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     .
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I?IVISION OF REGIONAL MEDICAL PROGRAMS

- - i

FMP AD HOC RE'JIEN COXP'IITTEE


3

b Jj;, !I
kqi . . Report by Mr. Rubel

    .+
4 j! Report by Dr. Goodman
pi+
5 ;I ~  Comments by members of public:
    /I
   !
    I
ti 1:        Rajeshwar Prasad (Nassau-Suffolk RMP)
   I!

Y

23

$9

/I
7 `1  Review of applications for Regional Nedical Programs:

Alabama.(Dr.'Vaun)                   68

Albany (Mr. Earrows)

72

Arkansas (Dr. Scherlis)

Ei-State (f4r. Toomey)

Lakes area (f,!r. Barrows!)

California (Dr.Heustis)

76

73

85

8O d

Central New York (Dr. Eess)

98

Maryland (Dr. Vaun)

193

Colorado/p7yoming (Dr. McPhedran)

Mev7 Jersey (Dr. Teschan)

Florida (Dr. Miller)

107

109

112

Greater Delaware Valley (Dr. Hess)         116

Hawaii (Dr.  Hirschboeck)                  119

Washington/Alaska (Mr. Barrows)            121

Illinois (Dr. Scherlis)

    Indiana (Mr. Thompson)                    126

  Inter-mountain (Mr. Toomey)                135

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  ,.
I: j;         DEPARTMENT OF HEALTH,  EDUCATION AND p?ELFARE
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I/
2 I!                                        - - -
  1;
  !I

DIVISION OF' REGIONAL MEDICAL PROGRr.MS

   REP AD HOC REVIEW COMMITTEE

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                                         /

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

Wednesday ,August 7, 1974.

     The meeting convened at 8:30 a.m., Dr. Herbert B.

Pahl, Acting Director,Division of Regional Medical Programs,

presiding.

PRESENT:                                                                        I

       EUGENE RUBEL, Acting Associate Director, HRP.

         SARAH J. SILSBEE, Acting Chief, Operations and

Development, DRMP.

MR. GARDELL, Acting Deputy Director, DRMP.

ROBERT TOOMEY, Greenville, South Carolina.

DR. WILLIAM THURMAN, New Orleans, Louisiana.

DR. ALEXANDER McPHBDRAN, Augusta, Maine.

DR. LEONARD SCHERLIS, Baltimore, Maryland.

DR. JOHN HIRSCHR~ECK, Milwau?cee, Wisconsin.

DR. JOSEPH HESS, Detroit, Michigan.

MR. KENNETH BARROWS, Fest Des Moines, Iowa.


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PRESENT (continued):

JOHTJ THOMPSON, New Haven, Conn&i

2

cut.

DR. WILLIAM VAUN, Loinq Branch, New Jersey.

SISY~-"7 ANN JOSEPHINE, Notre Dame, Indiana.

DR. , JL TESCHAN, Nashville, Tennessee.

MRS. JESSIE SALAZAR, Albuquerque, New Mexico.

DR. WINSTON MILLER, Minneapolis, Minnesota.

DR. ALBERT HEUSTIS, Thpe Rivers, Michigan.

DR. ROBERT CARPENTER, Ann Arbor, Michigan.

And Others.


1

PROCEEDINGS
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DOCTOR PAHL: Good morning,.  Play we come to order.   i

3   And at this time, may I welcome you as members of the Ad Hoc i

4   PW? Review Committee,  Pormny in the room, that will be a

5  significant advance this time.

6         I do want to say how much I appreciate having both

7   the review committee members return on such -- after such a

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short interval,  and also such a fine turn-out of our national

advisory committee members, council members.  We expect to ha7  !

a total of twelve.

Can this br turned down a little bit?

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      We expect to have a total of twelve of the council

members present today,  and with other commitments, I believe

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there will only be two council members here who will be preser

tomorrow, that won't be able to sit in on the proceedings tode

Thus,  I think we are extremely fortunate in being able to sal-

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vage a very difficult situation and conform with court order

requirements and commitments to the Regional Medical Programs,

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and as well as possibly get into your summer schedules.

      I want to welcome to this table specifically Sr.

Ann.  We are pleased to have you back.  And I see Dr. McPhedran

and I believe the others were here at our previous meeting.    j

     We have as our agenda a relatively short open session',

,fith a few reports from me.  I believe some news of great intere

to you from Mr.  Rubel concerning the legislation.   And then,

,

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following some comments from visitors we will go into our    i

closed session and get on with the day's work which I believe'

will be a rather full day.

      Again, I want to say how much we as a staff appreciat

having all of the assistance of the committee members in send?
ing in comments and telephoning us about their thoughts SO

that this day can be made.as productive as possible.

      I would like to make a vew comments before asking

Mr. Rubel to give his remarks.  First of all, as I indicated

earlier at our previous meeting omformer acting  deputy dir-

ector, Mr. Cleveland Chandlis has accepted a year's leave of

absence with the National Academy of Sciences to engage in a

study of the Veteran's Administration Medical Services and

Delivery System.

     This is a year long activity and he is -expected to

return to this agency at the end of that time.  Bob official1

started Monday of this week and we expect to see a good bit

of him, since he is just down town, but nonetheless we have h

to fill that position with the many requirements on my offic

and so I am pleased to announce that Mr. Gerald Garde11 will

continue to serve as acting deputy director.

Having done so while Mr. Chandlis was away for six

weeks at a training session at Harvard.  So Gerry is joining j

our ranks on a semi-permanent basis, depending on our life-time

as Pap.


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1       And I am very pleased that he has accepted this ccn-

2  tinuing responsibility.  'l'he court order has been signed and

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the litigation has come to an end.  We now know how much monel-

we have finally to distribute and it is about what we indicate5

to you last time.

In practical terms we have $28 million dollars of

7  remaining releasafiscal 73 funds for or following tomorrow's

8  council meeting together with whatever unexpended balances

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remain available for support of the regions.  So the total that

we would have approximates $29 and a half to $30 million dollar:

11   for awards after tomorrow's council meeting.

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     And we will obligate our remaining RN2 funds to the

P.XP's prior to August 31, which is our commitment.

      I would like to take this opportunity since the

council members are here and others will be coming a little

later to indicate that there was an approval of 88.7 million

dollars by the council for RMP's.  And we following consulta-

tion with the administration decided to award 84.4.million

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which made it possible for us to reserve 28 million for this

review cycle.

21        We felt that that would be prudent in view of our

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*knowledge that there was going to be in the neighborhood of

forty some million dollars in requests coming in before you

and the council this time.  As a matter of fact the applicatiozr

before you today to%al 46 million dollars .in requests, so

5


I think that was a wise decision following the last council
                                                                           I
meeting.

    I won't go into all of the specific decisions post
council last time because I will take this up tomorrow when

YE meet just with the council.  I did discuss these decisons

uith the committee at it's last meeting.

    I expect that you are all very interested, however,
in knowing something of the status' of legislation which has    ;

been changing so very rapidly.  And Nr. Rubel has consented :

to take time out from what is these day's an extremely busy   i

schedule to tell you what is, I think, some good news, and      :

possibly give some indication as ;o what you think the time   i
table might be from now on despite Washington Post headlines /

to

the contrary.


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           The clean bill is known as HR 16204.   There are a

  couple of copies floating .around town.  They are very difficult

   2.
g 1 to get at the moment, but within the next several days I am

9  sure copies will be available and if you are interested the
lo I/  best way, really, is to contact the document room in t:?+iouse,
11 '1 or one of your representatives.

                                           7

MR. RUBEL: Thank you, Iierb.   :`is most of you probabl;

know by now,  the Health and Environmer whatever it is

called, subcommittee of the Committee on Interstate and i'oreiq~

Commerce did report out a bill two weeks ago and that bill is

on the agenda for the full committee this week.

.

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The subcommittee spent over a we&k having a so-called

policy discussion,  sent the staff back to do a draft.   A draft

was given to the committee.  Those are all the e-letives that

we are deleting.  And the committe then spent almost three   1

weeks on -- I'll try to talk loud and we can do away with this.

      The committee spent almost three weeks in marking

up the bill.  I am sure that history is going to talk a lot

about something called Omega.  This is the draft that they      j

are working with.  Whenever the government printing office

actually produces a draft they put a slug on top with some

*kind of title, and this was called Omega.

       We hope that this was going to be the last one. So

   I
24 1  it was descriptive.  And after three weeks this bill is the

25 '1 product.
il         It is a long bill.  I think a hundred eleven pages.

i j
Ii


1

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Complicated bill, and Ithink it is fair to say that i,. is a

product of the subcommittee.

3       There was very excellent attendance throughout the

4   deliberations.  The votes typically had a total of nine or

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ten from,.a membership of 11. So that there was very good sit-

ting power, if nothing else. And virtually every member of the

subcommittee contributed in some way or other.

     There are certainly very many controversial , items

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both in the bill, and that people proposed that didn't make it.

In many respects it is based on the original legislation
first proposed by Congressman Rogers, and Roy, and Hastings

back in December, and then re-introduced with changes by the !

13   three of them.

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Several months later.  HR 12353, and HR 13995.

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Certainly the structure that is in this bill is very similar.
What we have are Health Systems Agencies at the local level.

Private non-profit organizations, at the state, a state agency
as well as a state-wide health coordinating council.

      Those are the structure that they have created or

proposed.  The coordinating council is composed, two thirds

of its  membership comes from the health system's agency. And

the third appointed by the governor.  The state agency is an

agency of state government.

    The composition of the governing board of the health

system's agency is one half plus one consumer's and the remain-

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ing members,providers.

So that there is clearly a feeling that everbody

has to participate.  There is,there I. s a very definite decisior
made to preclude our local agency being anything but a privat e

non-profit organization.  There was an attempt to allow units
of local of local governme or a multi-purpose planning organ-
ization like COGS, or economic development organizations to b

e

allowable, and that was not accepted.

      We had a lotof debate about the functions.  I guess

the major issue here was to what extent rate review, review of

rates to be charged by Health Care institutions should be   i
                                                                           1

a responsibility or should not be a responsibility of this   1
                                                                           !
                                                                           !
mechanism.                          /
                                                                           I

After a lot of debate one way or another that .was/
                                                        1

finally excluded completely.  That was one big issue, certainly

the issue that should concern you the most. The way the bill

is structured now, there is a limited resource development
fund, able to be used by each of the local health systems

agencies.

There are limitations on what this money can be usz

for.  It may not be used to pay for the delivery of services,

* or for instruction.  There is a limitation on the dollar amot

that may be expended for any  particular project of $75,000 i

any given year, .and there is a limitation on the number of YE

that a particular project can be funded: two years.


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At the state level there is a coukinuation very      I
                                                                   I

much similar to what we%: have today in the Hill-Burton program'.
                                                                           /

But certainly that is a vehicle for the development of re-     ,
                                                                           I

sources.  There was a proposal made that a fourth unit be      1

created at the state level, non-profit organization whose jobi
                                                                           /

and role would be the development of resources.

And a mention of implemention of resources developmer

at the local level, healthrsystems agencies would have been 1
                                                            I

deleted.  That attempt failed.  It was not accepted by the sub-

committee.

I think the notable changes that were made -- the bil
                                                                   /

does provide that if a state wants to participate in this pry
                                           1

gram, it must either enact a certificate of need, or have a ' j
certificate of need program, or participate under the program,
                                                                           I

under section 1122 of the Social Security Act, that a review I
                                                                         I

of capital expenditures.

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!

I think there is a very clear commitment on the part
                                                          !

of the committee that we need controls over capital expendi- [
                                                                           I
tures, in addition to 1122, wherethe penalty is loss of inter:5
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and appreciation payments under medicare, and medicaid.  The 1
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committee decided that a state would have to enact laws on -its

own, to prohibit any third party payer from making those    \

same payments.

And further prohibiting any institution, if it pro- i
                                                                    I

ceeded with a capital expenditure that had been denied, from

,


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charging any individual for those same capital costs. So

that within a relatively short period of time,  we will have,

            ,
I am prettysure, in place around the country a mechanism where

an institution  proceedswith a capital expenditure without

the approval of this mechanism that is being created here,

it will not be able to get re-imbursed after any payment to   i

                                                                           /

pay for the capital portion, the interest ad depreciation of i

that expenditure, although many for services within that inst?-
                                                                           I
                                                                           ,
tution would continue.                            !

       Would continue to flow.  Well, I could sit here for

two hours and go over all the details of the bill.  Let me ju

spend a couple of minutes talking about time-tables.  Every-

thing that is going on in Washington is dependent upon the
action to be taken by the House on Impeachment, and any trial

in the Senate.

     And it is very difficult to know what is going to

happen to other activities during the same time period.   The

critical point here is not so much the House, but the Senate.
                                                                       1

The Senate held hearings way before the House did on this kind;

of legislation, as you probably know.  Senator Kennedy intrct i

duced S 2994 which is a variation of the original Rogers     i

bill.

       The subcommittee, the House subcommittee kind of      '

dumped all of its legislation in the laps of the full committee,

Whatever it is, the public welfare or something or other, chair6

                                                                           I

                                                                           j


1   by Senator Williams.  They have been holding mark-up sessions 1

2  on manpower legislation and rumor has it that as soon as they I

3

.finish with manpower they will take up planning. When that j
                                                                           I

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happens, I don't know.                                                      /

     People keep telling me tomorrow, but it was tomorrow
                                                                           I
three weeks ago, so I begin to doubt their veracity.  People /

are expecting more than we can deliver.  It is conceivable i
                                                                           I

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that it will be next week, though.  On .the House side, I thin;<
                                               !

the full committee will report out the bill, either by the end
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of this week, or at some point next week.                        I
                                                                           I

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I don't believe there is enough-time to have the bili

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reported to the House floor prior to the Impeachment debate

which is now scheduled to start a week from Monday. So we, lik

most of the parts of government are very ,nicely entangled with

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the national debate which is going on.

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      Fortunately, there are no immediate problems ahead.

There is no immediate need for legialation to be enacted to-

morrow.  We have, through a variety of circumstances many --

managed to forward fund all of the pieces of this puzzle. I

am still reasonably confident that we will have some type of

legislation by the end of September.

22

Or sometime in October.  Gut I was more than reasona

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confident several weeks ago. We are just going to have to see

what happens.

       Herb, if I could,  I would like to switch to another

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5  for Health Policy within HEW.  Origl..,:illy they wanted to put

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a change in the allotment formula.  Welli today the formula

is heavily weighted toward rural areas and the weighting is

removed, and it would be based on population per capita incoce.

And the need for facilities in the state.

19        Two, the budgets that exist in current Hill-Burton

20  law where a certain amount of money is available to state for

21

modernization. A certain amount for construction, and so on.

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Even though this bill would be kind of pour from one bucket to

another.

24

We've taken the buckets away and we've got one big

2.5

pail,now.  There is one allotment to a state, and there is some

subject.

MR. BfiRROWS: What happened in the National Council

on this thing.

FIR. RUBEL: Excuse me,  the?-:3 is a National Council

it in the Office of the President, and it is definitely in

HEW.  A council of fifteen,members -- no more than eight of w?:i:

are from the same party,  and no more than three are Federal

officials.

With all kinds of expertise on it.

DR. HIRSCHBOECK: Is there any remaining Hill-Burton

functioning?-                           ,

MR. RUBEL: There is pretty much Hill-Burton as ~:e

know it today. With, I would say, several major changes.  3e ,.


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1   purposes.  But they  are very minor.

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Finally, the authorization level in the House bill j S

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considerably less than what we have under current authorization.

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The author. .ration for fiscal 75 is 125 million.  150 million

for 76.   1.5 for 77.  When the appropriations for fiscal 74

for Hill-Burton was somewhere in the neighborhood of 200

million dollars,

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      It is tied in much better than what ws have under

current.law with a planning apparatus which will be no longer

a separate scheme.  It goes out and develops a facility plan.

It has all got to be done as one package.

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     Now, the Senate does not appear to be going in that

direction, and that is certainly not the direction that the

administration has been pushing.   I would not -- it seems to

me that that is one of the major issues that still needs to

be thrashed out some.

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      The extent to which we continue to rely essential11

on state apparatus or do w, * move to some kind of project grant

facility construction. There!.was an amendment proposed by

Congressman Nelson that would have converted the program to

a project grant program.

       And the vote was five to five.  Therefore, it did

not carry, but there was some significant feeling behind it. ;

And of,. course, Senator Kennedy  proposed very much the same !

kind of mechanism in a separate bill.  How that is going to

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Jerk out,  I don't know.

DR. MILLER:  I understand the new -- has the minimum

copulation of 500,000, maximum 3,000,OOO.  flow do you view the

ransition from our present CBBB agencies to this kin:: of an

organizational change.                                                       /

     MR. RUBEL: It's a little bit more complicated than    i

~,000,000-500,000. I wish it would be that simple.  We can go

)ver three million if the area includes an SFISA that has a

copulation of three-- an SMSA is a standard metropolitan static

:ical area.  We have hundreds and hundreds of them around the

:ountry.

      You can tell below 500,000 as well.  Under unusual

:ircumstances you can go down to 200,000.  Andmder highly un-

    *

usual circumstances you can go below that. I have been  going

[round telling people that I am a year from now probably going

:o be the world's greatest expert on the definition of usual

ind highly  -- I'll be able to quote from verbatim, exactly what

i-

::

:hey mean,  essentially they pun it.

      What kind of transition from our current B agencies.

First of all, let's make it clear that we have a lot of or,ganiza.

:ions that are going to be competing and a lot of individuals

hat are going to be competing. We have B agencies, we have

n many places RMP's,  and in other places we have experimental

.ealth service systems, and in other places we have Appalachian

Legional Commission agencies.


1

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                                                            A"

And then we have a whole variety of others.  AC$?XiS

2  that have put themselves togetiher to act as planning agencies,

3

even though'. they have never been sanctioned, or have gotten

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any money under 314(b).

