everyone along with the review  guide

                  and it is my understanding that each of you in the folders that

                  ou had In front of you have about five or six blanks there,

                  e have got additional ones if anyone runs out.  But subse-

                  quent to each review, where Dr. Hess or Dr. Teschan is one of the

                  reviewers, I would like to ask each of you to, as we go along,
                  to, the best of your ability, to try and complete a rating sheeti

                  .Lor each of the regions where you have been asked to review it

                  @nd to either let myself or Shirley Simons have those.  Because

                  we are going to try, as we get back on Friday, that will be one

                  Dasis upon which we will try and give the totalgroup aLain an

                  impression of how the two -roups have looked at  their  respec-

                  tive regions.

                           We also will need to get from you, from the group,

                  some kind of recommendation, as toyour recommended level of

                  funding with respect to each region based upon their current

                  application, recognizing that in the overwhelming number oi,

                  instances, regions will also be submitting applications in Julyi

                  3ut we do need that.


                            I think we have heard enough about the kinds of




                                                                            7

                   constraints that we are operating under.  Not the least

                   of which are lack of really good current information in      many

                   instances.

                              Time is obviously something we are going to be
                   wrestling with I think for the next 2-1/2 days.

                              There are, for those of you who  may  not  have  brought

                   all of your applications with or misplaced one in the cafe-

                   teria, or indeed If there is a region you weren't asked to      re-

                   view you might be interested in taking a look  at,  we  do  have  a

                   small supply of applications for all of the regions this

                   panel is concerned with back on  that  table  behind  Tom  Simonds.

                              So feel free to pick up an  application  if  you  have

                   any desire to do so.

                              -As far as conflict of interest is  concerned,  we  have

                   tried to arrange these two panels so that at least in the gross@

                                   'tutional sense, people from Great MidA,--st are
                   geographic inst-L

                   Looking at the eastern and western  parts  of  the  country  than

                   vice versa.

                              In other words, Joe and At are  from  Michigan,  we  are

                   not going to be dealino- with Michigan  and  hopefully  at  least
                                          CD

                   you won't be dealing with Michigan in this context.

                              DR. HEUSTIS:  We couldn't really help you   on   that*

                              MR. PETERSON: On the other  hand,  there  may  be  in-

                   stances,   Ican't think of any, but where based on your own

                   knowledge,  where you feel there is some potential conflict    of




                                                                       8

                  interest that-- if that does occur) that you acknowledge itland,

                  we will -- then the individuals can leave the room whi le that
                  region is being discussed.  HopefuLly that will not occur,   be-
                  cause we tried to arrange the groups where the obvious conflicts

                  of interest would not arise.

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

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

                  the reviewers                     ason will not be able to be
                                who for whatever re


                  here on Friday.

                            CharLie IvIeCall, when we asked him to participate in

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

                  standing commitment that forced him to leave late tomorrow
                  afternoon, and thus I am going to have to make some adjustments

                                                                                n
                  vis a-vis the regions CharLie has been asked to participate i

                  the rev.-Le@i.  But if there are any others of you -- Iaul.

                            DR. TESCH-AN:  I am paled on airline computers--

                            MR. PETERSON: That seems more like a bowl  of  jelly,

                  from airline computers I have dealt with they are not that shar,--.

                            DR. TESCHAN:  Loused up so there is not much I can do

                  about It.  So I will let you know.

                            MR. PETERSON:  You are going to let me know if You

                  have to leave early?

                            DR. TESCHAN:  The reservation says we will be leaving

                  Friday morning.

                            @IR. PETERSON:  Okay.




                                                                              9


                               DR. TESCIIPN: Ear  ly.

                               MR. DE LA PUE14TE:  I have only one commitment this

                    afternoon that I could not avoid..

                               MR. PETERSON:  So as far as you are concerned,Joe,

                    we need to avoid Looking at the regions, Northern New England

                    and a few others you are coinc, to be the reviewer on, we have

                    to defer  those  until  tomorrow.


                               14R. DE LA PUE14TE:  Yes.


                               14R.  PETERSON:  Okay.

                               MR. BARROWS:   I  have a 4:30 f Light on Friday.

                               !AR. PETERSON:  No,  Ithink we calculated--

                               @IR. NPISH:  We would Like to get to Northern New

                    England sometime today if wecan, because Spencer won't be

                    here tomorrow, if we can work that out.

                               MR. PETERSON:  What time is your engagement this


                    afternoon?


                               MR. DE IA PUENTE:  Three o'clock.

                               MR. PETERSON:  Okay, -vte wil-I do that this afternoons

                               It may not be a good decision, but that is what is

                    important in Washinoton -- don't worry about the judgment, do

                    It on time.

                               In addition, because some of the staff       Spence

                    Colburn Is a prime example, but not the only one        some of

                    the staff that have departed       but have been brought back -Lor

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



                   have to do some adjustment there and I think I have  Identified
                   most of that in my discussions with Dick and Frank yesterday$
                                                                                  i
                   but we are going to try to handle all of the applications
                   Spence has the backgrounds on, because he is going to be out o@,
                   town beginning tomorrow in connection with his new job in

                   the Bureau of Quality Assurance.
                            Well, with that brief introduction, before we get
                   started, I wonder if there were any additional questions in
                   terms of details, procedures, or quite apart from details and   i
                   procedures, profound philosophical issues,, sorm of which I

                   would be willing to take up at lunch.
                            @IR. BARR(3TS: I believe some of us are bet er pre-
                   pared on some than others,  T went down mine alphabetically,
                                 PETERSON:  You are better prepared on Albany?

                            MR. BARROITS:  Than I am on the last two*   I hope  to do


                   that tomorrow.
                             I think Paul is in the same boat.   I don't know ,lbou'u

                   the rest of us.
                             MR. PETERSON: Well, again, if I should  call  for  an
                   application where you or someone else would like a little more  i
                   time, if you would Let me know that, I will, on sort of  an  ad
                   hoc spontaneous basis, at least in the beginning we have all
                   kinds of flexibility.  When we get down to the last two appli-I
                   cations, our flexibility is considerably reduced as to the num-

                   ber of adjustments we can make.





                                                                           1 L


                             MR. DE LA PUENTE:  One issue we could discuss


                   very briefly, it has to do with vacancies that  many  of  the

                   applicants have made in view of the fact we are dealing with

                      i
                   just one year and that has a. conflict, you know, as to-- we

                   let them fill all the vacancies because as far as the money is

                   concerned, they are within range.  I have a problem.

                             Does anybody else have it?

                             14R. BPRRO@TS: Yes, we have that, we have  it  from

                   another direction.  -Assumin,, they get the budget, wil'I they

                   be able to fill the vacancies and do the job within the time

                   span available?

                             @. DE LA PIENTE:  Precisely.

                             @M. B-AliRO,t[S: I would cyuess we had better take  a

                   look at those on an individual basis.  They tend to vary, criti-

                   cal shorta@e of staff or--


                             DR. TESCHAN:  One philosophic coanent, I think yo.Q

                   put your finver on as usual, mainly the local decision may be
                               CD

                   the ultimate reality.  RMP's think affirmatively in the most

                   distressing circumstances and I think riaht  now  the  stance

                   in many of the RMP'Ldis to think affirmatively about the transit
                                                                                    I

                   tion in the future.


                             I think quality of the professionalism even in the

                   short ran,7e -- talents, if anybody has any -- is goihcr to pick
                             CD                                          CD


                   up the staff in whatever mode it will be.

                             Whatever is recruited for next year is available for




                                                                             12


                   .Lo I low-on.


                             I am not nearly as much worried.

                             MR. PETERSON:  There is only one thing I would have to

                   say, the issue Joe has raised, we did see the  RMP's  with  the

                   announced phase out in January of 1973 go down in the agmrecrate
                                                                              C) CD


                   and there are obviously considerable  variations  here  from

                   roughly 1400 full-time sta.ff to about 700.  In other words, las

                   fall, Septer.,Lber, when we got to -- well, it was the  November

                   application, but it sort of reflected the s  ituation as of last

                   September, the Rx',IP's were down in terms of program  staff

                   about half of what they had  been prior to the phaseout,

                             By January o@" this year they had picked up about 300i

                   additional people. That was durinc,  the  period  when  neither

                   they nor we knew what the court was doing  to  order,  and,  in
                                                         C>

                   other words, it was at a time when  I  think  the  imponderables

                   were even worse than they are no@i.

                             At least now I can see down the tunnel for 15 months,i,

                   maybe less. It is only 13 months  now.  It  is  almost  the  end

                   of llay. In December and January, I  really  couldn't  see  down

                   the tunnel for more than at the best six months.

                             So I don't think that  answers  your  concerns,  Joe@

                   but I think it is not irrelevant.

                             DR. HESS:  I think III founded though It may be, we

                   must have some confidence between the Congress and Administra-

                   tion that the intents that are now  being  expressed  will  find




                                                                            13

                  expression in so me legislation that will allow this type    of

                  activity to continue in some form or another.  I think that is

                  what you are sayin@.

                             I think that has sort of been a backdrop   and if thEY

                  fail to come through, you know, I guess  that  is  not  our  response

                  sibility.

                             But at the same time, looking  at  the  public's  need,  i

                  and the fact that this type of activity has proven itself to

                  be effective for doinf7 a job that needs to be done, that

                  somewhere or other there is enough  broad  support  that  somewhere';

                  or other the political element of this system  will  find  a  way  to

                  continue it.

                             DR. TESCH-AN: I think the corollary  for  me  from  all

                  that is we should make some efi'ort, i hope  we  oet  some  acree-

                  ment to that, make some effort to make sure that as well as

                  possible, each of the re@ions is  ready  for  the  transition  for

                  the follow-on.  I think this is the time to get ready.

                            DR. HESS:  Yes.

                            DR. TESCHAN:  Even though the imponderables shut ofL'

                  the enthusiasm for that in the region, I think    perhaps we doLild'@

                  help stimulate what chances need to be made to    vet  regions  in  i

                  line.


                            SISTER JOSEPHINE:  You know, in going over som o.L

                  these applications, 1 have noticed in  many  cases  where  they  were
                                                                                      i
                  looking for stafg they picked up staff from CHP  pro-rams,  whic'iill





                                                                              14

                    to me is the direction toward the change    in  total  administra-

                    'Uion, and this should be commented wherever  they  do  this,  be-

                    cause I think this is addressing  itself  to  the  transition  you

                    are talking about.

                              MR. PETERSON:  WELL, I am sure there are @oina- to be

                    all kinds of issues of both a, generic and specific nature sur-

                    facing during the next two days.' We might kick off and I

                    thouZht my sense of geography what it Is we might kick off

                    w I th I,'Laine, since it is in the upper right-hand corner of the

                    M(?.P of@the United States, itcbviously is not at the head or end

                    of the alphabet, neither the larger or smaller states, but that

                    is my rationale.   Besides, Spence Colburn, that  is  one  of  the

                    states we are lookinc, to Spence  for  some  additional  comments,

                    since we do have two reviewers there.

                              I wonder, do you want to  Lead  off  on  that,  Charlie?

                              DR. McCfiLL:  Be glad to.

                              MR. PETERSON:  Okay.




                                                                         5

                           DR. McCALL:  I wish I had had an opportunity to re-

                  view this program back when I found a, direct line, I found

                  opportunity to look at a quality program@ and it obviously has.

                  strong leadership at the staff and advisory group level.

                            It comes through loud and clear this program makes

                  great plans not only in transitioning what is coming, but in
                  continuing and financial support from other sources. -And  I

                  really don't think there is any-- there is no question raised
                  in my mind in terms of their conflict, in terms of their stated

                  objectives end their program, the lements to achieve those

                  objectives.

                            The only question I had in my review was since ti-eir

                  funding seemed to be a little low currently, and I assume that@
                  was because of all of the vagaries of the past years that we

                  have been going over and the excellence with which the prorran
                                                                             CD

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

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

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

                  mendation.

                            DR. TESCHAN:  Who Is the grantee?

                            DR. McCALL:  Medical--

                            MR. PETERSON:  IL@dical Care Foundation, Incorporated.

                            It is a private nonprofit corporation and has been

                  since day one,

                            DR. MOC.ALL:  I will confess when I received these two




                                                                         i6

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

                  material, just padded in here, and I since learned  they  were

                  asked to come in with a complete application but I enjoyed

                  going through this application. It is clear,  it  Is  informa-

                  tive, and I really found this operation useful certainly.

                            MR. PETERSON:, Al, you also looked at Maine.

                            DR. HEUSTIS:  All I can say is I had two Impressions

                  I received these two beautifully bound books and thought who are

                  they trying to convince?

                            I received this other one from California  with  the

                  other material, and I didn't really think they were trying to

                  convince anybody.

                            Beautifully done -- graphs, different styles  in the

                  typewriter, different colored paper and so forth.  And. I looked

                  at it with a negative prejudice.

                            DR. McC.ALL:  I a-ree.

                            DR. HEUSTIS:  -And I read it.  Everything you said isl@


                  true.


                            DR. McCALL:  Unbelievable.

                            DR. HEUSTIS:  This is the  only one I reviewed  that

                  had any need or basic population data.

                            DR. McCALL:  All there.


                                                                               t
                            DR. HEUSTI8:  This is the only one I reviewed tha

                  indicated the other than the RMP support that was  going  into the

                  current programs,




                                                                          17

                              This had a pretty definite and clear-cut attention

                   to process ac@ far as priority ranking in how you got  that  way@

                              All of the questions I had were answered and a few

                   of the questions I didn't have also were answered.

                              I thought it was well organized, that certainly

                   their record right down the overall list we had, all of the

                   different criteria.

                              I took this document which you have in the review

                   sheet and broke down each paragraph into the number  of  thin-@s

                   that you mentioned, plus a few of my own.  And on Maine, I

                   rated everything that was ratable in the good column except

                   for the reflection of needs identified by comprehensive
                   planning, which I put down as insufficient  data.  This  may  weLII
                   be about as comprehensive planning has not identified a ny

                   needs and not been doing the overall job.
                              I would support any extra money that anybody has  inii
                   goinv to the Maine program as being capable  of  bein-  extremel'
                                                                                  y
                                                                                   I
                   well spent, with creat results -as far as continuation pro-

                   jects at cost levels.

                              I was particularly impressed that they were  able  to

                   get some help from the state government.  Not  only  in  pickingi
                   up some of the projects that RMP had started, but help from
                   state government as I understood it, at least to go into the
                   regular day-to-day operation of the program for  the  next  fis-

                   caL year,






                               I feel very strongly and very   positively about this

                    program,   It was a refreshin-  one to read and made reading

                    some of the others -- well, it   even compensated.  It was a   ver-y
                       %                                                              I
                    refreshing one.

                               DR. McCALL:  No collaboration, but   I obviously had

                    the same impression.

                               My recommendation was  funding  maximurA  eligible.

                               MR. PETFRSON: What  about  the  other  reviewers  who

                    may have questions or comments about 14aine?

                               DR. HIRSCHBOECK: I  don't  have  any  comments  about

                    the application.  I haven't seen it.  But I have always been

                    cur3-ous about the interface with neivliboring states an

                    Northern New En-land, whether this is   well taken care    of.

                               DR. McC.A LL: If it is not spoken to one  way  or  the

                    others I have no knowledge other than the application.

                               DR. HEUSTIS:  Any more than 14icIiigan's at least as it

                    used to be a  number of years ago  doesn't  say  anything  about

                    Ohio or Minnesota or Wisconsin; maybe it should have.

                               DP,. HIRSCHBOECK:  How they relate.

                               MR. PETIMSON:  Maybe Spence or Frank have something

                    to say on that9

                               MR. COLBURN: They have been very close  working

                    staff, three programs, tri-state who has New Hampshire and

                    Maine end Vermonto all of New England.

                               The New En@land pro@ram, an epidemiologist used




                                                                           19

                   to go to Maine quite frequently and he has helped the Yiaine

                   pror,ram, has capitalized on what was done in Vermont  with  re-
                   gara to coronary care networks,,safety  program,  Now  they  are

                   movino, into the area of establishing Guidelines  and  standards

                   within the corona,ry care network foi- treatment.  And I thitiK r,.n-is

                   is capitalizing on the success of that ty@ of activity in Vei-

                   mont just as an example of the exchange that takes place be-

                   tween those three pror,-rams in the upper part of New EncLand.  i
                                                                          CD

                             MR. B.APRCIEIS:  If the titles of the Project,are at

                   all valid, the direction of the program seems to be excellent,

                   very much on tar&et.

                             DR. HEUSTIS: There isn't any  question  in  this  par-

                   ticule,r program where there has been great leadership, at

                   least material available to me, by the proo-ram staff.

                             They haven't tried to sit back and say,   1%, hat   would

                   you fellows like to do and we will fit it Into an overall
                   pattern."  They have come out and said: This is what we went t6

                   do; would you be willing to work along that?

                             That is the kind of regional program that I think is

                   carryinc,- out the real mission.

                             DR. McCALL:  They list their new projects, continuing
                                                                                   CP

                   projects, list those they are requesting no further RI-@IP

                   funds for, exceeds-- either they have finished their mission

                   or have other source of funding.

                             DR. TESCHAN:   I want to ask about the CIIP relationship,





                                                                         20

                   I am not quite clears there are no functional (b) Is,

                   Chattergy has not done anythinu with the (b)fs to try to
                                                 CD

                   get them going or he has and they aren't functioning, or--

                   I an, not quite sure, or can you tell?

                            DR. HEUSTIS:  I cannot answer.


                            MR. PETERSON:  There are four orfive.


                            MR. COLBURN:  Five.


                            MR. PETERSON:  Functioning, there are five funded,

                   be (a). (b), (c).

                            DR. TESCHAN,.  He is getting no statement of prioritie:

                   objectives?

                            DR& HEUSTIS:  None from (b)ls.  All I could say was

                   there was really insufficient data presented on what the

                   (b)ls were contributin- to come to any value judgm-.nts,at

                   least on my part how the cooperation was.

                            MR. PETERSON:  Again, I think Spence or Frank will

                   have to help me with this.  I do not recall that 14aine is a

                   region where the CHP comments either were negative or pointed

                   a direction, but perhaps I am wrong.

                            I,M. NASH: Spencer, didn't he invite the (b)ls in and

                   have them sit around durinc, the discussion of these applica-
                                            C>


                   tions?


                            DR. HEUSTIS:  Excuse me, may I     I misspoke a moment,

                   ago,


                            I looked in the wrong column.


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                                                                            2 L


                              DR. McCA LL:  He, rea 1 ly me t w ". th them ahea,C of t iriie,

                    the (b) a-encie@-- even care into the R@ review I think.

                              DR. HEUST@LS:  I have down  "@tended  cooperation  and

                    coordination with the CHP is good.  Hivhest possible effectiVE

                    relationships are good.  Joint activities are satisfactory."

                              I misspoke; I was looking at  the  next  column.  Sorr

                    I misled  you.

                              DR. TESCHAN:  Trying to get a feel,

                              DR. McCALL:  It seems they did.

                              1,C .BA RR O@,S It would be awfully difficult for us  I

                    to pull dollar figures out of the air for  reconLnendation,  but


                    would it be feasible for us to say break these down into

                    groups of fives and the preferences we think they should share


                    in the  bud@et?


                              It sounds, for instance, this should be one of the

                    top ones.

                              MR. PETERSON:  I an. not sure when you say break there,'

                    down into aroups of fives, what--

                              MR. BARROWS:  Top --

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

                    assessment activity?

                              MR. BARROWS:  If that is what it Is to be., then, then

                    fine. I thought we had to come up with some  financial  recolln-


                    mendations.


                              NR. PETERSON:  We do need to come up with sorw


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                                                                           22


                                                                                d
                    recommendations. It is obvious if the recommendation  excee

                    the total supply of money, there is going to have to  be  some

                    adjustment. But perhaps I can answer your  question  in  part.
                    At least it was our hope that as a result of  the-review  dis-
                    cussion and the rating sheets that had been ab,le at the  time

                    we get the two groups back together, be able to sort of display

                    literally what the two groups had come up wi h separa ely

                    and probably failing out into not unlike a bell-shaped curve,  1

                    there were some at one extreme considered among  the  better,

                    some at another extreme that were considered poorerp  with

                    parenthetically the amounts recommended for them, and I think,

                    perhaps triparte -- again I don't-- but this w  ha    ope

                    to be able to do. Because I think it  is  difficult,  because


                    some of this indeed is comparative.

                              DR. McCf,.LL:  -And we are goinr,, to come back and look


                    at what we have recommended here.


                              MR. PETERSON:  That is  our intent.

                              DR. McC.ALL:  Set maximum rating, I would like

                    $2 million requested.

                              DR. HIRSCHBOFCK:  How do they deal with their fund-

                    ing?  They don't get as much as they have?

                              DR. McCALL:  Yes.  It has been In use  all alone,


                    one has been in use and is effective.


                              DR. TESCHAN:  Do you recommend two?

                              NR. N-ASH: It is target figure, bear that '@n  mind.




                                                                          23

                              DR. McCALL: I didn't when I put my $2 million down,
                    I didn't see the target figures and it exeeds it by over half

                    a million dollars.

                              DR. HESS:  I would like to introduce another element

                    in this discussion.

                              What is the population served by that EMP?

                              IvE. PETERSON: Slightly under, one million if  my--

                              DR. McC.ALL:  -About a million.

                              MR. PETERSON:  The State of Maine has a little less

                    than a million people.

                              DE. HESS:  I think that factor has to  modify,  put

                    into Considerations.
                              Now, another factor is what, within that document--
                    apparently they have done a better job than most in term of
                    outlining the health needs of the population.  In my own mind

                    I don't think of Maine as a-- well, It is a rural,  but  com-

                    prised o4 at least my image is of pretty hardy self-sufficient

                    people who, you know, can take care of themselves pretty well.

                    And that may be a reflection why they have oot such a vood

                    application, I don't know, leadership there.  It  bolls  down

                    ultimately to a handful of people.

                              But be that as it may, I think we have to -aodify ourl

                    thinking about how the needs, of the people in Maine  compare

                    with the needs of people in Mississippi or-Alabama,  or,  you

                    know, other areas of the country.  And look at the

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                                                                              24      i

                     relationship between funding recommendations, the'size of the
                     popuLetiono and what we know about  the  health  nee6s  of  that

                     particular region.

                               If they have got a million people, just to give us a
                     rougher Index, and @y2 million application, roughly '@2 per
                     capita,  RMP funding for that; at the other end of the scale t    erE

                     are lil4P's that come out with something like 25 cents per capi   a.

                     And I am not su,7cresting a, capita thing except I  think  we  do

                     have to keep In mind the needs of the   population, how  lar@e    i

                     the population and the amount of money that is goinc, in.
                                                                           CD

                     There ought to be some kind of rational way to rationalize

                     that at that level as well as just how good the program  is.

                               DR. McC.ALL:  I totally agree with you, having come

                     from a region that had 12 million people.  And under ,ny
                     great leadership was reduced to .@1.2 million funds.
                     D

                     So that is a very important point that I am very sensitive
                     to, and my only reason for taking this hi@ii level at this
                     point is to say we don't know where these others are r--oing to

                     shake out.

                               If you are goinv to come back when these things are
                                               C>

                     finally looked at in terms of the total dollar available for

                     quality, needpopulation served, it would be final figure,
                     this program comes throu@h at such high quality to me I would

                     like to see us not start low   and not be able to give them the

                     maximum they should get when   you look at the overall.


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





                             DR. ILESS:  These folks sound to me like  peop.Le  -viro

                   can make efficient effective use of money.

                             DR. HEUST@LS:  Thio is really what came through to    i


                   MP-*


                             DR. McCALL: They are going to  function  if  we  don't

                   give them a dime.  I think you shouldn't penalize them for thv,,@.
                             MR. 13ARROWS: That is important;as a taxpayer  I  hate'

                   to see these bucks spent on the basis of  need  without  produc-

                   tive use of them.


                             DR. IIEUI@.,TIS:  I recognize need, but in these troubled

                   times it seems to me efficient productive use  of  money  might

                   be things that would impress the Congress rather more than

                   taking another program that I reviewed that has  a.,Iar@e  need

                   and a large problem and not as L7,ood a program.

                             DR. HESS:   I am not recommending puttinLT a lot of   i

                   money into a poorly managed program, but to carry   this  argu-
                   ment to a ridiculous level, if they could use @"5 mill-Lon,  woulIci

                   you give @laine '4@)5 million just because they are a top-notch

                   pro,rre.,,n you see?

                             DR. HEUSTIS:   I think you have to balance  relative--I

                             DR. McCALL: Fine thing, I am not  sure  I  would  even

                   recommc-znd- @2 million.

                             MR. BARR(I-@S: I wanted to bring this down, bring

                   another factor into the decision.


                             DR. McCALL:  It might ,@ake it easier for you to   try







                                                                                    o i r,'-
                     to make some better jucic,,r@.ent of all these thinvs at this p   La
                                             ID                       CD

                                MR. PETERSON:  I think, you knows our judgmental

                     process which is collective and right now bifarcated,

                     I am not goinv to intrude too much on that.
                                  CD

                                Let me only mention one thing, Maine is requesting

                     sli@htly over '@'2 million.  It is one of the few re-ions which

                     has indicated to us tais  is  their  total  package,  so  their

                     ,@2 million is not goinv to be a supplemental or additional, or
                                            CD

                     further request in July.
                                Their target figure,  column  C,  was  rou-hLy  @1,4

                     million.  I think that again looking at it in terms of some

                     rough per capita,  Maine  indeed  exceeded  the  national  norm

                     at an earlier point in time by  virtue  of  the  fact  that  it had

                     been considered a good program at the tirmvie were steering

                     towards selective  funding.

                                I think what I have heard is a range from @2 millionj

                     and somebody said  they are goinrT to continue whether we give
                     them a dime or not, so we have got@.between a dime.atid Q@2

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

                     floor?

                                14R. BARRA-IS:  That Is the thing that bothers me.

                     We do not have a target budget for our whole business.  If      we  i

                     had something like this and then could say classify them,;and

                     then cut the melon when we get them all through on-the amount


   Ho  REPORTING CD, INC.
   32OMamchusettsAvenup N.E.
   WashingtQn, D.C. 20002





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

                              Just picking fioures out of the air, I am afraid

                   our results will be very fortuitous.

                              MR. PETERSON:  I didn't mean to.

                              DR. HEUSTIS:  It seems to me you have on overall

                   assessment five categories.

                              MR. PETERSON:  Right.

                              DR. HEUSTIS:  In all good conscious, more data is

                   available in Maine about previous funding than any of the

                   others I reviewed and there was just insufficient data about

                   background and use of money and about progress to really make
                       C)

                   a valid fundinT judgment on the basis of the written material

                   that they --athered together with all of the constraints.  I
                   feel very strongly the same as you do, perhaps the best w.e can

                   do is to say that this is an interior program and it is

                   entitled to maybe better treatment if the need Is there and--

                   of coutseo if there are two superior programs and both have

                   needs, I would agree with you.

                              Some of these things on the basis of more infornativi,i

                   we could come up with dollars.

                              MR. BARR(IIS:  Even divide them into groups, the

                   plus oroupr average group and minus group, and cut it Like

                   that,

                              MR. PETERSON:  Let me see if I can heLp.us out of

                   this.  Since we will in one sense be operating against a


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                                                                         28

                   benchmark of a target firfure, vill-at I hear. the group say.I @,D
                                           CD

                   is that it would like to make a recommendation vis-a-vis

                   Maine -- correct me if I am wronc, -- that says here Is a
                   region that, in our judgment, without giving a specific amount@

                   it should perhaps be 9,bove the tartc.-et-figure, whatever that

                   Increment is.

                             I think we, again, as staff, Dr. Pahl is the

                   Director, in the final analysis, who is going to have to divide

                   $109 million or A@LL4 million up, certainly is going to be

                   influenced I think by virtue of the fact that this whole re-

                   Vi
                   -ew process  is ooeratino, with a great deal of lack of infor:,.,a

                   tion and the like,  -Ard that the pluses or minuse-.- will be in-@i

                   dremp-ntal rather than order of magnitude.

                             it is more defensible to say let's cive this region
                                                                CD

                   20 percent or 10 percent more, as opposed to 100 percent more

                   or less.  Because I don't think any of us feel comfortable


                   with that process.

                             I wonder if in those terms sombody would

                             DR. McCALL:  @laybe to help you have tte figures,, the

                   sense is there in what you are saying, I think  we all recoc,,.---

                   it, with all the constraints and time) we have  to come into

                   focus.   We really can't go back and write all  the imbalances  i

                   and 'inequities that my exist. Maybe@pl.@, million reconraendati 'n
                                                                                  C',
                   does that, it is a little abov  requested, It reflects its
                                                 e

                   super.Lor rating. If there are others, that is the' sense.  -And






                    it would take into consideration per capita needs and other

                    things as well as their quality,.

                              DR. TIfURd,4AN: Second.

                              MR. BARR(aiS:  Their request Is $2 million,

                              DR. McCALL:  Yes.