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      And a whole variety of others.  The b..sl specifical;:
says that the Secretary shall give priority to an application

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that has been endorsed in effect by either a B agency or an

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Rm? .  But what priority means, I don't know quite at this       :

time.  I guess that is something that we are going to have to:

work out.

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    We have many, many, many, many B agencies  today

that have areas that are too sma\l.  Virtually everybody

agrees to that.  When the original 500,000 came out, I said

i4

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that would be into arbitrary, and then the 200,000 came out

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and -- to cite you one example, we have .a B agency just recent1

started a year ago on a Navajo reservation.  Well, that is an

enormous area.

They have something on the order of a population of:

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180,000 in the whole Navajo and Hopie reservation. What are

we going to tell them. You can't have a planning mechanism,

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you have to go get the white men involved here.  Just political

not a very astute way to do things.
     Everything is moving in the other direction.  ::e11,

I suppose that is a highly unusual circumstance.  There are

goi.?g to be very, very significant changes and I would say


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we will only give very surface treatment to arguments that say

2  well we want to do it.  This is the proposition because this j

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is the way we are going to do it today.
   I don't believe that should be the major criteria. ;

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I" t not discuss the area designation process, but there is I
in the bill a process laid'out to figure out, to divide the
country into health service areas, and the governors of the
individual:.: states will have the primary job.there.

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   And it is going to be up to them to look at these

kinds of things  pretty critically.  We have an opportunity
here to set a pattern that will be useful for a lot other thir
Hopefully, to avoid some of the mistakes we have made in say,  I

picking the agency.

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Perhaps in picking RMP areas. Perhaps even in desig;
                                                                    I

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nating PSRO areas.  So it is going to be a nice.  A very attic

six months. Thus the time period for the area designation
process to be carried out.

       DR. BARROWS: Will administration be centralized as
in the case of RMP or will it be de-centralized.  Or do you

know?

   HR. RUBEL: Well, the statute does not speak to that.
,There is language proposed in manpower legislation tb   -,jould I
mandate that there be central administration.  I don't conceive

that that will happen, here.  In all of our planning is under 3

the assumption  that it will be de-centralized.

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i '          Let me, if there are no further questions on the      I

2   legislation, shift to the famous 5 million dollars that was :

3  -the subject of much litigation work over the last several       s

4 j/  months.    '1 not quite sure where we were the last time we ;

met, but an order was entered, I guess about three Weeks ago.
                                          r

Now, a final order that settled the litigation, and,

~ in effect, well, not in effect.  The Secretary was -- I Will j

~ read it to you -- provided however, that the Secretary of   /
                                                                           !

IIEV pursuant to the authority contained in Section 9-10 of   i
                                                                           I

.the public health service act may obligate on or before 90   j

days of entry of this order not more than s 5 million dollars 1

of the heretofore obligated portion of the aforesaid fiscal   i

year 1973 appropriation.  Isn't it fantastic the Way lawyers

talk?

     To grantees other than the regional medical programs

constituting the planned plaintiff class.  Such grants and I

contracts under section 9-10 of the Public Health Service Act

may be made only for the folloWi.ng activities: one, obligations
to augment current efforts in development the state of the   i

art of health plans with major emphasis on the development

                                                                           .
of criteria  for expensive facilities and services such as
.
radiation therapy, and open heart surgery, and thenalong

list of specific projects.  VJe are pursuing very vigorously

the use of this money right now,  F?e intend to utilize it all

to the extent that we do utilize it all under the contracting


1   authority, and therefore there is no requirement for a Xational

2   Council review under law.

3        I did make a commitment to the council when we last:

4  met to re+:>rt on how we were planning to use this money.   And

5   because I can't be here tomorrow, I wanted to take this opgor?

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tunity to do so.                                         /

      I don't know to what extent we have had copies  of (

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the document that we have had developed distributed, but if it
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MRS.SILSBEE: Yes, it has been.

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   MR. RUBEL: The court order said to augment the cur-j

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rent efforts.  And there have been very significant current i
efforts on our part to try to help the planning process along;

What. is it and how do you do a better job of it.  The document

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that you have is really divided into three pieces.                1

     The first piece describes things that we have already

accomplished.  Things that have already been done.  The second

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work that is currently under way, and the third part,which

begins on page 25, describes our plans for the use of the

five million dollars.

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     I can only describe for you in very'general terms

* specific projects, and I can't really go into the question

of dollars to be outfitted to these, because since this is a

public meeting , .we have got a lot of contractors out in the

world that would be very interested in what our thoughts on

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how many millions of dollars are ping into each of these

things.

      And we are very much determined that this is gcir.g

to be a nice, open, competitive process.  But following the

awarding of contracts,  all the materials here will certair.1:

We have divided our work into really five pieces,

four of which are described here,'and then there is a fifth    *

catch all, which will only use the minority partof the money,
-but we have got a variety of activities that don't quite

fit into either of these.

                                           `
       Any of these four.  And this is what the court order

Said we should give emphasis to developing planning approaches

and -criteria for health services.  We already have several

major contracts under way.  This is an attempt at going even

further with the results of both of these efforts.

      Approximately a year from now we will have contained

in one place and it will probably take up this whole room, but

in one place kinds of criteria standards to be used for deter-

all of these major kinds of services and capital expenditure

items that are out in the world.

        There has been an enormous amount of work done in t.h2

past, but it has never been pulled together.   It has never been
critically analyzed.  It has never been made accessible, and


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if you read this brief description here as v:ell as things
previously you get a better understanding of what we are talk-
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ing about; from my.point of view there is really nothing more

important that we can do.
                             .i

     The other two pieces relating to that effort are

to try and get a better understanding of how institutions
should share and how does a planning organization deal with

the problems of sharing of services by institutions.  Again,

a lot of work done, but to what extent it gets to the gut

issues that you have to deal with, when you are out in the

real world, is debatable.

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       Finally,  the third -- how should we deal with tech-

nological advances and with the mushrooming of new"things,

how do you make decisions today when you don't quite know wha

the future is going to bring.  And I use as an example here    t

                                                                           ,

constantly the EM1 brain scanner.                                       1

     We have virtually every institution in the country j

trying to buy one of these things.  There are a lot of people

                                                                           1

telling us they are obsolete already. The backlog on ordering i

them is ten months, or thereabouts. They only cost $350,000 i
                                                                           !
apiece.

     The profession hasn't quite figured out what kind of

quality standards you have to have,.  Meanwhile by the time      i

we 're over we will probably be spending  by that time include

the cost of these things and the training of the people to


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1 /I operate them.    I don't how.  Many of hundreds of zillions
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2 ;I of doliars.  How do you cope with that kind of phenomenon.
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Another example is the problem of coronary 'J:lr?ass.

;"id all that travail that we have gone through for at least

ten years now trying to figure out whether it is useful or

not.  If it is useful, we probably need to doublt our capacity

to perform open heart surgery,

       If it isn't, we have too many open heart surgery.  /
                                1
units right now.  Okay. Now, how do you&al with that in a

planning environment. Not a very easy question to answer, but
it is simply something that we think needs to be grappled with,
The second.major area relates to the data collection and analy-

sis.

       And I won't dwell on it.  We are of the opinion that

there is a hell of a lot more data around than people know

what to do with, and our focus is not sorremuch on the col1ecti.o

but how do you use data.  And I think that this is something

that will be useful to virtually all of our agencies, around j

the country.

        The third -- knowledge about our health care system,

How do components interact is the-  ,jor thing that we are

. trying to pursue here.  What are the impacts, for exaz.ple of
introduction of the health maintenance organization in the

community.

What does it mean and what kind of dislocations occur


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Cake another example.  What happens if you put in a neighborho:?

wealth center.

Sfe make these decisions all the time; somebody says,

Aay , we are going to move but we really don't know what it

neans for everybody else.   And the approach that we want to

take here is much, rather than theoretical, trying to look at

specifics, look at specific communities, trying to assess what

happens when there is a major change.
    '??hat happened in Sacramento,California, when Xaiser

moved in. And try to just describe what has happened ,as a way
                                                                      
of beginning to be able to say, okay, this is what happened.

NOW, how do you try to deal with it.   Things that happen are

both positive and negative.  There is a plan for something else

to happen.

In another,community, or in that same community at

some later date.   In general, we are. trying very hard in all

of our work to do as much description as we possibly can. I

am o'f the opinion that we have not spent enough time describing:

what we have done.

     We spend a lot of time trying to figure out what kind

of impact it has.  And the people come along and say what is

it that you have done and we can't show them.  You can't docu-

ment.  Ne are so busy doing that we don't spend the time to

get it down on paper.

Finally, the fourth piece is how do we have people,


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1  how do we get people out there, that can do the job, or prhaps

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do the job better than perhaps they are doing it today.   And

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The first,  what kind of -- essentially what kind of /

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short term training is useful and desirable.  About the health /

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care system, and about the'.specific tools that people need in

order to do this job.  The 'second, and something that I am ver

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excited about, something that we are calling now, the Center

for Eealth Resources Planning Information.

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     We are in the process of setting up an information

exchange mechanism that just doesn't exist today.  This is the

medlars of planning ad development.  How many of you sitting

around the room have said, okay, we need to work on -- let's

say,? a renal disease plan, and you say, okay, what is anybody

else done in-'the world.

And there is a frantic looking around, and the only

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real mechanism that exists today is word of mouth.  Within a

relatively short period of time.  -- we hope some time around

Harch --  that it will be trivial for anyone in the field to

know exactly -- let's take the EM1 scanner, what kind of work

                                                                           .

people have done.

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      And within a matter of days, or at the most a couple!

of weeks to actually have hard copies of what other people have

produced.  I have observed this is not just confined to plan- 1

ning agencies, but RMP's as well. We have an enormous amount of

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1  duplication of effort around the country.  People going th,rcs,-:?

2  :xactly the same searching and struggling, which is  CcIylletel~:

3  Ind totally unnecessary.

4      But there is no organized way to get that inforr?atic::

5  Xansmitted today from one place to another.  Chirpee is also

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Jhat we are calling it. It stands for Health and Resources 21x%-

ling information, and also listed in the new legislation as

something that would become our responsibility.

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      DR. SCHERLIS: Will you catalogue other than formerly

tublished information?

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:ataloging.  General kinds of things.  It will be on cataloging
materials that have been developed by operating institutions.
Jith some attempt at screening so we won't put stuff in hera

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;hat is awful.

       We are not, the major focus is not on trying to be

1 great abstracter  of the literature, because the literature
.s not going to help you most of the time on this stuff.   "here

Isn't much of a literature.

     DR. SCHERLIS: Any request?

       MR. RUBEL: No.  The purpose here is to provide a
source of .information for people that are out there attenFtir,g

:o do this kind of work, to find out what other people have

lone to get access to it.  Yes, sir.

      .    DR. SCHERLIS: I would hope that part of your funding

KXhaniSm would require that YOU have this material subm,itted


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back to you in an appropriate format so that infornation can

be made available.  One of the difficulties I have found ~:it:?

reviewing the comprehensive health plan agency functions or

RNP functions ,is that everyone is discovering, all over the

country, all over again, and the repetition as far as the

development of either education materials, everyone having his

own audio-visual laboratory, his own computer.techniques for

EKG, interpretation.

   The list goes ad infinitum. The same is true,  if

not of P9M alone, but I would think it would be more true of
the board of efforts of planning CHBMA planning agencies,
     NR. RUBEL: Absolutely.

       DR. SCIIEPLIS: While Chirpee sounds good, the tempta-
tion is to sa.< it might be for the birds, unless for a need!
to have a format built in this which would demand that you as
part of your funding mechanism insist that the reports come

back in usable forms, for immediate feedback because I have
been'impressed with duplication of wasted facilities at CIIP

and at PtiP levels.

   I am sure they have accomplished a great deal, but
now we are starting out new, that this won't be just an atterrpz

'or an effort, that there would be some attempt in this to
insist that if money is provided the information be forthcorin:
and be available for distribution.

XR, RUBEL: Well, absolutely.  That is exactly what


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our intent is.

     DR. PAXL: Thank you, Gene, are there any other

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questions?  I appreciate, very much, Gene, your spending t?e

time today,  since we do have the great majority of our council

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members here, also since you won't be able to be here to?.crrc:7.

So thank you, and stay as long as you can, this morning, and

return this afternoon, as we go into our deliberations, if

you can.

Before asking you to listen to a very brief report

the kidney activities, and

from Dr. Alvin Goodman concerning

this is important because we have

in this area, in the present appb

some twenty five applications

ications.

I would like to, both for the record, and,I think

for those limited numbers of individuals on our review coz.i:te~

and council who are members of the legal*profession indicate

that we certainly have the utmost respect for both the legal

profession and  I am not directing these comments to anyone

in particular.

MR. RUBE-L: I'll stand by what I said.

DR. PAHL: We've both had a lot of experience this

year.  I would like to introduce Dr. Alvin Goodman, the Progriir:

Director in the Bureau of Quality Assurance in our sister age-s:

the tlealth Services Administration.  The Program Coordinator,

the end stage renal disease program who said that he would be

able.to take a few minutes this morning and give you the currer.:


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;tatus of this activity because we will be takinq administratit?

action on these specific projects as a result of, I guess, the

development of the programs.

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so,  I would here take a fe:J minutes and bring us up

date.


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DR. GOGDMPJJ: Sure. ~11, we have begun the imple- !

mentation of the program, when I spoke, I guess it WaS t0 the!

council about eight weeks ago.  kJe discussed briefly what the

J?. -:ram was to consist of in terms of its regional approach:
            .I

a 2 U-2 present time the regional health administrators have

received their packets of instructions and are now sending

them, setting about to determine with health planning consult

and providers of care their regional networks in the network

areas.

So we are only going to serve to be another headach

to Gene and his people.  In developing networks, and network

areas, prior to designation of health service areas.  We told

them not to divide health service areas when they designate

thc?$*r areas.

But since no one knows what a health service area

is the admonishment may not serve any type of a purpose. In
                            -

any event, this cooperative network of institutions and hospi

tals bringing together all their resources tobear on kidney

disease without duplication is&out to be designated during

this and next month.

And after that is done, that basis is done, the reg

'lations will have appeared by the end of that time, and medic:
review boards and so forth will start coming into being.   rAnd

that, too, has to interface very strongly and tightly with

PSRO's.

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The major problem in term:; of relationship with

what may, wh;,  must be our antecedent organization rcgi.onal

prcgrams.  Th... problem that is very  recently posed is the

the request for funding on kidney projects that have: *c>rne

                                                                           /
through and perhaps  and perhaps not.

    We are going to research it, to what degree this is

true, whether or not the applicants have taken cognizance of

the fact that there is now a new additional legal mechanism`
in which to be certified to be a provider or supplier of care

that is, the medicare program, and that would be incongruous

for one agency of government to grant the where with all to

an applicant the ability to provide care, the machines, the

dialysis  machines, for example, and so forth, or money

for personnel, w-herein the applicant organization has not

secured  approval to be such a provider of care for medicare i
                                                                           I

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from the social security agency.

     Therefore, there is, on.. the one hand, an application
                                                                           /
for money for a grant from PNP, but on the other hand, there j

is a highly new national program, and the bulk of this care    I
                                                                           I

falls under social security regulations.

         And  the Bureau of Quality Assurance which I represen.

'has responsibilities for medical aspects of thatprogram, the

medical council and social security.  This poses a .l certain

discipline that would have to be followed by the applicant

organization.


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      i?caning that the   rds would be subject to certain

caveats that money could no  be expended unless the appropriak-z

approvals were secured to the lkdicare program, and those

instances where a new or extension of services were to be

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supplied, in end-stage renal disease clearly through the        ,

Nedicare program.

     And the applicant organization must secure that     i

appropriate approval, otherwise we would wind up on the horns
                                                                           !
of very serious dilemmas.  And very serious legal ajudication:

                                                                           1
problems,  if this is not done.                                           /
                                         I

A perusal of the applications, of 25 plus application

would indicate that a large number are requesting either new

or extension of dialysis or transplant facilities inciuded     I

whilemder the Medicare act.  Another segment asks ali organ

procurement programs, educational programs and actual procure'

7

ment.  And the organ procurement also falls under lledicare     t

reimbursement, as well as effected, fall under our regulations

our future permanent regulations.

So we have to develop a joint health and social    ;
                                                                    !

security attitude as to what we do. I -- about such applicatic

and what caveats they may be subject to and the third group    1

of applications fall under computer and data systems.  And in

time there will be a national Ilcdicare medical data system,     *

or information system addressing both demographic aspects as

well as manpower aspects.


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And quality medical c`are aspects.   Fnd one I-1,-~:; to

ask to what degree that individual application from a particuf.:.:

and specific regions requesting funds for such activities       :

are very duplicative and as well to what extent social securit;?

Medicare will pay twice if at all for so much duplication in

activity.                                                                      /

      When clearly in,PIedicare will support those activitie

which are designed on a national basis.   And so all of these

matters will have to be looked at very closely with our col-

leagues in RMP in order to decide exactly what to do. So

all I have posed, really, are two problems, the tentative

solutions that have to be subject to certain caveats.

       Decisions  are still) pending which should take

place in the next few days, . and I suppose that is not unique

since we discussed problems before,  one is another one in

a particular discipline, but anyhow, through it all I do see

a kind of silver lining,  in that agencies are now cooperating
together, looking at these problems very clearly. That while/
                                            !
Gene was talking before, regionalization of that fits.     I

     We areaztually engaged in regionalization of efforts

                                                                           I

at the medical care agencies at this moment.  And I think all!

this type of seeming impediments will come out and wash and    *

there will be a system a year or so from now that will be

working relatively smoothly, thank you.

'DR. PAIIL.: Thank you very rmch, Al.  Are there any


1  questions on either the kidney area?  I believe that Dr. Shrine:!

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is not here today.   And Dr.  Merrill will not be able to make
                        .