                              MR. PETERSON:  You are saying recommendation of

                    $1,5  million?

                              MR. C OLBURN: I was going to say in the past,the

                    previous procedure was to make a  recommendation  regardless  of

                    the availability of funds. Then you  know  the  distribution  of

                    funds would be based on total recommendations.

                              MR. HASH:  I think Dr. Pahl wanted some sort of


                    recommendation.


                              DR. HESS:  I think it would be helpful if we go

                    through and we come to grips with a specific figure on each

                    project, and then come back if we want to adjust it at the end

                    of time.

                              DR. McC.ALL:  This is what I am integrate nT into  the

                    $1.5  million.

                              MR. NASH:  I think that gives us a benchmark to woric

                    with as we move along.

                              DR. HEUSTIS:  I wou Id have great d If f ic u Ity on

                    anything except political orounds of recommending that you

                    approve anything except the reqoest. I  can--  if-you  asked  me

                    to make a technical decision, the prouram is worthy of support@@


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   320 Massachusetts Avenue, N.E.
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                                                                               30
                               If you ask me to  make  a  political  decisions  there  is
                      not enough moneys then it seems  to  me  the  political  decisions
                      at least as I see It, ought to be made  at  a  higher  level  than

                      which I have said at the present time.
                               SISTER JOSEPHINE: I would  like  to  say  I  made  a  site
                      visit to Maine with Dr. Brandon and Dr. Vaun, who is in the
                      other i7roup, end I guess in 1969 or 1970.    It was at  the  time
                      when theyviere first be(,-inning to get their  resources  together.
                                             CD
                      -And I had an opportunity to stay several  days  and  so-a  couple
                      of us went around and we visited in different places in the
                      state.  And in response, Dr. Hess, to the number of people,
                      you know, I am so impressed  with  the  distance,  the  distances,
                      the scattered population -- really, the total lack
                      almost of services, you know, that were available.
                                I was also impressed as  we  sat  end  talked  with  the
                      peoples with the fact that, you know, they had already been ir,-
                      volved in the process, the  people'viere  listening  to  what  they
                      need.  And the program that has been developed, you know,,
                      I would be reasonably sure  has  been  developed  in  response  to

                      needs that were really identified, and I don't feel that is tyUE

                      of all programs.

                                DR. HESS: No,  I  am  not  questioning  the  needs  were

                      identified.  I think that has been well done.

                                14R. BARRCFWS:  Introducing the equi y,

                                 If we adopt this thing, what   we are sayin(ci then  is


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                   we have concluded our formulas as an outstanding programy and

                   E,,et 75 percent of what they asked for.

                             DR. THURlilP.N:  No.  Not at all. I think what we are

                   sayin,7 is can any group operating at $1.5 million leap to

                   $2 million?

                             Now,.i,in seconding the motion, I am not proposing

                   we give 7!) percent. I think this ib a re-ion that gets

                   results.

                             I rather doubt if it would be able to leap -to 'qk?2

                   million.


                             MR. BARR(7.,@@S: You are brinoino, up a very valid con-

                   sideration, do they have the capacity tp  do this job; in

                   effect, they are askinr,- for two times present bud@et.
                                         CD
                             DR. THURTA.,:AN: The other thing we have to consider is,i

                   there has never been a human being who wrote a grant who

                   didn't add something to it.

                             DR. HEUSTIS:   I disagree, but go ahead and make  your

                   point.

                             DR. TH@l,!AN: That is my only point. They knew they!

                   might as well ask for everything they could c-et. But I don't

                   believe it is possible for them to spend $2 million in a

                   reasonable way.

                             DR. HESS: That is a 100 percent increase.

                             DR. HEUSTIS: Mr. Chairman, the thing that    bothered

                   me was the fact the only fi-ure we have on this sheet is this




                                                                                  32

                      currently annualized level of what they are getting.  This
                      doesn't take us back to what they did before they were out,
                      and not having that information and not having the informa-

                      tion on how well they had spent their money before they were

                      cut, I am just wondering --
                                 IM. NASH:  That figure, Doctor, does not include
                      a large supplemental award for EFS or HSA activity out of
                      1972.  -Actually they have been operating at a level over

                      .@l million.

                                 Spence, do you have

                                 MR. COLBMN:  I am trying to recall

                                 DR. HEUSTIS:  I am just saying on the basis of one

                      year of restricted allocation
                                 MR. NASH:  You are talking about ability to handle

                      a large group ofmney and this actually isn't that.

                                 @IR. PETERSON:  There are, as Frank points out, in a

                      number of regions, @laine isn't the only one, where the current
                      annualized level which is really the present six-month award
                      times two, It is that simple, is perhaps misleading -- not in
                      all instances.  In some ways the column C figure, which reflec,,c
                      a percentage of the immediate pre-phaseout level is more indic@.
                      tive of the kind of annualized level, approximating the kind
                      of annualized level that lvlaine and nearly all the other

                      were operating on prior to January 1973.
                                 But a,--lain, in-the interest of moving the discussion

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    320 Massachuse!ts Avenue, N.E.
    Washington, D,C. 20002




                  along, we have got a situation here now where  two  reviewers
                  one in effect has laid a recommendation on the tabl@e for
                  $1.5 million, I heard -Al indicate that he would have  problems
                  with anything less than the full amount  requested.  I  think
                  simply in terms of the order in which those two figures were
                  mentioned, I would ask if Charlie regards his $1.5  million  as
                  a recommendation to that effect? If so, if there is  a  second?

                            DR. THURIIAN:  I seconded I
                             MR. BARRO/TS:  Did you say a real Index of their
                    pre-crisis fundi ng was this targettea available thing.
                             IYM. PETERSON:  That target figure is an extrapola-
                    tion from that and it more clearly approxiiiate8 the level of
                    activity in the re,-,ion than necessarily the first column which
                    doesn't reflect in some instance rather significant supplemental

                    funds.
                             Maine, for example, had a good deal of actiVity
                    fund for a couple of years which,now does turn up again  in

                    some of these projects.
                             MR. NASH: Actually at one time  they  were  managing

                    $2,872,000 in one year.
                             DR. TESCHAN:   I would like to make the point,
                    Frank, If we would be able to have that kind of figure,  at
                    least ready during these discussions, that would answer  that

                    kind of question.

                              MR. PETERSON:  I think we do.


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   32OMassachusettsAvenue,N.E.
   Washington, D.C. 20002






                              MR. STOLOV:  For every region we have computer

                    funding printout.

                              MR. PETERSON:  Is there any  other discussion?

                              Again, I think I have heard  a motion, a second,for   i

                    $1.5 million, and I think if there Is, I would put the question

                    to the group.

                              Those in favor of the motion?

                              MR. BARROleIS:  Is the $1.5 million based on what you

                    just said is not a significant increase in the level of

                    activity they have been carryinc,?

                              IvM. NASH:  No.  In fact, it is a decrease from one


                    prior year.

                              DR. HESS:  But they have also cut back in staff

                    probably.

                              MR. NASH:  No, they maintained basically pretty


                    well staff even through the phaseout.

                              They lost a few, but basically it is pretty much


                    the same staff.


                              MR. PET@SON:    I wonder if I could ask the question.,

                              Thix e in favor of @@1.5 million?

                              (Shoii ofhands)

                              14R. PETIMSON:  Oh, we are,going to have one of these'.

                              No, divided --  all right.

                              No, It isn't divided.  I  am sorry, Sister, and we

                    have r,,-ot nine people; Iwas looking at the ei@ht, four for a n ri




                                                                                35


                    five a-ainst.

                               IC. BARROIIS:  Could we p Ll t the z'PL.5 ml ILion on the

                    hook.and come back to it?


                               DR. HEUSTIS:  I think we should do this,


                               Is this motion lost then?


                               MR. PETERSON:  Yes, it has.

                               DR. HEUSTIS: Is not column C the amoutn  of  money

                    available for 'Lunding ',.his fiscal 1975?

                               14R. PETERSON: That was our estimate at a time  when


                    we weren't even as sure as we are now*

                               DR. HEUSTIS: So it may or may not have  any  rele-

                    vance to the previous fundin,7 levels of tile prograiio')

                               YLR. PETERSON:  Oli, I  see.

                               The column C does have relevance to the previous

                    funding levels, Al.  We took pre-phaseout levels, annualized

                    levels, and  calculated  a  percentage  thereof.  -At  the  time--

                    it still does, it adds up to '@114 million.  At the time we

                    did that, that was our best -uestiiote of rouc-hLy what we were
                                                   CD                CD


                    going to have, and we  were  trying  to  give  regions  a  target.

                               It so happened that we  are  going  to,  in  all  likeli-

                    hood, end up with either '@'109 million or $114 million.

                               DR. HEU,@,TIS: lilay I suggest If we have  to  make  what

                    I Call a political  decision,  could  we  Lay  the  funding  amounts

                    for each of these programs on the     table until after we have had

                    a chance to look at them all, and     then we can look-at the


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   32OMassachusettsAvenue,N.E.




                   request, we can look at what you have got down here and then
                   we can go through and decide what can we do to com@ out soirie-
                   where within the available money and be fair.
                             DR. TESCH-AN:  I think we could easily Indicate that
                   Maine is in the top, divide the regions into approximately
                   three big groups and with the details of the population, and
                   the kind of other comments we have had.  Ard then begin to

                   adjust after we see the total group.
                             MR. PETERSON:  Is that the sense of the group that we
                   lay recommendations as to funding amounts aside until Thursday

                   afternoon, Friday morning?
                             IC, BARR(I-IS:  No, we could strike a tentative figure,
                   but I personally don't feel that we are doinc, justice to
                   these by just picking a figure out of thin air.
                              I have no way of knowing whether 6pl.5 million is

                   better than @l,,450,,OOO or @ol,750,000.
                              To me it Is just picking a  figure out of the air,
                              DR. HIRSCHBODCK:  We have to deal with this proble-rft,

                    those who are not applyin- for July Ist money.
                              This is exactly the significance here.
                              If we do not take that Into consideration, we might

                    be short chanuing them considerably.

                              14R. PETERSON:  Charlie.
                              DR. McC.A LL: I am concerned, as we had reviewed,
                    on the whole,  the gaps, the changino- situation, and we are


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   32OtAassachusettsAvenu,;,N.E.
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                     cominc, here In the last chapter of this p'                     tur
                                                                  roo-ram,  the  struc

                     @laving-been designated, very fine people still here, but @qina.Li

                     in nLunbers, overworked, mechanism   torn asunder.  And even when
   is                                                                                   I
                     it-was there, we knew there  were  some  inequities  and  son)e


                     things that needed correcting, we were wor  ng on,

                                It seems we are  really  taking  on  something  that

                     really doesn't make sense.


                                To think with  all  those  limitations  we  are  not--


                     as last gasp, use some sort of judgment, start a new bench-

                     mark, write all of  this  in  terms  of  population  and  everything

                     else.


                                Not that I am not for doing those things; it seems

                     to me this is not the point in time at which we are armed wi-thi

                     and able to do that any better than takinc- all of     the problems

                     and our disagreements about them, the former benchmark, and

                     usin- it as where we start, and then  ,noclify  up  and  down  in

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

                     go throu,,,h all of these and now come up with --,ome  sort  of


                     new--


                                MR. BARRCJ@IS: I wrestled with that in my own mind ano-

                     came up with this generalfeelino,-, whether right or wrong, any--,,

                     body can say, but I felt we had a responsibility to preserve

                     reasonable stability  of  the  procram.  But  we  should  take  away

                     from programs that didn't appear to be able to use this one-ti.,Tie

                     money effectively within reason and give that extra money to





                    the programs that are doina- the top-notch job.

                              DR. HEUSTIS:  Great.

                              MR. BARRO,@IS: 1-Thether that is good policy or not,

                    that Is the way I came out with it.

                              DR. HESS: Ancl you do that purely on  the  quality  of

                    the job and setting aside any other factors  about  the  region?

                              I,,IR. BARRO@IS:  Well, one factor, the population

                    inequities being on historically, and I don't think we

                    can dramatically change that now in this short time,.

                              DR. HESS:  It is not a matter of changino, it.  But to

                    my mind it is not a matter of carrying that to excess.

                              MR. BARR@,iS:  I would keep a reasonable stability sa-y--

                    int- treat the averace in one way, cut down a little bit on  tie

                    pro-rams that are not too effective andpive that  money  to  the

                    pro-rams that are. But not make violence with 30 percent to

                    190 percent.

                              DR. THUR@N:    I hope we won't have this emotional

                    kind of discussion with each application.  A lot of us would

                    like to have more information than we have to make a decision,

                    yet we have never had enough information at any time in the

                    past to make any better decision than what we  have  been  asked


                    to make ri(xht now.


                              I don't see any difference as we sit here, except

                    the understanding the proo-rams as they exist have.gone through
                                              4D

                    Living hell as far as from  an  organizational  standpoint.  But


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                                                                               .i @    I
                     either they have had the relationship and capability of

                     doin@ it, they have known their state, they have known their

                     capability -- but the only rationale -- I don't mean that in

                     a, derogatory concept.  The only rational comment was Sister's
                           tD

                     because she was there.


                               To me I am not the least bit concerned about reach-

                     ln,-@, into midair pulling out a figure in May of 1974 and I
                                                       C>

                     was concerned in June of 1972 doing the -same thing, with the

                   .same kind of program.

                               So that I think we are trying to find an excuse

                     for our lnabi I,-ty to approach something in an irrational

                     fashion when we have always approached it in an irrational


                     fashion.


                               So that I just-- this sheet doesn't mean a damn tii@Ln@

                        pardon me, ladies -- doesn't mean a damn thing to me, becalt:   Ise

                     here is a program, the people have come in, excellent .7rant

                     w ri ters I
                              two reviewers have been snowed -- ar,-ain, I don't

                     mean that derogatorily -- been snowed by this    preparation,

                     Sister has said  that the people in @ia,ine are interested  in  lt.i

                     These peoole have 9,sked for $2 million.  They   have got one year

                     of self-sufficiency for a small population.  -And then they

                     have @.ot to carry these proc,,-rams without us.

                               What more do we need to make a rational decision tlic,,n


                     those facts?

                               14R. BARRA[S:  I don't say this is going -to be




                  without us, the succeeding programs contemplated by Congress
                                             C3

                  will absorb at least some of this?

                              DR. THURI@,IAN: Let's see,if yoti and I knew the answer

                   to that, we would be the world's greatest --

                              DR. TESCHAN:  What i-s the punch line?

                              MR. PETERSON:  What is the figure?

                              DR. HEUSTIS:  l@,Lr. Chairman, I @7OUld offer a motion.

                              MR. PETERSON:  Fine.

                              DR. HEUSTIS:  To bring this to a head.
                              Motion was for @PL-5 million, request is $2 million;

                   I'll be rational and split the difference.
                              MR. PETERSON:  Is that a motion for $1.75 million?

                              DR. HEUSTI,'>': - @i)1.75 million.

                              MR. PETERSON:  Do I hear a second?

                              DR. TESCIIPN:  I will second it.

                              MR. PETERSON:  Second to get a vote.

                              Any other comment?
                              Question:  How many would recommend -- and I thin
                   we do have the sense that all of these are tentative plus, min,@s
                    kind of motions, it is again a rough motions It Is again--
                   how many would concur at '@@1-75 million for the Maine R14P?

                              All those that do,show their hands.

                              (Show of hands)
                              14R. PETERSON:  That motion is voted down also I

                    think, four toflve again.


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                             I dontt know whether we are moving  in  the  right


                   d lrec tion.


                             Do we have another motion?

                             DR. TESCHAN:  Let me fly this one.,  10 Percent

                   more of recommendation to Dr. Pahl that he consider llaine in

                   the top group; secondly that he  consider  funding  at  more

                   than the approximate ratio that he has  dealt  with  before, on

                   which these fio-ures were completed, say some thing like  10
                                 CD

                   Percent or so more then that, on up to  the  totalamount  of

                   the application, depending on availability of funds.

                             DR. HEUSTIS:  I @fill support that.

                                           That sounds good to  me.
                             l@. BARP,,UiTS:            C)

                             DR. HESS:  Cop out.

                             DR. TESCHAN:  Sure,  it is a cop out,

                             DR. HEUSTIS:  As I  understand your motion, you are

                   leading us to put these into  ranking things, so  that  some

                   will be financed more than before, some at  about  the  same level

                   and some at less than figure to be decided after we have all


                   of the evidence*

                             I think this gets me off the hook from making

                   political decision for which i do not feel qualified.  I   am

                   perfectly willinc- to make a political decision.

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

                   figure end that for us to avoid the need for making that recor,,;-

                   mendation, difficult thou-h it may be, even though it feels





                      like we are rolling dice@ as we like to Pride ourselves in,
                      you bei-ng very logical, rational people, but ;then if', comes
                      right down to it, you h  ave to take a Leap and make some judt-

                      me tit s.
                                 I would say I think we ought to not avoid the re'-

                      sponsibility that we have been asked to assume and do it even

                      thou,7h we are uncomfortable about it.
                         CD

                                 With that preface, I would like to offer a motion

                      for @L.6 million.

                                 14R. PETERSON:  We have a motion of $L.6 million.

                      Do we have 9, second?


                                 DR.McC.ALL:  Second.


                                 1,4R. PETERSON:  Question,

                                 DR. THUP14AN:  Call for the question.


                                     PETERSON:  Call the question.

                                 DR. HESS:  -Pre you asking for?

                                 MR. PETERSON:  Yes, for those in favor, @1.6 miiiion,p

                      five for and four presumably against.

                                 Okay, the recommendation of this group, by painful
                      process and high degree of tentativeness, is $i.6 million.

                                 DR. THURIAAN:  FulLy with the understanding we may


                      come  back.

                                 DR. HESS:  We may come back and revise this.

                                 This is kind of a breakinc-in process..

                                 MR. BARROVIS:  We are cutting the melon without
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    1-@@, I., I'll





                    knowing how many shells we want to cut.

                             DR. TESCHAN:  Bic)-ht.

                                 PETERSON:  Dick, you had wanted to say somethin@.

                             NR. RUSSELL:  Yes, I was a little bit disturbed and
                    concerned durin@ this discussion.  It seems to me we are get-
                                  C)
                    ting two issues mixed up.  One is the role ai this group in
                    terms of making recommendations for funding leveLs; the other,
                    as Dr. Heustis talked about, was the political part of the

                    decision Dr. Pahl and the Administration will have to make in

                    nia,kin@ the funds actually available

                             What I heard in this discussion -- I have no vested

                    :Lntere.-;t 'Ln llaine whatsoever -- here we have an application
                    that apparently is ,iell put together, the projects do fit the
                    goals and objectives; historically this program has been very

                    strono'.  -All the pieces fit together.

                              I think it is that type of Information on which th@i-s

                    group should make Its decision.
                              Now, In terms of the target figure where we have
                    programs that don't come across as stronr.,,I think that is goin@,
                    to be important to look at that, so you do have to take that
                    into consideration.  But I really don't think it should be

                    whether or not the actual funding made available will come out

                    as your recommendation

                              You do have a chance--

                              DR. TESCHAN-.  But, Dick,, you are not helping, you


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                                                                        i4 '4

                   are at variance with the imperatives to come up with a number.@i
                             I am comfortable with that kind of ambiguity, say

                 "hoorah for Yiaind and leave it at that.  But if we are

                   under an imperative, maybe we should settle the question,
                   are we or aren't we.  If we are, we have to go beyond where


                   we are,,

                             MR. PETERS014:  Herb PatiL's decision in terms of de-
                   cidin@ signid- agrant award, statement for Maine with a figure,
                       CD

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

                             I think with a Council that insisted upon a review

                   committee, kind of restructured review process, 13 new members

                   that while it is true that the Council is in a sense the

                   formal recommender, I think they are going to have more diffi-
                   culty coming up with numbers if we don't provide some bench-

                   mark for them,

                             I think, Dick, at least in our skull sessions, in the

                   precedin-- daysi you know, I think we can belabor a-nd overdo

                   the numbers game.  And I am speakino, personally, not as your

                   chairman.

                             I think we as staff, and Herb -- you know if there are

                   no numbers, we aren't all that helpful.
                             MR. RUSSELL:  I am not saying-- I think you need

                   numbers ultimately.

                             IAR. PETERSON: Right.

                             1,4R. RUSSELL:  But the viewers have a chance to rate






                    the  RMP'S.

                              DR. ,McCfii LL: I think there may be some Abstaining.

                              MR. PETERSON:   I am sorry.

                              DR. HEUSTIS:  Mr. Chairman, I object to this.

                    lyle spent already too much time on this.

                              DR. 14cCA LL: I don't mean -- I am talking about

                    the future.  I am not talking about calling for Y@ine.
                              In the future.  I don't want to go back and do thati

                    on this one.

                              DR.   HEUSTI.S:  I have the very strong   I like what,
                    you said and-I like what you said and it seems   to me even

                    though we have done it before, and I wasn't a party to it,

                    I may have gone along the same as you did. But it seems as

                    though if we give him the arnnunitic4 if we have extra money,

                    this is what you do with it, this Is who you give more and thiis

                    is who you take away, that is our primary function.

                              DR. TESCHAN:  I feel better about that,

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

                              DR. HEUSTIL@i.-  Not bound but as he makes the political
                                                                                     I
                    decisions, I don't know the gentleman, but being a politician
                    probably to better or lesser degree, and sombody    questions it@

                    he says, "But, haha, the Ad Hoe Co@@, ttee, -Advisory Council,

                    this Is what  they recommended."  And he justifies in some

                    instances where it is convenient, he justifies it.  And he is

                    no different from any governor or any legislature that tries    to


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                                            t his budget so 'that he doesn't havel
                   get a, protTram person to cu
                           CD

                   to mt-,e-the political decision.
  is                        DR. HESS:  Al, just let me comment on that.
                            If I understand the purpose of this ad hoc  review,

                   it is to brino- some additional perspectives to bear on these
                               CD

                   very complex issues and so to ask this group to weigh in our
                           best we can all the various dimensions that should goi
                   mind,.-, -as

                   into decision making about, you know, this national  program

                   on a region by region bqsis. And that the most  preci.se  re-

                   flection of the summation of those judgments is in dollars

                   at this stage of the game.  And that the role that the Directo.,'
                   iLrid Council are not bound in any way, shape or form by those
                   recommendations, but nevertheless that is  the  most  concrete

                   translation of 'udgment that we make.

                            MR. BARRO,4S:  Pete, let me make a. proposal that may

                   simplify this whole problem.
                            We clearly have two distinct  philosophies  on  this
                   thing and we are going to be tallcinv about that all night.
                             Could we do this, could we let  these  numbers  come
                   out of the air from the frequent revelation  from  the  record or 1,
                   wherever, get them altogether, take a look at them when we are

                   all done and go over them and do--

                             MR. PETERSON:  We propose to do that.

                             14R. BARROWS:  Do our equity on it.

                             MR. PETERSON:  I feel less concerned about spendinc.-
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                                                                          47

                    a Little time with the first few applications, because I  thi ni,c
                    this is where we are gol.n,, to have to wrestle with some issu@@;
                    and set some guidance to ourselves as to howue operate.
                             It seems to me there are at least three things that,
                    will go to the Council and Herb Pahl, at least there are
                    three inputs from this uroup.  There Is a, number that may be   e
                                           CD


                    softest and least offensive.
                             There may also be in most instances  some  kind  of
                    half quantitative rating based on several people; and thirdly,i
                    there will be the o,-eneral sense which I hope staff will be

                    able to reflect accurately and which in the case of Mainequitn

                    apart from more or less, that there was a. general,  general

                    sense consensus that this was, n.ll things considered, a com-

                    paratively good stron- program that had %,Iaine stability durlnc,i
                    the period of the last 18 months.  And I think, you  know, it
                    is not as if the number is the only thing we are go  ing to feed
                    him.  I think we need to keep that in mind,  So we are triano-u!-

                    lating.

                              Sister Ann.

                              SISTER JOSEPHINE:  Yes.  May I say one other thing.

                    I think the 53, out of 53 pro-rawq there are  only  6  that
                                                  CD
                    are complete,as we are going to review  them,  that  aren't goi rE"

                    to have anything for the Cray Lst review, or the  July  Ist revi.F--I,,,.

                              I think that that is a consideration also, we have

                    to keep in mind,and this is one of them and I th ink this is





                   very important.
                              MR. PETERSON:  Well, I would like to ask the group
                   at this juncture, It is ten after twelve, our cafeteria is
                    probably most crowded now; on the other hand, by the tire
                    you a,-et to certainly 12:45, the fare starts becoming severely
                   diminished.  Not that it is all that great to start with.
                              It seems to me  we have crot to make a decision
                    either to go to lunch now or try to wrap up and let our
                    beLlies push us in terms of one more before we go to lunch.

                              DR. THUR@IAN:  Move for one more.

                              Nobody here needs the fare that badly.

                              DR. HEUSTIS:  Who do we give these things to we

                    don't need any more? (Indicn,ting)

                              MR. PETERSON:  You can put them under the table.

                    Hand them behind you and somebody will put them back farther.

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

                               (Lau,hter)
                               @M. PETERSON:  I ,Ionder  If we could take Albany.
                    This Is an Instance where, by virtue of the fact of a recent
                     last-minute cancellation, we only have one reviewer, Mr.
                    Barrows, and move on with -Albany then, since you said you were

                    best prepared' for   lbany.








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                   .A LBA NY                                             4 9

                             MR. BARROWS:  That is a small tribute to my prepara-

                   tion, I assure you.

                             I think most of us on this committee can make

                   extended and culpatory statements of the same kind, that were

                   made on behalf of staff,  I quite honestly had difficulty

                   in doinv, justice to five applications.

                             I say that in advance, because if I didn't say it,

                   you would detect it as I went along.

                             In any event--

                             DR. THURI,4AN:  We won't be critical.

                             MR. BARR(NIS:  No, but you would cut hell out of the


                   budget.

                             To end the suspense,  I have a pretty good impres-

                   sion of the Albany proolram.  It is a 24-county proc-ram.  The

                   grantee is the Albany Medical Collece,  These were all the

                   figures, but 1 had to go by them.
                             Budget request was for $i,056,000.  Their present
                   funding for half a year was $556,000 so about the same level

                   of fundin@ they are seeking.

                             The director Dr. Kraft, has been with the program

                   since its inception except he has be director since January

                   1973.

                             The chairman is a retired physician hospital adminis:-


                   trator.

                             Executive committee represents a wide variety of


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                  Interests and remarkable -- Includes edu(-ation, labor, com-

                  munity agencies business, and so on,

                            Staff of 70 full time, two part-time professionals.

                  They plan to add two more.
                            Their survival, staff survival through the phaseout

                  looked to me good.  Variance ranges from two to eight years.

                  Regional-Advi8ory Group 43 of them.
                            I noted the director Is an ex-officio member of RPG.

                                              10  I think that puts him in a
                  This is a philosophical thino-.
                  peculiar position to influence the whole process.  -And from
                  the looks of the staff, I think this is kind of a one-man

                  type of programs but that is just a guess.
                            The executive co,@4 ttee exercises planning.

                  Basically the committee structure looks Pretty good.
                            Logical structure, I can't say who dominates from

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

                  ated.
                            Their goals and objectives are very well articulated
                  and very con@;,ruantp as the record shows the RMP mission.     i

                            The proposal situation to ,ae better than averave





                   compliance with their own stated objectives.  I had more
                   troub @ with that factor*  Everybody states the same objec-
                   tives in glowina terms, then they go off and do something
                   else; but I think they stayed pretty close to their objec-

                   tives.

                            There is no CHP agency in their area except in Western

                   Massachusetts,  They are working with that one.  That

                   seems to be harmonious.  And they are trying to get another

                   one off the ground.  So I think their CHP agency relationships

                   are good.

                             I think they have got a reasonable chance o  SLIC-
                   cess.  14uchp of course, is going to depend especially on these
                   pro-rams designed to serve the underserved areas.  Much
                   will depend on future funding from a variety of sources.
                             Icame up with a good to excellent rating for the

                   total proaram.

                             I summarize it this way:  ARMP has retained

                   essential strengths,  Well =named and well oriented.
                   Proposals consistent with basic RIMD mission."ReconLnend
                   funding proportionate share of what is available, at least

                   equal to past level.
                             MR. PETERSON-.  You have heard Mr, Barrows' review.

                   This is one we don't have two reviewers.  Check with Frank,
                   I don't think any people around the table in their prior in-

                   carnations had at least site visited Albany, but I am sure
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                                                                        52

                   there are some of youIwho have some impressions perhaps have

                                                                       So
                   had some specific information about the Albany RMP.
                   before I check with staff, I was wondering if there is any--

                   from the rest of the reviewers whether there is anything
                   specific or general they want to add to what Mr, Barrows had

                   to say?
                             DR. TESCHAN:  What Is the population?  I missed it.

                             MR. BARROIIS:  24 counties.  Metropolitan area --


                   Albany, Schenectady

                             DR. TESCHAN:  I just ,neant millions.

                             MR. PETERSON:  We don't ha-ve a fact book, do we?

                             MR. NASH:  No, I don't know.

                             MR. PETERSON:  I will have some population figures


                   after lunch.

                             My guesstimate in the Albany area is probably

                   approachin- or over a million certainly.  It may be a couple
                             C3


                   of million.

                             You have Schenectady,  Rensselaer, Troy -- you

                   also have a lot of -'Adirondack, without too much population

                   except up around the  Plattsburgh area.

                             MR, BARROWS:  Pushing over a million and a-half.

                             I have one quest2!on.  Let me just throw out, obvious"
                   ly, on th e basis of my information, it is terribly difficult
                   for me to say what is the proper problems for relating to

                   liother federal initiatives," that is particularly true in the i,


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                  case of emergencies here*
                                                      there has been $L38)000
                            The activities  for which
                   looked to me to be fairly consistent In that they were more
                   preparing to get ready for entering the emergency systems
                   program than they were in doing the same things that the
                   emergency systems program I understand is doing.
                             I am just mentioning that as something that ran

                           ray mind.
                   through
                             MR. PETERSON:        do you or Norm have anything--
                   there were a, number of projects listed inthe summer here that
                   reLate to HMO'S, E24S'@ et cetera.  Are there any significant
                   problems or policy issues that you see posed by these?
                             141. NA SH: I th @ the HMO, I be lie ve , is afeasible

                   study.
                             MR. PETERSON:  Within our guidelines, earlier policyi,
                                                                                   i


                   c,uide line
                             so

                              MR.NP@@H: Yes.
                              Yes,Ild say EM activity Is continuing.
                              MR. PETERSON:  Sorethin@ started by the EM leglsla-


                    tion.

                              MR. NASH:  Yes.
                              MR. ANDERSON:  Also pro-ram activity supports
                    previous approved policy we had; It  complements.
                              MR. PETERSON:  And I know  Albany is one of those
                    piaces that are few in number now where there is no major




                                                                         54

                   (b) agency in the Albany area.  There Is one they overlap
                   ,with in' the Berkshires, northern Iliassachusetts.

                                      I
                            Albany said, "Throw this sheet away"  -- not--
                   figuratively.  Albany Is a region which, again, we ha.d indicated
                                               CD
                   target figure of about 1.5 million.  We have an application
                   here which is entirely continuation program staff and some
                   projects continuations.  They have indicated that they will
                   be coming in with an additional application on July 1 for
                   new starts totalinf7 about half a million dollars,  This one,
                                    CD
                   this request totals just slightly over a million.  Thus our
                   estimate at this juncture is that tlbany will be reqi@esting--
                   happens to be a couple of thousand less.  Just about that

                          f icure.
                   target   CD     But the present application is for @l.,-'6,ooo.1,
                             DR. TESCigiN: I wonder, management assessment, re-
                   view verification, if there is any indication whether, In
                   essence, the grantee is behavinu according to policy?  Any

                   evidence on that?
                             IAR. PETERSON:  Norm, we did have some problems I

                   know some years ago, but boti, with respect to review and
                   management, review process has been verified and found in

                   compliance.

                             MR. ANDERL'DON: Yes.  Right.

                             MR.NASH:  Right.

                             NR. PETERSON:  Are there any recent management

                   assessment figures?





                              MR. SI1401iDS:  That is one of the very early ones.
                    That has been several years ago, would have no relevance  today'.

                              MR. A@TDP",RSON:  We Here program staff, support

                    what Mr. Barrows said.

                              MR. PETERSON:  Can you lift that up four decibeLs?

                              MR. fiNDERSON: Durin- the phaseout period,,  they

                    were able to maintain pretty much the program  staff$  kept it
                    pretty much intact. The RAG did continue to meet  on  an  every-I
                    two-,,nonth basis.                                              I
                              They continued to maintain a stable level of opera-

                    tion throughout this time period.
                              DR. TE'",@'HAN:  Would you identify the program as bei,,,@

                    in the big middle o,,roup?

                              MR. BARRGJS:  The big--

                              DR. TESCH-AN:  Middle group?

                              Would you put it at the top of everything you   have

                    seen or bottom?

                              MR. BARROWS:  I would say  probably top of the  middle@


                    group,
                              I was impressed with something concerning which I.

                    have mixed feelings, perhaps more than  any  other  pro@ram
                                                                          CD

                    that Ilooked at,  They have Addressed themselves to the   prob-
                    lems of the underserved.  That is a  high risk type of activity'.

                    So prospects of success are low.  Brownie points for trying
                    to do a good job are high.   I co,@- o,,,It with a stand-off on Ui





                             I don't know how the rest of you feel about this.

                             MR. @MSON:  Are there any more questions com-
                   ments, observations from the review panel members?  Staff?

                             Norm?  Frank?


                             MR. NASH:  No.

                             DR. TESCHAN:. Do you want a motion?

                            .MR. PETERS014:  Yes.  I was go ing to say it looks

                   like -- much as I regret it -- novi this is a request  only

                   for *1 million.

                             DR. TESCHAN:  Yes.

                             MR. PETERSOii:  So I don't think we are--

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

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

                   considering the later--

                             14R. NASH:  Even if you consider what the@- Propose to

                   come In with July Ist, they would still be a little less than

                   the targeted figure if you give the targeted figure any force.

                             MR. PETERSON:  Yes.  I think here we clearly have toi

                   be guided, Paul, by the fact while in Albany and in many, many;

                   others of these,we will be seeing a second request which will

                   total X or Y amount that really our recommendation at this

                   session, certainly the other inputs will have a bearing on tt,.e;

                   second set of recommendations, hopefully many of  the  same

                   people will be involved, that we have L-ot to look at  this re-

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




                   guess I am saying
                             DR. TESCHAN: 14otion for $ipo66,ooo then,  approxi-

                   mately.

                             MR. PETERSON:  That Is the maximum.


                             Yes, John.

                             DR. IIIRSCHBOECK: These request figures include  tie

                   indirect costs as weLl?

                             MR. PETERSON: These are total costs I  believe,  tha

                   is a battle I think I have finally ,on. We used to  show  you

                   people direct costs whichwas very deceptive. These  are  total

                   costs, direct and indirect. And that is vihat it costs to  run

                   the Albany proo-ram.

                             DR. TESCH-AN:  Do you have the indirect cost rate?

                             MR. BARPaiS:  Yes.  Somewhere.

                             MR. PETERSON:  i@edical Collegeo it is probably in

                   the neighborhood of 40 or 50 percent of salaries and wages.

                             DR. THMIIAN:  50 percent on salaries.

                             MR. PETERSON: That is rou@hly what you are  runnin--


                   on,

                             MR. ANDERSON:  6o percent.

                             MR. PETERSON: Probably the best guess I  will  make


                   in three days.

                             DR. TESCHAN: The record ought to show that  is  one

                   of the things that kills a progra m in Congress.  And we ought tb

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



                   Albany group to recognize that fact, and see whether or  not
                                                                                    I
                   they can begin the staff processes necessary to get them   rea.dyi

                   for corporate grantee.

                             MR. PETERSON: This I don't  think  has  ever  been

                   actively considered in Albany, has It?

                             M. 14A SH: I don't think so.

                             MR. PETERSON:  I know what you are saying,  I don't
                   know whether it is even in our jurisdiction to recommend it  or@'i

                   to move it, or whether that is our duty; but  it  seems-to  me  if

                   we have responsibility for the program, for the public

                   accountability of funds, that this is  one  critical  issue.

                             MR, BARRO@IS: They will be doing  that  under  any pend

                   ing new legislation, won't they?

                             DR. HEUSTIS:  Mr. Chairman.

                                              -St Ale
                             MR. PETERSON:  Ye

                             MR. HEUSTIS:   Out of t@e projects I reviewed, it

                   seemed to m California and   I think Maine made no provision that

                   I could see for any indirect  costs whatsoever.

                             MR. PETERSON:  Thae are private nonprofit corpora-

                   tions established essentially for that purpose, so.those be-

                   came direct costs.

                             DR. IMUSTIS:  This is even for--

                             MR.  SIMONDS:  Both of those programs right now are

                   in  process of negotiating indirect costs, because they are

                   managing funds  other than RMP funds, so if they don't,




                     RMP ,noney is going to be spent on the management  of  these  oLit-I

                     side.
                              DR. TESCHAN:  They  generally  pay  Indirect  costs  to
                     universities, but the direct administrative costscoordinators
                     put together varies with the years, as  you  may  remember,  and
                     10 percent being a pretty good figure to put on it.
                              DR. HEUSTIS*    I think Maine had a policy,  if  I  re-
                     call correctly, of not being indirect cost to anybody*  I
                     don't know whether It is carried out and  I  may  be  in.error.
                              14R. =, ERSON:  Paul, I think many of the thin-s you
                     say are true, but I wonder .whether the issue  of  direct  cost
                     or indirect cost is something which this  review  group  --  it
                     mayiriore appropriately be a matter of Council.
                               I happened to a number of years ago once sat and
                     tried to take on indirect costs at National Foundation on the
                     -Arts and Humanities and I had three university presidents
                     ,-Zittina- on that Council.,  Princeton, fellow just left the
                     University of Washin@ton, and Brown.
                               I didn't realize what kind of tic7er I had walked into.
                     I at least at that juncture        acknowledge  everything   you
                     say, but I, one, question whether the review group is really
                     the forum in which to deal with it, and two, at least in the
                     next 14 months, I can see, of  some  stability,  whether  it  is
                     a polir-y we are probably going to accept  as  regions  take  it
                     on themselves and many have, but Albany  Is  not  one  that  has




                  made any move to disassociate itself from a medical college
                  and sets up a nonprofit corporation.
                            It is a cost of doing business.  It may indeed
                  have done the program harm,  Again, a personal view.
                            DR. HESS: Maybe the best thing can be done, notelin
                  the comment, the question was raised and would be worked out

                  administratively.
                            14R. PETERSON:  Right, and I have done that.
                            Did I hear a motion recommending the amounts request

                  ted for this application, @l,o66,ooo?
                            DR. HF,,,ULTIS:  Somebody made it end I support it.

                            MR. PETERSON:  Okay, you seconded It.

                            -Are there any other comments
                             If not, those in favor of that recommended amount

                   raise their hand.

                             (sho,i of hands)

                             MR. PETERSON:  Everyone*
                             Anyone against or abstaininn'?  I think I saw nine

                   hands up.
                             All right,  we have in an hour and ten minutes
                   which comes out to 3r,', minutes per application -- disposed of
                   two easy applications.  So while I am encouraged, I don't
                   think any of us ought to cet overly encouraged.  I think  It
                   probably would be a good time to break for lunch, as I say.
                             DR. THURMAN:  Will we finish today?





                             MR. PETERSON:  If we take some class action.

                             What would be a reasonable tirie to ask the group to,

                   reassemble?  1:15?  1:30?

                             DR. HESS:  1:15.

                             MR. PETERSON:  Can we try and  be back by 1:15.

                             We will start with Northern Nei,, Enrrland by virtue

                   of the fact Joe has a three o'clock deadline.


                             Thank you all so much.

                             (I-Ihereupon, at 12:30 o'clock, p,-m., the meeting

                        was recessed, to reconvene at l@15 o'clock, p.m., the

                        same day,)




                  ,NORTHERN NEW ENGLAN.U

                                        AFTERN0014 SESSION
                                                               (1:17 P.m.)
                            MR. PETERSON:  We were goint@ to pick up with Northern
                  New England, but I did want to mention a couple of things.
                            Again, on the rating sheets, I am not going to,at
                    least to the best of my abilityo let you get out of this room
                    tonight where you have reviewed a region without lettinu me hate

                    those rating sheets.
                             Secondly, to the extent that any of you have,as I
                    think perhaps llrl, Barrows did, had some notes from whence you
                    spoke, even if they are in longhand, I would also appreciate
                    your leaving those with us, althouc,-h I won't Insist upon that.,
                    Because there has been a f7reat deal, as you know, of litigatio
                    about correspondence and notes in Washington of late, and I

                    don't want to get into that.
                             MR. BARROI@TS:  What was that you were referring to?

                              (Laughter)
                              MR. PETERSON:  I should also have mentioned this
                    morning that if any of you need any assistance with travel andi@
                    the like, I think we can handle that and maybe I can ask Shirley
                    or someone, but to the extent you have got those kinds of probl,-
                    lemso let us have them and we will take care of  that.
                              Finally, and th!6 Is really directed to staff,  I
                    would appreciate it, for the benefit of Mrs. Chian-, that
                    when staff does speak up for the first  time, if you would




                   identify yourself -- not for my benefit, not for most other

                   people,.-but for her benefit.

                            With that brieC. if not lue@,.Cil introduction could

                   we push on for Northern New England, sometimes known as Ver-

                   mont,


                            Joe de LaPuente.

                            MR. DE LA PUENTE:  This is an application for the

                   support of proo-ram staff and selected continuation of on-@oing
                                CD

                   projects.  They will present some new projects that have a

                   high priority in their July Ist application.

                            The prouram is committed to addressing Community
                   problems and the development of their solutions.  By now they
                   have developed P- cardiac care management system, a respiratory

                   disease communications network, a high risk infant care and

                   transportation system, and a strategy for addressing emergency
                                                                      C)    CD


                   medical services issues.
                            Their present thrust will be that of encouraging ends
                   developing coir..munity involvement in program development, in
                   pro-r@i,m plannin--, and in program evaluation.
                            The region -is particularly involved in the continued!,
                   evatuation,and improvement of the medical care system, land they

                   are doing it by developing specific guidelines and delivery
                   of selected services.  They are doinu it through the support of
                   "Disease management committees towards 'the assessment and the!
                   maintenance of established guidelines.  And also they are doit-,@,


                                                                              eiri
                   It through the support of providers enga@ed in improving  'h
                                                          CD                LI

                   programs towards the maintenance of established guidelines.
                            They have Linkages with the Department of Medicine
                   at the University of Vermont, the State Health Department, the

                   Medical Society, voluntary agencies, and most hospitals in

                   the state.

                            Community support seems to be demonstrated  by  the

                   continued involvement of their Regional Advisory Group  during

                   this period of indecision.  Their Regional -Advisory Group

                   continues to be intimately Involved not only In the management

                   of the proc,-ram, but also in the development-and support of sLib'r,
                   stantial prooram priorities. The Regional  Heart  Management

                   Committee, for examole, includes 29 standin@ members, and
                   they have continued the,@r activities durino- the last 12 monthsL
                                                             CD

                             The present core staff Includes eivht persons,  four

                   of whom have advanced degrees.  Their steffino- pattern appears
                                                                CD

                   to be very similar to that existing prior to the phase-out

                   order.

                             The present vacancy pattern may represent an  oppor-

                   tunity for the director to develop a sta.ffinc7 pattern more

                   consistent with his future proo-ram plans.

                             Their present request is for a core budget of

                   $432,800, including i'?'292,800 for salaries and wages. Their
                   request for the seven projects envisaged amounts to  @687,000,
                   for a total request of @'L,039,670.  Thi s represents approximo.t@l





                    40 percent core staff activities.

                                                             tinuqlly involved  in
                             The core staff, however, is con

                    the support of disease management committees.
                             Their present application is  for  $1,039,670.  It-is
                    estimated that their July I request may amount to $1,,839,670
                    compared with a projected availability of $lol99,300.
                             I will not go into the cluster of projects.  I was
                    very much impressed with the type of projects that they  have:
                    a, regional end-sta@e kidney treatment program, a project  o

                    increase the capability of rural ambulance and emergency  room
                    personnel, a reulonaL proc,-ram for hicri-i-risk Infants and
                    mothers, a regional respiratory disease program, an ambulatory',
                    pediatric care project, a voluntary problem-oriented,health
                    care inforr@ntion system, and a program addressing the sources

                    of communication among school children,
                             1-n summary, this recion possesses a @ood track record'
                                                CD

                    in obtainin@ community support for its activities.  They  want

                    to shift their prorreua emphasis to improve primary care and
                                      CD

                    strengthen community level organization
                              Presently they are involved in providing an environ-11

                    ment where quality assurance can become a living reality.
                    Their present request alone exceeds that of previous  funding.
                              But special consideration should be given to determine

                    whether or,not the staffing level presently proposed is

                    consistent, both with the activities proposed for  the  coming




                   year end the level of support tha-t they will probably receivers,

                             This is not to detract from h(y much I  m,@s  impressed

                   by this reoion In terms of how precisely they develop their
                   priorities, how the project they have forthcoming agree with

                   those priorities.  So I have a recommendation.

                             MR. P.-bTERSON:  14aybe we should hold that, Joe.

                             14R. DE U, PUENTE:  Yes.

                                  PETERSOlq:  This is an instance where Dr. Jams

                   was the other reviewer, but I wondered, Bill, since you had

                   been up there either in a structured or kind of offhand fashion,

                   if you might want  to  briefly  address  Northern  New  En@,land  and

                   then I will ask staff iL'  they  have  any  comment  before  we  open

                   it up to the whole group.

                             DR. T'@a.URI,,@IAN:Ihad your e:-@,phasis---- first of all,

                   since our site,visit, there test been a change of directorship.;
                   The new per---on q-ec,-.qs to be a relatively strong leader. Tile re
                   has been stability of a corporation now where there wasn't

                   before, which was one of the recommendations that was made

                   at the time of the site visit.

                              One of  the  stron@  continuing  strengths  as  Joe  indi-
                                              CD

                   cated was the RAG chairman  who was the strongest person at our
                   meeting, much stronger then the director at that point in til.,,,e@

                   is still  there and still actively involved.

                              I think that some of the things that was su,@Ic,,ested

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





                   people here know that Vermont or Northern New Enc@rland had      I

                   more data than anybody in the country, including  Census  BureaLI;

                   -And the feeling was that RMP money did not support that in a

                   significant way.

                             They have cut it back, but it is still there, sig-

                   nificant amounts in the project they are  bringing  forth  right


                   now,


                             I would second what Joe said from the standpoint

                   community pro-rams are certainly strong as are the disease

                   committees and those have c ontinued to develop.

                             One of the most significant things to   me in  reviewin(-

                   this now is that when we were up there before,   the state Liaiodns

                   were not well worked out as far as continued support for  nia,ny

                   of these programs. This is  now very clearly defined and  woric-

                   inu quite well.
                     CD

                             Staff is quite sj,,.all. Staff goal, 10 percent of  the

                   total money related to the project, but   that doesn't come  out

                   in their proposal, It is written, but  that  is  not  the  way  the

                   figures come out.

                             I th ink the projects in essence show good cause,

                             Kidney project is needed in their state.

                             EMS,despite data base, does not expect,  what you

                   expect to show in the application.we  have in front of us,   they

                   have one of the best high risk  infant  programs  in  the  country.

                             I think they have certainly met the goals and





                    priorities with this application  and  I  think  that  they  will

                    with the others,

                               I have  just two concerns.  The  first is  each  of  the@

                    projects is  overbudgeted  for  what  they-expect  to  accomplish

                    in a period of time; a.nd the second is they    clearly state in

                    the application that core  staff  should  be  10@percent  of  the  i

                    project and yet it is  almost  50  percent  of  the  project.  Su

                    that I think subsequent to the  time  that  expense  and  our  group

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

                    erence to the advice letter that  went  forward  from  staff  after'

                    review committee and Council,     And I think that the director

                    is an unknown factor because he is  totally  new.  He  was  not  in@

                    the procram then.

                               I Would SL',pport everythinc.- Joe said.

                               MR. BARRU,,[S:  Could you identify on  this list of

                    items the ones that you say are--

                               DR. THURLI.AN: 007 has a  very strono- --  ER,  emergency

                    services program has data base information.  The respiratory

                    disease Is very much that way,  -And, of course, 037 is P@--L

                    mary data proo-ram. And 038 is  ao-ain  data  base  pro@ram  related

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

                               So tho6e are the ones that still have    a heavy  -- th,,,,t

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

                    have seen  it then. It was  nothin-  but  one  floating  base  of

                    data.   So I think IV-his program hs come a lono, way and certainl@-







                    deserves--
                             14R. BARR(31S:  You say these items are too fa,t in une,.,r

                    data bud.-et9.

                             DR. THURI.IAN:  Yes, sir,
                             MR. PETERSON:  Let me ask staff, before we fully
                    open this up, as to whether there are any particular concerns
                    or policy issues that we see posed by this application, which
                    I would hasten to point out is essentially a continuation of
                    program staff and some ongoirib previously ongoing pro-jects
                             It totals a little over a million dollars.  We have
                    an indication from Northern New Enc,-Iand that they will be in
                    for alriiost-- -Loor roughly @'800,000 worth of activities, all new
                    with their July submission.  So that it is a little difficult,  1
                    I suppose, to deal with what is no more than 60 percent of
                    vlhat we anticipate, although this is sort of core and on-r-oinc,

                    activity.

                                     or Frank, do we have any particul
                              Spence                                   ar infor.T;a-

                    tion concernlng the policy issues?
                              Yi.R. COLBLTIN: I have no kidney, PSRO, liMO.Idon't

                    think we have any conflict with policy.

                              MR. PETERSON:  Okay.


                              Frank.

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

                                  BARRGIS:   Let m ask a question.

                              14P,. PETERSON:  Okay.




                             NR. BARROVIS:  The continuation request is based on
                    some thino-s that have been suggested,are really not all that

                    productive.
                             Does staff have  any idea what is going to come in
                    or will they zero in more on immediate needs?

                             MR. COLBURN:   I didn't.
                              MR. PETERSON:  Spence probably,ha,s been away from

                    DR14P, away from us--
                              14R. N-ASH: llost of these regions gave us a'projected!
                    dollar figure of what their July application contains.
                              DR. THM@f@,tN:I think through their application,
                    you feel strongly they  are coming in more id '.-he priority
                    line.  It never specifically says that as Frank says,    But
                    their proposals that they are discussing in the distance   in
                    their actual application Lor continuation indicate that they
                    will be much more in the line of priority, rather than this

                    group,
                              MR. B-ARRGN'S:  I take it you would be Inclined to
                    be more generous with what is coming up than what they are

                    asking fcrhere.
                              DR. THLIR14AN:  Correct.  I am interested in seeing
                    what Joe's proposal is.  I think I  would be different.
                               MR. PETERSON:  -Are there any other of the reviewers
                    who have comments, questions, observations?
                               DR. HESS:  General policy question about renal, In




                    the material we were sent ahead of time it was  indicated thr-u
                    this is an area, of at least decreasing concern as far as RI@IP,

                    because Social Security rules, and so on, permit funding there
                    .A nd yet, on the other hand, We@iere told this ,aorning that, YC)U@
                    know, their restrictions are essentially  lifted,  so  whatever

                    was being done two years aco could still be done now.
                                              C>

                              In this area of renal disease,  what  is  permissible

                    and what is not is still a little fuzzy in my mind.

                              mr. peterson;  let me try to clarify that,.althou@h
                                                                                  CD

                    I don't think I can state it very feli.tiously.

                              There was, of course, with the enactment of HR-10

                    the extension of Iliedicare to really cover most end stage.

                    On the other hand, most of the R14P activities, both prior   to

                    tha.ttir.qe and now, are more aimed at resource development,

                    training, and some other aspects,
                              One of the things that  we have a.s a matter of  rou-
                    tine,I guess, in the earlier award we made, sort of a formula
                    basis during the past year, have had to do, is, Ln efL'edt@-
                    here I am groping for words and perhaps some of  the  other  star'

                    can be a little more clear on this.
                              As you know, under the Social Security,   those Soc-le.1,
                    Security amendments, the reimbursement for the  actual  end  sta-e
                    treatment, dialysis, transplantation, is  restricted  to  certain@
                    approved facilities and if facility is not approved, they have
                    to request an exception under what are still Interim





                     regulations I believe.
                                In the process we have,  In  effect,  told  regions  th@%ti

                     before you go ahead and fund anything,, you need to make sure

                     vis-a-vis that particular institution sponsor@ et cetera,

                     that this is a facility that either has or-- you know, the kind

                     of approval for reimbursement under Yiedicare or is in the

                     process of getting an exception.

                                I am not sure that really answers your question,

                     But we certainly -- we have not in our previous approvals            i

                     nor is clearly in this case,    we have not said  end-ste,,cre  kidney

                     activities are no longer eligible for support.

                                I do think we probably, even if the     program  were   to

                     continue, Rlj',P,  for two, three, or four yea@    we would probably

                     see a downswign in that as reirabLirsemnts arrangements begin
                                                                         CD

                     to possibly be@in to pick  up  the  other  costst  the  kind  we  have
                                    CD

                                We, of course, pay for little or nothinc,  in  the  w,,-@y

                     of direct.patient services*

                                I)R. TESCHAN:   llaybe experience  would  help;  that  is,
                     as Pete has been pointinc,- out, the HR-1 primarily has addressed

                     reimbursement.
                                Indeed@ they have  tried  to  oet  a  quality  because  of

                     the limitation of where centers are.

                                The instructions we have here I think are      very ex-    i

                     plicit In saying we don't  fund  things  that  will  result  In  nevi
                     facilities being constructed, or new services made available




                     without prior clearance Nqith       But what all that discus-

                     sion leaves out is the enormous piece of work t-tidt nothinc,,@

                   covers, that has to do with building relationships between      cen-

                     uers and organizing some kind of rational patient flow, so that

                     the right kind ofpatients relative  to  their  stage  of  renal   i

                     disease reach the right kind of talent end facilities. And that

                     whole thing has to do  with the community end and educational

                     function which I don't think can be paid for under SSA so fari

                     as I can tell, although I notice  your  comments  just  at  the

                     end there, that is very-- I mean, if that is substantiated,        i

                     tha,t is great.

                               We were wondering where additional fundirLfr, of those,
                     thl@n@s is. We were concerned SSP-,, in dealino- with these thin@,@'
                         CD

                     ard in the regulations, totally ic'nore one   of the most impor-

                            ntributions; namely, the organization of the patients
                     te,nt co

                     flow,  And we are disturbed about that. It seems to ,ne there

                     is a big job for Rie to do in that.

                               DR.HESS: I was a little     confused about that   state,,ren@4t-l

                     because RMP never wos,or supposedlyin business of subsidizing

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

                               .P,ny time you train people to care for patients to

                     some extent you are subsidizing it, but the bulk of it was in
                     organizational wo@ developing a plan, the workino, out of--
                     collaborating relationships this kind of thing we     are taLkin@

                     about.




                              I have, you knows wondered whether if indeed
                    that was being picked up by some other Mechanism  So it is

                    just unclear.
                              14R. PET@RSON:  I think. our concern, RMP's concern ati

                    this juncture  is that the kind of what you referred to as
                    indirect subsidization sort  of  activities  not  continue  or  be

                    created in an,institution or facility that doesn't have or

                    isn't likely to have the patient care reimbursement under Lt.
                              P sidelight, if you will, it is not relevant to this

                    application, but there is  almost  a  separate  quality  of  care,
                    many PSRO arrangements  being  established  for  end  stage  renal
                                    CD

                    disease treatment  find that is what Spence and some of the

                    staff left here are workinT on specifically In B@
                              We find that in many of the rer.,'.ons, these local   re-@
                    view boards -- that is I believe  what  they  are  called,  isn  t

                    it, Spence, but they really have a quality assurance function
                    among other things,that local review board at the regional
                                                                            CD

                    level will be handled out of the H.-bll regional offices; that

                    in many re-,-ions they are turning to existin,-, kinds of RI-,,IP

                    arrangements, resources, people that have been collected      bo

                    establish  that.

                                That is not true across the country, but certainly

                    in  some  states -- I recently was in  California where there

                    would be a number of such local rev@w boards.  -And that pro-

                    cess is being greatly facilitated by the kind of planning




                    rese-Lirce development end people have been pulled to,-ether
                    under the aegis of the California RI,IP  in connect-ion with some!,

                    of its'end sta--e renal disease activit@T.

                              We have had reviews by Joe and Bill.

                              -Are there any additional questions, comments from

                    the other reviewers or from 2taff?

                              DR. HEUSTIS:  I would like to hear Joe's recommenda-


                    tions.

                              l@IR. PETERSON:  Yes, I am sorry@ Joe,

                              Thank YoQ.- @L.L. I don't kno@iitiat I would do without


                    you*

                                            -'f the rec
                               (Discussion oL          ord

                              @IR. DE LA PULIEE:   The chairman wi-IL  have  to  check

                    me on this.  But it would 'ro something like this:
                                         000, at thisstage of the game, with strongl
                              Thus  @700,
                    recommendation  for maxirqu-,m funding on the July I application,
                    if they  are  the types of request from  tqe  size  of  our  expec-

                    tation.
                               MR. PETERSON:  Let me make sure I heard that;      more

                    importantly that all of the othei-@heard it#
                               $70b,000 recommended at this point against

                                                                                       7
                                       I mi-       ques                                4
                    a  slightly  over     'Ilion re     t, but with a strono, coroLlar
                    recommendation that the anticipated @800@000 request     that   we I
                    will see in July and you people    will be lookino- at then be looked
                    at  if the proposals in a very fair Light; is that the sense of





                   it, Joe?