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either today's or tomorrow's, is that correct?  Tomorrow's

council me5   "7.

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I.!cil, thank you very much Al.  I appreciate your

coming down.

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     Before we go into the comments and so forth from

the public I would like to take this opportunity to -- since

the review committee and the council members to my knowledge

have never really met together before,  I would like to take

this opportunity to introduce to the review committee the

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council members who are here, and who are sitting very quietly

and listening.

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       Hopefully, then,  we'll have their session tomorrow.

And since they don't have microphones, perhaps I may do the

introductions.  And then I would appreciate it, if perhaps,

the committee would just introduce itself to the council membe

because you will be sitting over the course of the day and I

hope you will have some chang e to meet and say hello to each

other.

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So if we may start, on my left. Of the room.   I woulr

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like to introduce Dr. Janeway, Dr. Wammick,  Nrs . P<c,nrgan , Dr .

Gramlich, and Mr. Hiroto.  And then, on my right, Dr. Watkins, i

Ws. Klein, Mrs.'IIartinez, Mr. Ogden, and Dr. Komaroff.   And

we,  I guess, expected Dr. Shriner, we expect him later this    !

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morning,  is that correct?

      He may very well come in a little bit later, ar.c I

would like, start& on my left, to have the committee intro-

duce themse: .'::s to the council.  I thin this will give us

the necessa:  break before we go  into : .x  further session.

DR. PAHL: Fir. Toomey?

     MR. TOOMEY: I am.Bob Toomey, and I am from Greenville

South Caroline, the Director of the Greenville hospital system..

      MR. THUIU~LAN: We don't need that. Bill Thurman frcm

Tulane University School of Medicine.

        DR. MCPHEDRAN: Alex McPhedran from Augusta, ??aine.

     DR. SHERLIS: Leonard Sbxlis, University of :~Iar~lan~

Medical Center.

        DR. HIRSCIIBOEC::: John Hirschboeck, St. Mary's :ics?ita.

Milwaukee.

      MR. BARROWS: Ken Barrows, Des Xoines, Iowa.

     DR. CARPEXTEI?: Bob Carpenter, from the Universit:

of Michigan, Ann Arbor.

      DR. HEUSTIS: Albert Heustis, from Three Rivers,

Michigan.

.          DR. MILLER: V?i.nston Miller from Health Department,

Minneapolis, Minnesota.

     MRS.SALAZAR: Jessie Salazar, Albequerque, New I,Iexico.

o    SR. ANN: Sr. Ann, from Notre Dame, Indiana.


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DR . VAGN :  -- Vaun,  from :!ew Jersey.

DR.  TI!O;`I?SOiJ : John Thompson, Yale University School

Jf ;-ledicine.

DR. PAIIL: Thank you very much.  This is an opportunitl

also to v!ake us all up.  But I do hope you have a chance to

neet each other over the course of the day.

Before we ask for'any comments from the public, I

gould like to ask the committee whether there are any additiclnal

questions or topics which should be discussed at this time,

clarification of anything that we have said so far, or points

that we haven't brought up.

If not, I would like to indicate, because the council

Eembers are sitting here, that as the review committee knows

~7~3 will be reviewing again at this meeting applications from.

20th Haryland and lqassau-Suffolk.  This is not news to the

review committee.

      This is news to the council members. So if the review

committee will pardon me for a moment,  I will elaborate on why

that is so.   And that will save an explanation later and I thin::

it is appropriate to perhaps,  some of the comments from the

Jisitors who are here..

      30th the review committee and the national advisoF1

council recommended that these two regions I  both not receive

funds for the application in question last time as well as to

tve the regions terminated in an orderly fashion.  There was full


1  discussion by both the review committee and the council for

each of these applications.

3           However, followinq the council meetinq and because

4  and I have to phrase things very carefully, because ws were

5  managing a program within the constraints of an existin.'

6  court order we found it as ad administration not possi.    to

7  carry out the second part of that recommendation,:that is, to

8  terminate the regions in an orderly fashion.

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But rather to merely implement the first part of the

recommendation, which was to provide no funding for the applic E

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tions in question.   And I don't think this is probably the  1

appropriate form, and I am not certain that Im the right party

to be able to kecount the many discussions that we had with

our office of general counsel.

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     But I am pleased to inform you that once we found thi

we were not able to implement  that second part of the council

recommendation we acted quickly as a staff to so inferm those

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two regions, and to do two additional things.  To make it poss

through extension of the deadline to have the regions review

what they have proposed to submit to us, and I believe the

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deadline was extended from July 1, for applications, to July`

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7th or 10th.

And also, we made our staff available to the staffs j

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snd regional advisory groups at both regions in order to assist

:hem in understanding the basis for their recommendations, and

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to provide any assistance we could in helping them in presenz::~

their applications which currently are before us.
    So 1 am h&-ppy to report to you that we believe ti:at

through these activities we halA  for y<   consideration today,
                                                  . .

and for the council's consider;?   3n toix   lfO\? ,  the two ap?lica-

tions, which perhaps are somewhat strengthened as a result of

this rather intensive activity, particularly on the part of

the staffs of the regions, together with a good bit of over-

time work on the part of our own staff.

       The real basis, and I should try to indicate that tc

you is that the applications  last time represent technically

supplements to existing grants.  <The budget period for cur

REV's is from last January 1 through June 30, 1975.  That's

the budget approved for all regional medical programs.

That applications that we did *last time ars technical

are supplements to the existing awards, and therefore,  are in-

appropriate  for recommendation to terminate an entire pro-

gram on the basis of a supplemental request.   The reason I

gave this  explanation at this time is because I know that we

have the coordinator of the Nassau-Suffolk Regional !ledical

program here,  and I know that he wishes to make i: statement in

.a few minutes to the groups.

      So that I thought you needed this backglc!und pre?ara-

tion.  I.believe we ma:yalso have representation from the

Haryland regional medical program at the open session of tcrr.cr-


1 i row's council meeting.

SO, again, I think the group as a whole should under-

3 : stand these status.*'

  .
.a i,           `4R 0   -BEL : If I might, I did make a short stc    3nt

j io the counci  ,rhen it met, on this subject the last tj.      I

6 ':>lould just like to reiterate it,  It is pretty clear to ,

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7 :/some may disagree, that we are going through a transiti<     I

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8 :Idid not mention, again, it's on the specifics in the bi:i.

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9 ;:that there are some specific transitional provisions.
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10 ii      Very clearly, I think, indicate that the subcommittee':

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11 iidesire that there be come orderly phase out and phase in, that
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12 $zhose that should hav- a an opportunity to com,pete have tlhat c?-

13 $ortunity, and don't forfeit it because they have been put out

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13 agencies, actions that we are about to take :<ith respect to

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iexperimental health delivery systems, all point in that directlcr

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f.
iT7 ;,ie are not asking here for an abrupt cessation of all activities

iland something else is going to get set up some years from now.

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1:       On the other hand, to
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iizations operating today  where

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@re not being productive, and that further ex?enditu;  i of

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ipednral funds is unwarranted, you and the council have the
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;responsibility to make a judgment.
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ii     And if you find that that is true, we should not be

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the extent that there are organ-

there is a feeling that they


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in the business of wasting public funds so th-  .is really

what the issue is'here.

3         !;e have that same issue with respet .': to some CIIPB

4   agencies and we ha   had that same issue wi'   .respec!t to

5   the experimental h; .ith delivery systems.  t'i.id it is not an

6   easy job,  that you have.  I guess that is why we have asked    I

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you to work with us.

But I hope that you can make whatever decisions

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have to be made in that context.

        DR. PAIIL: Dr. Thurmon?

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         DR. THURNON: If I may just ask for one clarification

you made the statement that we cannot terminate a program

because of the supplementa.llsituation.   Is that because of

existing court order, because it is not true for other federa:

programs.   When you ask for a supplement, someone evaluates

your ongoing program and they say it isn't worth it.

      You can terminate a program.  There are several

other examples, of that,

      DR. PAHL: We were informed that under the wording

and restrictions of the court o:?:Ier that is the way we were

advised by our office of general    <e1.  And when we go in+

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the closed   ;sion I will merely      remind to the :^':     _) I- L1

that as Gene has just indicated,  the J:cview committeea1ir.l the :

council may take.whatever specific action on the application l

in question.


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      That again, with these applications, boyon:J m; ::.ing

recommendations to funding levels for this application !     !USC

3   we are still living within the spirit of the court order: '.o

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other recommendation would bc appropriate or could be impl.

mented.

      Of course, again,  let me say that as a program we

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would implement the action on these and other applications

following the council recommendation in such a. way as to

manage the affairs both of local RJ1P and ourselves as well

we could over whatever a period of time available funds would

provide for the continuation of either those or other ,'pro-

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grams.

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DR. THURJION: Thank you.

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DR. PAHL: Now, Dr. Scherlis.

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         DR. SCHERLIS:  I am unclear in terms of what health

system agency survives at the present time. You spoke about,

if we felt that some RMP's then you would want an input. I

guess, that applies to B agencies as well. What do you see

happening at a local level?

        Who is it.  Xho says we are what at a local level?

Who decides this?   Does someone raise the flag a little highe!

ii   ~(3 area, or -- speak a little bit more loud1   how is

this  decision to be made at a local level?

         MR . RUBEL: Did everyone hear the question?  If1

understand it boils down to who picks the new organization?


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As I indicated before, you really have a tWO-Step PrOCCSS.

One, of area designation.  And as you designate the area       /

that is going to solve a lot of problems to the extent, that '

                       that I have hr: 'y-6, about
for e:,.  ->le, one of the big issue5

shoulc; : there be one health service area for t,   ..tate of ;

Iowa, or should it be divided into pieces?

     If the decision is state-wide expenditure -- that

is going to give you one set of organizations that might be
                                                !
competing, and if you divide it, into several pieces that is   /

                                                                           I

going to give you another set of organizations, so that the

decision on area designation indirectly is going to have a

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large impact on which organiz'ations as such can compete, now,  I

of course,  individuals can go and work for all sorts of people.
                                                                           ,

     The bill provides that in terms of selection of       /
                                                       !

                                                                           1
agencies, it's up to the Secretary to make this selction with (

several constraints.  One, he has got to give priority, as I 1
said before toapplications that have been approved' by the    j

                                                         !
B agency, or the FcFIP, or the W? in the area,.                       /
                                                                           I

     What priority means has yet to be determined.   SeconC.

the governor has to approve the selection.  That's all the latii
                                                                           /
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says.  The,bill says.  There is no provision for how you go. !

=about putting this together in this bill anymore than there is

today, under 314(a) or (b).

       Or title nine, or the PiQ? legislation.  Presumably :

it is clear.  We can only fund one.  :You can't have more than

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one agency i.,   :I area, so you have got to select within the

constraints ti:at I mentioned it would be up to federal officiai:.:;

3  to make a decision as to one or the other.

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DR. SCHERLIS: Let's look at it as if a state has it's

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state planning agency, whatever that is called.  And it is --

under this, you have potentially, if it's a large state, you

have I assume health system agencies.  Is that right?

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MR. RUBEL: Every state w.ould have one.

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     DR. SCHERLIS: Well, these local state agencies, Will

they be appointed from the federal level, or the state level?

      MR. RUBEL: By HEN, except that the governor has to

approve of the selection of the agency.

        MR. THOMPSON: It's going to be the damndest boo,

ha ha, we've had for quite some time, so there is no reason

for anticipating it.  Can you imagine a CHB agency designating

another   ncy to .take  it's place without handing shits out?

     DR. SCHERGIS: I said, the B agency saying we want

a B agency.

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MR. THOMPSON: That's right.  And we're not going to

prove anything --

MR. RUBEL: Surely.  Sister Ann?

SR.  X?N : When you are talking in terms of identifyinc

a program as being  productive, do you measure this productivit:

in termsof an integrated program, or individual fragments.

I mean, individual projects, but a fragmented program?

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NR. RUDEL: Well, it's very hard to talk about it in

2 I/ the abstract.   I would venture to say that sure there is      :
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'j something being done worth while by the most terrible organiza-

  iOIl,  no matter what it is about.  I would look upon it, with I

*-fiven money to the organization be throwing it down a rat hole

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that is, you are just going to waste money.

      How well the plan' is put together.  ?!aybe it is

fragmented.  Or isn't fragmented.  I wouldn't put as much

smphasis on it at this point.  But that is my own private view i

Pnd this is something that you will have to decide for yoursel f

:?e are not here, you know,  under other circumstances I would

probably give you a very different response.

     But recognizing all of the trials and tribulations

me have had over the last two years, it's a wonder that we

lave got anything out there.  And it would be pretty simple for

1s to tick off a hell of a lot of organizations if we xanted  :

                                                                           /

to.  And that is clearly not what the review committee did and

lot what the council did.

So did that help at all?

SR. AN?J: Yes.

DR.  THURiiON:  Sr. Ann is charitable, above all else.

Xnd also mild today, very mild.

      DR. PAHL: Is there any further discussion on the    1

:opic or other points that the committee wishes to address?

        14R. THOIIIPSO:4: There is only one question.  It wasn't /


1   addressed.  And that is how fast the PSRO's are ccming up.

2  Decause many of the proposals we have are to help SOcbbOdy

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get ready for a PSRO.

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Now, whether it's defensive or offensively, we don't/

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know exactly which; From the wording, so I would like to have

some comments on you know how fast they are moving.

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DR. PHIL: we don't have a representative, I believe,

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in the room, fromlPSR0, but I would like to perhaps reply by

stating what we have done in an administrative fashion relatil

to the IVIP activities which are related to PSRO's.  l.?e have me

with Dr. Goran, the director of the Bureau of Quality Assuranc

under who the PSRO program is beirlg implemented.

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     We have arranged with him to have  his office provic

the final decision making as to whether an l?JIP request for a
PSRO type activity should be funded or should not be funded,

and once that decision is made, both the applicant, thz regiol

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medical programming, we are informed, and we then release the

funds which we have already awarded to the n'4P's but held in

escrow until such decision has been made.

    So, to answer your question, from my information,
the PSRO pr?qram, from Parklawn Building, seems to be moving

together  c;:  . . . . ..ly .  And that a number of awards both have been

and will be made in ths coming months.  And insofar as that

activity- and our activity go along in some sense in parallel

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f astiion.


1       Ke have administratively qiven the decision making ;

2  authority to the Bureau and to the proqram before funding

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2ur activities.  Now, that is not a completely responsive

anst:"  3 your question, and I think we would ha:  to qet :

somesc .:'jj Ie from BQA to tell us the exact status of :,::eir activity.
    I honestly can't say unless there is somebody in the

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room who can.  Judy?

       MRS. SILSBEB: NO. I was just going to say Z.2. Thompsor
nTe have submitted a number of paqqe 15's in these applications.

up to BQA.  I understand a memorandum is in process telling us

yes, no, or maybe. And then this process will be qin. So we j
                                                                           /

lave really,thrown the ball to them.

        ItR. RUBEL: I can comment in a general way in terms . i

of where they are.  There were some major contract, 92 odd ;
contracts negotiated prior to the end of the fiscal year,
for several purposes. We do have several, as I understand it.

Conditionally designated PSRO's.
     The first one was in Utah, with a big Utah, and they!

are proceeding to do what the  PSRO's are supposed to do. The j
great bulk of the contracts would not fit the conditional desiqr

tion, but they were for setting up -- and I don't kna;' quite

'the jargon that was used, but essentially planning kind of

mechanisms.

     And that is what the great bulk of activity is around,

so far.  And I think this fiscal year is going to be largely

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a planning year. We'll know probably by the time the year is

.over. But maybe it doesn't actually Operatinq ox'~~~mizatiOnS

maybe it will be more than that.

      That is kind of where they are.  You are absolutely

right.  That some of the proposals, certainly in the last

batch were offensive, and some were defensive.   And we are

very much concerned that RMP money not be used to thwart

the admission of PSRO's as enacted by the Congress.

     MR. THO?IPSON: You know, this whole thing reminds me

of a very well known parable in the New Testament, which was

called the prudent steward.  The 'steward was being called up

to his king for an accounting and hehew he was in trouble so
he went out to the people that he was in charqe of and he
said how many barrels of oil do you owe my master, and the qu

said 50.

      So he said all right.  Twenty five.  And then he

went out and he qave away all his masters's qoods.   Before

he went up to the master. And the master took a look at this

and said you indeed were very prudent, and even if the good

I

word is good, is prudent as evil, perhaps this K*OU~. !IIC a    i
                                                                           1

better world.

     So it seems we are going around passin?;: i.xt money to;
all of these people that is -- a great deal of it., while not I
                                                                         I

being poured down a rat hole as you called, is going to support
other institutions whose jucture we aren't too damn sure of


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1 /I
11  either.

2 `I         In other words, here, we are qoing pass CHB a big,
I/                            ,
:s 11 chunk over here.  Well, CM3 and IVIP may be phased out, you

jj -
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1:i:ow, the same time.  So it is very difficult, you know,

ho dec... .Z down which kind of hole you know. I+? are labeling
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holes now, that's as far as we've gotten.

      DR. SCI-IERLIS: Is. that parable correct?

SR. ANN: That is related to my question, too, you

know. Because in terms of productive, you know, some programs
may have seen their role as essentially a banker role, and

that is related exactly to what you are saying, and you know  1
                                                                 !

that maybe we are not concerned at this point about that. I    I
                                  j

get that impression.               I
      MR. RUBEL: I share your concern.   And I have watch A

        I have got to focus on the future.        i
it as well.                                   I have to     t

focus  on the hope that three or four years from now, when
                                                                           I

we have a similar group sitting here, we don't keep talking    !
                                                                           ,
                                    1

about the same holes.

Transitions are difficult and this one has taken    !
                                                                1
                                                                    I
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far longer than it should have.  I will leave it to the schol a;

and historians to do the disection and show us, you know, 1 I

what we did right.  And what we didn't do right.  You know,

we have got to get on with the job.