                              MR* DE 1,A PUz'ZITE Yes, that is about the'size of  it.

                              DR. TESCHP.N:  Second.

                              @IR. PETIMSON:  Is there any discussion on that?

                              Yes, Al.

                              DR. HEUSTIS:  I was not doing the fire parts  Only

                   thin- I know about is what I heard you say and what I read

                   in the staff document.  But as I looked@at the staff document,;,

                  iat the numbers for the projects  that  were  indicated  as  having

                   perhaps more than their necessary sehre of checks, it adds

                   up to a substantial number.

                              Then I like what  you said about the program staff

                   perhaps thinking twice about filling the vacancies and reacting

                   to the other, and it seemed to me that maybe you    were being

                   a little generous recommending "'?700,000.

                              The figure I had tentatively written down was 'i)6oooot_,.

                   I v7as wondering could I have your comment as  to  why  you  chose
                                  C>

                   the seven rather than perhaps six?

                              MR. DE LA PUENTE:  In the spirit of havino.- them

                   make   their own choice, 'Q@1000000 figure I had in mind, to  pe-r-

                   mit them to  get staff if they feel it will fit with the new

                   projects that are goinc, to come out  in support for them, givinc@

                   them sort of the benefit of the doubt.  So they can do  hear

                   own administration. And not fully  saying  go  and  fill  all  the

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



                             DR. HEUSTIS:  You are not bothered by the 25 percents
                   for program or central staf-f rather then the 10  percent  which
                   the-t y say in the document? Or did I misunderstand you?
                             NR. DE LA PLTE14TE:  Tell me that aoain.
                             DR. HEUSTIS: I thourht I understood  you  to  say  the

                   written document said for their central staff, they were in-
                   terested in havinr,- about 10 percent. Did I misunderstand?
                                     CD

                             DR. THU.Lqjll-4N:  That is correct, I said..
                             DR. HEUSTIS: 25 percent  according  to  the  document,
                   50 percent, 430 -- not quite 50 -- out of a million,

                   43 percent.
                              Does that not bother you or didn't  it bother you when
                   you made your recommendation  That is probably where our dij"-!,

                  -ference is.
                              I'M. BPRR(Yvl'@-' Discrepancy of that magnitucie,I won,,3eri

                    if there could be an error?

                              DR. HESS:   In the accounti.no,-,
                              DR. TE-@CH-AN:  First of all Ithink unless  you  have !i-@,

                    enormous program,  primarily contractual work, to run a programi
                    on 10 percent I think would be a, little  unusual, especially
                    when you see  the developmental activity  staff should be In.
                    I think 10 percent would be unrealistically low.
                              DR. HEUSTI@:  Iaa not disagreeing, but   this is what

                                            ram.  This is all I am going by.
                    they said in their proC
                              DR. TESCH.AN:  I think that would be a mistake.




                              DR. HESS: The  total  staff  is  14  people.  Bulk  has

                     uo be for programmatic activities, not for staff'personnel.
                              MR. DE LA PTP',',iTE: This is what happened, the way  I
                     fig ure before is actually about  40  percent  of  the  management
                     core staff activities, however the core staff  Is  going  to  be

                     continually involved with management committees, which is a

                     pro-ra,,@,tic issue.  So whether you call It a program or    core
                       ID                                                CD
                     staff, council -- they support -- it is a group of staff that
                     spends an awful lot of time with these diseased  manac7c-ment

                     CO.%raittees and they gLve them other support.

                               D% HEUSTIS:   Is 40 percent too much?

                                   DE LA P@, NTE:  LIO percent would be  too  much
                     definitely, in my opin-Lon, if it  was  just  staff  ronagin@ the 1

                     projects or beinc-- supported by the RIIP.
                               If it is the staff doing  what  I  call  intramural

                     support and supporting some of  the  activities,  then  it  is
                     not really 40 percent, probably comes down to 20.     And thau

                     was the reason I looked at it,

                               DR. HEUSTIS:   I don't care to pursue it.
                               1,M. PETERSON:  @le do have a motion,  $700,000, which

                     has been seconded with the caveat  that  the  favorable  cast

                                                                                    I
                     towards the July  request  proposal  subsequently  warranted.
                     guess there is a concern of the group that the $400,000-plus
                     may be a, little on the large side certainly  in  terms  of  the
                     action taken today, but a@ain if one looks at the -@800,000




                     request which may be coming in that that perhaps could be

                     expressed.

                               Are there any other    convaents?

                               I.,M. DE LA PUENTE:   I would like to include    LI U LIU L
                     comments of Dr. Heustis,   concerning personnel situation in the@

                     ward problem.

                               MR.  @ERSON:  Okay, that     concern be   expressed.

                               DE.  DE LA PIC@LTTE:  Right.
                                    PETERSON:  Particularly until action -- we don't@i

                     know how many  projects they will have to manace until their

                     new activity is Looked at in July.
                                You know, it is possible    the group's action would be!

                     much less than what they request in July.

                                Certainly that @concern I have down, Joe.

                                    DE LA PUET-ITE:  Okay.

                                MR. PETERSOII:  If there are no other corfiments or

                     questions, may I have the question.

                                Those concurring with that recommendation raise


                     their hand.

                                (Show  of  hands)

                                IC. PETERSON:   That is everyone, including a weak

                      yea" -Lrom Bill Thurman or tired riding on the airplanes

                                DR. THUR14AN:  Tired.
                                MR. BARR(3[S:  If I were the coordinator, @G chair,,,,@ak

                     up there, I would very much appreciate ',,,nording the basis for
                     our conservatism on continued funding and basis for relatively





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

                                 PETERSON:  Let me make sure.  I see no reason
                    that it wouldn't be.  The basis for the less than requested wa,@
                    still a concern with the overly richness of the data involve-

                    ment in some of the projects.
                              Is that correct?  Is thatan accurate reflection?

                                 DE LA PUENTE:  That is right.

                                 PETERSON:  -ALI right, having disposed of Norther.,
                    New En-Lando I would like to suggest we try to move now to
                         C)


                    West Virginia.
                              Joe, your r@-eetinv isn't until three.  You are more

                    than welcome to stay until then.

                              On the other hand, I am goinc,- to avoid brino-ing up

                    any other regions this afternoon that you are reviewer on, so

                    if you do want to le@,.ve, feel free to do so.
                              He will be here tomorrow, I assume that.
                              DR. TESCHAN:  I am not ready to talk about West

                    Virginia on the bas'-s of the application.
                              I would have a little bit of past history, you knoii,i

                    previous contact.
                              PM. PETERSON:  I am not sure what you are saying*

                              DR. TESCHliN:  I think it would be better if I had a

                    chance to read the application.

                              l@. PETERSON:  Okay.  What you are saying is we





                      to put West Vir,,inia until tomorrow.

                                   We have to get it in      the iTiorninoo beca,use  Charlie

                      i@IcCall is  goinc, to have to    leave I guess around two      o'clock.

                                   DR. TESCII-AN:   Be happy to accommodate a busy        co I lear-,t;e .

                                   MR. PETERSON: Well, if we can't come to grips           wit--    i

                      if you prefer puttin@ off West Virgine, until tomorrow morning,

                      I am will,-n(,- to do so,if that doesn't pose any problems for
                                    C)


                      Charlie.

                                   I wonder in that case, though, how are you -fixed


                      with Cornecticut?


                                   DR. TEcCl@-14:  Fine.

                                   14R. @b ERSON:  Because you are also a reviewer there.4

                      I thought since we were sLidiri@,, with the easy ones, maybevie

                      ought to take a look at       Connecticut at this juncture where

                      Al and you a-re the reviewers.

                                   ,Al, you came second     last time.    I will let you lead

                      off,this time with @he nutmeg         state.

                                   DR. HEUSTIS:  Thank     you.





                    L; @q t@u -I.Lk/ U I

                               DR. HEUSTIS:  This application from    Connecticut

                    is the'first  of  two  applications  and  together  they  anticipate
                    that these two amounts of money will  approximate  @2.6  m-LLlion,'@

                               The current request provides  for  one  year  for  central

                    staff or core staff, or prorram staff, which I  think  I  am  usILr,

                    all interchangeably, although I know there are some little

                                                                                    @oi
                    inuendos as faras differences.  And there is approximately D

                    percent level of increase  requested  for  the  core  staff  over

                    the level, pro rated level of funding in which they have for      the

                    first six months of 1974.

                               They  have  sometwo months request for continuation     n

                    each of 13 specific projects in eight proc7ram areas.  The
                                                                CD

                    only pro,7ram area in which they have more    than one  project  is

                    in the area of hypertension, where there are five.

                                              blems with this document,
                               I had  some  pro

                               I found it to  be written in extremely general  ter-,n@@

                    with very  minimum attention to process.

                               There was much  repetition.  -Also  it  referred  back

                    from  one place to another,  something  that  was  allegedly  covereG

                    in an earlier section. Some  important  thino,-s,  And  I  just,-

                    when I  checked back at the earlier section, I had great difficult

                    in findinr,,. I couldn't help but  get  the  impression  they  were
                               CD
                    trying to  use all of the right  words  they  thought  would  impresF

                    people.

                               I couldn't help but uettlncT the impression the




                   RegionaL Advisory Group was following the lead of  most  people
                   that were requesting projects and staff as well,'rather than
                   providin(7 any direct and stroticr leadership in program develop-

                   ment.

                             I saw no great evidence of ,ny real central staff

                   Involvement in a true leadership role, It may  well  be  there,

                   but I just wasn It able to see it.

                             The predominant Leadership seemed to come from the

                   chairman of R-AG.  I had to base my decision on he Is-the

                   fellow who responded to all the problems and his response
                   seemed to me again we,s not really how to adjust to the problem

                   or how are you wrong in bringing up the problem,  but  kind  of
                   why diW t you come to the meetings and if you had come  to  the

                   meetin@s, you would know all of these things.
  0                          I could be very sympathetic with his point  of  view,

                   but it didn't seem as thourh he really approached  this  7roup,

                             Now, the Regional Advisory Group has been a well-

                   rounded compliment ornpresentation  including  the  representa-

                   tives of 5(b) and the l(a)  agency that I could identify.

                             One other representative of a planning group on   it.

                   It was quite obvious that they, at least at the time this

                   document was written, they hadn't succeeded in getting compre-.

                   hensive health planning to understand or appreciate @7ha     ey

                   thought they were trying to do.
                             There are many letters from the planning  folks  that





                    helped to bring this out.

                              They do have a  hig4 medium and low  priority  desig-

                    nation or rating system for both accomplishment and for the

                    request.  But there is no su-mmtion, whatsoever, that

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

                    w,tion whatsoever as to what kind of criteria they used for

                    high,        and low, in this area,,  And i t came out that most

                    of the ones as for as they requested were  high.  I  think  eighti

                    out of the nine.  -And as far as progress, there were five,

                    and four or five hi@hs and  four mediums.  There weren't any


                    lows.

                              Then it referred to seven states  hadpriorities  whichi,
                                                                                     I
                  -I had one devil of a time Pinding,  I  finally  found  one  tiny
                    paragraph in the middle of a parpe in which some  very  YeneraL

                    thino's were said about seven specific areas, but there   weren"U-:

                    any specific short-,term priorities or objectives by which thec.-e

                    seven important areas could be implemented.

                              It is a new process which involves a number of com-

                    mittees in the RHA and says this took place over  a  period  oi
                    time, and I certainly read by inference that there were meet-
                    ings, that therewas a process.  But very Little information

                    about them.

                              While quite a bit was    made of the complex of

                    workable system of reo-lonalizatiori, the y were tryin,, to carry




                   out complex yet worl-,able-- (inaudible)     and formal   network

                   of cooperating institutions

                              The reference to accomplishment was in    very genercii

                   termts,

                              I gathered that,sofne of the projects which they

                   had started they continued funding, but the extent as well as
                   the meaningfulness of the effort.was unclear as well as it was

                   also unclear as far as continued funding as to which areas
                  ithis had already occurred in or which  area  it  was  hoped  for.
                              In general, I was riot impressed with the staff activ,,-

                   ties.  For example, the central staff, as far as the material

                   that was presented, and on  specific  forum,  it  said  something
                   about the staff plans will rapidly unfold ao-ainst background C--'
                                                                 CD

                   the CR,@,111's program facilities and strategy and will further

                   see CR@@,,IP's responsibilities to emerging national  priorities.

                              This kind of lanc,,,ua@@e doesilt say very much.
                                               tD C)


                              IJ,ateria,l reported what the staff had done.
                   Golly: it seems to me they   must have done more than   they wrote

                   down.

                              They developed a ,7,ood staff. They achieved some
                   alternate financinr,- of prof-,rams, staff skills, assured central
                   direction.  They did do some planning and specifically m--ntionf_-C.
                   hypertension pror,-ra-m end they claimed more effective coopera-
                   tion with CHP.   But a@ain, the nebulousness of it all bothered


                   me .





                             In ratinr7, in thinking about this, fortunately

                    Connp.cticut was not very hiuh on my list. I rated prorrra.,n

                    leadership from poor to adequate, equally unkind to program

                    -staff.'

                             Regional -Advisory Group, except for the review pro-  i

                    cess, gave the saw kind of ratings for past per ormance and
                    accomplishments, objectives and priorities, and feasibility

                    because I couldn't tell whether these folks had any feasibility

                    of doing what they said they were doing, because  the.tliinG   i

                    that I suspect is that in complete contrast to  Maine,  they
                    must be doinu some things they just did not  put into the appl@i--

                    cation, they just must be.

                              I rated this as a poor application  and as far  as

                    funding rriechenisiii, we will r,,-et to in a moment, it seemed to
                    me they ought to be on the very short end of any funds that

                    M-Lc.7b.t be available and so forth.

                              MR. PETERISON:  O@cay.

                              DR. HEUSTIS:  I did -- I was disturbed.  Connecticu

                    was the first one of the five which I had that I looked at.

                              I Yias so disturbed by it end by my reaction

                    I guess I was disturbed by my reaction to it -- that I ,lent

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

                    and z;o@ of the criter-La we used, and some of the background

                    Judy had,, made myself a chart which I endeavored to not only
                    pick out the ;nain headiiic,@--, but every one of the subheadings c'-r'




                    the paragraph and tried to rate these Foods fairy and poor,
                           CD

                    to see "even thOU2;li this was a subjective evaluation, w
                                                                           as

                    there any -- were theyjust being too unkind.  -And it just

                    came out the same way.                                         i

                              I am sorry, but that is the way It impressed me,

                              IC. BPRRU@IS:  Doctor, Let me ask a question for

                    clarification.

                              Are these deficiencies you speak of, do they appear

                    to be the end        of a lack of leadership and management

                    capability and staff?

                              DR. HEUSTIS:  Yes, sir, and the Rlll.'.

                              Again, I hope I thorou-ialy qualified this, a LI I

                    know Is      I read.

                              l@,M. @@TERSON: I think I would like to ask Paul, who
                    was the other reviewer on this, if he has what he would like to

                    add to  it.

                              I know, for example, John Hirschboeck was on a

              so    site visit 104 years a-o in Connecticut.
                              Paul, what do you have to add,  subtract from, ;ihau

                    you have heard Al say?
                              DR. TESCHAN:  I would like to add a couple of -- oh,,
                    supplementary points which will not chance the basic them I
                                                             CD


                    don't think.
                              First point Is as you read Connecticut, it is unique:
                    in my experience, having talked to the predecessors of the




                   present --roup also, in that its basic Philosophy says if
                   health care is going to be approved in a state, in any region,,
                   it is goinu to be done throu,-h primarily interinstitutional
                   netwo@ starting from the university centers, and throuoh
                                                                          0

                   faculty type and educational contacts in community hospitals.
                            If health care is then going to be benefitted as
                   individual consumers in the state receive it, it is going to b
                   by those consumers coming to those centers influenced by this

                   network.
                            That is, there is virtually nothinv other than the
                   outpatient department of the hospitals in which the full-
                   time staff have been impressed by the prior history of Connec-I
                   ticut R'L4P.  The individual ambulatory patient is goinc- to be
                   particularly benefitted, that is not quite true, there are
                   exceptions.  But the overall driving basic thrustthat program
                   apparently has been monochromatic like that, at least as a fund-
                   a.mental concept.  It is quite different from ,nany other R@IP's.,
                   And I gather HaroLd, Stan Olson probably had wrestling
                   matches on this same subject, but if anybody didn' t know that
                   about Connecticut, that is one fundamental piece of it.
                             Now, it followed from that that the budc-et has      I
                   certain characteristics.  It follows that if you work at  it
                   you can find out of req@-.,,ested total amounts -- and my figures
                   are a little different, they are added up a little differently,@-
                   out of approximately, I came out with a  fic,-ure of  942 000,




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

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

                    Connecticut.
                             That is, how far out I don't know.  I don't know

                    whether this institute for health manpower is not a child or
                    progeny of the universities; it may be.  Could very well be.
                    It may be the EfiS. I can't find the sponsor to be sure.   It

                    is stated as Yale University.

                              It Is a committee of some sort that appears to be a

                    sponsor.-  I can't tell whether that is a child of the univer-

                    sity.

                              Otherwise, it appears all the cash is  floviin@ into

                    and through the universities and is not turning  up  with inde-

                    pendent applicants or independent group.
                              So you have to sort of figure whether  you  buy the

                    philosophy and if you don't buy the philosophy,  you  are
                    uphill against the X years of 167, seven years of precedents

                    that istuation, so that is one main  point.

                              The other point is that the staff is missing  a

                    controller and is missing an evaluator.  And  our  feeling is

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




                    raise serious question whether the staff canim-nage the busine@


                    of the-prooram.

                              I would agree fully that the RAG chairman appears t(

                    be the active person in Connecticut.   Everythinom seems to hl-nr.'Te@

                    around him and his activity, that that CHP  is  a  disaster


                    obstruction.

                              I thought whoever wrote those letters in reply cit

                    least, among all the wordso  seemed to do a professional Jo

                    about  @Lnin@-- up the facts. I aoree with your comments on the
                               C>                   CD                              I
                    argumentative nature of it,  But there were I thought a gouu

                    deal of professional stance., documented, and seemed to  be

                    well  done.


                              DR. HLUSTIS:  CHP*9

                              DR. TESCHAN:  No.  llany of the arguments CHP brought

                    up were after the fact, almost written in ignorance, because

                    he was able to show in that CHP's own district CHP -nembers had

                    been contacted.  Interview indicated that.

                              Well, comin-r out to the other end of it, there are

                    minor differences in the rating.

                              I felt that the feasibi lity was  probably  prett
                                                                              y

                    high in view of a seven-year precedent that  that  kind  of activ:@--

                    ty does ,iork. If I buy that, my problem is, is it a performance

                    Does It setp up the pike?

                              I think if you  are this far down, activities are

                    feasible, I looked at a below-averao.,e rating.  However, I felt




                 somewhere between 80 and 100 percent of the   program staff
                  f undinr, that is two-year extension and yearls extension of
                  staflf, either somewhere between 80 to 100 percent of that was
                  at this point a reasonable step in order to carry them throuc-h,;!
                  a,t least to their July I application, with the  contingencies
                  that the staff positions be recruited for. And  that  the  new
                  application does need to be considered in terms of widened
                  participation and initiative come in from elsewhere.
                            I also feel the domination of  university, which,obvJ.c)us-
                  ly from every corner of the thing, the  theme ought  to be est,,ib@@
                  lished as a precedent, it ought to be  undertaken, running  by

                  itself.
                            And the application projects are primarily invoLvi-n@@
                  -Students of various sorts doinv primarily theoretical studies,
                   rather tiia hav-Lng something actually happen.
                             So I think that, you know, I would move to  chan@,e
                   the grantee and to @,et this influence totally excised Ln the
                   course of the next little bit, and to shift this  thing  over
                   to a situat4,on where other applicants will have a chance  to

                   begin to do it.
                             14R. PETERSON:  Does that--
                             DR. TESCHAN:  The alternative is to stop the Rilip

                   funding,  That Is possible to do.
                              MR. BARROIIS:  Do any of you fellows see any prospect,

                   of turning this thin.@ around?
                                        CD





                              (Lau,hter)

                              l@. PETERSON:  I wonder if I might help--
                              DR. TESCIIAN:  Question, turning it around     if
                    you mean turning it all the way around, so that all--

                                  BARRAIS:  Even sort of in the direction

                              DR. TESCHAN:   -- all the habits of the seven years

                    are reversed, of course, is abstllrQ,
                              But I disagree with the notion we are dealing with  a-i

                    one-year story.
                              I viouldn It make this suggestion if I thought this

                    were a one-year proposition.
                              Last year wech-alt with It as a one- to three-year

                    proposition.  I don't think that is right.
                              MR. PETERSON:  I wonder if I might do this before      i
                    I ask staff to comment, there may be one or two staff cori-Lients'

                    then throw it'ooen for broader discussion.

                              John, since  you were on a site visit. which was

                    made  when?

                              DR. HIRSCIIBO---CK: I think three years a-o.

                              IAR. PETERSON:  That lonc, ac.-o?@

                                                                                      C)
                              Everythino- has been a year and e..-half, two years a
                               DR. HIRCCHBOECK:  I have to agree with    -@iost of

                    what Paul is saying, although I riust say the grant idea,
                    when R.14P went into Connecticut, it had a @ood test, identifying

                    every hospital in the  schools with medical   schools, so a





                   full-time person is linked with 'Utic medical school and trial

                   hospital, whether that is v, @iorlcn.ble thing in the United

                   States.  Whatever results have occurred will perhaps give the,


                   ,9, n s@l er,

                             There is something that has happened I think, but

                   whether this is going to continue in the way that Clark orig-

                   inally thouf--ht it was goinv to, of course$ is not the case.

                               am par"u-'Lcula-.Ll@l impressed with the fact they stil

                   don't have anybody in evd-tuation and their staff is lean.

                   This is the major crit-4c i sri. This is pretty much a one-rnari

                   show, as Dr. Clark left shortly after that.  Morse is his

                   deputy.  lie has followed throu@h the sanieway.  So I don't

                   think there is much more to say.

                             @IR. PETERSOll: Frank or Sp,-ince, are there some

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

                   of them

                             1,2. NASH:- I think that was @he major thing, CHP


                   really    yes.

                             I,IR. COLBURN:  @lith rec,-ard to the chief of staff,

                   they are not supporting those positions any more,

                             I think this request is to bring different chiefs

                   into networks to exchanger

                             DR. HIRSCIIBOECK:  I might say too, there was an on_

                   goin@ fi@ht      the medical society.  I don't know how that

                   will end.




                                                                                    914

                                      PETERSON:    It hasn't resulted in the same      py r o t e'@, i-,. -

                      niques,  letters -- they were more adv e,need,      they   sent   tele-

                      gr@.ms to the National Advisory Council.       Nobody  has  pl-iomd   us
                      yet.  lvlaybe because we don't have a phone in this room, I don",t

                      know.

                                 Paul, I think, made one important factual kind of
                      point. 1-te are loot,,-inr  here  at  a  request  which  Is  essentially
                      to continue a nurnberof   on-c-,,oing proc,-ran@s for just  two  months.

                                 DR. HEUSTI@':    Just two months.

                                 l@. PETERSCP,\T:  P@nd  then  to  continu(5  somewhat  expand

                      not a great deol,core    @-taff,and  we  will  probably  be  taking   a

                      look at the lar@er port!-on of the picture in July.  So that

                      I think I have  heard  both  -Al  and  Paul,  and  some  of  the  other

                      comments,  I  have  phrases  duan  like  "liot   impressed,   troubled,
                      be low average rating-, short end of fundinrr,       That     certainly,

                      I think we have vot a cost as to how we would look at that
                      larger portion in July perhaps.  But we are lookinr,,- at a
                      relatively  modest  portion  in  terms  of  duration  and   amount   of

                      funding in this particular application.

                                  Other comments, observations?

                                 DR. TESC@N:  That su--estion        is to fill those vaca   n-


                      cies.

                                  I think theevaluator has to be in there.  That is ti-ic-


                      point.
                                  I like the idea they have had      the evaluator separate




                                                                                   95
                      from the planner inthe staff.
                                 lai. NASH:  Dr. Shan---  I thin[,- this  is  probably  Dr.

                      Clark's evaluation  on  evaluation.  He  didn't  want  a  sinc,,Ie

                      individual  on  his  program  staff  to  have  ttat   responsibility.

                                 I don't  know  if  this  comes  through  in  his  applica-

                      tion, but he relied very heavily on     the procram planning,

                      program setting, prioritizing, evaluation      of activities,   on

                      a review evaluation committee.


                                 I think another stp,.ter-,--nt should be made about   t@ii si

                    .reo-ion, they are   to be processed, certified by RI@IP.

                                 The basic  reason  is  the  staff  aswell  as  previous

                      site visits, almost everyone who reviewed      the   program   agrees

                      the evaluation conlmi-ttee  in  Connecticut  has  done  in  the  past

                      and appears to  still  be  doing  those  fucntions  that  we  feel

                             nal advisory group should be doing.
                      a regio

                                 For that reason they have been     so  advised  of   this, c--,-

                      withheld their due process for that reason.

                                 DR. TESCHIN:  I think you know my      reaction to  that'.

                      would be that funding becontino-ent on     getting  that   squared
                                                        C>


                      away.

                                 I-IR. NASH: It  concerns  me  a  little  bit  because--

                      I certainly  understand  the  concerns  of  this  review  crour,  here

                      because we have them also, but if you look at the current

                      application onthe one hand and try to take action based on tri@s

                      application  to ,nake seven  years'  history  in  that  rer-ion,  thi,





                                                                                :7u

                     would present me a problem, perhaps Dr. 14cCall one, if this ic@

                     what the group wants to recommend,

                                I would think the July application might be a better


                     place--

                                DR. TESCHAN: I  think  if'it  were  approved  In  July,

                     if we'vere to look at  the  ConnecticQt  application,  and  recom-

                     mend fQndincT that sho%  the  ramifications  and  other  issues

                     turni.nc, up, I think the rqessa@e would be spelled ouu-  in  dol-

                     lars, spell it out.

                                l@4R. NASH:  Yes.

                                l@IR. PETERSON:  Any  other  comments,  observations?

                                DR. HEUSTIS:  Is  my  arithmetic  incorrect  there  was

                     a 50 percent increase i-ti.the money, ona  pro  rated  basis,  re-

                   -questeo for the central staff?

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


                                DR. HEUSTIC,: Evaluator -LPor  those  two  important

                     positions,I 'wonder what the dollar may be.     They  may  well ha,,7e@


                     made  a  data--


                                DR. TESCHAN:  I don't have the data.

                                DR. HESS:  Is the funding sheet available, printouts

                                MR. PETERSON: I thou--ht you were  goinD,  to  ask  a

                     question   about what was the  arithmetic  really  added  up  to?

                     I  was  reminded of 1-4ark TwE),in's man who only spelled a  word


                     one way,

                                DR. HEUSTIS: So six  months  award  "k@168,000,  one





                                                 which at least according to my
                     yea,r request for '@")1179)OOOP
                     arj-thrac tic is three  times  that,  or  50  percent.
                                MR. PETERS01i:  It doesn't seem right just look'nf-,
                     at it, el-fht to twelve kind of junk, but I must say      am not

                     that familiar with the figure.
                                DR. HEU@@TIS:  Maybe there are other factors in this,l

                     I have no breakdown than the   total amount.
                                I,ffi. B.ARRi3TS: On this sheet you show $297,000 for

                     six   months.

                                YiR. PETERSON.   I have tha.t sheet, toQ
                                I,IR. BARFC@,,'S:  As compared with what we are asking for

                     395-4790.

                                DE. HEUSTIS:   I have-@158,000 for six months.

                                @IR. BARRU-I.S: Summary proo.ra.m to  date.

                                I,IR . C 0 LB U,-RN I know one problem. One of the incre@ce
                     'in prorpram staff is due to  the  fact  DIIS  activity was funded
                     out of pro,-,ram staff, rather then a separate  project.

                     Tha.t.is what it is.  Staffin- pattern is consistent with what

                     it has been for seven years.
                                DR. HEUSTIS:   Okay.  Can so= approach be made as fee,

                     as the-AMS--DMS to limit that for two months also.

                                MR.. C OLBURN: I  think  ltis  beinu   done.
                                                                  CD

                                DR. TEL,C@N:   It is a ti-io-month f in, ure.

                                DR. HEUSTIS:  I am lookin--r on page   3.  I see the

                      158  OC)O.





                                  MR.  COLBURN:  P,-nge  3.9
                                  DR.    HEUSTIS:  Fare   3, bottom of  the paoe, "'158,000

                      for six months.

                                  Next  to the last    line above the total.  And

                      'I'@,'479,000 for the full year.

                                  M. COLBURN:  Yes.

                                  DR.  HEU,13TIS:   159,000 times three is three undred

                      times      almost I","479,000.

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

                      for projects for two months.

                                  In other words, take program staff throuo,,h "'I)675,000

                      through June 19'T@

                                       PETERSON:  How could it be--


                                       COLBURN:  @@uestion of requested support for

                      staff throu h June L971.; and projects throuc,,h.August L, 19"4.

                                  DR. HEUSTI'@:  But the -staff starts first of June         19-i-"'*

                                  14R. COLBUs-"dl: It would be 12 months then,  12 months


                      staff,  two   months   for   projects.

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

                      I have concern about 'Lt.


                                  DR.  TEr@-CHAN:  Do it ric-ht.

                                       PETERS014:  Yes. We    always seem to be embarrassed

                      by nu,-nber.@.. Whether it is the @,laryLand lottery or what  have

                      you, it    is never the  ri,-Iit  one.

                                  Given the nature of this application, which is for





                    program staff for 12 additional months, but the limited    n urit e r

                    of on-@-o@Lnc,- projects for only two months, thus totgllno,

                    )637,000 volume, does anyone have a recommendation as    to

                    e,,,no unt either of the reviewers or someone else?


                              DR. HEU'@"TIS:  Would you care to commit yourself?

                              DR. 'LESCHAN:  Sure.  I move to fund either between

                    80 and 100 o--rcent of the amount requested;i  namely,

                    80 to 100 percent of $6j6,220, with hopefully   the conveying

                    to-- perhaps it is too late to  convey to the group concernitl@-

                    .their July I application the concerns we have about it.

                              DR. HEUSTIS:  Do you feel stronvly about the    80 to

                    100?  What about 80?

                              DR. TE.SCHliN: I would be perLectl.y happy with 80


                    percent.

                              DR. HEUSTIS:  I can support 80.  I would have trouble

                    with 80 to ioo.

                              DR. TESCHAN:  The only reason for the latitude, I kn@,"

                    it Is  slightly hypothetical a situation.  The other feature,

                    if the  funding doesn't have all the money needed to get these

                    people for--   Ifeel the salary level,5 I think hypothetical

                              DR. HESSL:  They certainly have the option within tl-,e:.

                    total funding p,.3,clcac,-e to reallocate.

                              'DR. TESCIIAN:  So 80 percent is fine.

                              @IR. PETERSON:  80 percent If any arithmetic is wort'Ll

                    a dime, is about -,')509,000. Somebody had better check me,







                   on that.
                              DR. HEUc,-TIS:  Did- you,, make a@ @,motion?
                              DR. TEZ")C.L@N: Yes, I move 80 percent fund of the

                   request for a month.
                              l@. PFTER.SOli:  We will say '@,')510,000.

                              DR. HESS:  That is somewhat low.

                              IvM. PETERSON:  Your feeling
                                                          is that is low?


                   That is a  recommendation.
                              DR. HESS:  That sounds Less than 80 percent..

                              I am auestionLng the arithmetic.

                              DR. TEQ-CHA-N: @@)508,000.

                              DR. HESS:  You dropped it by one-sixth9,

                              DR. TESCIVN: it would be a fifth.

                              DR. HESS:  Olmy, I guess that is  right.

                              MR. PETFJ@@@@'ON:  Is my arithmetic at fault?

                              DR. HEUSTIS:  No.


                              DR. THUR.@,,IAN: Second.

                              DR. McCA LL: Second thin,-, you have clone right.

                              1,R. PETERSON:  Was that a second?

                              DR. THUR.,4AN. Yes.

                              YiR. PETERSON:  Is there any other comments, discus-

                    sion, with respect to Connecticut?

                                                             to provide funding,
                              We have a motion and a second
                    i)500,000 -- @10,000 for this particular application, recoc.-niz-,n.--,
                    that a major additional amount, if I can read, nearly '@42




                     is anticipated in the July action, so we are dealing with t     he

                     tail of the doov at this juncture.
                               If there is no further discussion let's call the

                     question.
                               Those in favor of the recommended amount?

                               (Show of hands)

                               14R. PETERSON:  Unanimity.
                               Okay, there is no need to ask about those who are         i

                     against or thos e who are abstaining.
                               14R. B'@Rr%G,,IS:  A@ in, in order to save a lot of extra!;

                     work on their part and acony on our part, it would     be approp-
                     riate to tell them this future discussion would be     contingent   on

                     chant7e in  direction.
                               DR. HESS:  Not change in direction.  All they can
                     do is be niore selective than they might  have  been  in  what  theyi
                     submit, because they have to submit what is already piped.
                                One of the things so amusing about this discussion
                     we have two new reviewers who hadn't reviewed this re@ion be-
                     fore, they come up basically with the same answers I have           i
                     heard,twice) maybe three times.  There have been strong
                     messages, including special site visits of that region, tryin
                          C)

                     to turn them arounad, and it goes on and on,

                                The comments, trying to turn this    around one year,

                     before, you end up funding  is totally out.
                                ALL you can do is cut off disapproval to--

                                DR. HEUSTIS:  Help[hase out.





                              DR. HESS:  Help them phase out.  Evaluation.

                              You are not going to get evaluation that rqeans any-

                    thing in one year.

                              MR. PETERSON:  What   gather Joe izsa-ying, we are
                    still continuing to send a. message of essentially the same

                    kind.
                              DR. HESS:  Yes,  Thumbing your nose in a sense, aLl
                    direct.',.on they have gotten from the review committee, Council,@

                    staff, all the way down the line.
                              DR. FEUSTIS:  Still give them 80 to 100 percent.

                              14R. B-ARRGI,,15: Pete, how do you answer a phone when

                    Senator Ribicoff calls up?

                              I,[R. PETER SON:  Careful Ly and courteous ly

                              (Laughter)
                              I have never had a call from, Senator Ribicoff or

                    the other 99 members of the U.S. Senate,   Tha-t doesn't Mc-an

                    they don't call.

                              MR. NliSH:  Their staffs do, I wamt to assure you.

                              MR. PETERSON:  See, Frank c,-ets those calls.  I
                    suppose he at least starts where I do, courteously.
                              DR. HEUSTIST. Is it possible, parenthetically     ma@y'!

                    I speak off the record for a moment?

                              1,M. PETERSON:  Yes, off the record.
                              .(Discussion off the record.)

                              IIIR. PETERSON:  I don't think in most rec,,i-ons the




                    flack we have had in years past has riot been essentially fromi
                    a Con,@.ression al delegation, although there have been exceptic'@zs

                    to that.
                              That hasn't been a major problem on a re@ion basis.
                                                                      C:)

                              I think we are at another juncture we have to make
                    -one of those crucial decisions.  We can go on with another
                    region and if so, we are probably goinr.r- to miss coffee.  The
                    cafeteria is operated around here for the benefit of what,
                    I am not sure whom, help or customers, closes at three.
                              We can take a, quick ten-minute break, butI thi rk

                    it would have to be a quick break.

                              I hear one vote.

                              MR. 14ASH:  Two votes.
                              MR. PETERSON:  Ten minutes which would mean 2:35.

                              Okay.
                              (@Thereupon, a short recess was taken.)
                              MR. PETERSON:  We are mis,-,inc, Bill Thurman of the
                    group.  Because I haven't had a chance to check with
                    Bill   we still will have t-i-ne for H.-@iaii if Bill wasn't
                    really prepared.  With him not in the room, since he is one
                    of the revewers, at7ain to extemporize, perhaps we might pick
                    on  Central New Yorko which you indicated, Joe, you were prepared
                    to address, and then we will pick up on Haiqaii after that.
                    I that way we will take care of one of your additional recion,@:

                    Charlie, Central New York.




                    CE-i,4'TRAL IM@4 YOR@

                             DR. McCALL:  Yes.
                             1,M. PETERSON,:  I will Let you sort of be the second

                    reviewer on that.
                             Let's pick up on Central New York, then.  Dr. Hess

                    and Dr. McCall are the reviewers.

                             I will let you lead off, Joe.

                             Central New York, Syracuse.
                             DR. HESS:  First just some uenerat consents,
                             I had some difficulty setting a very good feel for
                    this proc-re,,,n from the application, and I have hadno prior
                    personal history on the basis of site visit or having been in
                    a primary or secondary reviewer on this region.
                              I do have so-@ie vague recollections being in some di,.:@@7
                    cussions, but those are not of much value at this point.
                              But 'what I would like to do is just go over and coal
                    raent and convey, summarize for the corffqittee's information
                    what I have been able to abstract from information available,
                    and then have this supplemented by Stolov who is familiar

                    with the region,
                              First, in terms of program leadership, I --ort of get
                    a rftixed feeling here, on the one hand, the application indi-
                    cates how active the RAG has been.  The number of meetings,
                    something like 15 meetings of IU.G in 12 months, and the PJ-IG
                    members of the RAG have been on  the review committee and inti-i
                    m,,-itely involved with reviewing projects and this- t@rpe of thir,@,io





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

                    that the WG has been speiiclit-ir,, a lot of time on  Central  New
                                                    CD

                    York      activities, and it   is stated that they  reef--firmed

                    the-,@r goals and priorities.   However, I did  not  find  in  this

                    particular application their    goal statement.

                               They do talk about   major thrust which I would infer

                    are similar to goals, at least they have stated certain direct

                    tions they plan to follow

                               DR. licCALL:  Health resources, planning, rer.7ionali-

                    zation, and primary care.

                               DR. HESS:  Yes.  So that there is that       incongruity

                    the goals and priorities I do not find to  use,as      a yardstick

                    to measure some of the other things here.

                               They indicated in an   area they  have  given  due  con-


                    siderati-on to that.


                               The program staff is quite small.     At  the   present

                    time there are five fuLL-ti,,ne professionals,   one   part-time

                    professional. They propose to  @o  up  to  eir-ht,  eight  full-

                    time Professional and one part-t2Lme plus    four other personnel.

                    So it is a relatively           staff.

                               I would gather  -Lrom  some of  the  background   inform

                    tion,  howeverp  that  the  management skills of  this  staff  leave

                    6-oriethinr,.to be desiredo that there  have  been  concerns  con-

                    veyed to  the staff from Council  and  from  central  RMP  staff that

                    ha,ve Iguess to say mi ldly if not   been completely acted upon or




                    accepted, and perhaps someone, Mr. StoLov can fill us in on

                    that.
                             I mentioned  the Rer.,Iional Advisory Group.  They ha,vei
                    had goals and oriorities and the listing of projects, priority,
                    rankings have been @iven included in the application, but hc;i

                    that fits with their overall priorities I can't determine.
                             Now, on terms of past  performance end accomplishments,
                    their report Indicates some thinf,-s which to we are quite
                    exc I t I n6 For exz),mp le @ le t me j us t read a paragra ph, or two
                    here. "In the north area of the re,@ion,"that to me Indicated
                    if they can take a major credit for it, I would consider it

                    a rather substantial accoiiioli-shment.
                             The report states: "As n, result of our efforts and

                    cooperation with health care institutions and citizens groups
                    over 60 doctors have come into the area, within the Last tiio
                    years, This is more than 25 percent of the total number of
                    doctors practicing in this area,,, prior to our effort. Success-
                    ful physician recruitment can be attributed to our widespread

                    thrust."

                              Then they list ten different activities in whichthe
                    R14P enr,-aged in that area,, which they believed were related,
                    and somewhat instrumental in attracting the 60 new physicians

                    into the area.
                              I will just indicate one of these is a series of @iel@L
                    baby clinic3developed by citizens group using professionals




                    whose time is donated by institutions.  From one 1972, the
                    operation has expanded to fifteen clinics in April 1974.

                    @o in this area, in particular, it seems they have a re-

                    marl,,,able accomplishment.
                             They have a, number of activities In the area of pri-
                    mary care and in health education net@ior@ they have actively

                    been involved Ln EI,7iS development in the region and so on.
                              So that I think there q..re a number of prograrimic plt,,12-

                    es -'L,,i terms of accomplishments that they deserve credit for.1

                              I have gpoKen about the objectives and  priorities.
                    The proposal, I have had a little difficulty relatitir,., to   i
                    specifically the proposal, the projects to     well, as I rqen-
                    tioned, there are no objectives, priorities;  there is the
                    provrar=ic thrust.  But I would gather most of those program-
                    ric thrusts are core staff activities rather than project related

                    e,c t 2L v 1 tLes
                              The feasibility, I have some difficulty judging that!


                    one.

                              Their past performance has been reasonably good.

                    I would think that in these types of thinrrs they have done
                    previously, coordination, organization type of things, that
                    you I-.now they have got a pretty good track record and probably'

                    is feasible.

                                                                    asonably good
                              The CHP relationships  appear to be re

                    although it is indicated that due to the time constraints,





                     that all these  have not been specifically reviewed by CHP
                     prior to  submission,  aLtho@h  there  was  some  indication  there,
                     have been some telephone contacts, some effort at liaison       with

                     CIIP during the time available.
                                14y overall assessment of the program  was  that  iu  is-I

                     I would rank it in averarye category with some pluses and some

                     minuses, the pLuses in terms of some of    the thinus they have    i

                     been able to accomplish, the minuses mainly being     in the
                                                                                        I
                     management area which in part I think is reflected by the

                     mture of the proposal, the way the proposal is put together

                     and or@anized.

                                I sort of had the feeling perhaps they may be a, some@-

                     what better program than the proposal reflects and I am not


                     sure,

                                But a-s I indicated, I am impressed with some of the

                     things that they had done and they are reportin@- on.     So per,-.@,-@

                     I can stop there.

                                lv2. PETERSON:  Okay, Charlie, you were the other

                     reviewer on this one,

                                DR. 14cCALL:  All right, sir.

                                Just a few comments to basically agree ,4ith Dr. li-.ss'@


                     evaluation.

                                There is a tone in the rather poorly put too-ether

                     proposal,  optimism end enthusiasm, which I think most  of  us  I-"-

                     to see, that you couldn't tell from this application how %q.2LL






                                                                        and he
                    founded that optimism end enthusiasm were, however
                    has already alluded to,       the small staff in spite  of m@i r,@ y
                    projects, multiple activities, without goals projected.
                    It'is afragr.,iented programs doesn't  hang together well. But

                    it's accomplished in sort of a  short-gun way many  things,
                    but with the multiple activities  related to small staff It docc
                    raise serious question of capability of monitoring such diffu&e

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

                    I checked de--ree of  CIIP. relationship.

                              Nothing from the CIIP In here. Application  says
                    what the process is, but the only thing we are asking  for here
                    is really a, continuing application.  They really aren It re-
                    viewed now, but some 84 proposals are to be reviewed by CHJI,
                              So I felt that I couldn't really say that that was

                    plus or minus at this particular point.
                              And last question, they have  the arthritis prooosa"-

                              This is legitir
                    in here.                 .ate, I suppose, as a continuation
                    project. Jerry can tell us whether that creates any problems.
                              @IR. PETERSON:  Okay.  Do you have any sort of sum-
                    mery, one word, one phrase impression oL' the region, Charlie?
                              Yours was sort of average, some pluses,.some minuses'7,

                              DR. HESS:  Yes.

                              DR. McCfi LL:I also had  him  as an average region,  i,
                    almost exactly.  I think, we would have the same pluses a.nd






                    @ninuses.


                                   BA@qaIS:   Before we get around  to  numbers,  nia
                                                                                    y

                    I ask, budc-et 100 -- 20 percent, "'L47,000;  E14S  radio  conmuni

                    cations.  Is that the purchase of equipment or is that

                    sorpethin--- else?


                               MR. P.FTERSON: Jerry, would  you  react  first  to  the

                    arthritis point?

                               l@,IR. 5TOLOV: -As far as I know, the only  project  we

                    felt did not get CHP  comment  was  the  hypertension  to'some

                   .time constraints up there.

                               -As the arthritis, I have not  been  in  contact  with

                    the-P,rthrit'Ls Review Group. They are  t,?,kinu  into  considera-

                    tions whether or not CHP did respond to it  and  they  wil  1,

                    through their own m@edhani2, ,iies2aoe to Council  or  others,

                    will let us know whether (b) contents were missed.      But   the

                    only project that hasn't been seen  or  reviewed  in  the  rc@gion

                    was the hypertension project.

                               As to the EL@LS, the EMS we put in the items to be

                    looked at in terms ol' only the mobile  units  were  not  cart  of

                    the rCCIL,.est, and interestingly enou-h, the RAG looked at    the
                                                          CD

                    r,iobileunit almost as a, -second project and rated that  low, but

                    gave the Bay stations a higher  priority,  as  you  see  in  their

                    application.

                               This was a tarr-on throu h local pressure, to the F,,IS@

                    council,-, which they are supporting.  So total EMS is not just




                    equipment, but to continue their EMS councils and also to go
                    to complete the base station network, but they slipped in the
                    mobile units to Let Washington make the decision.  This Is the

                    way I interpreted it.
                             MR. PETERSON:  How much of that particular "'147,000

                    is mobile units hard@,iare?

                             MR. @TOLOV:  @6360150.
                             One point not mentioned, which is a plus, is this is
                    based on local rnat-chinr,-.  Very stron- point for the rbo-i.on, th ir

                    equipment was locally rnatched.
                             DR. HES@@:  BrincoD,ing in outside funds, much of this is
                    shared funding.   -And they have had a@ pretty good record of--
                    well, they have listed o, nu,,-.qber of activities, they have
                    started, which are now phese(3 out as far as RI,IP funds were
                          ed, so they do have a Food record, of gettinrr thinrs
                    concern                      CD
                    started, or@-anized, goinr, and findin.- other fundin  sources,
                    I think they certainly deserve credit for that.
                             MR. BA@qC?,,[S:  is that outside support for this

                    ,$147,000 raobile unit and so on?
                              MR. STOLOV:  What was  your question?  Was there
                    outside support?  50 percent matching on form 16.
                              MR. NAL@IH:  What they did, Mr. Barrows, the first
                    part of the Z@,IS activity they o,rpreecl with the hospitals @n
                    the area to purchase half or pay half of the costs of com-
                    munications equipment if the hospitals would put up the other





                                                                                      I
                     17,a If Now, they are proposing I think to do essentially the    I

                          thing on this.

                               14R. P.LTERr-'Oli:               ocaL funding in the
                                               Q300,000  Plus,  I

                     vih6le conjury of El@,,IS activities.

                               What we  have  hereof  course,  is an application

                     which is lar,),ely continuation, thatriay be a Little misLeadinc-,,.

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

                              tppLication with just a very           nou
                     800                                     snia II a@
                         ,OOO                                           nt ol new act

                     vity.

                               '@bni-- of the continuation, I think it is particularly

                     true of the Ei','IS, is continuation at an expanded level of fund@

                     in@.  You w@i 11 note from your table that we, have an estimate t;!,-i
                      CD

                     CentraL New York is @oinc- to core to us in July with like -,I

                     lion dollars plus  in  new activities, while they are requesting

                     now roughly --  not  quite q.')800,000 against a tarvel-a, overall

                     target figure  of  rou-hly a@'ain c3, million dollars.

                               Were  there  any other thinc-,so Jerry or Frank, of

                     sir,-ni.f-'Lcance, policy issues, ,najor problems or other thin@s

                     we want to point out to the @roL@,p?

                               IIR. STOLOV:  By and large, the CHP relationships    he.e

                     been -ood.  In fact,they are the subcontractors to the E14S


                     councils.

                               Again, the hypertension was an oversight.  We don It

                     know the arthritis.

                               As to the  ,nanal,@,ement assessment, the gentleman



                                                                              LLD      I
                     who prep,-,,red the report is away doing other management  assess-i
                     ra(@nt to d,,,y.  @le have only received a brief feedback on it.
                               YR. HASH:  Do you have -,ny general ideas?
                                   SIMO@TDS: Didn't even talk to him about it.

                     Nothin- about it.

                               14R. STOLOV: It appears  the  fiscal  management  end  wa
                     considered much improved  or  found  satisfactory  upon  review.

                               There were  other  mriavement  problems  related  pos-
                     sibly to how the director conducts  his  business.,  et  cetera,
                     but the major thin,, we did want him to focus in on was the
                                       L3

                     f i-scal          aspect.
                               There is just one other thing.  Goals, objectives,
                     and priorities were forwarded   to the region throu,-,h the  las
                     letter from council as not being syste.,n@,tLeaLly  identified.
                     Based on that we do have that and the Director, his onsl,,,er to
                     this was that he put staff on to do modified review process,
                     rather than redes-'-Lr,-,n his goals, objectives and priorities.
                               So that is where It stands now.  He still has not, '@-o
                     the best of our satisfaction -- or my satisfaction -- changed
                     the g6als, objectives and priorities, but at the @ar,,e time h

                     does address it in his project.
                               I-IR, PETERSON:  -Are there any other comments, objec-@
                     tions, observations from the review panel members?

                               I,R BARRA@TS:  I would like to ask  one.
                                If in the li"ht of the relatively   modest ratinc- thi-,r-,,




                     program has come up with, if we were to scale back there with
                     a reOLl-@est here, would it have any wholesome effect on riakitio.,

                     them a little more selective   or i Little sharper on their riev,,  i

                     project applications?

                               DR. McC.ALL:  They are going to have to be fairly

                     Selective, they indicate they have 8LI--
                                    IIARRO@TS: They are goinT to  ask  for  another  800.,

                               liM. PETERSOII:  They a,re cominc- in with astatement

                     of    mi I I'@on.  You know , this may have changed.   Obviously    I
                    .it has if you loot,, at the EMS.  Qne of the recent character-
                     istics OL, Central New York was that it  tended  to  have  4  lot  of

                     small -Lnvitational contract type proposals, you know -- Q5,000,

                     ,@10,000, @25,000.   So that   84 may not add up to, you know

                     much more than a million dollars.  I don't know, but that        cerli,

                     ta.!-nly was true in the recent past.

                                    STOLOV:   I think it was        million, adds up

                     to about     ,nilll-on now.  We estimate about c), million.

                                I ean't ,,nswer your questJ.on.

                                I think  the review committee   has to further discuss


                     it*

                                1,M. PL,'TMSON:  I think what we are'faced with in many

                     cases here certainly is -Lor all practical purposes thin-s are

                     in the pipeli ne and movinr,- out there and may not have had

                     final ILAG action, but nothing we do or -zay   by and Large in tey,,-s

                     of July applications, if  I  got  on  the  phone with the Senato"




                    from l@ew York this evening, which I am not about to do, arc
                                             CD

                    we h,3d something very definite to tell Central New York or
                    any other region, I think the timing is such that the cast   ol'
                    application we are going to see  in July is pretty well set.

                              DR. l@eC A LL: Simply Idon't know how, many dollars,

                    'vi ewould limit the number you could fund and Limit the number

                    of activities that would be monitored satisfactorily.

                              DR. HES'-O':  They Haiti already, if their performance

                    on the july application is the same as they will already

                  .have prioritized those project applications so,wher, decision

                    is made, they will already have the framework for rating their,'

                    decisions about which -et  funded c,,,nd which don't.  So in that

                    sense they are well organized and prepared.

                              I,IR. PETMISON: -And the group in that sense would

                    have sc>.@pe rou--h notion that if you gave them 50 or t@)O or go

                    percent of the request, how that would fall out, rou@hLy.

                              DR. HESS:  Yes.


                                                                                    01-i@
                              MR. BARR(7vl@@- But giving t,@em,,say, @700POO or @800,

                    they are askin@ for now wouldn't whet theLr appetite for the

                    remainder.


                              M. PE@TERSON:  I can't answer that,

                              DE. HESS:  I would like to get to a recommendation,    i

                              MR. PETERSON:  Certainly.

                              DR. HESS:  In goin@ over   the applications, it se-...-

                    to rcie I could pick out   well, approximately $180,000 worth




                     of applications  that  most  of  which  are  low  priority  on  their

                     list and which  would  not  do  great  damage  to  the  program  in

                                                                     '@;200,000 more  than
                     my estimation.  And would still give them

                     the"  are currently operating on and there      is another    batch
                        y

                     coming down the pike for July, and would require them to

                     be selective --  for  this  batch  --  and  then  we  can  further

                     exercise some selective advice via funclina, Level In the       Jul
                                                                                         y


                     batch,


                                 I think that would-- you know, we can deal        with

                     them  in  a  fairly  what  I  would  consider  fairly  even-handed and

                     equitable fashion.     So I would  like  to  recommend  "@'615,POO for

                     this particular package.


                                 DR. TESCHI@.N: Second.

                                 l@IR, PETERSON:  @")615,000 against the  request  of  not  i

                     quite $800,000 at thl-- juncture.

                                 DR. IIESS:  That's right.

                                 D R . C f@, L Li was going to say recommend @Q@6oo,ooo.

                                 DR. HEULTIS:  I will support his.  Maine was the same,

                                 MR, PETERSON:  Did I hear a, second?


                                 DR. TE'@-CMN:  Second.


                                 IvM. PETERSON:  Okay.

                                 We have a motion and   a second.    Is there any more

                     discussion or comment with respect to Central New York?

                                 If not, those in favor?

                                 (L'how of hands)




                              1,M. P.-LTERSO'ii:  -A@ain, I think I see unanimity.
                              Okay.  I think we are again doing reasonably well
                   not very good circumstances.

                               'Would like to, because we have spent all  of our
                   time thus far with rer.7ions that are at least for our adminis-
                   tra'tive purposes in the Easterit Operations Branch or Desk,
                   I would like to switch our focus, if you can, for a moment
                   D'c ros3 'he continent end take up at least one or two regions
                  @out of the.Western Branch.  I couldn't Set much farther away.
                   I thou-ht we would try Hawaii for starters.

                             John and Bill Thurr,,i-an are the reviewers on that,
                             I rairht ask you to Icicl,, off on that, John. I believe,

                  you were on the site v,.sit out to Hawaii.





                               DR. HIR.@C.IiBOBCK:  Yes.


                               @IR. PETERS014:  You have lost ,,rour tan I see.  That

                    was sufficiently lonr,- ago.

                               DR. HIR"';CHBOECK: Yes.   Thatzs January.

                               Well, the rec-ionaL medical probram   of Hawaii, as I
                                            CD

                    review this application   and read correspondence of what has

                    @ppened since our visit, I am pleased in the very positive      cher,,-e

                    of direction and ini;,)roveiiient in the affairs of the program there.

                               So although the history has been turbulent-in the

                    past, it seems there is some opportunity now to see some pro-

                    gress bein,-,- made with new  leadershi
                                                          P.D

                               The present coordinator,   Sg,toru IzutsLi, was a coordi-L-,-@--

                    tor for the E'acific BC-Is,-n Program. He is now, since fle,y Ist,

                    coordinator of the Hawaii.


                               The staff is quite stable.  There have been no

                    serious departure as a result of phaseout activity.

                               Staff is presently full-tinio  equivalents of 1575

                    with proposed expansion.

                               The question of  proo-rani leadership I think is now


                                                             -or seems to have
                    somewhat resolved in that   the coordinat


                    taken over,well -- certainly t@ way the application was put

                    together, If this is an example of his ability to take over,


                    think this Is one evidence.


                               There is a new rate chairman and the relationship of

                    the grantee agency apparently has also been approved.





                               It seems to be a criticism a small clique was

                    operating the re-iont).l rxdical program of 11,3,waii and I

                    think this is pretty well cc.-one now with these changes.

                               fis far as the program staff is concerned, it is a

                    reasonably good staff.  They have an economist there who

                    eve n as a result of the visit I wa.sn't quite clear in my own

                    mind just what his role was other than perhaps work in the

                    problem of cost control.


                               The rest of the staff had strong community      interest

                    and certainly the man involved  in  char-e  of  the  Pacific  BasLn

                    now seemed to have everything well    In hand to take over -the

                    responsibility.
                               The local involvement of the staff I,,ith other agenciel-@

                    seems to be quite evident.  This is not ,,n ivory    toiqer stafL'.

                    They seem to be involved l@n many, many thing--,

                               Re,@iona-1 -Advi----ory Group hasn't changed very mulc'n
                                 CD

                    since its inception until recently.  It's I think n-n average


                        Lonp-I advisory r-roup
                    reg,                      -s I know them.

                               Review evaluation of projects  was  carried  on  with  a ii

                         L                                                   ation C-01'17.
                    special committee or project implementation and evaLu

                    mittee.  This seems to be done almost apparent from the

                    Rer,-ional Advisory Group.

                               Past performance and accomplishments, program has

                    had its troubles.    It perhaps has not risen to the challenge

                    of rrreat opportunities that presents itself In this  far-flun,,,r,




                   pro-ram, where innovative ideas may have been experirrie
                                                                         nted


                   with.  It has been using more traditional approaches to ,nony

                   hea,lth care serv5-ces, and much of this, of course, is right

                   viel-iin Ilawail itself.

                             Only recently, according to the applications that

                   are in this particular package, has there been a great

                   spurt of projects for the Pacific Basin; the new projects

                   are being proposed for the  Pacific  Basin.  Truly  not  great  in
                   dollar 9,niount, but they are for the 'benefit of specific    I

                   peopLe*

                             The objectives in priorities-are, again, as I -said,

                   rather traditional and we think there micht be others they

                   could come up with as a result of the opportunities,  increase

                   in medi-ot-il program.