,

As far as I am concerned, under the very difficult !

conditions that we have with all the Congressional uncertaintic


1

BOW do you move forward?

2            DR.  TIIUPzlON:  I don't ccmpletely share John's opinior li

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of this,thing. Both"the CIIB and the IMP functions arc going

to continue, i '-7 are going to continue under new management,

5  and how wall t:is merging of the two is conducted is pretty

6   much  a matter up to people like us. "). .'. ' ._

7        DR. PAHL: Judy. ..' ,'a : **,

8            MRS.  SILSBEE:  I will say., John,  in terms of the PSRC

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review, th,ey started out with a very adament -- the RMP's were

getting in their ball park, and as time went on, they studied

the situation, they weresort of glad in many instances tohave

them there and release the funds.'

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      DR. PAHL; Is their further discussion?  If not I woi

like at this time to call for comments. From members of the

public who may be here, and I would like to ask that anyone

who wishes to make a comment, or submit a statement to the

committee to please identify himself and the organization he

represents,  if other than himself.

     And to keep the comment not too long, since I belie\

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we have a full day.  But I do know first, I would like to

call on Mr. Prasad, because I know he would like to comment.

And if you will please come at this time and introduce yourself

and make

d

your statement.

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IIR.  pmSAJ.l: Thai';!< you very much.  I am Rajeshwar :

?rasad.  I am Executive Director of Ilassau-Suffolk W?P. ?:.

.

iordand Scherr,whose paper is being distributed to you, xas

supposed to '::z here.  But being the Chairman of the New Yor:=.

State lIedicE;. 3oard his presence was required elsewhere.

And he'll be here tomorrow before the national advisor

council.  And I would brief.ly describe his -- the salient and

important aspects of the paper which has been distributed to

fou, which he has requested to be incorporated in the minutes.,

     He wished to share VI~?!T you the intended program      :

shich Nassau-Suffolk RMP has !:' xn up in response to our locali

leeds.  As I already told you, the paper has been distributed,;
and I hope you will have time to go through it, which gives    ;

3 clear picture of Nassau's FUIP program.

    I do recognize the comments mad& by Xr. Rubel and     :

Dr.  Pahl and Dr. Goodman, and I think we have taken into

consideration all those comments before, also, . in develcpinc

our  region's program.

       First, the peculiarities of the Nassau-Suffolk region:

with it's two and a half million inhabitants.   We have two

counties which are very different.  IZassau County is a fair-11

sophisticated county, which needs primary serving traditiozally+r

deprived population groups. Supporting services and building a

network for health care delivery.

6    On the contrary, Suffolk county is a rural county,


53

i   which is, actually, at this point in tim?, in a transitional

2   stage from rural to suburban area.

3          Which has serious manpower facility and service

4

shortages.  The program for fiscal year 1975 seems to meet

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the outstanding and particular needs of both the Counties.
Secondly the projects which have been submitted and are --

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they are built on the accomplishments of the past in the

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areas of renal disease and medical services.

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     And I emphasize here that we have two projects

which are considered projects with the stress on the education

aspect. Two medical services projects which emphasis training

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of ambulance personnel, and nursing personnel.  Of the remain.

eighteen projects, I would say some  fourteen relate to the

ambulatory care which is the primary thrust of theprogram

for 1975.

The thrust is on to meet the area's greatest needs.

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Which have been recognized by FQII? as well as our local CHB.

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It is a two pronged approach and that is what has developed il

our identification.  Of the primary care projects which are

,elated to direct patient care, we have implemented health

care pl -8,:'ects which are designed to obviate or n.itigate  huma-

disfun: an.

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          Dr. Scherr and his follow RAGS members would also

like to state publicly that these -- of course on one of them
the program has recently ramonstrated the present leadership


1  to have both its bylaws and due process certified which is

2   quite a job.

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        Moreover, the granting organization has recently

undergone an audit by HEW and I must'stres.   hat in the con-

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ference which was held recently,  the audi.Ws:s commented the

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agencies fiscal procedures.  Now, the current program strateg

and the viable organization of RMP for full consideration of

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our application before you.

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Thank you, very mucy.

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      DR. PAHL: Thank you, Mr. Prasad.   Are there any

questions that you would like to direct to lllr. Prasad?

       If not,  are there other members of the public who

have any comments or statements to make.  If not,  I think we

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will adjourn this portion of the meeting, which will terminate
                                                                           I

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the open session, and because of the full work we have ahead i

of us, I would appreciate it if perhaps we could get coffee    ;

                                                                           I
and doughnuts, and with your permission, bring them back to

the table, and perhaps start our day's activities so that

we don't delay unduely.

      And if we could reconvene in fifteen, or no more      :

than twenty minute:;, as soon as we can get through the line; 1

I think that would : fine. And members of thepublic will not'

be admitted to the next session.

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(Whereupon, a short recess was taken.)               I
                                                                    I

DR. PAEIL: Could we come to order please?

i
Y

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This session starts our closed portion of the meeting.   The

review of applications.  Pnd I have really jur;t.one or two

things to say, very briefly, and then we will get rigilt into

the x    ';3ws,  with Mrs. Silsbee leading our activities.

First, really for the record, I wish to indicate the*

general rule of confidentiality of these meetings, and the     :

discuss&s.  Secondly,
               I would like to again review for you i

very briefly our current funding situation so that you would I

know the frame work in which we are reviewing these applications

      And I want to make one or two points which perhaps !

will be helpful in a general way, as we go through the day.    /

Forty six million dollars are being requested by 53 regions     :

for this set of applications.  We had anticipated having ap- *

proximately 43 million dollars in requests, but vith the     

reintroduction of both the Maryland and the Nassau-Suffolk

applications, this 43 and some odd figure millions was increase-:

to 46 million.

     As I mentioned just a while earlier this morning   1

ye had 28 million dollars remaining from the released 73 impounc

funds for award, following the council meeting.   And xe also

have in the neighborhood of one and a half to two rzillions

of dollars in unexpended balances, from prior budset periods.

      Among some of the RMP's.  It is our belief, and WP,

will be discussing this with the council tomorrow, but since

most council  me&ers are here, and since it is -- I&e1 it is


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appropriate that you know our total picture, we arc going to 1

offset those ;Inexpende(A 1 balances with arrow cxrrcntly available

3  funds which : .S the net i: c-ffect of increasing the funds available

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to us for awards after the council meeting by one and a half

to two million dollars.

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Thus the budget figure is just under 30 million

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dollars.  Is what we have to distribute to the RMP's following

the council meeting.  I believe we, will be pretty close on

target.  The award process after August council meeting will

complete the obligation by us of our fiscal 73 and 74 funds.
     All fiscal 74 funds already had been obligated as of

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June 30th` 1974.  And the awards that we will be making this

month, we trill distribute to the FClP's all funds available to

us at this time for support of PJIP's.
     The only additional source of funds that may be ava:

able for us to distribute to RNP's could be a small amount

which may remain:, as a result of the five million dollars, wh: ic

under the court order has been specifically  allocated for

other purposes as Mr. Rubel indicated.

     1-d for which he is planning to let contracts, hopej

go over all the five million dollars, and he has 90 days in

which to do this.  If at the end of 90 days there is any of

that five millions of dollars left unobligated, that reverts

to our program for distribution and support of the RNP's.        /

      *    So if that, none of that were obligated we would ha1  I


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an additional five million to distribute, but in practical

terms, I believe all or certainly the great majority of those

dollars will be obligated so that we will have at most a very

smal!  r:mount since we won':. know this until October,   I beiieYbV;-

Otto! : 20th, is the90 day period from the Court order.

What we all plan to do and we have a draft resolution

for the council to consider tomorrow, what we plan to do is   ;

distribute my such residual funds on a formula basis in pro- I
                                                                  i

portion to what the decisions have been by the council over  [

this year for the different regions.

So that each region would share inr;roportion to its I

current funding from the several decisions made on the applica-
                                                                           I

tion that were reviewed last time and this time.  That is a ;

little complicated but what I really wish to say is that you

have before you 46 million dollars in requests.  We have, perha!

29 and a half to 30 million dollars.   Isle are not asking you

as you know from our non-meeting last time, we are not asking

you to reduce each application's requlJ
                       peted amount by a uniform

percentage to arrive at this 30 million.

    We are asking you for the full benefit of your reviews:
on the merits of the applications and we would anticipate
                             _^

that there would be varying degrees of funding within that

set of applications.  So that different percentages would apr>i::

The other point that I would like to address briefly has to
do w,ith the requests of these: applications for funds which


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would be used to support specific activities beyond June 3Ot`h

1975.

In a number of specific instances, applicants have

recjuested budgets which would carry those activities, no+;     . .

through the June 30,1975 period, but for an additional se::.ind
year of funding through June 3Oth, 1976. Now, I would like
to make it perfectly clear that all RNP's whether they have
         .

requested specifically second year funding or not have the     1

option locally as we give them the money.

After this council, and as we gave them money,after

the June council, they have the option to the regional advisor:
groups decision making authority to decide which projects
will be supported and whether to perhaps fund a more limited ;

number of projects for, if they wish, a two year period.       .

     Because this can be done by letting contracts. There
is a problem in this which we all are very much aware of,       i

and that is if the RMP's terminate June 30, 1975, with contrac;

outstanding beyond that date, there is a logical question of

who will monitor those activities.

It is a most appropriate and legitimate question, ar,<

if I sat here before and indicated to you and told my staff
we are all very much concerned about it, but as is the wi?'
with bureaucracy we don't have a definitive answer for you.

But logical possibilities are the forthcoming organizations

under the new legislations, will absorb such continuing activi-


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ties.

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       IIill-Burton has several hundreds of milli:;ns of
dollars in continuing obligations out in the fields.   so t:2

are not ovc  ' concerned about having a few IUIP activities.

So either t:li: forthcoming organization will.absorb those res-

ponsibilities or the DIIE? regional offices will be called upon

to monitor continuing activities.

Or Washington headquarters staff under the name of

some group or other, will monitor the activities. What I am

really saying, therefore, is that as you look at the applica-

tions in here, you should be aware that most people have asked

for one year funding, through June, 1975.

But that if they have asked for funding beyond that

period of time, it is legitimate, to ask and legitimate for

them to conduct their activities in that sense, unless there

is a specific prohibition on your part, to deny the activity

that is the recommendation by the council and concurrence by
the council to deny that activity in toto or to deny funding

you should recognize  that by awarding funds knowin!

for a second year funding,  you are denying funds obviously

since their is 02. ,' an approval of 30 million dollars to othe!

I?FIP's o  So what you give more to one program, obviously must

come out in some' undetermined fashion from the remaining tota:

RMP'S.

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5 7

Now, I want to mention one more thing so that there

is no misunderstanding, and it bears on the discussion by Dr.

Goodman in the kidney program this morning.  This is a very

complicated set of activities because it involves the Nedicare

reimbursement.

And Bureau of Health Insurance, Bureau of Quality

Insurance, and Regional Xedical programs.   As he  indicated to

YOU r and as I did also, we are making. administrative arrange-

ments with Dr. Goodman's office andMedicare so there again wil

be like the PSRO activity no funding of activities which is

inconsistent with legislation which is on the books, but over

which we have either no control, and certainly no real respon-

sibility to administer.

       And this connection, we will probably in certain

cases no permit kidney projects to be supported bey3nd June 30

1975, regardless of what the applicant may request in the appl:

tions before you.   Because of the problems  and schedule of the

Bureau of I-Iealth Insurance, Bureau of Quality Assurance, and
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Medicare Programs,
b            they are trying to establish a national

etwork and it will be highly inappropriate for RMP's to fund

or twc: ;.zars , certain kinds of activities which obviously wi`l:

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ye inc   stent with what we know to be the government's guide-
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tines, directions and requirements.

l!Jow , we 'will be guided in these decisions by those

equirements and by those officials who are in charge of the


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kidney program.  So you do not have to concc:t:! yourself       I
                                                      !

unduly, except to recognize that in the case of kidney, there j
may well be an administrative requirement not permitting fundin?

beyond   n one year, d  :tite what the app1."~,2nts have request@ :d o

5           NOW,  are the:!  anv questions on ~.at I have gone

6   over, or is there anything that I could clarify for you?

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       If not, I think this represents my full comments and

I would like to turn the meeting over to Nrs. Silsbee who

will conduct the reviews.

       Yes, ?lr. Toomey?

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     MR. TOOEIEY: Perhaps I missed it, but suppose you
have a onepar project in which there is a -- which is SLOW

in getting started, or in which all of the funds are not used

up and the program hasn`t been completed, and perhaps there is

another three months.

What happens in that overlap of time?  Does it phase!

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out?  Does somebody else have to,monitor the last few months?

     DR. PAHL: Let me say that none of us are really

certain what is going to happen.   Because it depends on the

passage of legislation and the time table in which that occurs

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In the House bill, which has been submitted,by the full corn-

mittee, but not acted upon by the House, there is language       I

which would permit the extension of CIIPB agencies experimental,

health service systems and RMP programs, if necessary to go   j

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through an additional six months beyond June 30, 1975.

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l I/     In order to accomodate the t:: :ition problems

2  if the legislation is delayed in passago, I honestly, therefcref
                             3

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  .can 't tell yo': what will happen, but as usual we will know :~hen

      zt there,   nd all I can say is that you are free here to

     the reco ndations, certainly on the one year period.

6     And I feel certain that there will be an appropriate

7  administrative regulations'developed  we find out when and :

8  what legislation is passed, to accomoc;ate that.  That is  /

9  more than a platitude.  I just don't have a decisive answer ;

10  for you.

11 1       DR. IIEUSTIS: Dr. Pahl.  Are the instructions sufficier

  II
12 1 I 1-y clear so that everyone knew th(at they could have applied I"or
                                                                           i
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13 1 a full two years as well as just the one?  Let me just paren- :
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14 thetically add that the majority of the ones that I reviewed ;
15'   ask  for funds for only one year.

16 11
II     Xy reading of the instructions even though I believe
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17 I/ I am familiar with what you said, about the possibility that :
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18 ' the second year did not clearly convey to me that you are reali]

19  asking for two year programs.  So on the recommendations which:

20 I made I have just arbitrarily deleted all the funds for the :
  I
  second year.

And then they could be put back in again.  If this

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ii 23 11 were overruled by a higher authority.
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24 //          DR. PAHL: We did no4: encourage, by any means, two

year'f unding.  At the annual meeting, I am not sure when that


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now was, March, I blieve.

      We clearly  stated to the assemblage +A--.:'; tv;o year
                         .
funding was a possibility, under the conditions which I hava

described.  But that generally we were talking about having
budgets for one year through June 1975, and the reason we had
to take that posture is a very realistic one.
    The administration has made the decision that RMP's
may not expend any funds beyond that period, and a number of

our R'lP's are free-standing corporations and we get into this

set of problems, but there is the possibility we did not. en-

courage it, we do not encourage it.

       But if it seems to you, and to the council in. spe-

cific instance that it seems meritorious to provide those

additional funds, perhaps we can accomodate it administrathe-

ly;   Yes I  Dr. Miller?

          DR.  NILLER: It seemed to me in that -- there is ano:::<
thing that must be going on hsre. And that is where an IWP
applies for a project that has a budget of 150 to 300 thousand

dollars,  on each project, even though there is a ten month
situation they must in effect have it in mind that they are
going to spend whatever they can in ten mor)ths, and contract

for the rest of it.

     Is that a permissible kind of thing?  I was pretty

critical. when I reviewed these after that kind of thing. But

maybe I was too critical.     .:                            -
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       DR. PHIL:  YJc 11. j-t i s permissible.  It's hard to know

I,lhat's in people's minds and so forth.   It is permissible.

3  What we feel will be the self-correcting device is that we

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have fewer, probably on the average, for a given region than

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the region requests.

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     So that is usual when the money's do go back to the
region with the award statement there will have to be a decis

by the regional advisory group as totwhich projects and for

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how long.  And in that sense we are fortunate, since we have

fewer funds than requested dollars.  I believe this will be

our internal self-correcting mechanism.

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Judy, I believed you wished to --

MRS. SILSBEE: 110,

DR. P&L: Jessie?

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      MRS. SALAZAR: Dr. Pahl;  I have been trying to find

to talk when this is appropriate.

     DR. PARL: Could you please use one of the microphon, es

so that the reporter can follow?

     MRS. SALAZAR: I was wondering since we are meeting

in joint session today with the National Advisory Council mem

that it would be appropriate for us to have a statement from

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a council member, perhaps you can do this. On a little of the '

background of our two resolutions that we passed in our main  ;

conference of why they were some of the discussions, and some I

of the considerations thizt went into their turning . them dcwnc

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                                          G2      I
   The auestion'has to do with a council actiirjn
DR. PAIIL,: _

/I                                                                           I
2 ii on the two recommendations made by the committee.  The one
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3 i[ recommendation thatwas drafted by the committee and passed on'
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4 /I to the r. ,..e.: kl concerned the cooperation, ifyou will, by CIIPB i

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' id agencies ti:;:.! planning groups,  in relation with working with i

6 IUP's and notifying them of what their actual area wide plans

7 /I are.

   I!                                                                           I
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8     So that applications can be reviewed more appropriate1
g by the planning agencies. The reason, I believe, the the count
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10 1ci.l did not deem it necessary to act was first of all, Mr.
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11 Rubel was present at that meeting, to represent, if you will,
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12 I/ both the comprehensive health planning program as it's national/
13 Idirector,
   I    as far as in his responsibility for the forthcoming /
                                                                           I

l4 ilhealth systems agencies organization,
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i     And gave assurance, I believe to the council, that    i
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16 !he would, to the extent the time and conditions permitted before
17 'Iwe evolve into something new,
I                work to effect greater cooperation

18 I both from national headquarters and local groups with RMP's; I

19 and I believe this assurance was of such a nature that the     I

20 I council thought it therefore inappropriate to act upon matters 1
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21 //which are really not it's responsibility.    .
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22 I      Namely the comprehcnsiv- Q health planning program and j
23 "with the assurance of the director of that program here. So   I

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24 'satisfied that a statement was not required.  The second recom-i

25 mendation which was an action to preserve PNP experience and !
                  /
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relationships and had to do with recommending to IV~lP's that
they look to their infra-structure as being appropriate for

the transition period.