                             They are fairly, fairly rational. I  will  read  SOI"le

                   of the@n;  Encoure e innovative arrangements for organization

                   of health services, methods of financing, reduce unnecessary

                   duplication of health resources, encourage improved produ,.ctiv@;t,,.-
                                                           CD

                   of individuals and organizations, and so on.

                             The proposal itself is for the continuation of  some

                   on-@oinL@, projects that were started this year, and a nu,,nber of@

                   new projects. They intend to  have  substantial  package  in  for

                   the July lst review.

                             .As to thejbasibility cf this particular program

                   carrying out its program functions, likelihood of  proc.,,oer,@ty, @i




                    progres   I thi nk under tie new - leadersiai P we w I I 1 have a chatit,,a

                    to see whether there will be improvements.

                              I think that in general thin--7s look pretty optimistic
                                                           LD

                    compared to what they were before.

                              CHP rele,tions@ips,certainly here is an area of
                    great improvement.  This is evident in the application.     Underi

                    the old re-ime the relationship with the CHP, H&-C, was  almost

                    nonexistent, althou.@h the director of the CHP was a member

                    of the advisory c,-roup, yet collaboration at a  working  level

                    -wa@@ apparently not very evident.

                              And now I notice in  the  application  that  there-is

                    active criticism and comment about the various projects that

                    have been proposed in this particular  application.

                              The whole problem of CHP in   the Pa-cificB-asin is an

                    unknown quantity as far as I am concerned  and  there  is  only
                    one (b) agency in Hawaiian Islands itself, so that It is a ver,

                    unusual type of situation to deal with, although this is a
                    very a,etive CliP ao-ency at the so-called state level,
                              My overall assessment. is I would say  avere,@e  with
                    possible imorovement in the near future as a result of the

                    chanr-e in management direction.

                              IvM. PETERSO'Lll:  Thank you, John.

                              I wonder, because of   the'lonr,, history of Hawaii, the,i

                    kind of problems that we has had there, I had intended, in
                    spite of my best intentions, had for"otten, I had intended to
                                                          CD




                    depart on this one from our for-@t and idas c-,oing to ask Dick
                    Russell initially to fill you in, because there have been 20
                    many developments literally  within the  Last  few  months,
                    And if you have no objections, Bill, I will try and make that
                    ha,lf good and ask Dick to perhaps fill In some of the
                    background very quickly as it relates  to  Hawaii  and  the
                    developments literally of the past tvio, three, or four months
                    since the new coordinator come on April 1,  I think it was,

                    rather than I,,Io-,y 1.

                               It is a matter of months in any case,


                               Dick.

                                   RUSSELL:  I think Dr. Hirschbo--ck has covereu

                    some of the points very well.
                               I would like to say that this particular    q,pplication',

                    was put to,-ether under the direction of the dept.ity  prior to   i

                    Dr.   Izutsu assLLnin-. coordinatorship.

                               Unfortunately the deputy -s still operatinc- un er     e
                    old  philosophy that anythin@- was fair.  There is goinE to be    a'
                    lot of money.  He still hadn't gotten the message about what

                    the  problem had been with the pro@ra,m -- he has it now.

                               The Regional -Advisory Group has  not  yet  come to the

                    maturity of setting   priorities. This  has  been  done  bya

                    small groups planninF,-Impleraentation-evaluation committee.
                    I think they try to do a c,-ood job, but it is all on a,  personate
                                               CD


                    criteria.




                              In view of the s, Dr. IL'zutsu 'Ls now orienting
                    RegionaL -Advisory Group, new mei@ei,s as well as t@-e OIL! raeniber@,-,
                    and at their June -- I think It is June 23rd meeting, they

                    are -oiiig to reset priorities.
                              I think 35 letters of intent they have now that wilil
                    probably come in as projects as well as those projects in thi@-@

                    application.
                              In other words, by that time he hopes to get some
                    sort of system where the Re@ional -Advisory Groupvil.11 in an

                    .ob-'ective manner seu- priorities.
                              I was in Hawaii for a week wi-th Dr. Izutsu,   a rLd   is

                    a completely new program, no dodot about it. @adersh-I   p here
                    is unbelievable.   He has iiliip@occl the staff into shape. They
                    are part-@@-cipatinrr sh,@ritl,-, information which before the inforr,,,.a'-
                                     CD      L)
                    tion was not shared with icey staff nor was it shared with the
                    Re,.@ioriaL -Advisory Group, It was a cl!qL-,,e, no doubt about tha' L,
                              The RPG has been revamped.  Dr. Izutsu has gone bacl,@
                    to our advice Letter, which came out of the November 1973
                    visit.  ldr. Barrows was on it.  lie has gone back -- Dr.
                    Hirsc@'boeck had a. copy of a progress reoort,   All I can  say is

                    what he says -Ln there is indeed fact.

                               The Hawaii ',L,Iedical Association is now very wiLLLn,-,,,i
                    to be involved in the pro-r@n-m in view of the absence of the

                    former coordinator.

                               The University of Hawaii School of 1,;Iedici.ne,





                    Dr. Ro-ers is very much Interested in being involved now as
                    well as Mr. Michael, dean of the School of Public Health.

                             CHP relations, night end day, it is really great*

                             The co,,nmunity's image to the RMP has changed in the

                    six.or seven weeks -- he tells the same story to everybody

                    and that is a rarity in that RMP.

                             We have just recently, as was noted in the summary
                    here -- there is a duplication between trust territory,  cerebral
                    cancer projects, and one taab has been submitted to NCI.  I
                    worked with NCI staff.  TICI staff is in touch with Dr.  Izutsu.1

                                                               in with NCI,  and thi
                    .P,nd he is plu c-in@ the trust territory aga                  .;s
                    is the type of-- he is really the Rl,(iP, now has become fecilita-I

                    tor which it has not been all these years.  He  is  having
                    meetincps between hospitals -- hospitals never met before be-

                    cause nobody ever called them together.

                              Tlaereis a -,rantee relationship with relation'to

                    EL,.IP that's very good.  @le had some concerns because the execu-

                    tive director of the Research Corporation  of  Hawaii  was

                    what do you call it -- proctor?  Dr. Izutsu, soffe  were con-
                    cerned there might be this type of influence on Dr. Izutsu,

                              I sat in a iieetin@ between these two -nen.  Dr.
                    Izutsu gave it straight from the shoulder with the grantee as

                    with anybody.

                              It is unbelievable what he has done.

                              There are some weak spots In the staff.  Dr.           I




                     Izutsu in seven weeks hasn't had time to cure all of the ills

                     of the past, but no doubt in my mind he will.

                               DE. TELIJCHAN:  lfhet is the population?

                               IvE. RUSSELL:  Of Ha@iaii?


                               DR. TESCH-AN:  Of the re-ion.

                               MR. RUS,','E LL: 100,000 in Hai-i a i. i

                               14R. PETERSON:  100,000?   I think  it is over a mil-

                     lion in the Island of Honolulu.

                               14R. RUSSELL:  800,000 in Honolulu2

                               II:R. -@2ETERS014:  Ancl trust territory.  And all that
                     c- r e e, t b ic,, expense of blue water doesnlt7 add a heck of a -lot,

                               I im-3,(@-ine a million when you add sand crabs -- we

                     spent  occasional beer-drinkinr sessions in 1945.
                               There may be people   there now, weren't  many then.    i

                               I'M. RUSSELL: Not @olny people, but it is a 3 million


                     so,uare mile area.
                               14R. PETERSON:  Sister Ann, who often thinks ttn

                     distances comin@, from the west, l@'laine, Utah, and even -Alaska

                     I think, pale  by comparison to what in one sense is the turf c;:

                     the geography  of the Hawaii R"i'4p.
                               Bill, you were the other reviewer on this,  I wonder@@
                     what you have in the way of addition-,I rel@n-Lorcing/sub-
                     tractinv'kind  of comments, both to what Dr. Hirschboeck

                     and Dick  have mentioned?

                               DR.  THURIIAN: There are   two points that have co.-,,ic.





                                                                                   7-

                                  three points I would rflakep and  that is cOM-
                      over   here,
                      munica 1. tion situation) I)J-ck.has discussed, is very obvious

                                                          ople and  they    recognize
                      they have not really talked to    pe

                      Iam sure they will take care of it.

                                 They still donl.t understand the priorities.  They

                      a,re ill defined and they are working on that,

                                 I think  the  last  thin g thatdisturbs you about the

                      thing, all of us  knew  this  before  from  when  Len,  Shirlis

                      and others went  to  Haviaii,  was  when  projects  terminated, no-

                      thing ever happened from then on, you know.        o hid,-.- ever
                      came of the projects that were funded     in  the  past.   Pndt

                      think that is going to be the real thing here,

                                 Really it depends on whether or not     they develop

                      some llqiiali projects.

                                 if they  can't  develop  Hawaii  projects,  this  is goin-,,

                      to be still not a  c--ood  program.

                                 ,Almost everything they have put In there is basic.

                                 MR. RUSSELL:    I did just get the minutes of the plan-

                      ning-impleraentation-evaluat-'Lon con-nittee, what point they
                      are screening -- last eieek they were letters of intent.

                                 Here one hears comments, we will consider this if

                      these three letters of intent are taken, worked together, as        c@

                      sin le project.  So this type of thing is occurring,

                                 You know, herep again, when we talk about      unified

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


                                                                                  I
                   geography, is in excellent position to pull the resources
                   together and work together.  I think this is the type of direc@

                   tion Dr. Izutsu is going to give the program.

                             MR. PETERSON:  IvLr. Barrows, I didn'trealize you had

                   been on the site visit.

                             MR. BARRA-IS: I was.  As these fellows found it,

                   I found it completely fascinating, positive sure for me-.

                             The pro-ram is hard to compare with the ones we are
                   ,--customed to first in terms of geography, when you start thinki
                   .ing a-bout the Pacific Basin.  AsI recall, it is somth,-nE like-!
                   seven hours flight time to c,-et to the nearest point fropi-
                   HonoLulu, -ind so you can't be making daily calls-- the  Pacific

                                                         we are famil
                   Basin is terribly tough from ,,nythinEr            iar with
                   econor@u.cally and socially.  Therefore for health resourcesit

                   is almost wholly dependent on government operations.
                             There is no private, to provide health care.  It is

                   quite unique in that respect.
                             Back into Hai.,,ali itself, the islands are physically

                   sep,o.rted, which poses some problems for the"  You can't have  i

                   ambulances shuttlinr,- back end fort4 that kind of thing.
                   And then on top of all of this@ their social attitudes still
                   reflect considerable Oriental influence, and they look at
                   thin,-s a Little differently than the way they do in Chice,@o.
                       C)
                   Maybe t'@iey shouldn't under our creed, but it just happens to be.'.

                   that way.




                            So I think when you look at Hawaii, youhave got to    i
                    look at that qs this Is a unique -- judge on Its own merits ,.nci

                    not necessarily compare it.
                            MR. PETERSON:  Any comments from the other reviewers,
                            DR. HEUSTIS:  Has the word got to the new &Cminis-
                    tration about the great opportunity that, Dr. Hirschboeck
                    mentioned for innovation on the,part the staff had raised,

                    here is a real fertile field2
                             I a,,-a tftinkingttiatyou had such a thing off.tfte boast@
                  -of Maine, not 7 miles away but shorter distance, they  put a,
                    nurse with a television connecting herto the mainland, -thinf,@-S.
                    like this, where she can Teta less well trained  person can

                    get consultation.
                             Has li@-waii thou ht of anything like this?  Can they

                    be stimulated to do--
                             14R. RUSSELL:  We a,re talkinrr about two programs; we
                    talkin,-, about the proLrram In the State of Hawaii, we are also
                    talking about the second program which is the PacificBesin,

                    So Ihave to ask,.you kno'wl--
                              DR. HEUSTIS:  I just understood from comments, I
                    had not read -- the comments about the vreet opportunity for
                                                           C)
                    innovation apparentlyfcom the standpoint at least I heard the
                    reviewer saying was not exploited     taken advantage of,

                    capitalized on.
                              DR. THUR14AN: I think my answer for that would be




                   yes, In the pro,-,ress report the new man has just forwarded,
                   he aees what has been talked about over and over age-in.  lind II
                   think fromthe way he writes, he has got the moxy to pull it of@'o

                             DR. HEUSTIS: Okay.
                             DR, THUPIMN:  He understands what you are saying
                   and wha,t we have said in the'past about 'It. So I would feel
                   comfortable, he may a,-et egg on his face but Ithink he knows

                           a,re talkin- about, ye.S.
                   what we
                             DR. F@USTI.S:  Just corollary, does he need'support
                   -from us, help getting the egg on his facb?
                             DR. TIIUR,';'.4 I think Mr. Russell is providing that
                    support In a very rqeanin,,-ioul way.  Putting grease skids
                    under the last ,rian was a very essential thing.
                              MR. RTJSSELL:  Yes, I think he could use support front

                    the reviewers.
                              You know, quite frankly, no one quite knows the

                    prob le  we have had there.
                              If one looks at this type of application, the types
                    of projects in th,.s application, and a new direction that the
                    pro-ram staff is a-oinc- totake; facilitators, it seems to m
                                     CD  CD
                    this is perhaps where they might want to concentrate a little
                    bit more on perhaps in the future than being so project

                    oriented as in the past.
                              DR. HEUSTI'@:  If in sone way, In whatever way Is
                    appropriate, he could get some encouragement so that he





                    could oo to whoever the traditionalists  are  and  simply  say

                    this is what the Re(,,ionaL -Advisory Group or the  Council  or

                    the staff whink I should be  doing in getting support,

                    sometimes this Is helpful.

                               DR. THURIIIAN:  It might be worthwhile for us to con-;,

                    sider in our proposal he be asked to consult with those who

                    are beyond the traditional realm.

                               .As Mr. Russell indicated, the @uy whojust took overi
                                                             C)

                    the school of public health out there is  an  innovative

                    schemer for delivering hea.Lth core.   It is his big bag.   I

                    think if we were to push  Dr.lzutsu  tovia,rcl this man--

                                  RUSSELL:  They are already together.  I sat in

                    a joint reetinx with them, together.

                               DR. HLUSTIS:  P, fellow like this needs all the

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

                               DR. HESS:  He only has a year to  go, so far m  we

                    know, under this particular pro-ram,  So I   think our enthusiasm

                    fo:r you know, specific recommendations for  gettin- all @ea.red

                    up and wound up have to be tempered by that life span.

                               DR. HEUSTIS:  Something is going to be there.

                               DR. HESS:  Yes.  But it sounds to me like this guy

                    will find his way in.  Figure out what can be done.

                               SISTER JO'@-EPHINE:  Two things I have been impressed

                    two ways of -ettin- a procramto bone up Is either to   deny

                    funds or pressure the poor  coordinator to Leave,






                                                                        when we
                                  RUSS-LLL:  He just happened to resign


                    were out there.

                              DR. HEUSTIS:  Tha.tls right.

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

                              DR. HIRSCIIBOECK:  I will make a recommendation thgti

                    maybe we approve the @1.5 million.

                              14R. PETERSON:  That is the full amount that they

                    a-.re requesting this time. They are coming in we understand,

                    and I think Dick has much better intelligence on this

                    rec,-ion than we do on most, in terms of what is like Ly to- be


                    comin@,, ",-n,

                              They are cominc., in with another request in July,

                    'which wLLI perhaps bear more of the imprint of the new doordi-r,@,',-@-
                    tor, the reconstitute of lll,,G, et cetera. Roughly a half  MiL-

                    Lion dollars.

                              I am readino' my figures correctly.

                              We probably, over the two sessions, will be  lookin@,-

                    at close to a 'y2 million package; three-quarters of it  is  re-

                    quested at this time, a.ge,inst, again, a benchmark or target

                    figure of about  rL,1.5 million.

                              DR. TIIURI,4AN: I am going to have to take issue wi he

                    a fellow reviewer and say I would cut this $1.1 million to

                    4')L,2 million to let's see if he can do all the things we are

                    looking at.  That is the only place I would disagree.  I

                    think it needs our approval and support,  but I think @1.5




                    million, althour,-h they are already at $93@(,OOO -- he is In a
                    situation now where I think with adequate staff support, he

                    can bring about a change in this program even  though It is
                    only for a year, to answer Joe's question.   But I thiik @L.5
                    million  is a Little more than they will be able to utilize
                    if they are coming in with another half-a million dollars.
                              DR. HEUSTIS:  Thaty would leave some money to take

                    care of the half  million.
                              DR. THUIUIAN:  Yes. I would put it at $1.1 million

                  .I   believe.

                              DR. HIR.@CHBOECK: I think I agree with you.

                              DR. HEUSTIS:   I Qupport your motion.

                              MR. BA-RI@O@,TS: 1. think they mic@hlv- relgx a little bilv.@

                    It might go too far.  Give them a little  bit of encouragements!

                              DR. THUR@N:    I would wake a substitute motion

                    of @l,l million.

                              DR. HIRSCHBOECK:  I second it.

                              MR. PETERSON:  John seconds that.

                              I gather one of the important things we want to
                    convey, because we are talking about a dollar  figure, but  thati
                    the Croup, and presumably the Council, if it   listens to your

                    advice end what have you, th@ the group feels  that the pro-
                    gram is at least showing indications of moving In   the right

                    direction.

                              We are going to ask  the new coordinator to do what




                                                                               133

                    he has probably already started  to  do,  started  to  looking

                    beyond the traditionalists out there; so the figure of

                    million, which has not been voted on yet, we need to be care-

                   ful that isn't interpreted as a largely negative signal if I

                    heard the discussion.

                               It has been moved and seconded   we recommend $I,l ml.l@@-


                    lion in this case.


                               Are there any other comments,   observations,   or

                    questions about Hawaii R14P In this application?

                               If not, will those in favor,  if  they  will  raise


                    their      either one will do.

                               (show of hands)

                               IIR. PETERSON: regain -- I don't know whether It it the

                    lateness of the hour or  monotone of the chairman or what, but     i


                    we seem to be drifting   into the  complacency  of  unanimity.

                               DR. THUI@i,,IAN:  Never, never.


                               MR. PETERSON:  Never.

                               I was going to try possibly to put a little life into

                    the meetina, by suggesting that if we have dealt with Hawaii,

                    now, we might pick,up on another one of the Western  I)el@Zlk

                    re-ions.  This happens to be -Arizona, Paul Te,-zchan, by virtue  0-@

                    Dr. James not beina- ?.ble to be here, will be the only reviewer,
                                       C)

                               I think staff will have some comments here.      But

                    if it is satisfactory with everybody, we will move from Haw,,,,ii

                    and the- blue Pacific to the southwest and  take  a  look  at




                    l,'rizona,.which I think is one of the fastest gro@7ing st-ates

                    in the Union.


                               Paul.




                   "ORIZGI;,A

                             DR. TESCH-AN:  In contrast to tt,e fastest growirio,

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

                   production.

                             The application is for proir3m staff and for six

                   projects, five of which a,re continuing.

                             There are evidences of three  more coming to the end  1,

                   of funding in the process of  working up the various pa,ges of

                   the form,

                             In going over the application, we are  unable,  realL@,

                   to find what program goals a.nd objectives have been stat-ed.

                             There is moreover in sorae of the ancillary inforrrp--

                   tion we were sent In the sunL,"ary of program status, iSSL@es

                   raised by staff onthe basis of theLr visits, et cetera, tha,t

                   a review verification is pending, pending conformance to

                   DRI,IT policy. And the issues are that the bylaws  need  revision

                   and the RAG membership needs better representation

                             The application is silent on the subject of bylaws,

                   bylaws revision or anything about the process.

                             The RAG membership, the application  is silent  on  the
                                                                              .1

                   question of RAG membership chanr--e.

                             The membership continues to have   18 individuals.  Tl-;ey

                   tend to show at the rate, according to the  application descr'LP7

                   tion, of'Ll to L2 per meeting.  And in Lookinc, at the member-  i

                   ship of the @.G, one does not vet the impression that the
                                                  C>

                   principal leadership of health     of the health forces in






                                                     e thi n@
                    Arizona are in fact members of th
                             There are issues of  racial balance and I a.m not a
                    good enough geographer of -Arizona to tell how  Geographic
                    the balance is.  But it would appear the issues that  9,re
                    raised in that document are still with us as far as I can

                    tell from the application, no change at all.
                             hlow;'ithe staff is indeed stable since L967 and you
                    get the sense that there is not, as a matter of  facts  so.me -
                    where between the coord'i-netorEAG chairman, executive committee,
                  .abiLity for pro-ram leadership and direction in lj.'ne with at

                    least the administrative issues having to do with rev'LeAl oro-

                    cess verification.

                              On the other h-.rAd, there are issues of expansion O-"

                    health service sites having access continuation pro@ect for one
                    more year, extension of medical manpower, a recruitment procrr,@lil
                    extension for one more yea.r, and a fairly localized health

                    inforwtion dial-access type of pro--ram, which by the title
                    itself provides health education which is also scheduled for

                    extension.

                              There is E,%IS project and hypertension control pro-
                    ject. There is a carry-over into two more counties of a stre@-

                    tococcal infection projec@ control  project.

                              There is in addition a rather surprisingly, I t@.ink@

                    from the buildup, apparently a, cessation of the continuation

                    education service area project. It comes to the end as we see!
                    it in the end of 1974 according to the  application.





                              However, I thl.nlr- in supplemental l,nformat ion I  got
                    across that I have just received and.have not carefully      stuOie@@,
                    it may be that there is a further extension of that, because
                    In the application on page 19 the PP.G suggests that there
                    slao,lil(i be maintenance of activity In the continuing education

                    service area project.

                                have to ask for staff help    on that particular point@,
                    particularly In how  there Is actually organized, in view of tried
                    fact there appear to  be in the sites pages 19 separate committees

                    -in various places which are sopposed to identify local needs

                    a-rid assist in development of those local programs.

                              IliR. BARRO,@4;S: Are those rura.l?

                              DE.            Well, I, would i.T,-ar,,)ine small

                    They are not in Phoenix and Tucson primarily by any -r-@ieans.

                    They are scattered out  quite  wi-delir.
                              The interestin-- feature -,bout that particular pro@cl--
                    statement, ho@iever; why I  am, o.inbi-uoLis about it, Why T tho@,, t
                    its discontinuation was a   plus, is   because the evaluators, at
                    lea,st the capacity for evaluation,    pan-e 61 of the application,
                                                            CD
                    say there a,re at least three ba.sic   changes that have-- two baz:'.c
                    changes have to be made to qualify     for further R14P  support

                    beyond June 30, 1974.
                               Did you want to clarify?  I certainly wander am urid
                    that one,  because that is the state  the  application  is  in.
                               MRS. SADl-t4: The CESA program,   try are  goino-  to
                                                                               LD




                   continue it for three more months without  additional 4L' u nd s
                   requested until It cets a, complete review., They may come in
                   July I but I am not sure,  They have had problems with it.
                   The staff feels that it should change its emphasis even

                   thou,-,h it does have that many committees and it is throuc,,ftouu-
                   the state.  They also feel the medical school, university In
                   @enera,l, should have taken over some of it, or some medicaL

                   society or some other professional organization.
                             In order to help the staff, they asked an outside
                   co.,nmittee, ad hoc consultant, to come in and evaluate C ESP,
                   I guess unfortunately for staff, the outside committee felt
                   It was marvelous,, end recommended to PAG that it is a very
                   uood activity end ou@ht to be continued. And I was at the     G
                   rneetir,c, where all of this was being discussed. The way they
                   handled it was, as I  -,aid, just asked for two months without  i
                   additional funding have (0, complete review of the CESP, progr<@:.,.-,,.@
                   If they do come in a-ain, there be a different empfta,sis that
                   it not-- well,several ti-iingsp one is that there be a different
                   emphasis in terms of need, patient care need,   rather than
                   just what you think you would like toknow,
                             Two is  the university and heft,Lth professionals
                   put some money in themselves. -And they were going  to  have  all
                   of this ready by July 1.  That Is iihy-- but it Is not in here

                   for money right now.
                              DR. TE'@CHAN:  I mentioned this simply to say it




                                                                             ijg

                    seemed to me that the comments   made richt here showed  m

                    more staff.  I had been developing a fairly @destrian    picture@,

                    of staff function and all of a sudden  I  come  across  some
                    very good "sort of either it shapes up or we don't continue Lt'.1'

                    a nci I thought that is great, that is a plus on that.  And I i,iE!,S

                    seein@ the thing end  based  on  thetarminal  date  here,  And

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

                    that.

                              So I am sort O.L at a, questionmerk  on  program lead e r-'

                    ship under insufficient basis.    That really is pretty limited

                    jud ment.   It is hedc:,-ing one's bets pretty severely.

                              But it looks to me as if--  it  looks  like  there r, in,, y


                    some pluses,rraybe sor,,ie ,ainuses.

                              I would say I can't quite--  it  sounds  Like  the sta--"f,l

                    is rriovinc, particularly because of their access  projects,

                    s,                                  stef' has more  life  in it
                     @on projects.  It looks like the

                    than the application would su@c-'ec,,t and that the i@G is inade-

                    quate to deal with this situation.

                              So I left the leadership in questionriark, progrcri

                    staff probably satisfactory, and it is because there are PLL,-Ises

                    andr,inuses, and that the Recrional Pdvisory Group has to set

                    Goals, objectives and priorities, they have oot to come to

                    grips with the rev-Lew process requirements,   the bylaw system,

                    and I don't have any evidence that they know how to  do  techi-ii--

                    cat review.  I don't have evidence.





                                      @IRS. S.ADIN:  Yes.   Okay.
                                      14R. PETERSOTI:  We are back recentlyi guess it has

                          been   couple of months now.

                                      14RS. SADIN:    One month.

                                      14R.    PETERSON: One month        she has in Arizona, on       ci
                          review verification visit, which I think it is very relevant
                          this consideration and I wonder if you -- I am not sure at

                          juncture, '@Oaul.
                                      DR. TESCHAN:      I am goin,--, to finish Lp readin,.T--

                                      YiR. Pl,,TERSOII@l: Why don't you do that, then there are

                          some  issL-@es  sta,ff  micht comment

                                      DR. TEc@@CH.'m'N: That would allow you to comment         as  yo@

                          @0,

                                      IIIR. PzfE@@'So",q:

                                      DE. TE"-"CHPll:   In pa.st performance, it added up to
                          be satisfactory I tt,.ou-,7@ht in the sense that substantive
                          proble,-.is of availability @:,-nd access, I didn't get a sense
                          there has been any-,@nput from the region in the defining of
                          They did launch renal, end so Llorth.  They got funding after
                          termination, continuation funding for this.   So it was from

                          poor to @ood on ti-ia,t.
                                      Objectives and priorities, @ain we don't ha,ve
                          that, for pro-ram,  -And that note was noted in CHP corres-
                                          CD
                          pondence, which was in this application very extensive.

                                      -Also the arguments back and forth are very





                     interesting.  We will get to tha,t in a moment.
                                The proposals I simply wasn't able to      clett-rmLne  what
                     the explicit objectives and so on were, and I have the dis-
                     tinct feeling, ocrain CHP comes up here, In terms of 6(c),

                     the CL-IF has been virtually silent in any useful way.
                                That is to say, when this comes to the CHF,
                     say something to which Dr. lvialnik should address the @ogram
                     they  don't  help  him.  What  they  do  is  complain  after  the  fact
                     in loud and sor,,,-@vihato  oh,  vituperative  language  which  doesnlt

                     help enythinc, in particular.
                                  LD

                                I should add at that point the correspondence        between

                     the director end the CHP, various CHP'S, is very interesting

                     in  that  where  the  replies  have  been  has  beenvery   substantive.
                                You cet a feeling there is a professiona,L expert
                     who knows how to reply, how to deal with the situation, in

                     those arguments.
                                Feasibility,@ie felt what was goiri- on could be

                     achieved,I felt this was a below-avera@@e situation.
                                 It currently, based on their     request, has nearly
                     49 perc nt of the total bud[--,et will @,-o  to program staff as    we
                             e
                     see the story.  You know, depending       on which numbers you use.
                     But it Looked like a hinh degree,            amount  at  most  of   the
                                                u     CD
                     activities are    either firizona Rl,',P staff--  there  are  two  pro-
                     Crams out of the total of '@@'l-3 inilLion; namely, to the time ofi
                       207,000, which  appears  to  be  the  league  of  Cities  ',nd  Towns




                                                                              142

                    .Arizona Ifea,rt I..ssociation) that a-re not either the Colle,.,,e

                    of Ijedicine or the RI.,IP.

                               There are two Colle-e of Medicine proposals which

                    come to "?88, 000.

                               So there is a, large proportion of RMP in ColLec-e

                    of Medicine  type activities in the application.

                                   @-TERSOii:  Thank you.

                               Do you want to comment on  what Paul may have   said,

                    but also the issues that appeared to you as a result of     the

                    review ver,'Lf'ica'U-'Lon? It was made in ApriL-',4ay.