I believe that statement was subject to a number of

5   interpretations.  As one viet.?d the different I?J@ situations.

That again, with the amount of information that was being

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generated at that time, and it has almost become a flood of

information from headquarters concerning the new legislation.
     What this implies in the actual constructive activi

which are being engaged in now.  Which I can mention in a mom

to acquaint first hand RJIP organizations CHP organizations

and Hill-Burton organizations with the impact of the proposed

legislation will have upon these organizations.

      That again, perhaps it was unwise to adopt a formal

statement.  I believe the statements were well received. They

were discussed, but for those reasons it was not felt necessa

to take formal action.  With regard to'the last point   I men-

tioned, namely the constructive steps being taken, I don't be1

1"Ir . Rubel either mentioned or if he did, did not emphasize tha

during the latter part of December, and early October, there
have been organized already three separate regional meetings

to which I have already been invited.

   Representatives of RMP's CHP's and Hill-Burton progry
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and the purpose of these two day meetings, one here in Wash- i
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ington, and one in San Francisco, and one in St. Louis, will i


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be for certainly the federal administrators to impart informa.

::  tion as part of the agenda.

:

And secondly, I'm sure, to have those several

4  groups interact  :;ong themselves and thirdly to have those

E  individuals and ,.::ganizations  convey feelings, concerns and

E  needs back to the federal establishment. 'This has already

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occured in the sense that the meetings have been arranged and

the organizations  invited to send participants.   So these

steps implement, I think, what Mr. Rubel was saying, and are

a good faith action on his part.

       And thus, in a sense it was not necessary for the

council to take formal action.'  Now,  I have tried to summary

from memory the set of circumstances which pertained at that

time, but if anyone on the council would like to either correc

or amplify any of what I said I would certainly be happy.

      Is that responsive?

      MRS. SALAZAR: ThankLou.

DR. PAHL: Are there any further points before we

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enter?   Dr. Carpenter?

      DR. CARPENTER: I am concerned a little bit about,

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this, still about this possibility of second year funding. 1

In that I think as our discussions go along we may -- it's

possible that the committee will becom, 0 more generous as they

become more and more aware of the possibilities that exist

with that kind of latitude.


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       And so to try '1.   zt some constant:! ,boE'I   ,en our

dGci.sion today and our de,- &.sion it would hely, me to know wheth

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the members of th- 0 rest of the committee vie?? this as a major

consideration in our deliberations.
    I think principally it comes up to me in relation

6  to the fact that a number of projects suggested seem to me

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to be patently ridiculous within a ten month period. They

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are not nearly so obviously impossible if the region has 22

months in which to complete them.

And I am not, you know in the end of all of this

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we are going to distribute all the money anyti:ay.  It's just

a question of the nature of the kind of forrzula that we want

to end us   with.

And Z think that varies, depending on whether

we are now quite generous with a region Ynat is asking in this

application to double its funding.   On the basis of a one

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year application there is no reason on earty to double the

funding.

       That is, if this is in essence a two year applicatic

it's not a bad region, then, I can't be, sure they  couldn't

do something, and I can't be sure they could. *

       DR.P?AIIL: Dr. PIcPfiedren?

DR. PARL:  I believe  as we

go through the applications
                                  I

this` matter will be taken up.   I am

really just calling your /
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bttention.  That you should b':  rare as a group that administr;

;ively the regions regardless ~:1: the level of the funding
:hey receive this time, and also of COUrSe, from their current:

available funds, make their t>.srn decisions as  %o whether they

,ish to have fewer programs for a longer period of time, or

pend all their money within the one year 'period.
   And then trust to ,fate as to what will be required

rext spring. We can't sit here and make those decisions hecau:
hey are local decisions.  You should be aware of what the
tpplicant is requesting and just your recommendation -- adjust
our recommendations in the light of what you think would be
est for the total program and for that region specifically.
   Pnd I can't give further guidance besides pointing
but the need to be need to be aware of it.
    Are their furtherpoints to be raised?  Or discussion

.o be made on the points that have already been raised?

       If not, I would like to turn the meeting over to

YS. Silsbee, who will lead us through the applications.

        E-IRS .  SILSBEE: I was going to announce that Dr. Cassic
ill be late, but I think he may be right on time, since he wa:

.ue about 11:OO.   But Mr. Barrow does have to leave early so .
'e are going to start out with Alabama.  But then we are going

o intersperse the applications that Mr. Barrow has been assigr.

0 as we go along.,

       Not all at once.  I think that isn't a very good way


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to do it. But his regions are Al.b;:.ny, I,::kes Area, Karyland,

New Jersey, and Washington-Alas`=a so those will come out .of

the alphabetical order.

But let':, :;tart out with Alabama, and the primary

revi:3er is Dr. Va:: +

        DR. SCIIERLIS: 1:'hat kind of a time frame have you

concocted for us today?

         MRS. SILSB-EE:  Well, we have 53 applications --

101 we have 48 applications, and it is now ten minutes till

eleven.  And we not only have the comments of the people here

but we have the commentsof the people who were here in July.

Dr. White, and I was going to say Dr. Thurmon, but he is here.

       Our missing member, so I was trying to do a calculat

and I decided it wasn't worth while.  But it's about three

minutes,, two minutes; now in looking over the comments that

you have written it looks as if there has been some coming

together:  of the reviewers' comments in a good many instances

      So I think if you feel there is a need for some real

discussion don't hesitate to do that. Because, 'by and large,

most of them seem to be in some kind of agreement.  But becaus

the council is here wanting to hear your rationale for the

funding recommendations, and staff is, also, interested in tha

because we have to provide the feed-back to the Regional Medic

Program, and your reviews, and perhaps the primary reviewer

could state this and then the reviewer either add or say nothi

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8  nchanged from the previous assessment.   Can you hear?

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You know, as the case may be.
    xhat you are recommending and why you are recommend:

it in succinct fashion and then I think we can go through

them, and then there will be some discussion on scme of these
I don't think we should hesitate to do that.

Okay. Dr. Vaun?  Alabama.

DR. VAUN:  Alabama.  The overall assessment appearec

MRS. SILSBEE: Can they hear?

DR. PABL: Let me make a general request, because

our reporter is trying to get this meeting on tape today to

have members use microphones,       `
     DR. VAUPJ: Could we make a presumption that most

people have had our comments and might have read them so that
we won't have to spend time reading them?,

         MRS.  SILSBEE: The review committee has had your com-

ments .

DR. VAUN: Council members have not.

         HAS . SILSBEE: Council members have not.

        DR. VAUX: So I guess we are obligated to read them.

         XRS. SILSBEE: I don't think you have to read them

-in total, Dr. Vaun.  But in terms of the gist of rxt.

     DR. PAHL: The highlights, I think, !.;o?i.d be.

DR. VAUIJ: That's all I put in any-day.   So I have

to read them.  I.!aybe I'llstart at the end wit3 my recommenda-

1 i


other people sitting around the bars b~cnuse they represent :
ihe National Advisory Council regions come up for review.

Please keep in mind thtzti bot91 council members as well as revie

:w

committee members should excuse themselves from the room when
applications in question are reviewed.                    
   So I wou.l,d appreciate it if you could keqj that in

mind. Go ahead.                                                   -:,

    QR, VArJN: The general aspects of the Alabama
program did not bother me. There was one project; project

134 -- which aspeared very similar to the previous r:%zuest
                  .,

on surgical cancer to which we reacted negatively ltist time.

ihe ,- I question the priority of such a submission for such a

large sum of money devoted to this, and there is some background
                                                i

as to why this seems to be a high priority in t:&+.
                                b= state of  1
                               j

Alabama, which Perhaps, even though I question the feasibilityi
                               i

of implementing some aspects of the the para-naial program    i
                                                   t
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in one y%ar*                      I
      &se comes this one year :3usiness, again, in my   i
                                                                           * i
                                                                           2

.fj.nal recomnendation 1 di&~'t CCXI~;L~~~~ this.  SO pe haps it i

is unimportant. The rcquasted fundin level of 8611t.55~ &11,&s

I recommend that it be reduced by the amount of the uteral     I

surgical cancer screening in for 181,000, rounded out to six i


1  hundred eighty thousand dollars `recommended funding. Some

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thought was given to the possibility of eliminating these

                         e
project funds, might deprive the state of other sources of

money for uteral c  :vicaL cancer screening.

5            In as rn;;  as we do not know the other sources of

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federal funds we cannotassume this.  Also, in as much as it

was very infeasible that the otherprojects would need all the

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funding for the one remaining year.  Whether Alabama did

or did not implement the uteral cervical cancer screening

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project with the decreased level of funding would depend on

their own priorities,

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     The recommended level of funding, then, is $680,000

       MRS. SILSBEE: Mrs. Salazar?

         NRS . SALAZAR: Judy,  1'11 read this.

        DR. PAHL: Excuse me, we will have to use the micro-

phones.

         PlRS .  SALAZAR: I am sorry.  On Dr. Vaun's question

about the other -- just one question about the federal funds.
The point that Dr. Vaun -- could we, maybe staff it, at this
point, have some additional information about it?

         MRS.  SILSBEE:'Mr. Jcwell?

.       MR. JEWELL: PIrs. Salazar, the only thing I know is

that there is a big push on Alabama for cancer now, because

the Governor's first wife died of cancer, and they have

established -- have broken ground for the Lauraleen Wallace

Cancer Foundation, and this is a conglomerate of other federz


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local and state, and volunteer funds.  To 1, :.LLd this institution

it is just a traditional building fund, PIUS a big push in the
                          .

state for local cancer funds, to establish this.

         r"iRS.  SILSBEE: Did that answer your question?

         MRS.  SALAZAR: Yes.

         XRS . SILSBEE: Dr. Vaun, is there furtherciiscussion?

Mrs.  Salazar?

       MRS. SALAZAR: No.

      MRS. SILSBEE: Dr. Vaun.  You made a recommendation.
Do you want to make that a final motion?

        DR. VAUN: I'll move that the funding level for
Alabama be six hundred eighty thousand dollars.

         MRS.  SILSBEE:  Is their a second?

      XRS. SALAZAR: Second.
    MRS. SILSBEE: The motion has been made and seconded
that the Alabama application be approved at the level of eight

hundred --
     DR. VAUN: Six hundred eighty thousand.
   MRS. SILSBEE: Six hundred, eighty thousand. Excuse

me.  Is there further discussion?

      (Ho response.)

.

ImS .  SILSBEE:  Al.1 in favor?

VOICES: Aye.

    PIRS .  SILSBEE: No?

t    (No response.)

                                                                  1


1             PiRS .  SILSl33:  The motion is carried. Now we go to

2

Albany. Fir. Barrows?

3        MR. BPJ?.RC%7S : I was like the rest of you concerned

4

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with thn, inter-regiona, equity.  It occurred to me that pro-

grams of equal quality should share in the available funds

6-  on an equal basis.  As a rule of thumb, I took an average

7   prog=m as being entitled.to about sixty five percent of its

8

request.

9

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Better or worse than average being proportionately

moved up and down, whether you agree with that rationale or

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not.  That is the one I used, to explain my recommendations.

Albany looks to me like a top notch program. I think we are

all agreed on that.

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It has,  I would say, only one deficiency by my Stan,

dards, keeping it from being excellent, and that is it seems

to have involved the practicing hcalkh professionals in a

17   rather minimal degree, at least that is the way I read the

18   data.

19         I think it is one of the unique strengths of the

20  regional medical program, but it is a fine program nonetheles:

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I think they ought to get about 80 or 85 percent of their    I

.request, or $450,000.  And I think Dr. Carpenter came up with

a more generous analysis.

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MRS. SSLSBEE: Dr. Carpenter?

25

DR. CARPENTER:  Thank you.  My unaccustomed generos:

72


li  equires some explanation.  I gather.  I may bo  :'i'~ ~ayetd by the

.2  act that this is the only application Y read that really did

3

uch for me.

4      And I was :i ..lressed, first of all, that the original

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pp- ..::ation in Hay w;. by and large a request for continuation
nd my own experience with the region was that in the time they

ad to apply, it really was very logical to say the least for

8  he regions to make that kind of a decision.

9         Furthermore, most of the projects that they proposed

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eemed to me to be really miraculously well designed for the

hort time funding that was available.  So I gave them back
he money that had been administratdively taken away from them
fter cancel's decision and added a good part of this applicati

nd came up with a recommendation for $524,000.

17

18

      MRS. SILSBEE: Well, one of you could come up with

ine figure, and one of you has come up with another.  Now, do

ou want to negotiate, or allow, or do you want to discuss it

'urther?

     MR. BARROWS: I would be willing to go up a little bit

`o fund this particular program, at almost 100 percent of its

equest is going to detract from the funds available for other

rqually deserving agencies, programs.

     MR. MILLER: It is a question of the -- there are two

rejects in this group for $130,000 to.$136,000.  Do you r-call!,

I ,/

.hink*they can use this money effectively in a ten month period?


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For these things, primarily care of children of low income
                                                                           1

families? And data systems for foster --
     :IR. IMRROX'S: I would contribute, one of the remarkab=ie

strengths of this program is that it has done a fine    of     /

providing cost sharing from other institutions and cc'. ~uity.~
SO with respect to the longivity of the program, and its i;n-   j
                                1
pact I I think they would get high marks on that point.   j
                                                                           I

MRS. SILSBEE: Is not the primary care for low income

children the kind of trial thing, that Bev Myers was trying

to do with the other regional medical programs?

DR. CARPENTER: Yes, I think that's right. There is

a   -- RHP contribution to the projsct. Those weren't the

projects that bothered me.  I think 59 and Gl are weak. i)ut

I felt the two you mentioned probably could -- probably were

worth the price.

MR. BARROWS: To me this long, would you Split the

difference?

    DR. CAPSENTER: Sure.

  14~s. SILSBEE: Would you all do the mathematics?

Five hundred thousand, Do I hear a motion.

  MR. BARROWS: 487 would Se more precise.

i87.

.

MRS. SILSBEE: Do you want to make a motion?

MR. BARROWS:  I'll make that motion.

MR. CARPENTER: I'll second that.

t    MRS. SILSBEE: The motion has been made and seconded


hat

87.

the Albany application be approved at the amount of

Further discussion?

(NO response.)

  MRS .  SILSBEE:  All in favor?

VOICES: Aye.

MRS. SILSBEE: Opposed?

(No response.)

MRS.  SILSBEE:  The motion is carried.

MR. VAUN:  May I just make one observation?

MRS. SILSBEE: Yes.

        MR. VAUN:  I am a little disturbed on that because

zhere is one program here that I think should get more than

I.00 percent;  the level of the request from Albany is not

that great. There are several programs that I think submitted

very, very inflated figures, assuming that they are going to

get cut.

        And there are others who really submitted a pure

down budget.  So I'm not sure because award them 100 percent
that we are depriving a good region of something.  I think

we may taking .a lot more from somebody, but I don't think man>

of them deserve.it.  Some of them deserve it.

.          PIR .  BARROh& : I am more cynical than you. I think

that all of them were inflated.


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76

MRS .  SILSBEE:  The next aDnlication to be looked

at is Arkansas.  Ve will skip Arizona for the moment.   And

the primary reviewer on that is Dr. Scherlis.

         DR.  SCHERLIS:  Are we skipping Airzona for any   ;

                                                                           I
particular reason?

MRS.  SILSBFX:  Because Dr. Teschan isn't here yet. i
                                                                   I
                                                                   I
DR. SCFERLIS:  This region had been reviewed in    !

detail at the time of the May-June review panel and was given

an over-all assessment of averageat that time.  Mr. Roger

Ward had just been appointed in an acting capacity.  The

Arkansas May 1 application was recommended for approval at

a funding level of 1.4 million, with the additional 100 under

the arthritis proposal.

The July 1 application request was for 816,000 plus

In this there were 18 new proposals,  Kern felt that the 18

ProjectS:represented an array of proposals which would

even

challenge any RMP/in the absence of previous.proposals which

were approved at the time of the last review committee.

There was a significant question as far as those

I
i

projects which were givenlow priorities by the RX? of Arkansas i

including a d:sease center for S176,OOOi  Also included were

* a miscellaneo  array of projects including Arkansas rate

price project,

Some of the projects given even higher priorities

appear to represent a collection of average to less than


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77

average proposals.  In view of the level of funding pre-

viously granted, the over-all assets of the ARkansas Regional

r4edical program and the number and types of projects now

submit. ' , a funding level of S400,OOO is recommended in

place c; ,. th., P $810,000 reauested.

      SO I move a funding level of S400,OOO for the

Arkansas Regional Medical Program in the present review cycle.

        DR. CARPENTER:  I am the secondary reviewer, and

I think that is a good motion.   I second it,

         MRS .  SILSBEE:  Do you want to discuss it any

further, Dr. Carpenter?

        DR. CARPENTER:  No, not unless someone else questions

it.   I have written on it.

         MRS .  SILSBCE: O.K.  This is the first application

that we have reached that has an EMS training project in it.

And just as we have fanned out activities from PSRO, the EITS

systems and EMS training have been sent over to the Bureau

of tiealth Resources Development.

      We have not yet received an answer from them on

any of these.  And I think the reason why might be interesting:

The EMS training program has been decentralized, and they

'don't know who the applicants are and they don't know what

the approvals are.

       And these will not be avail&e until sometime in

September or October.  So in order to not hold this up, we


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will put a caveat in every letter saying keep in touch with /

your local regional office and make sure that your activities

do not duplicate the other activities.
     That is about the only way we can do it and keep

going.

The motion has been made and seconded that the

Arkansas application be approved at $400,000.   Is there

further discussion?

(NO response.)

MRS.  SILSEEE:  All in favor?

VOICES:  Aye.

MRS. SILSEEE:  Opposed? ', '.

(No response.)

MRS.  SILSEEE:  The motion is carried.

I


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1              I<R:    ILSEEE:  The next application that we will

2    look at is R.:   tate.   MS .  Toomey?

3

4

         Pm  `:yOO!!EY :  The situation at Ei-State apparently

has changed   :ently by reason of a change in management.

Dr. Felix ht!. taken charge as the coordinator.  And from the

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information that I gather from staff, he has moved in rather

well rather quickly and is'doing rather an excellent job of

coordinating particularly with the planning agencies inthe

area.

However, despite the fact that they have had a

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change in leadership, that doesn't change the report that I

wrote, which says that the organization presented a minimal

image.  Its leadership continues to have problems.   The

Regional Advisory Croup has turned over the leadership to

the Executive Committee.

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'19

       And this,  as far as 1. know still exists.   The

Regional Advisory Group does not-function, but the Executiue

Committee does.  They are and have been now developing a

relationship with CHP agencies with some success.  Despite

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the apparent success of the projects, there is little rcsemb- :

larice to the agreements and are, in my opinion, of lit<-:)e

'use or value.

And I don't remember specifically, but I've got the

numbers:  No. 57, 58, 60, 61, 64 and 71.  In addition, the

feasibility of completion, particularly of No. 61, is somewhere

79


1  between impossible and minimal..

2          For instance, the project number 61, I believe, of

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vrhich I spoke, which is a planning project for regional

health services development, says the objective is to coor-
dinate the total spectrum of health services in a lo-county

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area,

7         The coordinating group, based at the area's health

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care planning council, would gather information, make recom-

mendations, facilitate arrangements that would lead to a

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coordinated regional health system.  Specific areas of

investigation and implementation include:  outreach home

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care, hospital outpatient departments, health education,

rehabilitation services, hospital outpatient departments,

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health education, rehabilitation services, physical therany

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programs, hospital group purchasing, insured services,
development of common medical records and information systems,
uniform accounting systems and allied help, manpower training,
                                                                           /

18       Any one of these would probably be a two-year

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program.  Because of the picture that is presented with the :
projects, but more particularly really because of the picture'

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presented from the program and the staff and its past        .

* record, my funding recommendation was $275,000.

          MRS. SILSBEE: Mr. Witte, who was the other reviewer.

didn't make it today. And do your comments, E?r. Toomey,

reflect his?


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MR. TOOrlEY:   Yes.  Let me read his, because it is I

-- the application supplemental continuation application

requests $472,000 for initiation of 1C new projects,

including health, manpower, accessibility of health care,       f

                                                                           /

quality assurance, planning, long-term care, renal function- i

ing, and hypertension.

    The projects in this application, as compared with

the May-June application, appear to be in keeping with the
health needs of the Ei-State PMP region as identified in the

RMP/CHP planning.  The projects address themselves to primary

care, availability of trained manpower, quality of care

and the use of physician extendefs.

14r. Witte states that his concerns are:  One, what

would be the effect of a new program coordinator coming in
as the program tapers off; two, project 58, audit model and

project 60, quality of care, should be reviewed by the

Bureau of Quality Assurance to insure conformance with PSFC

legislations three, it is difficult for this reviewer to

understand the logic and method of the RAG priority system,

and, four, all of the projects that apparently reflect local ;

needs, many of them are overly ambitious and this reviewer
doubts that they would ever see fruition with only one year   j

of funding.

The July request was $472,000; the recommended

level of funding, $270,000 to $300,000.  Fly recommendation


1.   was $275,000.

'V
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DR. VAUM:  I will second that.

          3
MRS. SILSBEE:  Does Staff have anything they want ;

4      add tr  t:his information?

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        i?R. HEUSTIS:  May I ask a gue: .lon while he is    i

getting ready.  Are we supposed to, all of us, have copies

7

of Dr. Witte's recommendations?  Several of us don't seem

8   to have it.

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MRS. SILSBEE:  You were supposed to bring them

with you.

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        DR. HEUSTIS:  We did bring them -- all that you sen

us.

        MR. TOOMEY:  I believe Mr. Witte's just came in.

      MRS. SILSDEE:   Mrs. Leventhal, did you put the

late ones in the book? 0.B.

Mr.  Zizlavsky?

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MR. ZIZLAVSKY:  I would like to take the opportunit :y

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to make comments on probably six or seven areas.  First of

all, Dr. Felix, who is the new coordinator, came in for a

one-day orientation.  I assure that he has been rebureau-

cratized.

     Secondly, Dr. Felix has made a commitment.  He is

responding to the National Advisory Council's past concerns
and plans to increase the Regional Advisory Group.  Thirdly,

Dr. Felix has been invited to the program planning committee 1
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of ARCH, which is the C!!PB agency.  And it seems as though :

he will be an active participant.

,

    Fourthly.; fifteen of the sixteen Projects -- this I

was a ,:evious concern from the May-June review cycle of the /

Reviec, 'L "ommittee as well as the National Advisory Council

were concerned with in discussing this with the program.

And I have asked Mrs. Williams to insert this in the books

also, that they have related fifteen of the sixteen projects
to this joint CRP-RMP health meetinq which was held earlier

in the year.

And I am not sure if that information is in the

booklets.  Projects 58 and 60 have been reviesed by the
Bureau of Quality Assurance PSRO, and they do conform to the

PSRO legislation.  There aren't any prohler.5 in this area.

      One of the past concerns has been their minority

involvement.  In doinq a rough assessment, out of their 72

projects 12 of their projects, or approximately 16 and two

thirds per cent, have responded to minority areas.

     We have some comment from the regional office which

came in at the eleventh hours.  And three of these projects

are basically favorable,  There'are comments to three of

' the negative comments that Mr. Tcomey r?ade.  Ar,d I just         I

point that out rather than reading all the comments on each

of these projects individually.

.    This is the only updated information that I have.


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MRS. SILSBEE:  Is there further discussion on

Bi-State?  Dr. McPhedran?

      DR. *McPBEDRAf?:  MO `  I agree.  I have been there      1

before. I move the question.

         MRS .  SILSBEE:  The motion has been made and seconded

that this application be approved at $2f70,000 --

        MR. TOOMEY:  $275,000.:

        MRS. SILSBEE:  $275,000.  Is there further dis-

cussion?

(hi0 response.)

MRS. SILSBEE:  All in favor?                               i

VOICES:  Aye.

MRS. SILSBEE:  Opposed?                                      I

(E-Jo response.)

MRS. SILSBEE:

The motion is carried.


Now , COULD PYC go to Lakes area,

I.`r .  Earro:~x3?

         rm. *.?'.r.,.,,A,.,:
             r'r n3?(yw   O.F.  I think we concl.uderi at the

last meeting that this V:JS sort of a coastinq nrogram,

barely average.  That would be the skronqest you could put

it.

     The new projects.look a little more related to

where we are today.  But the objectives that they are working

on -- my original recommendation t7c?s to give them average

treatment, which would give them about $196,000.   Dut on

reflection I think that was perhaps too generous.

So I came up with a'final quess at s150,flflO. I

think Dr. Heustis has a little different slant on this, and

we should hear from him.

YRS .  SILSBEE:  Dr. Heustis?

        DR. F?EUSTIS:  Let me say just a couple of things    :

generally.  In the first place, I am fully aware that we must

balance the money requested with the money available. It      :
                                                                           1

seemed to me on my first go-round on this on an individual  i
basis was not primarily to he concerned with that, but pri- 1
marj.ly to be concerned with the over-all quality of the     . ;

. nine categories that were specifically listed in the review

sheet.

       Secondly, my indicated analysis didn`t reinforce

that.  In other words, I didn't really try to balance the

                                                                           4
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1  request or do what Fr. Carroors has done -- come up with some

2   type of formula to guide me.

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     The second thing that I would point out that this

one and two-year situation, it seemed to me that, ir.  .. i ew

                             11

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and that is the way that I at least read the language when

I looked at it the first time, that anybody that asked for

money for two years was, in spite of the legal possibility  1
                                                                           /

of doing it, was perhaps stretching things a little bit.

     And if money is going to be granted for two years

it should be considered entirely separately.  So that I took

out all of'the funds for two years.  I think those in general;

are the things that I did.

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     1 was not impressed at all about this.   It looked

as though perhaps the staff was trying to avoid the previous
criticism of being involved too much and allowed the pendulum

to swing the other way.

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2!

     I came up with a recommendation of $lOO;OOO.  find

I would be pleased to split the difference with my col1eag.w;.

and would move $150,000, as he suggested.

        MR. EARROWS. .  That is acceptable to me.   I will

second the motion.

        MRS. SILSEEE:  F!r. Nash, did the reviewers get the

letter that Dr. Ingle sent in that the Regional Advisory
Group had asked them to have about the staffing, because


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1 ij  they felt you hadn't understood what the   :3ff situation

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3            YR. NASE:  As.'far as I know, Judy, it was put in

the btioks.

5             , o RARRC .:  I did not see it.

6             MRS. SILEHX:  I think maybe. a copy of that should

7 I  be made available.

8             MR. NASH:  All right.                                      I

9             MRS.  SILSEEE:  But this was one of the applications,
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16 \I that Council changed the recommendations of the Committee
f/
    last time.  They actually increased the level of funding

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12 1   somewhat.  I just mention that a& background.  But, in turn ,

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13 1.  the region has spoke.
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The regional staff had been asked that a letter

.bj 1 be provided to show how the staff worked'in the nonprofit
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DR. EIEUSTIS:  Let me further amplify:   As I look

18 1 over the individual projects -- you folks can read what is
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with what was going to happen or anytray what it was telling

me was going to happen with any of the money that was given

* to them..

         MRS. SILSBFE:  The motion has been made and

seconded- that the Lakes area application be approved at

$150,000.  Is there further discussion?


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(No response.)

MRS.  SILSBCE:

VOICES:  Aye.

MRS .  SILSBEE:

DR. THUPXAPJ:

All in favor?

-':oposed?

`c; .

MRS. SILSBEE:  What does that mean?

        DR. THURMAN:  I 'am opposed.  I think this is being
                                       - -

overly generous with a region that we have discussed at

length in May.  But to give them more money for these pro-

jects which are obviously designed to take care of the

criticism, I am just opposed.

MRS. SILSBEE:  I belieT'iethe motion was carried.

DR. THUlZMAM:   Yes.

be

      DR. HEUSTIS:  In other words, you don't want me to

as generous.  I will remember that th'e next time.


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l /'            MP::   ";ILSREE:  Could we go to California next,

  just so Mr. F' ::rows doesn't have to talk one after another?

4

Dr. Birschhoeck?

       DR. UIRSCHBOECK:  I think Dr. Heustis is the first

5

reviewer.

6             MRS.  SILSBEE:  Oh, O.K.  Dr. Peustis?

7           DR. HEUSTIS:  I`was very much impressed again,

8

as we were before, with the California plan.  They tried,

it seemed to me, to approach their problems as far as

setting up different categorial coordinators in a way that

would he productive.

The question of reallymrking on this along with

CHP:; and even though their comments were not available I

certainly got the impression that matters were being worked
out;because this was a strong and well-managed program~and

because of their great needs, I recommended the whole works

as requested, $5,592,000.

       P?RS. SILSBEE:  As I recall, the May application
was primarily a continuation so this is -- it was a continua-
tion; this is the first new activity.

.

Dr.  Hirschboeck?

        DR. HIRSCBBOECK:  F7el1, I think I &ffer somewhat

from Dr. Weustis --

          MRS.  SILSBFE:  By about 4 million dollars?
!
         DR. HCUSTIS:  I think we would take pride in the

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degree of difference.

DR.  FIRSCIEOECK:  First of all,  I think what I see

occurring here is the re-establishment of a subregional pro-

gram that they had once before.  At least there are certain

facets of that through this creation of these coordinating

programs for hypertension, access to care, et cetera.

And I am wondering whether this is really something

for a 10 to 12-month period.  There is an awful lot of work

to be done here.  And by approving this entire request what
we are doing is handing them a very substantial letter of
credit for a lot of other development beyond, through the

contract process.                      ,

        This is  -:one comment I have.  Secondly, I think

the kidney projects still confuse me in that a number of them

on the forms 15 are  scheduled to terminate on August 31st,

and yet continuing funding is requested in the form 16.  And

if we followed the practice of funding programs for just

three years as a general rule, we are extending quite a few

of these kidney projects into another year beyond the three

that was originally agreed upon through the PJIP system.

      So these are some of my questions.  There is :

'question about this being a fine over-all regional medic; ~
program serving a very large population.  But considering the

amount of money that they have received in the past in the
May application and what they are asking for now --- namely,


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$5,592,215 -- I think this is pretty heavy for the popula-

tion, and also in terms of the capability of the program

to digest all of these funds even though they are setting

up these subregional divisions again.

So I would recommend that instead of the total

amount that we go down to something like 2 million at the

most.

MRS. SILSBEE:   Mr . Russell, did you have any back-

ground information on subregional offices?

       MR. RUSSELL:  Well, what CCRW has done is when
they did away with the physical subregional offices they

retained the competency of some df those program staffs.

So they have been building on the competency of individuals. :
It is not a restructuring of this subarea office concept.

Does that help?

       DR. HIRSCHBOECK:   Yes.  I think that really explains

it. On the other hand, we are going back into what has the
                                                                           I
elements of a former program.  They have an educational
network which was approved in the last application, and now i

these access to care, the hypertension and the others --

well, it just seems to me that is going back to what we had

'determined wasnot to be accomplished in this particular pro-

gram I  to some extent.
   I guess my main concern is that the amount they

are *requesting as compared to the rest of the regions is a


1 ]1
  !!  pretty stiff amount.
  ;!
  I,
  .:
2 2;          DR. HEUSTIS:
jj             I just need a minute of rebuttal, if

  I!

3 !j  1 may, Madam Chairman.
  b'

. .

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MRS.  SILSBEE:  Yes, Dr. Reustis.

DR. HEUSTIS: I am not at this time really willing

  jj
6 //  to offer a motion to compromise, because I feel very strongly
7 /I
]I  about this program.  IfRMP certainly stands for the things

8 I/  that are publicly talked about, here is a program that, at
9 !
//  least to me, from the knowledge available to me from the
10 1:   two *-written documents,  tries to meet these.
  j\
11 /I       And if we are talking about shared services as a
i/
12 ji  coming thing and if we are talking about getting people to
13 'I !I
Ii work together from different institutions, from different
14 // hospitals on specific programs all over the state, it seems
1. .
15 /  to me that their concept addresses this very well, and, again,

16 j  with a good staff.

17 i          Sure,  it is a lot of money.  But here, at least

.

18   in my opinion, it is feasible of being used well and wisely
19 i 1  over the period of time.  And it doesn't bother me at all
II
20 /j  that this 5 million dollars -- 1 will help to make it UD on
I
21 Ij  some of the others I have to review.
   43

22 jj *
  1I
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MRS .  SILSBEE:  Dr. Miller?

MR. MILLER:  I ask the reviewers to comment spe-

cifically about projects, kidney disease information evalua-

tion, $207,000 for 10 months; neighborhood emergency


i 1: transpo   tion,  $108,000;  access program, regional coordina-

2 i. tion, $2'71,@00; access to care in Los Angeles, 9300,000.
1:

:3 i: pow can these monies be spent judiciously in 10 months?

4

DR. RIRSCFCOECK:  This is my major oucstion.

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There are so many of these instances.

DR. EEUSTIS: Well, my major concern was not with

the individualI.rojects.  And I cannot defend the specific

amounts of money because I didn't really see that as my

job.  But my concern was with the process by which these

were developed.

    And they do have in California a very extensive

and define.d state review process.  And I just limited my
over-all concern to the quality of staff review process and
those nine things without really getting into the specifics

of the projects.

I can't defend them one way or the other.

        MRS .  SILSBEE:  With respect to the kidney, Dr.
Milier, this will be a determination from Dr. Goodman to see

how this fits in. And it isn't something that -- if it is
a new activity it won't be funded probably.  But that is

something Dr. Goodman is going to make the determination on.

.        MR. TBOMPSOEJ:  IGo , 13 of these kidney projects

here.

        MRS.  SILSBEE:  Yes, there are quite a few.   But
some of them will be continued and some of them won't.   We


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   Ii
1 11 just don't know right at this moment.
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i            Mr.  Russell, do you have anything further, sir?
                               %
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3 11         MR. RUSSELL: Well, in terms of the time available,
   j;
4 /i 70 of the projects involved in this applicati'
ii                                are planned

   /;
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5 11  for a 12-month period.  As you know, Californ:'. co:.tracts
  i!

6  all of these activities so they can obligate the money.
,I
*I I/           MRS .  SILSBEE:  I's there further discussion?

8 //
Ii          SR. ANN:  Do you see that as a strength, to say

9 II  they can obligate the money?  Do you see this as a strenqth
10 s/ I  in support :of this?

11 !I         MR. RUSSELL:  Well, I think the best was I can    I
Ii

12 Ii answer that is: They have used $his mechanism very success-
   1,
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13 /i fully in the past.
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1:: Ii           MRS. SILSBEE: Dr. Scherlis?
  j -
15 1          DR. SCHERLIS:  Just to help me' get a better feelinq
11
16 1
i  about this, since there is a large sum involved.   There are

17 /I
/I 25 projects involving high blood pressure.  Is there any

18  hope that any of these will be continued, because they appear

19  to be more than just information type of programs.  They

20 1 appear to be screening.

21      What do you view as the future for the hypertension
   tr
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22 I! programs assuming the funding stops in 12 months?