                               MRS. SliDIN: It wa,s spent both times.

                               Actually I spent a lot of hire in   Arizona, lately.

                                   PETI'@SON:  Cl-Lra-ate agrees with you.  Californi,@.,i


                    too.

                               @IRS. S-ADIN:  There ,re several times-- sometimes we

                    leave too little to our reviewers.  I do remember a review

                    process   verification reports*

                               DR. TEc.'CI-IP,,%': One up.

                               MRS. @lf-DII,-,T,: I do have it.

                               We were there at actually   several sta,-es of our re-

                    view process.  One is where they just provide staff assistance'

                    in the development o'L' a project, project development, and we

                    saw one iihere-- this was in an appraised project, this is

                    their ad hoe committee, review coia.,i,-ttc-e met.  We saw ',-,hat

                    kta@@c.  -And we came back later, saw three different sL',a,r.--es.




                                 Their review really is pretty -ood.       Their staff

                     assistariiz- is good. Their  technical  reviewers  --  as  a  ,,natter

                     of fact, the technical rcv-ewers had ML,CH to saypbout this
                     pc),it.-ticuler potential, they 'wLere Looking a,t -all of those colrirnerA@,@,,

                     were taken into consideration and modified by the               it


                     came direct, so they did make those changes.

                                 Your comment about RAG, we have been sending letters,,

                     to  Irizone,  yearly  about  their  RAG  composition.  The  RAG   has

                     remained riore or less the same since it started--

                                 DR. Tz@'SCHAN:  Appointed by whom?

                                       "ill.DltN: Appointed by the dean of  the  l,iedic,,,l


                     School.

                                 Now, they had adra@Lt of revised bylaws end they

                     decided to shelve it becatl:..-e of -,ifiSA.  When Nie@,ere there

                     befcre the review visit, they said they were not  confo-,,,-,iin,,-,ro

                     They are now revising -- they have to have 30 days before they

                     can consider any ci,,an--,es, that is in their bylaws.  They know,
                                              ID

                     it is  said  In  their  letter  t@ey  must  revise  their  bylaws  and


                     they  will.

                                 And their revised bylaws of which we have seen draft,

                     and which trans-rratia,.-,,erqent has seen, looked a,t,  to  conform.

                                 On the  other  hand,  we  have  indicated  that  we  can't

                     certify until it is done.  So that will be taken care of.

                                 At their last RAG meeting ttiey-did vote to increase

                     their RAG membership by six.       -And  they  indicated  that  these




                     six @ipmbers wouLd be  from,  areas  not  presently  within  the  state,


                     both f-peo-@
                              ,raphi%^,aLly end nonprovider types.    And   this,   again,

                     Is In  the next letter, Dr. Malitc, after review process.

                                There was another visit, that was in January,       and

                     I made that one with Dr. '@,annon,  who'.used  to  be  in  our  Councii,

                     he had visited  -Arizona.  with  us  before;this  was  done@  because

                     their supplemental application, which      showed they  red, I ly had

                     ipLde  a  lot  of  chanves  since  their  pre-phaseout  applications,

                     we wanted to w-ke sure they really did it and it wasn't on

                     paper,   And there were a lot of chances.

                                Their ILAG had recommended,    for  instance,  they   work

                     with CHP and they hod visited and worked with CHP.  So this

                     -really the (b) Cents tellinc- what the needs are.
                                       tD

                                It may not be true    of Phoenix ari& Tucson, rei",iote

                     areas of the state they ore @)ork,@nZ there
                                                                    0  At the ir IIPG

                     meetinf,-, as I Indicated in that suiL-,iary I gave You th,,-s iro r n

                     there was a lot of discussion about what Dr. Hess Mentioned

                     this riorninr- which Is, you know, the cost; do you spend
                                  C3

                                                 where  there  are  150,000  peo@,le,  or  do
                     @350,000 in remote areas

                     you concentrate  on  South  Phoenix,  areas  that  are  hiuher  densL@@-

                     population?

                                That can be a philosophical question.

                                Agci,.in, in reraote-- they are,what they   are tryin- to

                     do is provide services and provide sites and provide where          YOL'@

                     can't support a professional now, they can't support one pro-

                     fessional -- it may not work  out  if  you  are  go-Lng  to  do  it  per




                                                                            14@


                    person*

                               DR. HESS:  This is an example of where I think @gup-

                    port ought to go.  They have unusual obstacles and limited


                    resources,


                               MRS. SADIN:  Yes.


                                                 -iink this is wh re RIT ou-ht to b
                               DR. HESS:  -And I ti              e


                               limited role in whatever it sees.
                    playing a

                               If government doe,-@n It play at Least a facilitating

                    role, it      be a long time before people get access to heal,h


                    servi-ce.c,.


                               Maybe you are misinterpretiti@ what I am sayin
                                                                             90

                                    ST@DIN: No, I am not.   I say you couldn't do it'

                    on a population basis.

                               DR. HESS:  You have to take -,eography, needs, and ob,-

                    stacles that have to be overcome into ci,ccount.

                               MRS.         That, by the way, is part of the pro

                    gram staff bud,,-et, even though ter,,ned an activity.  So the

                    prof-ram staff bud-c"-, is kind of not -i, true budget.

                               It could just as well do a project.

                               Your conumnts on leadership are kind of  interesting


                    because  it is kind of yes and no.

                               I don't know if I go off the record or not.

                               (Discussion off the record.)

                               MRS. SADIN:  IU-,G grantee policy will be taken care

                    if they pay any attention to their advice   letterand I im-,-, inc,,






                    they will.
                             What you Go about the coordinator I don't know.
                    Their review process, as far as staffing is quite thorough.
                    -A nd in terms of objectives, that is really kind of ironi.c,
                    because one of their main criticisms, when we wore there,   i us t@
                    before phaseout, was that they had the mostbeaLit'ifLil chart    I
                    onthe iialls which is still there -- I guess always will be.

                              (Laughter)
                              Shoqing not only just goals, b  ut objectives, sub-
                    objectives, sub-sub-sub-sub-objectives.  It reminded      one   oLil!'

                                     lented it looked like somebody all dressed
                    the vsitors cor@L

                    up and no place to rTo.  So they have that.

                              DR. DR. TFQ@Clil.. N: It is in the book, but it doesn't


                    come t',-irouoh.


                                ci
                                bi,  I         I
                              fall @IDIN:   It is in all their other books.

                              They do have very eloquent objectives.

                              DR. TESCII.AN:  What I recommended, was thinkircr o

                    recommending, was something like 80 percent or so of request.

                    Funding approximately 80, you know -- we go back and forth,
                    up and down on this.  But something like 80 percent of the

                    request.

                              In order to particularly cet the message that we
                                                         C>

                    encourage their move out of the metro areas, that is to say

                    It seems to me a movement is afoot which has a reason for

                    being supported.  We want to be sure that if the group @Leets,




                    that is the easel if we want to do this, that thevget that
                    raessa,--e and not other massages, that all the funding, et
                    cetera, should be contingent on the verifications that you
                    haVt-,, just already certified, so that this appears out of it.

                    That there should be some attempt to possibly in terms of the

                    total funding to double up on staff if they can, because the

                    staff costs relative to the total request is pretty high,
                    a.ithough I am not now talkin-,-, aboqt-- not core project so ra u c

                    But I think with the new applica-tion--
                              i,iRS. SADIN:  They are also putting some people out

                    as area, repre--ntetives.

                              DR.           Yes, I      that.

                              SISTEF,. JOSEPHIi,4E: l@y I ask, what is the possi-
                    bility of seein- th'@ reco,,rrnencl<ilu-ion t,,iat they move out of the
                    metrpolitan area. and some of the other recommendations you
                    Trade, the fact they are complyinf,- with it, to be visible
                                                     C)

                    by the time of the next, reviei,7; is that req.1istic?
                              I-'al. PETERSON: It is in the pipeline now. That is

                    the problem, Sister -Ann.

                              I think the only way it
                                                        niiTht be minimally heated,

                    helpful, would be if there is a la.rc,-e variety of activity
                    a-nd they were to sort of take that into account in their   pri-
                    ority setting or the mix that they submitted -- but reall.y, I
                    think if we don't have enythinc, in the pipeline or the drE,,win,:-.-,

                    boa.rd that @Lits this, they aren't Going to have it chain,





                     re ardless of how instant  that  communication  is@  and  how  foilc

                     foL, how heated.  Time Ju.,-Dt  won't allow.

                                DR. TESCIY@N:  I would Like to Dsk one critical

                     question.  When you look at that c,-roup of IP, and now adding

                     the 6 more you have just said, it is obvious Dr, Duvall

                     is goi-nl- to be the dominant personality in the group.

                                YIRS. SADIN: He has been, was,  I  was  at  the  RPG  mee

                     inc7,.  He does tLIrn votes around.

                                DR. TEZ')CI-ViN:  You say he is a leader?

                                              Ile is not goinc-, to be on the I@G an
                                                                                     y



                     more,,


                                DR. THUR@@,IAII: He is also not going to chanc,-e his


                     ru I.e.


                                '%IRS. SI--,DIN: Probably not.

                                One of our  recommendations is that they not do

                     their prioritizing verbally as 'it does happen tremendously.        i

                                l@IR. BAIIROIIS:  Would you clear why you want a         i

                     shift to their rural area, you have two             to cro on,  need1

                                         T
                     and opportunity.    @leed in rural areas is frustrating, no

                     question.

                                I don't think people have been working on for @O

                     years -- l@.n terms  of  opportunities  in  the  metropolitan  areas,

                     it seems to me there is kind of a swinging mood to o-et

                     thi-n-s done, to improve the delivery system.

                                DR. TEI-cliAN: Two answers to   that,   If  I   understand




                   what they are talkiriz a,bout, what li'utle,,os,@zamer phrases
                   go by on the progress side of-tho.se statements, I get the
                   feeling that there is some possibility of personnel recruit-
                   metit and new services to be established vben rural communities
                   got together,ancl mal,,e an attractive or possible.life style
                   for the new profession. So I five the feeling something  isi

                   irioving in that direction.
                            Secondly, the swinging mood you are talkinc., about
                   in rqy view probably could be taken care of with precious ii.ttl@,e
                   a,ss'Lstanc-- rather then dollar resources In other ,lords, that
                   is already moving and t,,icre are already resources in L.q a t a r e a,,,

                   to function.

                            !vFR. PETEi@")'O-i@ I,,re there any othn-r--

                            DR. TH-LT@1,D-'II: Yes. It see,,.qs t-or.,L---

                            i,IR. PETERLOI,
                                          Bi II.

                            DR. THU-.Lc@@'@i[IN It seems to me J\rizona is probably

                   the closest to Connecticut the review committee has ever
                   year in and year out.  I-.nd we have always made these very
                   strono- solid recommendations about how the pro@,ra@n could not
                       CD                                      CD
                   ex@Lst in the ,Pedicp-LschooL and how be damned if I see how It t

                   has changed.
                            Pl@R SI.. D IN: It has. I was on that site visit wit,-I,
                   you know, everybody else, when words were said. And as  I
                   said, all of t.,iese thin,@s, you icriow about having all these
                   eloquent thint-s, but not hLq,vi,nr,--- same staff, same coorditiatc-,-,,!




                   same chairr;Dn of the FAG for six-plus years, then It was totaL"-,,7

                   in the medical school and It isn't now.

                             DR. THURIIAN:  Where I disagree 'viLth you is they stiiL

                   thi@ik it Is. They think they control--

                                  S.ADIN:  They control because dean of .-he

                   @ledict'l School e@,Looints ,ae@ers of RAG.
                               sra saying in their reviwed bylaws, they are chan,@ir---

                   their RAG grantee relationship*
                             DR. THURIIAN All I am  reaLly saying is -- Dick, beer

                   me out of 1 am right or wrong -- every time we have discussed

                   -Arizona, review committee staff has been enthusiastic, review

                   committee has been pessi-riiIstic. And I still sit here and say

                   in all that time Lt ain't changed one little bit.

                                  SP@DIN: The funny part is I a..,n beinc@ an advoc@.'t-"e

                   ri@ht now e.nd it is particularly funny, because in t',,,,e off4-c-cl

                   I am usually not. But they have made some ci,ianges, they rea,li@..-


                   have.

                             DR. THUIII@,IAN:  it must h-,ve vote those people

                   80 percent of the money they ha,ve requested when you have a

                   sitting in the driver's seat six years can't tell you the
                   of day.  That continues to strike -ae as something short of

                   ridiculous.


                             1,T%S. SPDIN: He runs the prorram.

                             I.-IR. Bl@EP,(7viS:  Who is current chair,-aan of RAG?

                             IVMS. SADIN:  Runninc- for state legislature.




                              No,v,b,y of circumventing.

                              DR.           Run by Monte.

                              From the day it started it has been run by Monte

                    and@, will be run by Monte until the day it dies.

                              DR. TESCIIAN: The answer to that in practical terms

                    is for the new R-AG on the basis of the new bylaws to make a
                    cha,n,@e in the director. If the'@@rrantee doesn't agree with

                    that, to cha.n-e gra,nteec--,
                              In other words, it is@,o,ppropriete action is that of

                    the El,.G.

                              DR. TH17RI,!A@l: Thirteen months.

                              DR. TE@.CH-,'i.fl: That is your view. I tend to have


                    caveat on thaL-1 one.

                              lvj'R. PETEIISOIL    I do feel n, little -- not taK3-r.2;

                    sides in this -- feel a- Little like Bill, I heard this a Couple
                    of times before, but that doesn't c,,et us off the need to make

                    so.,r,-3 kind of recommendation.

                                        '@'i-3 million request here, an indication
                              We ha,ve a


                         in
                    that    the case of Arizona rou-hLy another  q?400,000 will be i
                    coming in in July for a total of  about @')1.7 million,, si.8
                    million,  which Ls very close -- slightly above that so-called
                    target figure, benchmark that I  have been referr'Lnr,,- to all

                    day.

                              I heard, not in tho form  of a motion, I heard you
                    earlier, Paul, say something like about 80 percent      which ii




                   really giving me another function if yot.A 'people talk in

                                                    f unctio
                   percentage term I have a second         n, fore out what

                   80  perceit of @%')I.3 million is.
                             In my arithmetic, which I hope wi 11 be checked again,i

                   that was like  1,080,000.
                             Now, that was not in the form of a recommendation,
                   but at least that translates your 80 percent you were thinking

                   outloud about 10 minutes ago into a. fig,-ire.
                             Do you or someone el,-,,e want to make a recommendation

                   as to the funding recommendation here?

                             l@i@ B.P@RR(7@IS:  I like that, because it is not in round

                   no,Ti'oer--- and it sounds as if it is scientific.



                             DR. T-@"@zCl!-AN: Of course, it is,@i.entific. Deep balar.c.-

                   between the pluses and the minuses.

                             14R. PETER7@'C,'@.1 I have always told my children never
                   to fib 'In even numbers. It Is not as credible as if you say
                   83.  If you --ay 83, people think you know what you are talkin@

                   about; but say 100,people question you.

                             Charlie.

                             DR. McCALL:  Did we have that as a motion we are

                   considering or are you asking for a motion?
                             Yi-R. PETERSON: I don't- know whether-- Paul, do you
                   want me to treat your 80 percents @'1,080,000,as a motion?

                             DR. TESCHAN:   Sure.





                              PE. PETERSON:  That is a motion. We don't have  a
                                                         u


                   second.

                              1,2. BARRO@IS: Second it.

                              MR. PETERSON:  lir. Barrows seconds it.

                              Do vie have any additional discussion?

                              DR. McCALL:  Call for question.

                              14R. PETERSON:  Okay, call the question.
                              How many would concur with that $1,080,000 reco.,n-

                      mencati-on?

                              (Show of hands)

                              i,IR. PETERSON:  Four.  Since we lost one-- was your

                   hand up, A I?

                              DR. HEUSTIS:  No, sir.
                              MR. PETERSON:  I didn't think so, but I just wanted

                   to be sure, since we aredowii to an  even numbered group.
                              That unfortunately -- not unfortunately -- that


                   will not carry.
                              DR. HEUSTIS:   ',,IaVe your motion. I will support it.

                    See if we have any strength.
                              DR. THURI.IAN:  If we can go forward with one more,
                    strono, staff letter for the 5,647th time, recommend for @800'e.;-;@-

                              80Q,Ooo.
                      @700,000-s,

                              DR.. HEU.STIS: I will support it.
                              14R. PETERSON:  We hear ",')800@000. Is there a secood'.','

                              DR. HEUSTI@@:  Second it.






                                DR. HESS:   That is below the current level.

                                DR. THURI,@AN:  Which is the exact Point-.  We have

                     i),Iways tried to clidi,,ei people by firing the director or not

                     giving them money.

                                SISTER JOSEPHINE:  I have to go back to the main         I

                     discussion. You know, I almost feel we are on the  horns  of

                     the dilemma of the Prodigal Son.  We are encouraging all of this--(

                     people with hundreds of thousands of dollars, and we were  very

                     hesitant to reward a well or,-anized prorrram. I think we have

                     to Look at the philosophy we -,re implementing.

                                DR. TE@,C@@N:  I am in the further dilemma, I am
                     deli@hted that in the framework and history'we have had with

                     the setting,  leadership you just  have  been  describing  that  thei

                     change in the bylaws has happened and  change  in  the  RfiG  has

                     ,--one under way,

                                Sure, we wou,ld like to have  some  other  things  ard  I

                     would be much ,@re satisfied  viith  a  much  more  dramatic  devel-

                     op,-.qent in several dimensions. But the reason I made the  motior@'i

                     specifically before we.,-- to split a balance so there is   an

                     element  of reward, that is why I dile.,ted on the point   of maki.nt-@

                     sure that reward idea got down to them.

                                DR. HESS:   Let me say if this  can  be  coupled  with

                     the recommendation that  the  projects  havinv  to  do  with  infer-

                     ring definition of what these projects are, expansion health

                     service site, that is reaching  out  to  underservci  and  'extended




                                                                               155

                     medical r@anpower@ that those you lino'yl are-- arrain, ttiL is
                     dJ-ppin@, into the prerogatives of the local region.    But my,con'-
                     cevn is ,Lf we cut the totalo what is it r,-oin@ to do to those
                                                                CD
                     thi,,i,-;-s? That if we can couple this with some advice, those
                     we see as extremely worthwhile activities, that we wouldo you
                     know, encourage they support, then I would feel better about

                     that.
                               But I a,m concerned about the possibility of, you

                     know, dilutinc,@ that tyoe  activity.
                               DR. TTrlUi@'.1,IP@N:    ore of my concerns, there I-.-
                                                CD
                     no  t v@ 'Lle in the United Stp-testiiat has better survey of the
                     needs of the State of firizora.  Why are they a,skin,@, for more

                     money?
                               They can tell you ri-,Iit down to the guy who filled

                     the tube yesterday what is 'virori.-
                                DR. HES-@':  Except I understood this was based on
                     study, prior data,.  This is nct.,,iiore survey; it is actual imple-
                     menta@uion of getti-no, services  out to the people.
                                DR. Ti-iUiU-4AN: I  have  to ,dmit I have not read It as
                     thoroughly as you did. But I didn't see that as lmpleraentatiorl,
                                DR. TES'@H-AN: Unfortunately all I read ha-. very
                     little solid evidence ofi,,,hat really is -oing to happen.     I
                     have read quite a number of these, had e. lot of stirrino,     ex-
                     peri-ences about a lot of talt,., no documented action.
                                When you have the evali@ator-   you have to hire, you




                                                                                    156

                      did n It get this kind of t I-,ing in the wr@i t Inr,-s.

                                 14R. BARRO,,15: Could we accommodate these veryin.,T

                      viewpoints with a sharply reduced budget, such as has been

                      proposed, coupled with a statement that if these promised

                      changes they have started are really reflected in their new

                      pro,r,n,--P,ls we may look more generously on their next go-round,

                      would that have any impact with them?

                                 DR.   IIEUSTIS: Next go-round is almost in the pipe-


                      line.

                                 DR. TES'aHliN:  That should be a riemo to us.

                                   iz u. C-D- h'u- e r

                                 DR. IIESS:    Is there -,oi@ to be time after the

                      Council acts for any cor.,Yrunication or rearranc.,--ing of priorit@-qs

                      of projects that are already written up by the re,,7,ibns?

                                 1,M. PETERSO'l@T: -Acrain

                                 DR. HES@":    Is that out  of the question?

                                 1,LR. PET'-rR,-'ON: It seems to me very Little,

                      Joe, as a practical matter. Our Council, and we would not be

                      communicating by and larf-;,e with any RMP based just on a reviei@,,@
                                                  C)

                      cb=i.ttee action, our Council meets the fourteenth-fifteentii

                      of June and auain, c,-iveii the best of all worLds, Instant,
                                     CD

                      good communication.      Pncl assuming the receiver on the other
                      end with min-mum of    dissonance-- you know, most of the RAGS i,,!.il I

                      have just, you know, they will have taken their         action.  The

                      stuff will be f loo7,.ng from a committee room into a set of




                     typewriters to become a final application,
                               So I think as a realistic matter, it is unfortunate
                     but I think it is no, we can't communicate significantly at

                     this juncture.   In one sense I think-- this was your
                     remark -- that kind of advice is almost correctly more of a         i,
                     memo for the record to remind ourselves in July than doing
                     any good in terms of really making a difference withiespect
                     to Arizonans -- or anyone elsels July I application.
                               DR. TESCIIAN: I would Like to ask Mrs. Sadin if I

                     can what would be the impact of this bud(.-et there?

                               What kind of staff investments in these fu@,anent-al

                     changes at this late, late date-- after all, it is more than
                     nearly two years since the  policy  came  into  effect,  June  19721,

                     when Courci.i first passed the f-LLth-sixth of June, finally

                     came out of the Ccuncilis office in August, or at least
                  I  published as of, the thirty-first of -Aur,ust 1972 pol,@cy  was     i
                     out.  Okay, this is @la,Y 1974, just a Little late in the day.
                                The staff probably has been chaffing at some kind

                     of a bit.

                                I am just wonderi n- what would happen if we sent a

                     curtailed  bud-et?

                                MRS.  SADIli: You know, I  am  leaving  Monday  and  I  am


                     glad.

                                (L@,.u,ohter)

                                IvE. PETE'RSON:  @avincT DIIRP.






                            MM. @RIN:  Leaving I)RMP.

                            I q,m goino, back to Arizona, because you have your
                   problem of-- you are talking about, you mentioned RAG po-Licy
                   I was at  the RAG raeetinu where I mentioned they were not in
                   conformance. They have to be in conformance.   And Dr. Duvall,
                   who sat next to me, said, '@,4hen I was in Washington, I ar@ued
                                                                            C>

                   auainst this policy."  He says this to the whole l@Gl
                            Now, you don't vet an instant reaction on"@,@ell,
                   okay, Mrs. Sadin, ,ie are goJ.ncr, to do that tomorrow.
                            You have these factors to deal  with. And-I thick

                   they are real factors.
                            DR. TESCIlAiN:  They are real factors.

                                           It is.
                            DR. THUR.Lv.PN:
                            Real factor.  We never want to undercut staff,  Never

                   be in that position.
                             DR. THM,,,LIAN:  You know, from sitting in before w,,
                   have always come back and said, "How is it going to affect

                   staff?"
                             MRS. SP.DIN:  I think staffs morality could be up-
                   lifted now, especially Billy V. and some of the others who
                   have really been tryin@ real hard to work with  the area-- it
                   is their push,tha.t has done this.  They are the ones who were
                   tryino, to terminate CESli.  It Is the staff, you know.
                   .And they got an outside committee to try to help them and Lt

                   didn't work out.





                                DR. TESCI-LAN: And they do  it  against  every  obstacle

                                MRS. .@.",DIN:  Every obstacle in the world.  It Is

                     staff that is tryin@ to do It. I would hate to punish them.

                     On the other hand--
                                DR. McC.P-,LL: Maybe if we up this to @86o,ooo, cur-

                     rent level. --

                                I,IR. BARROIIIS: I could -,-o along with that.

                                DR. iicC.ALL: And at the same time get  a  strono,  mes-
                                                                                C>

                     sac,-e, not satisfactory with, YOU know, recognizing some progress,,
                     some change, at least not  cut  them  below  their  current  level.

                                DR. HESS: Let me ask another   question.  Are their

                     projects prioritized -Ln any way or ca@n  you tell?

                                YLRS. Sl@I)Iii: Yes. They have it in the    application.

                                .And, you know, expansion of service sites wag the

                     lowest priority.
                                DR. TESCHAN:  Program staff was number one, as I


                     reca,


                                DR. THURI,,IAN: Yes, it Is.

                                DR. HE@.S:  Ti-.at is natural, but what about uoinF,


                     from   thi2?

                                IC S .  D IN  One was  program  staff,  two  was  hyper-

                     tension; seven is the lowest.  StreptococcaL infection -- no,

                     EMS was three, four was streptococcal infection, consumer

                     education is 'Live, manpower recruitment is six, and expansion


                     seven,





                             That was done verbally, 9,s I said,, and I really
                    think they would not have arrived at this priority ratinc,,  Lf
                    It had been done by written  document,  I  really  think  PeOPLe
                    chanc,ed their minds.  But nevertheless, those are the prioritie@-

                    you have in this application.
                             DR. THURI,4AN: R&-Yi has supported that  streptococcal
                    infection ad nauseum.  It never'should haveeven started.
                             IviR. BA RR (7yT SDi@, @IcCall, is that a motion?
                             li@. Pt,T,z,Rsoi@T: I think Bill did, he threw o u t '@'8 0 0,
                    and I don It know whether he reo-arded that as a, motion or whe'u-,'C:I-
                    he would be WiLlinf,, to adjust his motion to $86oooo.

                              DR. THIJBi',IAN: c--'o rao v e .

                              DR. TE'@@CHPN: Lecond.

                              l@. PETERSON:  We ta Iked i ni t ia I I.y about ro u.@i-i ly

                                                      t560,000 level.  I just throw!
                    'PI. I mi Ilion, now we are down to
                    it out for consideration b--cciuse I didn't want to extend this
                    caution much longer if we can --  we seem to be coming to a

                    decision.
                              I think one of the things that again we need to kee,--
                    in mind as a possibility here, and others, that one could
                    possibly make a orant award, whatever the sumo with some
                    fa,irly specific conditions in terms of some things tha,t  had  c,@
                    be met or reflected, or they didn't get that full amount.
                    That Is, aaain, a possible option that you may want to think

                    about.




                                                                                 lb I

                                DR. HESS:  What  I  am  concerned  about  is  that  priority
                     listinx, the things are goin- to be cut are the ones that I

                     would be most interested in seeing kept in.

                                Now, if that somehow, with the award letter, you

                     know, the feeling, thinking       they ought to reconsider those

                     priorities.  Ile feel in lic,,-ht, you know, of the need of the

                     region,  the  study  that  went  into  developing  those  particular
                     proje--ts, that theybucr,@ht to consider -.,-ivin,,T, a, higher priority.,I

                     Can't tell thcrn to  give  them,  but  strongly  suggest  they  give

                     high priority to   those two projects, I would feel better.

                                DR. TESC!iPiN: But they are on  ,-).nnual  review  status

                     and I think


                                DR. HESS: This is the last review, thouch, isn't
                                                                            C:)


                     It?


                                DR. TE@-'Cl@IA'ii: The point I am sayino- is the dearce

                     of national intervention in Local proc-ram is di4L"Lerent, is it


                     not?


                                DR. HESS:  They still are on annual.


                                DR. TESC@-LAN:  I don It know what status is now.


                                @S. Si@'DIN:  They were, it was taken back.

                                @.RU.SSELL:  We too have the same problems      with  this4,

                     We finally asked staff;  brou  ht  this  to  the  committee  and  to

                     the Council,   triennial status was taken away  from  this  pro@r-cri,,
                                DR. HESS:  That  modifies  it,then  you  do  have  a  bette'

                                DR. TESCH-AN: But- do you?  That is the plan.      Do You






                                                   iri on trienn!aL--
                    have mor  intervention here the

                                  Px'Jc@SELL: Yes. Dc,,potidin,,- on the de-ree.

                              In taking away the triennial status, the next

                    the program is being reviewed a year later was to be  based  on  I
                    Councills site visit.   Ancl then being phased out -- Dr.  Cannorii

                    went, and we are really not quite sure what happened, are we?

                              ,V,RS. SPDIN: Yes.

                              DR. IIESS:  The issue is what is our status inmla-

                    t@Lon@hip to being able to offer advice to them about changing

                    their priorities?

                              Is that ler--itir"@ate with them beino, in annual ste.tu@-


                    or is it not?

                              i@IR. PU'@SELL: I think very legitimate, because, as   -i

                    Rebecca pointed ou4 in the  letter goint- ba;ck to the review

                                               that they Xioritize their--
                    process, it was su@--e,,ited
                    well, projects by ballot or something to this efLect.     Arid we

                    ca,n always suggest they go back and do it. I dont mean they

                    have to.