DR. HEUSTIS:  From the past record, at least given

24  in the books that were available to us, their track record

25 ' is very good for getting projects continued that have been


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started.   SO I assume this would happen.

DR. CARPENTER :  They face the issues of a screen:.iaq

program.  In their -,form 15, do they indicate that they have

thought how the hypertension might conceivably get treatment?

        MR. THOMPSON:  We are falling into a trap here.

We canst review every one of California's projects.  We have

got to more or less come up with what we think is feasib!e.

        DR. SCHERLIS:  They are so wide apart, I am trying

to get a feeling.

        MR. THOMPSON:  You know what California has been

like.  F?e stumble on it every time it comes up for-review,

we shoot half a day.

MRS. SILSBEE: Dr. Hess.

DR. HESS:  Is a substitute motion in order?

MRS.  SILSBEE:  There hasn't been a motion.

MR:. THOMPSON:  Let's get a motion.

DR. HEUSTIS:  No motion?

       MRS. SILSBEE: No,  I haven't heard a motion.   There

are two different views -- unless, Dr. Hirschboeck, you'll

make a motion.

        DR. HIRSCHBOECK:  I will move an award of 2 million

'dollars.

        DR. VAUN:  I will second, that.

        DR. HEUSTIS:  The group should know that I have to

vote against this motion.  It is not enouqh.


  ;:
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iI          MRS. SILSBEE:  The motion had been made and
                                                                           i-
2 j j  seconded that the California application be approved at
  i!
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3 jj the level of 2 million dollars.  Is there further discussion?

  /I

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5                  ir:. *  i!ESS:  I would just like to indicate that I

6

would agree with Dr. Heustis thatthat is a bit low for the  j

                                                                           /

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quality of program and the, size of population and so on in    j

8

California.

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MR. BARROWS:  Judy, in order to keep this democra- !

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tic and not necessarily good parliamentary tactics, could
you have a show of hands on how many would prefer two and
how many would prefer 3 million, (to-get the sentiment?

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        DR. EBUSTIS:  How about 4 and 5?

        MR. BARROWS:  All right.

        MR. THOMPSON :  Point of order.'  There is a motion

on the floor.  I move the question.

         MRS.  SILSBEE:  That means we have to vote, doesn't

it?

        MR. THOMPSON:  That's right.

20

MRS. SILSBEE:  The motion has been made and secon-

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ded that the California application be approved at 2 million

dollars,  All in favor?

      Opposed?

     .~ Excuse me.  All in favor put their hands up.

There are one, two, three four.


I          Opposed?

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Ali right.  That motion has been defeated.             I
                                                                   /

MR. BARR&G:  I will move 3 million.

DR. SCBERLIS:  I second it.

        DR. THURNAP?:  I call the question.

        MRS.  SILSBEE:  The motion has been made and

seconded that it be approved at 3 million dollars.  All in

favor?

        DR. HEUSTIS:  Can we discuss it?

        DR. THURVAN:  I called the question.

        MRS. SILSBEE:  3 million dollars. All in favor?

Somebody help me count.

DR. pAPL:   Fourteen.

MRS. SILSBEE:   Fourteen.

Opposed?

DR. HEUSTIS:  For the record.

DR. PAHL:   One.

DR. HEUSTIS:  I believe very strongly in this.

MRS.  SILSBEE:  The motion is carried -- 3 million

dollars.


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MRS.  SILSBEE:  Let's do Central New York.   And

the reviewer is Dr. Fess, primary revietrer.

                        *
        DR. IIESS:  This is a region that was rated average

in the general review, this is a region that was considered

to be average in our May review of the over-all proqram.
The final funding decision at that time was S670,OOO.  The

general management of the.region appears to continue to be

effective.

     The goal statement that wasmissing in the ?ay

review has since been sent to DRMP and appears adequate. It

was not clear to me what the funding priorities were for

the different projects in this application.

      Another issue that was unclear to me was the
justification of the need for the amount of funding proposed
for some of the primary care activities, particularly the

funding, what I would read from the description of the plan

to fund the salaries of practicing physicians.   It seems to

me that the fees for service ought to pretty well .support     :

the physician services that were planned.

It is also somewhat impossible for me to tell what

their followup plans were for the adult health screening

+ project as well as it was unclear as to the priority of need

for the family planning, midwife planning project, number

71.

Given the over-all rating of this program and


the questions and what appeared to me as some areas of

  :,
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;t IE uncertain terms of justification for their requests, my

jl
3 jj feeling was that instead of a level of 655 which was requested
j! .
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.$ !! that a level of 450,000 would be an appropriate level.

  ji
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  I

MRS.  SILSBEE:  Dr. Miller?

8

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        DR. MILLER:  I share many of the same concerns

that Dr.  Fess reviewed.  But I would like to call attention :
to a few specific things which I think are important in this  I
                                                     !
application.

      The first one is that I think there should be a

general rule -- and I am not sure that it is a general rule :
-- but for the remaining, for a one-year period, the exnen-

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sive equipment should be rented and not purchased in these

projects.

      The one project, 063, proposed to buy an ambulance

for $17,000.  I think this should be rented if the project

iS activated,  The same concern I felt regarding physician

income, although I don't think that probably in the first
year the fees for service will pay the full costs of develop-i

mental service programs.

But there are five projects in here with salaries.

* to physicians or physicians' assistants for primary care

that total $233,000.  MY estimate .was that patients' income

ought to cover at least 25! per cent of these costs even in

I
/ the first year of such demonstration projects.
j
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          I felt also, as I think we are going to see all

!I
$7
i  day today, that many projects lat.. t documented evidence for
jj
  :!
7
CJ  the primary care projects, screening projects, followup

4   *krojects, comprehensive home care project.  In this case,

6

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5      t will either have a significant final output in one year

,!
11  or will be continued by sponsoring organizations after
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termination of RMP funding.

a

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10   that there will be some continued followup on projects like

11   this that could really not achieve any lasting benefit if

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      I actual feel that a condition on the funding for

many of these projects ought to require some documentation

they are terminated in one year.

      Calculating on the basis of these determinations,

I came up with a recommended funding level of $575,000,

which is quite a little bit more than Dr. Bess has suggested.

But I would be willing to either go along with the recommen-

dation of Dr.  Bess or somewhere in betweeen.

         MRS.  SILSBEE:  Does Staff have anything to add to

the situation?

        MR. STOLOV:  I just basically think it is a matter

of evening out the funding level.  Eut we have received the

22 -   .iorities due to the region's concern of   97 they allocated

L  the money.

ii
24 (I        They sent a sheet -- 1 thought it was your book.
;I
I-Jr. I/  All others that were made were in reviews.  And Staff can


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only say just one point with Dr. Miller about the 25 per    1

cent that is anticipated income reducing the grants.

Our grants management people teli US that if we

do that and the money doesn't come in, then we are shorting
                        . .

the region. And we usually wait on the other end for this

to happen.

      But other than that, it is a good observation, as

I say.

MR. MILLER:  It is quite possible to design pro-

jects with that in the budget.

       MR. STOLOV:  That is correct.

       MR. MILLER:  And when that is totally eliminated,
it obviously is something that should be corrected.

        MRS.  SILSBEE:  All right,  We have two funding

levels by the two reviewers.  Does someb'ody want to make

a motion.

        MR. MILLER:  I will make aroDtion that the Central
New York program be funded at $450,000, as recommended by

the primary reviewer.

       MRS. SILSBEE:  Is there a second?

        DR. HESS:  Second.

/

.

MRS .  SILSEEE:  The motion has been made and seconded

that the Central Mew York application be approved at $450,000,

Is there further discussion?

(r70 response.)


MRS.  SILSBFE:  All in favOr?

vo1ms:  Aye.

MRS. SILiEEE:  Opposed 3

(No response.)

MRS.  SILSEEE:  The motion is carried.


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ms .  SILSP,FE:  Now , could we go to Marylard? In

Maryland, the reviewers for F?aryland are Dr. Vaun and Mr.

Barrows.

Dr. Vaun?

DR. VAUN:  You took it out of sequence, Judy, you !

should have warned me.

Because of the previous rating of poor in RMP, it :
                                                                   ,

appears necessary in order to review leadership and organiza-j
                              I

tion.  Though I was not present for the last discussion,      I

last meeting, it does not -appear that the letters from the i

Vice Chairman of RAG or Chairman of the RAG did much to

I

objectively refute the comments of Dr. Pahl's letter of

July 2.

As a matter of fact, the reaction to Dr. Pahlk

letter and to some of the criticism from' CHP to projects

seemed to follew a similar pattern of how outsiders view

RMP and hoTthey view themselves, the composition of the staff

in RAG would not appear to have changed much overnight.

    The previous comments regarding the RAG being     j

heavily provided are still relevant and it should be mentioned

once again.  The staff, though small, lists an appropriate

spectrum of health professionals.
     The activities of the committees do not appear to    ;

reflect .a great deal of involvement.  The present submission,

as 3 understand it, contains a total of $724,786 for funds,


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                                                                           I
$252,961, feasibility funds, $50,000, project funds, eight

                                                                           /
new proposals, $rt21,E25.                                      1
                                                                           I

I

    The objective of the program as now stated is to, i

8.; ote , facilitate health programs aimed at urban and r, 21

Lf)T, end of quote.  The project proposals appear %-ong::.ent

with this stated objective.  GNP support, except for what

appears to be some bureaucratic wrangling at the upper

echelon level, seems to be proper.

      I believe that the RAG response is adequate to
convince me personally that lack of CHP support does not
detract from the merit of the project. Whether it will

detract from implementation is another matter.
     The only question I would raise in reviewing the
individual projects is the redundance which appears to          t
strike the hypertension proposals.  Desrjite comments to the

contrary, I do not feel they are different.  As a matter of

fact, it would appear the successful implementation of one

preceeds the other.

I

     PJG's condition6 on approval of project 69 can be

further suspect in this area.

       Recommendations.  I would recommend that funding

be $650,000.  I arrived at this through decreasing project

funding by $50,000, S40,OOO for number 69, the hypertension

project; and $10,000 from several others, tqqether with the

denial of $50,000 for feasibility.


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Feasibility money sounded like what used to be

called developmental funds.  And the performance of this

PXP would not appear to warrant such a grant.

MRS.  SILSBEE:   Mr .  Barrows?

XR. BARROWS:  I arrived at the "..:.&ical figure

for quite different reasons.  The program didn$'t look quite

as bleak to me as it did to,Dr. Vaun, but that was sort o$!

                                                                           ,
irrelevant.

The Office of the General Counsel has concluded

that under the court order we are required to keep viable --

1 hate to use that word -- but a viable PXP in Maryland.
It seemed to me it took about 250 bucks of staff money and
-they need at least 401),000 for project money to have any

kind of a meaningful program.
     So we came out with the identical figure.   I trill

second your motion if you made it.

        DR. VAUN:   I so move.

        MRS. SILSBEE:  A motion has been made and seconded
that the Maryland application be approved at $650,000. Is

there further discussion?

      (No response.)

HRS. SILSBEE:  All in favor?

VOICES:  Aye.

MRS.  SILSBEE:  opposed?

/       DR. THUWAN: No.
2.5 I


         MRS .  SILSRm:  Let the record show that there were

two opposed,  and also that Dr. Schcrlis was out of the room

                        .
during this discu:.sion.  The motion has been carried.


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T.IRS .  SIKSBFX:  Now we- are going to go back to

Colorado/Myoming.  Let me explain what I am doing here: I     i

                                                                           I

am trying to get Mr. Barrows,  all his reviews done before he :

has to depart for the airport, because he cat   with the full,'

he told us before he came that he would have to leave but

he came because he wanted to help make a quorum.

       Then,  in addition, Dr. Gramlich has departed some-

place.  So I am trying to fit his requests in.  So that is

why I am jumping around.  But we will do Colorado/Wyoming.

Then we will go to New Jersey -- just so you know what the

sequence is here.

O.K.  Colorado/Wyoming.

DR. McPHEDRA1J:  I am moving for this grant period :

that $200,000 be our recommendation,  And the justification

is as follows:   This is a request for $382,913.  I think

you have the figures on the white sheet, for 16 projects,

and six projects that weren't funded in the first Play appli-

cation.

       In Nay, the region was judged to be superior to

above average.  A request of about 1.9 million had been

made:  the committee recommended 1.6 million, and DRMP funded

. at 1.5.

,

      In reviewing the current material, I find myself    I

more in sympathy with the intent of the six new projects

which total about $109,000 than with the resubmitted projects


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which were the bulk of the S382,OOO.

And Dr. White, whose written comments were available

           .

to me, questioned TWO of those resubmitted projects specifi-

tally.   I have some  her questions about projects, but I

think they are real: beside the point, the main point,

which is I think that  this is a reasonable recommendation,

and I have discussed it with Sister Ann before.

So I move $200,000.

MRS.  SILSBFE:  $200,000.

       Sister Ann, do you have anything to add?

        SR. ANN:  Yes,  I concur.

        MRS .  SILSBEE: O.K.  The motion has been made and

seconded that the Colorado/Wyoming application be approved at

$200,000.  Is there further discussion?

      (No response.)

         MRS.  SILSEEE:  All in favor?

        VOICES:  Aye.

         MRS.  SILSBEE:  Opposed?

      (No response.)

        MRS. SILSBEE:  The motion is carried.


n3
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the

     MRS.  SILSBER:  Now we will

record show that Dr. Vaun is out

record also show that Mr. Eiroto

do Mew Jersey.   And let

of the room.   And let

was out of the room

when California went on.

The primary reviewer is Dr. Teschan. IJi.   We1 03me.

        DR. TESCHAN:  I-Jowdy .  The Committee will remember

that Mew Jersey was recognized as a superior region, that

it reauested 1.4 million in the May request -- that is, the

current funding.  The May request was 3-9.  The RYP funding

is thirty-oh-three-one.  The July request came in at ,about

three times estimated.

We have no reason,in reviewing the July application,

to change the assessment.   There are two major projects of

particular interest in their application.  One, the appli-.

cation brings it to our attention particularly, one is called

cultural awareness, addressing on behalf of a number of RPqP's

that have been involved in the planning conference the
problem of delivering health care not only to recipient

populations but with providers in various professions whose

cultural and racial backgrounds are different.

       So the issue here is, I think, joined in real

' reality.- And I w&s impressed with that approach.   Second

is the clear-cut -- and this in the long run.may be the most

significant part, significant effort on the part of New

Jersey and other regions, several of the regions who are


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working like this, to attempt in their interaction ::Lth CHP

to develop a sound mutual operations base for the evolution

into the successor.:formats, whatever the legislation both

in the States and  -:tionally may require.

        So that   khink, as usual, with the superb staff

in RAG and the cooperative enterprise among the various

Participants in the New Jersey RNP, the region is way ahead

of the game getting ready for the new era.

Dr,,,-Barrows and I had a chance to  discuss this

situation. My recommendation was for 1 to 1.1 million.

And basically, although the recommendation was large, the

request was large,  We thought that because of the liberal

treatment in the first-go-round it perhaps would justify a

balance between the request and something a little more

modest at this time.

       So I will yield the floor to Yr. Barrows.

         MRS. SILSBEE:  Mr. Barrows?

         MR. BARROV7S:  My reason is identical,,  It is an

outstanding program.  This is a very interesting application,

the July 1.  But in our June funding, we doubled the level

of their activity at that time.  And I share Paul's concern.

. that we have alreac   een generous enough.

      I totally agree with the 1.1 million dollars.   Did

you move that?

         MRS. SILSBEE:  Is that in the form of a motion?


i

DR. TESCHAN:  We so move, 1.1 million.

MR.  P,ARROWS:  I will second it.

`RS .  SILSBEE:  The motion has been made and

4  seconded .-,at the New Jersey application be approved at 1.1

5

million dollars.  Is there discussion?

(IJo response.)

MRS.  SILSBEE:  A11. in fairor?

8

VOICES:  Rye.

9

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MRS.  SILSBEE:  Opposed?

(MO response.)

11

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MRS.  SILSBEE:  The motion is carried.

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MRS .  SILSEEE:  FJOW we will qo to Florida. Dr.

Miller, and Dr. Perry, v!ho is the secondary reviewer, is

not here, but his comments have been available.

         DR. MILLER:  I will say to beqin with that Dr.

Perry's review, which was mailed out toall of us in advance,

ends up with a recommended funding level that is fairly

close to what my review was,. although ore did not work together

on it.

     This application is from a very strong RXP, and
it parallels the application previously reviewed of a very
ambitious program oriented toward a long-term view of pro-

gressive change.  In fact, you get the very strong feeling

that they don't believe RFP is going to die at all--and they
are going to keep on going for five years and are planning.

these projects with that in mind.

     I feel there is a serious question of the justifi-

cation for lo-month funding of such projects, unless there

is documented proof that the project will be continued and

completed with other support.  !Cy feeling was that they

should not be started.

       And there was no documentation in the application

' to show that they would he, although Florida has had an

outstanding record for qettinq additional funding.  In July

lst, the program was funded for 36 components, and the.
present application is for another 27 components with a


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to .! budget of 1 and a half million.

There are seven projects in the application which
          .

are broad lonq-term type goals and large budgets.  Examples

are the blood bank management control system, S31,OOO;

regional genetics program,  Slll,@OO; Florida rehabilitation

service system, S50,OOO; health care 'delivery in short-

term penal institutions, S200,OOO; early detection and

proper treatment of oral cancer, $101,000; glaucoma screening,

$174,000; Statewide arthritis program of $246,000.   These

budgets total $974,000, and I do not recommend that they

be given funding.

It is suggested as an alternative that the     .

excellent staff of FRMP pursue staff efforts during the year

to obtain commitment from other health organizations to

pursue the good long-term goals of these projects.

      Several of the projects smaller in size and budqet

also seem uuestionable from the standpoint of feasibiiity

for signi*  Int complete accomplishment in one year.   And

the region  should require some assurance that results will

be published so that some real impact can be anticipated

from these kinds of activities.