                              MR. BARR07vlS:  They have to follow what this  guy  says


                    anyway.

                              MRS. SIDIN:  There were people there sayino,,

                    considerinc,- wha,t you just said, I will cha.nge my vote,

                              tLR. BARRA[S:  That is what I mean.

                              It seems to me you are fooling around with esteb-

                    lished policy if we attach internal constraints on RPG




                                                                                    i63

                      through  this  grant.  But  is  it  possible  for  staff  to  infor-ma

                      say that these are the questions that occurred inthe review

                      committee and if you want to fair a little bit better, the next

                      time you had better--

                                 DR. HESS:  There is no "next time."

                                 MR. BARRO,4S:  There is when they come in for July Isit.

                                 DR. HESS:  It is too late.

                                 14R. BARROVTS:  No, if staff communicates now--

                                 MR.  PETERSON:  Can't   communicate   now.   I   think   this!

                      action has got to be confirmed by Council.

                                 Let me again,  to  try  to  get  us  off  both  the  substance

                      tive end time dilemmas would there be any recognizing that

                      it is not the usual order of the day, either now or in the

                      Pastp Vou'ld  the  group  perhaps  want  to,  in  a  sense@  partially

                      punt to the Council on this sa.ying we do feel either X

                      amount or somewhat lar@er amount, provided that a couple of

                      the t@iin@@s we think ourTht to be  of  hi-h  priority,  if  there  is

                      soim assurance that they remain in?       That one project you are

                      .talking about, Joe, is really a significant amount of money,

                      @339,000 or  wha,tever  It  is.  The  health  sites  in  remote  areas,l!

                                 DR.  HESS:  Yes.

                                 YiR. PL@'TERSON:  Otherwise  I think we are      you know,

                                 DR.  IIEUSTIS:  Excuse me.  Before  -vie  do  thi:s,  would

                              I for  the question on the motion  to  see  if  we  are  go,.nL--
                      you cal

                      to -.et




                                                                               IbLi    I


                               YiR. PETERSON:  -All rigi-it) let'scall for '-he question

                     on the motion:   A860,000.  filL those in favor raise their


                     hands.

                               (Show of hands)

                               MR. PETERSON:   Seven . And I think in one sense, the

                     problem has been resolved.

                               MR. BfiRRG,,IS:  This brirCs up the numbers, though,

                     to brin@ up another Council policy question.  Taking the whoi,,-

                     past history of review committees and councils dealing with

                     the regional programs, is it  appropriate  to  be  too  severe  in our

                     swin@s -- this is an old problem and is thiD the ric.-ii- time
                                                                                u

                     to apply an entirely new,  harsher  solution  than  in  the  past?

                               DR. HEUSTIL: This  is  the  thing  we  really  leave  to

                     the Council.  It is their responsibility.

                               @ffl. BARROII@@: It is their baby,  not ours..

                               DR. T-ESCHAN:  Do you then[,, it is  possible  to nor@e in

                     this connection, that the approve at this     Level, reconLiends tt,@e

                     funding to the RAG in lirizona that the COOI, 2, and 3 be

                     .funded.

                               It doesn't say how much, but it clearly states leve@     I

                     of priority.  They can rearran@,e the budvet.

                               Does that help?

                               I,IR. PETERSON:  WELL, I think, that is the kind of

                     first advice that you people       if that is what you  are  suo--

                     gestino, we ought to give to Council and ifcouncil feels
                           L>




                                                                                 165

                    strongly in  the sameway,  then I think that again, as advice,
                                                                                           9

                    ought to be passing it on  to Arizona.

                               DR. TESR.HA N:  I so. move.


                               DR.  TH-L',IR14AN: Second.

                               IM. PETERSON:  Okay.  That is on 1, 2, and 3, those

                    three   projects.   Okay.

                               Arizona Is our record for the day -- 50 minute region.

                    There may be some correlation between problems and time.
                               I wonder, do we want to try and put one more?

                    We have put one more region under our belt tonight.

                               IIR. BARP%agS:  Do you have an easy one?

                               IVIR. PETERSON:  No, I didn't necessarily have an

                                                                                           t
                    easy one,    I thought since        @uess it was l@L or somebody       i
                    ea,rlier in the day was -vionderinc- what we did when Senator
                    Ribicoff called, I thought we might escalate to potential          call.

                    and discuss greater Delaware Valley.

                               DR. THUP,@iIP.N:  Wonderful.

                                '14R. PETERSON:  Either John or Bill or Joe, feel

                    ready?
                                I think you indicated youwere ready on that, Joe.          I



                   GREATER DEUWARE VALLEY                               i66

                             T
                             ,)R. HESS:  I read most of it.

                             DM. PETERSON:  Do you want to lead off?

                             Both of you I know wer e in on the site visit, I  was

                   on. But that has been a long time ago.

                             Greater Delaware Valley.

                             MR. HESS: Well, there have been changes in  leader-

                   ship since I was there on site visit. The new coordinator  is

                   Dr. Dean Roberts, who had been the coordinator for Hanaman --

                   perhaps I had better give a little background here for this

                   region.
                             This region was organized basically around the five

                   Philadelphia medical schools and the @rantee is the University,
                   City Health Sciences Center, which is a kind of consortium of

                   educational institutions which was gotten together for funding!,
                   of educational and related proo.rams and research and so forth."

                             The Initial district was the @ynedicaischools which tc)c",-

                   the initial leadership and got the pro@ram coing,

                             This region,and many others, the problem then was

                   to bring in a broader balance into the leadership and manage-
                   anent of the program. Pnd that was one of our concerns when

                   was there-- were we together, BilL?

                             DR.. THURMAN:  @lith Pete.

                             MR. PETERSON: . December '72 I believe.

                                   UR14AN: '72.
                             DR. Tll

                             M. PEFERSON:  Or '71.




                                                                            167


                             DR. THUI@l@N:  17L.
                             DR. HESS:  And we were concerned about tryinc, to

                    bring a better be-lance into the management program.
                             We also recognized tha,t there 'were some good thing
                    going on thereo but that there v7as probably unduly hea,vy medic@.-,,l

                    school involverfent still at that point.
                              One cLthe good things I felt at  least  that  had  hap-
                    pened was that the schools had looked over  the  entire  RM?  and
                    had di vided up responsibilities for oroanizi.no,  supporting  a,nd
                    workiri,@,@ ',,,ilth health care institutions, providers throughout the
                    re@ions. There were five areas  within  the  total  region  which
                    were the responsibility of a c7iven medical school  in  terms  of

                    providing -@up,@or
                              They ha,ve developed area offices,    ou might say
                                                                   y

                    satellite offices, in each of these five regions, wi-,ich,.as
                    I understand it, are not medical  school  controlbd,  but  medical!
                    schools do relate to these coordinating offices.  And they
                    have been doin,- a, lot of orSe,niza,tional planning, coordi-natinc,,l
                    work in each of the areas.   So that  from  that  standpoint  the

                    region -.s quite well developed, well organized.
                              Going down the major cri,teri-.g,, the pro-,ram leader-
                                                                       CD

                    ship, at the time of our site visit I was quite favorably
                    impressed with Dr. Roberts.  I  don  t  now  what  his  performance
                    has been since@he  has been in that job, but he  seems  to  be  a I
                    man with a good back,-,round, seemed to be reasonable, and know






                     how to proceed.

                                Dr. Wolfe, I believe) was the 1,LAG chairman th--ns
                     sti.i I is the chairman of the ]iAG,, and again seemed to be for-
                     ward-lboking, had the best interest of the re-ion at heart.

                                He at that time was dee,no now he is vice president

                     for planning of -- I forget the name of the school, or college.

                     But it is an upstate--

                                I,,a. PZ2ERSON:  It is up in the Scranton or Wilkes-


                     Barre area,.

                                DR. HESS:  So he was a,wey from the Philadelphia

                     area and brought that perspective.

                                One of our concerns at that point    was the domination

                     of the executive committee of the RAG by the medical school

                     representative.  That seem,,--, to me to have been balanced out
                     a bitt  now, and there is a broader representation on the RAG.@
                                The program staff, they have a rather larc,e program i
                     staff when you consider both the central staff plus the a,rea

                     staff.

                                There is something like-- is it 2    7 all told?

                                So it is a large staff. But a,Lso we have to consider

                     IV-his is a larc,-e population area of Iiir--h density, including

                     Philadelphia, and the surrounding area.

                                I don't have population figures here, but ray guess

                     Is it is probably in the neighborhood of five or six million
                     people, so that that would require 'Lairly large staff to try




                      to cover the many organizations, institutions and problems

                      that are there.

                                 The Re,-,ional Advisory Group has been quite active.

                      They subdivided into executive co
                                                            irnittees and in addition,


                      there a-re area committees that relate to the area coordina-

                      tors find look at the problems with each of these five        areas


                      of the re--ion.

                                 They  do have a, set of -,oats, objectives, and pr-Lo.L -

                      ities a.,nd the application is well put together in that every

                      project relates.to acroal and objective.  So you know they

                      know her to think and    manage in those terms.

                                 Their pa,st performance, there have      been a number of

                      activities in the City of Philadelphia., metropolitan area,

                      a-.s well as in the outsk-late re,,,ions, that have been effective

                      in bringing to-ether health care providers and try to improve

                      both the quality and accessibility of care.

                                 The proposal is a sizeabLe one, both in terms of

                      number of projects and in dollar amounts.  Most of them seem

                      to be fairly well thou@@,@it out. fi@nd appropriate for the region.

                                 FeasibiLity is a little bit difficult for meto

                      estimate, but ir@ feelin@ is probably with the experience         o f

                      group and so on, that these are things that could be done.

                                 The. CIIP relationstil ps generally seem to be quite

                      good  as near as I could tell from the document. Maybe the

                      staff  will have som other comments, but it seems to me a





                    ,rood working relationship between the CIIP a nd Pd,4P.
                             My overall assess @-i-it of the rp-gior,@,a.s based on th! Si
                    was above average considering the complexity of the region anti
                    the organization.  There is one question that was a continuing
                    problem or issue, let me sa,y not necessarily a  problem,  there
                    is a, 1,9,rce proportion of the funds still goin- to the medical
                    school.  lind I was surprised o,t the apparently high salary
                    levels, at least compared to our school, of some of the
                    people who are pa-id partly It-lhrouc;-h the RMP budget.
                              I have no way of knowinc,- vihether commensurate servi-r@
                    ces are being rendered by those on part-time R@.,IP salary.
                              DR* TESCH.PN: How  ma,ny part-time professionals  r e

                            A lot of people?
                    there?
                              DR. THU.-e,14AN: Fi-fty-tv;o altogether, about ten or


                    twelve.

                              l@M. PETERSON:  Ten or twelve.

                              I am tryinla" to recall how many it was when wevere
                    up there. That may be somewhat Less,  but  it  has  always  been
                 I-phenomenon of the Gt-.'D pro-r@n,m, I guess it has al@iays raised
                                              CD

                    some questions In a lot of people's minds.
                              But I think it is twelve, roughly, my count, if tho@-,@e

                    figures are correct.
                              Bill, how did Gl!'O revisited look?
                              DR. THURIL4AN: I think I would second  what  Joe  said
                    from the standpoint -Roberts was a stronger person  and  one  of




                                                                             171

                    the few stron@p people we saw on our initial visit really, so

                    I think that could do nothing but help.

                              The l@egiotial Advisory Group is still largely 8.  One-

                    man realtionship and that is Wolfe himself, who does run it      ici

                    runs it reasonably well.

                              I think that they have developed some   new   projects,
                    but they have largely used idc;a,s from other people and other

                    proc@-i@arnz and have added minimum innovation to it*
                              They have not terminated some projects a@ain they
                                                                        LD


                    were asked to terminate multiple times.

                              I arree with Joe's assessment, I would just

                    emphasize the points he made; that is, there was not a, single

                    medical school budr7et in this whole proposal, that iza

                    realistic thincr, and one of them, for instance,  they  have  had

                    the chairman of  preventive medicine @ettin- 50  percent  of  his

                    salary for rQnnin@ a community hypertension program in on-- se@--

                    ment of the Pennsylvn-nia community, end that is not realistic.,

                              Where we don't have professionals, we are payin@

                    secretaries.  So that is acaJ.n an unreal situation.
                                               C)

                              Some of the projects are overfunded, but    I think

                    their analysis of their programs and proc-ress they   have made

                    since we were-there is significant  I think they     have come


                    a lono, way.

                              DR. TESCIIAN:.  How is the RAG appointed, do you l@no@,,,@i


                    that?




                                                                             172

                               DR. TESCIiA!i:  You 'viouldn' t necessarily pick it up


                    here.

                               IC-@. PETFR@SON: I dori It know, Spence?

                                  COLBUPN:  They have their own nominating com-


                    mittee.
                               They do have institutional  representation,  that  type

                    of thinu -- is that what you are @etting at?
                               There is Guaranteed representation from the Medical
                    School on the RAG, also on the executive committee.    But  all  1
                    six schools are not represented -- in fact,I don't think
                    we have more than three medical schools represented.

                               DR. HESS:  That is r(a(Iticed substantially.
                               MR. COLBUR'il: Policy Board of Director--- used to  callI
                    a,il of these shots, now t@iey have a. true executive co=,iittee,

                    Doesn't have a great deal of exoerience.
                               DR. HESS:  Ten part-t'Lire medical school profession,,tL,,:@

                    at the doctoral and @..ster level, so they are not all physi-

                    ci,,i,ns. @ome with n@aster degree.

                               DR. TESCHftN:  I just  was summarizing the general
                    notion part-time people are dreadfully hard to keep track of,

                    especially when they @re orofessionals.

                               I,IR. BliRRU@iS:  Am I right in rending these figures,
                    four segments of the university-based staffs total about

                    "e-250,000.

                               DR. THliRl@N:  You are.





                                                                               f


                                                                 lot of jrone,r
                               I,ffi. BARROETS:  That is a helluva

                               MR. PETEFSON:  Used  to be "e'600,000.

                                              I was ,,Oin.- to s,
                                                               -iy you airit -seen
                               DR. THURlitiNI.


                    nothing yet.

                               I-IR. BARRO,,@S: Lot me ask a question. They are  in-an,
                                                                                      i
                    area ;"Ith a, Large undetserved population.-- Have  they  addressed

                    themselves from that?

                               DR. THUR-,.,,IAN:  Yes.

                               DR. HESS:  They got into that from the very becinni-n--,,

                               That is where the medical schools have put a lot o'


                    their effort.


                                   B@ RR U,-l SIt is not all bad.

                               1,M. PETEI@@@0',',!: I wonder, Spence or Frank, if there

                    were any particular aspects of this application -- T don@t@

                    recall who it was that mentioned now whether it was Bill or

                    Joe about some project that my have -one beyond what we con-

                    sider to be the normal funding period.     Council did have a poL'---,,

                    of generally not to exceed three years, whether you have any

                    comment to that question, which I thouc,,ht I heard raised

                    specifically,,or any other significant point; policy issue or

                    problem as staff has perceived    them with respect to GZA?

                               I,,M. COLBUR14:  As I recall, they have several new


                    projects.

                               About the ti-rae 'vie phased out, they were fitting an

                    application for review.  They ,iei,e pliasinr7 out continuing




                            act ivi t, le s.   They went on  the  shelf.   When  they were

                            ted  to   phase out,  they discontinued  the other activities and
                            the @c@ran was almost  just,  you know, an  inch away from bein@.7,
                            completely ot-At of business in -Auo,ust of  1973 when  they qte,r'Ued@@

                            bee,tincr   pror-raras on a iaonthly basis,  spoon-feeding on

                            a quarterly basis;  so you have grossly here  the  new  projects

                            in the  application  not reviewed.

                                           DR.  HESS:      Tan continuous and  ten new.

                                           @IR.  PLTERSOii:       I notice froni our summary sheets
                            i-hich, need Leos  to say,  I am ,iot  very conversant with any of
                            these applications in any detail, but most                       of  the  projects       1,4 aA

                            elicited Cli? reviewing co=ictits.                 There were a couple where

                            they had  not.

                                           We  do have Tom @rath here from the PhiLadelphia


                            Refrional Office.
                               CD

                                           I don't  k@-io@,lwhether you, Tom,  had any particular

                            information with respect  to CriP comment or relationships  P.

                            this area; specifically,  @reater Delaware ValLey,  Phi-ladeLphi-a.

                                           TCI-;I:   To the best of my knowledge  the relationships


                            were reasonably good.

                                           1,M.  PETE'-RSON:      The  chief CIIP a57,-ency,  of course,  is

                            Philadelphia and  there also happened  to be an experimental

                            system there.   Thereis also another                   one  greater up north,

                            Representative FLood.

                                           l@IR. BPRROWS:   I-le  came  up with the conclusion  this





                                                                                       j- I


                      wa.s pretty appropriate?

                                   DR. HESS:   Yes, I rated it overall above z),,.vera,-,eo

                                   DR. HEUSTIS:  Budget somewhat inf Lated?

                                   DR. TH@, i',',.AN I think so.  They are askiriE,; for

                      @2,8  million  end  they  have  been  at  $L.7   million,   and   they
                      really  --  eyactly  half   of   the   projec@   continuing   project.  Irany

                      of them in the year phased down.         They  said  that   very   clearlyi

                      this is the last year of si.ippor@ either they will be termi-nati'i@'-L-,

                      or supported by someone else.

                                   So that I tend to say yes to that all        the    time.

                                                   'lienever indicated?
                                   DR. HEUSTI'     @l

                                       THIT%;,Y,@N: Not necessarily.     I'do  it  when  .t  is

                      not indicated.     It ,s a   f'autlt.  I  think   it   is   overinflated.

                                   l@. PETERSOii:   We do have -- this application is

                                   "2.  mill
                          CD                 ion  request  which,  as   Bill   points   out, i.,, a s
                      roL,, h ly a
                      cotis,Lderab ly above; their sort of f und in@ le ve I now i s rou@!,@  ly
                                                                     L.,

                      equal  to  the  sort  of  tarr-et  figure  we  have  had  an   indication
                      that they are @,oino.- to--   Greater  Delaware  ValLey  is  going  t   o

                              ing in with  a  rou,c7hiy  '4@I.3  million  second  phase  two
                      be com

                      request which would put      this pror,,,ram  at  least  in  terms  of  its

                      request  in  the  @Q4  mill!-on  rance,  so  9,gainst  that   backdropI

                      don't know whether either of the reviewers has a recommendation.

                                   DR. HESS:  I have a figure.

                                   DR. THUi-il@Y,,N: Go ,ihead.

                                   DR. HESS:    I would recommend     @2.3 million, which




                                                                                                         !7b

                          recognizes that  this is the good region                     reasonably good

                          region,  rated above average,  seems  to have                good  Leadership.

                          They   have   got    a    laroe    population,    many    underse@-ved,    who    need

                          assistance.   They seem to be addressing those problems

                                        Also I was aware of the JuL               Ist    estimate     i@eaLizin,)-
                                                                              'Y                               t@

                          that   there   is   goino-   to   be   another   big   batch   coming   in    at    that
                                                                         '@600,000     increment     over     their!I
                          time.   And this seems to me is a 4

                          current  level, which is rather substantial.
                                        It   seems   to   me    to    be    a    fairly    reasonable    compromiser

                                        MR.   B.ARRC,,IS:   35   percent   boost,   is    it    that    stronrp?

                          Over where they a-re no@i?

                                        IVIR.  PETERSOI-,':  Ac@ain,   Mr.    Barrows,    I    don't--    it

                          does -seem to me that  the          present six months fundin-. rate             in      i

                          many re@ions,  that  could         be coluniri one which is a function

                          of times     two.   It   has   one   sense   of   reality   and    the    o4.-her;  it   i

                          does   reflect--   it   tildes   son)e    things    in    some    instances    and

                          certainly is not indicative in most instances,  including                        tiii  s

                          one,  the kind of  level the regional is functioning at pre-                             i

                          January 1973.

                                        1,M.  BARROWS:      .@2.3    million    would    reflect    what    per-

                          centage increase over-- I try to get this feelfor other procrre,.T--,

                                        DR. HESIU:      I personally feel they have management

                          ability to use that.

                                        MR. BARRa-,TS:   What percentage increase?
                                                                               CD

                                        DR. TliUX4AN:   That would be 86 over  17.                 I am no  t  cn,







                         mathematician.


                                       I;IR. PERERSON:   A  little more than a third.

                                       IC.   BARI@0,-IS:   Seventeen isn't a real figure.

                                       DR.   I-LEUSTIS:   These white sheets show a, billion one

                         hundred thousand plus for a six-month budget, so that  is rea

                         istic;    174    to 674 present one,  six months; multiply that by

                                                                            "2.3 million.
                         two.    You     are not too far away from

                                       I,, a@ .BIRRC'e,'.S:   That find of   move--

                                       DR.   HEUSTIS:   Thereis a good deal            of difference

                         between the material in the white sheets and  the other on                         this:,

                         printout.   Great difference.
                                                                                                                 f
                                       MR . BA RR a@vi S   Your   recommendation    if    the     white     sheet@

                         is ri@,ht,  keep this about where  they are.                                            f

                                       DR. HEUOTIS:   Into,  @ive them a  little bit more.

                                       I,,IR. PETERSON:   I have got  to cry help to staff                  here."

                                       What are we tall.,Iing      about?

                                             NA@SH:   I am not     talkin@ about  the one on the

                         printout;     I am talkino, about the one               this  sheet here

                         (indicating).

                                       Is  this an accurate figure?

                                       DR.   THU@lAii:   Is that figure accurate?

                                       MR.   COLBIF,.N:   Pediatric,  pulmonary --           is that added

                         in there?       Included there?

                                       IAR.  PLTER@ION:     It may well have earmarked funds.

                         Also "@170,000--





                             1,Ul. COLBMilT:  You are right about @$L.8 million.

                   .P,fter estate visit. That is what we recori,,nended.
                             They were funded at that level, so half of thatwoulc@
                   be 'I-@900,OOC).  -And they had about 'q')400,000 for pulmonary, that!

                   is pretty close.

                             DR. TI-IUPd,@.N:  Mr. Cl-iairman, ray recommendation 2LS

                   $200,000 off from his, but I have no concern about  Joe,  say

                   'y2.3 milli-on. I was Lh @ki n,- '@,2. L ini I Lion.  But I can easi ly

                   live with ,"2.3 million, because I think this is a good  pro-



                             @IR. PETERSON:  Do you two want to talk together fox-i

                   30 Seconds?

                             DR. THU.@@1,YiN: I second the motion.

                             14'tl. NTASII: lb you want-, to include with that dollar

                   figure recommendations, any further recommendations fro,-,I

                   committee so far as removing additional funds from the =Uicai

                   School?


                             DR. HEUSTIS:  You are speaking to Dr. Hess?


                                    @,H: Yes.

                             DR. HESS:  This I didn't think was something we rea'Lll-y

                   have enour,-h information on now, but I think perhaps the concern

                   as to whether or not the re(,-ion is vetting value received for
                                               C)      u

                   the money that is goin,@ to medical school now, the RAG may or

                   may not need a little muscle to take a look at  that.  It  is

                   hard to ask that kind of question unless you have got some




                                                                                      179


                      reason for asking it.

                                 But I personally don't feel I am In position to

                      ,,m,ke a jud.-ment on this.    I don't  know.

                                 IvM. PETERSON: But you  do  see     that as--

                                 DR.  HESS:  Potential  concern.

                                 loIR. PETERSON:  Despite the fact figure is down from

                      $6oo,ooo to 250,000.

                                 DR. HEUSTIS:  You gave      Paul about 50 percent salary

                      obviously.  You would think he would be more busy carrying

                      out his administrative work-- didn't sound very realistic.

                                 DR. HESS:  See, there may be some compensating fac-

                      tors.  He may have sor.,Ie oL' his people doing some running

                      and for bud@et,-ry purposes, you know, it gets too much of a

                      ha,,tLe to out somebody on part-time salary for        so and so.

                                 DR. TE'@--,CHAT-1:  That is very optimistic.  Our exper-

                      ience 'Ls the opposite.


                                 DR. HI--SS: It  may  be  justified.

                                 DR. TESC@N:      Here is  where  a  site visit would be


                      helpful.

                                 DR. IlLcC.ALL:  Still talking about unknowns?

                                 liM. PETERSON:    Yes.

                                 DR. McCALL:  The way     it is expressed, it seems to rqel

                      as far as vie can uo now.  Call.    the question.
                                          CD

                                 MR. PETERSON:  Those     in favor of the motion for

                      @2.3 million with indication ofconcern, fed back, about the





                                                                           180

                    still quarter of a million dollars of medical schools, all

                    those in favor?

                              (Show of hands)
                              14R. =,.cERSOII:  We still didn't ma a,--e to --lip out
                                                               n

                    04L' the complacency and unanimity.

                              It is ten til five,  -As YOL),R chairman I am at your


                    beckend call.
                              Do you want to c,-o on with still aciother? I a.rl prc-
                    pared to do that.  If you want to wrap it up  for--
                              I,IR. B-ARRO@@IS: I have some homework to do.I

                    would just as soon wrap it up.
                              DR. THUIIl@@,@l I have a qui-c".@y -- no, I will conce i. V

                                  -1@TERSOY,, What is your qui-cky?

                              DR. TII @, ',,Il@N: Puerto Rico. It's aquicky.

                                                                    about a ten or
                              l@IR. FETEISCII: We are really tal.kina.

                    fifteen minute discussion.

                              DR. THnil,:AN:  -Pit the most, yes.

                              @IR. PETER.-'ON: It is a very unusual-- would that do

                    too much violence with your needs?

                              14R. BARRO.-,"E:  No.

                              I,]R. PETERSON:I hadn't pror-ramred Puerto Rico, but

                    let's pull it-out.

                              The reviewers ere on that, in addition to Bill

                    let me see that sheet of paper aGei-n, Bill -- I

                    don't think we would do violence if we confirm our review




                                                                              181

                    and recommendation with Jill in the morning.  -Again, I don'

                    think it Is ooing to take that match time first thin,,-, in the

                    morning, Bill.

                              DR. THURI,'@N:  I don't mind putting it off.

                              I,IR. Bl@RRaiS:  It might be a little more courteous.

                              MR.  PETERSON:  Ye4

                              Okay.  Before we leave, a couple of thincs here.

                    Feet free to Leave your Materials in the room.  On the other

                    hand, if you are goinr, to be doin,- homework with them, you

                    o b v -'L oLi@ly can't do thc,,t,

                              Secondly, I did have a, note handed to me late this

                    afternoon.  If any of you did not use RTET- -'If you please

                    that is the @-rain IBM card that buys an airplane ticket       if

                    you would return them, to the desk, to Mrs. leventh,@,.I, if  tiaerei

                    are any that were not used.                                        I

                              Before we break, on the other hand, I would like to

                    have your indication of what time -vie would like to @et startc-(,@.

                              By my calculations, we reviewed eir'lit re-ions today

                    which means we have 17 to Lo.'vTe did not really start the
                    review process until well  after  eleven.  We  convened  at  eleveni

                    and I took some time with generalities  So on the one hand

                    we are not in my view terribly in arrears.  On the other

                    hand, we don't have a lot to coast on.

                               I don It know how they are doing, but I just figure @,,e

                    would beahead of them.





                                 DR. TESCHI@l,',,': I would  like  to  stc,.trt  about  8:30.

                                 Y,R. PE2ERSO'@l: -All right, 8:30 with a Pledge        to

                      dis-pense with Puerto Rico and CaLiforni,  before nine.

                                 DR.  HEUSTI,'j:  AnCi  California  will  only  taVe   ten


                      minutes.

                                 1,4R. PETERSON:   I  know,  end  you  are  reminding  nie that@@

                      is  a  very  simple  application  at  this  juncture.  It   is   one  of

                      the few regions  which  the  Council,  alonr7  with  Ari--o,,ia  and

                               e,-pressed some great concerns about la-st November;

                      it was site visited.

                                 Bill  Thurman  was  on  it  and  I  think  without   telling

                      his story, it happens  to  be  a  site  visit  that  case  back  ,Iiore

                      than alLay@Ln,@, the kinds  of'  concerns  the  CounciL@-,d  at  the

                      t lrqc.

                                 Okay, with th,),t, I  wa,nt  to  certainly  expy-ec-s  ny

                      Personal tha.nlcs and appreciation for your                 worse to,@iay.

                                 I would only make the plea, at this juncture, it is           e

                      plea rather than intimidating request. If you haven't given
                      me your  review  sheets  for  those  re,-,ions  which  we  have  looked
                      at,  would  you  please  let  me  have  them  before  you  go  home,

                      then I will be able to ta,ke them back up to my office.

                                 Thank you and    we will see   you at 8:30,  this     half

                      of the room.

                                  (Ivihereupon@ at 4:53 o'clock, p.m.,  the  meeting

                            recessed, to reconvene at 8:30 o'clock, a.m.,  Thursdcn-y,

                            14ay 23, 1974.)