MY recommended level of funding was $506 ,000.

Row I will review Dr. Perry's recommendations for the record.

He noted the superior nature of the region and the fact that

he had site-visited their fine leadership in staff and PAG


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and their strong system of processing and objective review     1

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and monitoring of the projects.                                         t

      He noted that the P&G received 53 applications for j

this supplemental grant application, and that they eliminated

5   a number and submitted 27 only in this application.   The

G   recommendations, he says, I am quite concerned about some

7  of the larger projects and, the time frame in which to make

8   them operative and effective.

9         Since I do have such faith in their own review

10  processes and priority setting, I spent considerable time

11   looking at the breakdown of priorities. And their highest

12  priority groupings were 18 projects.  Among these were all

13   of their most significant programs dealing with coordination,

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area health planning support and so forth.

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     With the exception of one proj'ect, the regional

genetics program, all of their financially larger projects

fell either into a medium or a low priority category.   I am

not impressed with the ways in which this project can become

19   effective in the following time frame.

20         And he recommended specific funding limited to

21   the highest priority projects, 18 of them, at a total cost

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of $710,~000, and elimination of the genetics project corn-      1

pletely, which is 111,000, ending up with a recommended

award level of $600,000.

*     Madam Chairman, I recommend, I move that the

,


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Flos:-; :la Regional Fledical Program be approved at ~6Ofi,oOO

awa.rd.

       DR. TFYXWAP?:  Second.

           '.S .  SILSBEE:  The motion has been made and

seconded   .t the Florida application be approved at a

level of $600,000.  Is there further discussion?

(No response.)

MRS.  SILSBEE:  All in favor?

VOICES:  Aye.

MRS. SILSBEE:  C>pposed?

(No response.)

MRS. SILSBEE:  The motion is carried.


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         MRS.  SILSREE:  Mow we will go to Greater Delaware

Valley,  and that is Dr. Hess.

        DR. FESS:  In our ??ay review, we gave the Greater

Delaware Valley RMP an above average rating.  We noted that

there had been good leadership developed there and that

in general their goals, objectives and priorities t?ere con-

sistent and they seemed to be taking an effective regionwide

approach to their responsibilities.

     Since our May meeting the coordinator, Dr. Poberts,

has resigned and has been replaced by Dr. Wolf who formerly

hadbzen the PAG chairman.  And he certainly has a long

background with the Greater Delaware Valley PBP.and should

be able to provide capable leadership and continuity.            i
     One of the things that concerned me is the relative

preponderance in this submission of medium and low-priority

projects.  And related to that, the question is whether the

region could adequately monitor and manage the large number

of new projects proposed in the remaining time.

     In general these seemed to be of lower quality

than theprojects that were submitted in the May application.

I suppose that reflects good judgment on their part to save

the more uncertain ones to the last. Their request was for

a  *million, 70 thousand dollars, and my recommendation was

$600,000 plus a theraflex budget which relates to Delaware

which formerly was in the Greater Delaware Valley and then


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broke off and naturally does not have a P&P at this present

So that would -- 1 forget the precise amount of

the theraflex system --

MR. NASH:  $84,512.

DR. HESS:  $84,000.  So that would make a total

of $684,000, my recommendation.

         MRS.  SILSBEE: Dr. Thurman?

        DR. THUJWAM:  I agree and so move:

         MRS.  SILSBEE:  All right.  The motion has been

made and seconded that the Greater Delaware Valley applica-

tion be approved at the level of C684,0@0, of which 884,COO

goes to Delaware for theraflex.

        MR. NASH:  That's $84,512.  Put the 512 in there..

        DR. THURMAN:  Thank you, Mr. J?ash.  So moved.

We will take it.

        MRS. SILSBEE:  $84 thousand what?

         MR. NASH:   512.

        MRS. SILSBEE: O.K.  The motion has been made and

seconded that the Greater Delaware Valley application be

approved at $684,512, of which S84,512 is earmarked for

- theraflex in Delaware.  Is there further discussion?

(NO response.)

MRS.  SILSBEE:  All in favor?

VOICES:  Aye.


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MRS.  SILSEFE:  Opposed?

(No response.)

KRS .  SILSFEE:  The motion is carried.


1            MRS. SILSBFX:  Now we will do Hawaii. Mr. Russell

2   has been'to Hawaii so many times I am picking up the accent.

3    Dr. Hirschboeck?

4            DR. HIRSCEBOECK:  This region  "9 improved tre-

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mendously since the new coordinator has .Laken over.  And

this was in evidence in the June application or the new

application.  And this impression persists in the July

application.

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     The projects and programs are all well planned

and targeted.  The review comments by the CHP agency is

excellent.  The RAG is very actively involved.   And I

recoaWz+nd approval for the full amount requested, $486,750.

         MRS.  SILSBEE: Dr. Thurman?

        DR. THURMAN:  Agreed and seconded.

        MRS. SILSBEE:  The motion has been made and

seconded that the Hawaii application be approved at $486,750.

Is there further discussion?

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DR. SCHERLIS:  Just one question:  Is there any
                                                                  !

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specific delegation of funds or allocation of funds to the     !

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trust territories as has been the custom in the past?

     MRS; SILSBEE':'~~ Mr. Russell?

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MR. RUSSELL:   Yes,

MRS.  SILSBEE:  Did you hear the question?

MR. RUSSELL: Yes,  there are funds in as far as

25

the trust territories.


1 I;          DR. SCHERLIS:  They IJill be reserved specifically

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r: j      MR. RUSSBLL:  Right.

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DR. SCFERLIS:  All right.

MRS.  SILSBEE:  That isn't a part of the motion at

this point.  Do you want to make it part?

DR. HIRSCHBOECK: I will include that in the motion.

        MRS.  SILSBEE:  Before we have always earmarked

funds for the Pacific basin.  Is that necessary to do this

time?

       MR. RUSSELL:  I don't think it is, but --

      MR. 'THOMPSON:  YOU are giving them all the money.

You don't have to earmark it.

        MRS. SILSBEE:  All right.  The motion has been        f

made and seconded that the Hawaii application be approved at :

$486,750.  All in favor?

        VOICES:  Aye.

       MRS. SILSBEE:  Opposed?

(No response.)

MRS.  SILSBEE:  The motion is carkied.


1.             FRS .  SILSREE:  NOW we will do V1ashington/Alaska.    I

I!:   And that is Mr. Barrows' last one.  And let the record show

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that Mr. Ogden is out of the room.

        MR. BARROWS:  Washington/Alaska is another top-

notch program.  The July application is for 15 new projects.
They are all rather varied; they are all consistent with the

past activity of the program and its objectives.  They are

all for large amounts, too.

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     My recommendation is that t;e fund for around 80

per cent of their requests, which would give them by my

standards preferred treatment, or roughly $498,000.

         MRS .  SILSBEE:   Mr. Thompson?

        MR. THOMPSON:  I agree with the comments on the

program.  I was a little more generous, I think, because they

went through the trauma of a negative CHP review and then

found out it was the wrong CHP agency that was reviewing.

        MR. BARROWS :  I will take your figure.

        l4R. THOMPSON:  So my recommended figure was $530,000

        MR. BARROWS:  All right.  I second it.

         DR. HEUSTIS:  May I raise a matter of information,

Madam Chairman, before the motion is made?

         MRS .  SILSBEE:   Yes.

         MR.  HEUSTIS:  In the opinion of the chair, are we

being consistent when we deal with projects we all thought

were, excellent in the past in ,applying I?. Barrows' formula?


I am thinking we just talked about an excellent program in

Hawaii and gave them all they wanted.
                        I

    And no:q in the opinion of the chair are we beinq

fair?  I am sorry to put the chair on the spot, but that is

the only way I can bring it to the floor.

MRS. SILSBEE:  Well, the chair feels that it is

fair because the Hawaii application, last time they hadn't

looked at it in the same light. 'It is because --

DR. HEUSTIS:  I don't need any more explanation.

MRS.  SILSBEE: O.K.

MR. BARROWS :  I might add that I haven't been

applying that up and down the liffe.  There have been devia-

tions for regions both ways.

         MRS .  SILSBEE:  They have been changed by the other

reviewer,too.

A motion hasn't been made, has it?

FR. TBOMPSOK :   Yes.  A motion has been made that

Washington and Alaska be funded at $530,000.

DR. SCHERLIS:   Seconded.

MRS. SILSBEE:  The motion has been made that the

Washington/Alaska application be fcinded at S530,OOO.   A.11

.
those in favor?

VOICES:  Aye.

MRS.  SILSBEE:  Opposed?

(No response.)

MRS.  SILSBEE:  The motljlon is carried.


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         MRS.  SILSBEE:   Have P,lr. Ogden come back in.   And

we can go back to Illinois.

DR.  SCXFRLIS:  Under the specific direction of

the chair I will discuss Illinois.  At the time of the pay-

June review meeting, Illinois uas funded at a level of

$2,760,000, with an over-all assessment of average or super-

ior.

This program has had strong leadership with very   :
                                                                   

good relationship with the CFP aqencies.  The level cf

funding provided on the last review was essentially similar

to that which had been requested.

The present application is for a total of 1

million plus.  Review of their various proposals also included

the sum of $300,000 for a contract for a metropolitan Chicaqo
hospital information system and 10 net? operational prOpOSals

for the balance.

Some of the projects for which support is requested

ajre not up to the level usually received from the Illinois

regional medical program.  It was noted that approval had

not yet been recommended for the S300,OOO contract proposal.

There were no priorities listed, and it was a serious ques-

* tion as -:to whether the project and how the planning can

be accomplished within the one year frame, as suggested.

      The over-all appraisal of the superior qroup of

proposals was that they were at best fair.  The funding level


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    was therefore recommended which vas reduced to C750,OOO in

2  place of the 1 million plus that had been asked for.

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The statement that, cuote, it is recommended to

the RAG the funds be requested and if awarded sequestered

for this purpose apply to the S300,OOO.  And this seemed to

be cacheting the funds until such time as they might have

it to spend.

It was thought that perhaps a small sum could be

used for planning.  That is why the sum of 5750,000 was

proposed.  I therefore offer as a motion that the .Illinois

Regional Medical Program he supported at the level of

$750,000.

         MRS .  SILSBEE:  Now, Dr.  Slater was the other

reviewer. Dr. Scherlis, have you had an opportunity to

look at his comments?

DR.  SCHERLIS:  We discussed this together at the

time of the last meeting.  It was my understanding that he

was'also going to propose the same sum.  And he thought that

the total should be reduced by about 20 per cent.   I reduced

it by about 25 per cent.

So I would assume o:e are in essential concurrence.

. We did discuss this in detail at the time of the last meet-

ing.

DR. THTJREAN:   Seconded.

DR. SCHERLIS:  Pardon me; at the time of the last


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coffee discussion that we had, whatever thatvas.

Y.R .  TI1ONPSON:  The last nonmeeting.

         MRS.  SILSPJEE:  The motion has been made and secondec!

that the Illinois application be approved at S750,OOr).

Could I ask a question?

DR. SCHERLIS:  Surely.

MRS. SILSBEE:  You talked about some contract.

Is that part of the motion?

DR. SCHERLIS:  I would suggest strongly to the

region that the sum of $750,000 not be utilized for the.

$300,000 contract except on a minimum basis, possibly for

planning. This was concurred in.

MRS.  SILSBEE:  That is strong advice to the region.

O.K.

Is there further discussion?

(X0 response.)

MRS.  SILSBEE:  All in favor?

VOICES:  Aye.

MRS. SILSBEE:  Opposed?

(No response.)

MRS. SILSBEE:  The motion is carried.


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         llRS.  SILSBEE:  Now we go to Indiana.  That is

because it is next in the alphabet.   Vr . Thompson?

       MR. THOMPSON:  There is nothing in this request

5

which changes  i-3 previous impression that the Indiana

Regional Medic ,.. Program has not progressed measurably or

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matured substantially.  And I think the coordinator is

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not.

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The specific proposals may have --

MRS.  SILSBEE:  Could you use that little thing?

MR. THOMPSON:  The proposals may have been con-

sidered innovative in here.  One'of the regional medical     ;

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programs that they do not reflect there in the priorities      I

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as stated on page 19 towards innovation of medical delivery,

medical care delivery.

.

The relationships with the various comprehensive

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health planning agencies are obviously strained.  And even

the basic categorical programs they were asked to review got

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mixed notices.

The over-all rating of the programs reflected in

this proposal remains below average.  A suggested funding

level of $215,000.

         MRS.  SILSBFE:  And Dr. Slater was the other reviewer

He came'up with a slightly different funding level.

e      MR. THOMPSON:  All right.  V7hat wasit?


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MRS.  SILSBEE:  Do you-have it?  $255,350.

Do you want to make a motion of 215?

        MR. THOMPSON:  Veil , I will spl.it it with him and 1

& ake it $240,000.

        DR. THURMAN:  I am not going to second that. I     :

am going to discuss.

        MR. THOMPSON:  All right.                                   !

          MRS.  SILSBEE:  It hasn't been seconded so you can't

                                                                           /
discuss Ct.

MR. TOOMEY:  I will second it.

DR. THURMAN: O.K.  Can we discuss?

MRS.  SILSBEE:   Yes.

DR. THURMAN :  Why are we giving them any money?

MR. THOI4PSON:  Are you asking me?

                                                                   I
DR. THURMAN:   Yes.                                             /
                                                                   I

MRS. SILSBEE:   Yes.                                            i

        DR. THURMAN:  As I understand it -- and correct me

if I am wrong -- we have met the legal constraint and they

received money last time around.

       MRS. SILSBEE:  You didn't recommend phasing this

one out last time around.

        DR. THUPJMAN:  I know that.  But we are not going

to burn anybody's fingers if nobody gets the money this time

around, because these are supplements to supplements to

supplements, actually.


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         DR. PAHI,:  You may take whatever action you desire

on the present application in terms of recommending or not

recommending funding.  They are not supplements to supple-

ments.  They are supplements to the has! . grant.                   .I

         MI?   ZOMPSON:  In answer to yc.~r question, I gu-.ss

the primary reason that I recommended funding as I did was

the fact that at least there was within the project applica-

tion -- for the first time, I might add -- at least some

concern for something other than a categorical grant.

        Now,  this was for Indiana  a fairly major move

although- again it was not reflected, you know, in their

proposals.. Now, Dr. Slater specifically deleted some grants

that were again primarily concerned with specific areas,

and came up with somewhat the same kind of review.

         DR.  THURMAN:  Again my concern is that Dr. Slater's.

comment says, pedestrian, poorly written, lacking in clarity,

no conceptual design, reruns, nobody in the State understands

what anybody else is doing.  And I just -- that is the reason

I question it.

         MR. TFOMPSON:  Well, as I say --

          DR.  REWSTIS:  ?!ay I offer a substitute motion?

         DR. THUPXAN:   Pardon?  IF Mr. Thompson would accept

it, I would offer a substitute motion that we not approve any

money for Indiana in this review.

        DR. HEUSTIS: I would support the amended motion.


MRS.  SILSERE:   Fir,  Thompson?

VR .  TI'O:~IPSO~J :  I would not accept that.   I think

3 i: we are being a little harsh.  And when I say the attempt to
  

change the Indj *la RMP was more than just lip service.  They

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do have in thi.  .,eCtiOn an attempt. to involve both RAG and

non-RAG representatives in the establishment of priodties

for the REP, which is, for them that is a long way down the

path.

     And this is presented on table 1, which makes me

think that at least they are trying to drag themselves into

the sameplace that most RMP's were in before they were killed.

        DR. THUFNAN:  I call for the question.

        MRS. SILSEEE:  The motion has been made and

seconded that the application from Indiana be approved at
$24*,*00.  All in favor?

        DR. HEUSTIS:  Excuse m.e,  Madam Chairman?

MRS.  SILSBEE:   Yes?

I

        DR. HEUSTIS:  Was not his amendment supported at
                                                               . -

zero?

          MRS.  SILSBEE:  He wouldn't --

          MR.  THOE?PSON :  f would not accept that.

*          DR. HEIJSTIS:  If he gets support for his amendment

he doesn't need his acceptance.

         MS. SILSBEE:  Would you want to explain that?

         DR. SCHERLIS:  I would move the chair seek counsel.


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DR.  THIJRYAN :  From whom?  Basi

tally what I really j
                           I

asked, Al, was if Mr. Thompson would accept my amendment.      :

And he said,.no, hz wouldn't accept it.  So I didn't put     ;

you and II;' ?lf in   position of overriding h -- basically :,

without h.l.:., permis:   ..n.                                                   /
                                                                           I

I did not offer a substitute motion.

                                                                           ,

        DR. HEUSTIS: Well, may I move to amend his motion?;
                                                                           1

         MRS.  SILSBEE:  I suppose so.                               I
                                       j
        DR. HEUSTIS:  I would move $100,000.                     ,

        MRS. SILSBEE:  Now * you've got to get somebody to 1

second that.                                                                  j

        DR. HEUSTIS:  That's right.  If somebody supports j
                                                                           ,
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it.                                                                           k
                                                                           I

        A VOICE:  Seconded.

        MRS. SILSBEE:  Does that mean the motion is now      '

amended?

DR. MILLER:  Can we have discussion?
                                                                   /
                                                                   1
MRS.  SILSEEE:  Yes, sir.

DR. MILLER:  The comment that was given to US by   /

the Staff here,both CHP A and B agency comments were largely

negative.  I wonder if we could incorporate into the condi-

tion also of funding that no projects be funded without

resolution of the conflict between the B agencies and the
                                                                           I

RMP?                                                                     1

         DR. TESCHAN:  I would like to comment on that.   We


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disagree thoroughly.  Unless we have a great deal more

specific information about the guality of, the CXP B and A
                        ,

review process in that State, the negative CIIP comments,

I don't believe, have any credence until we know more about 1

it than that.                                                                 1

                                                                           /
        MRS. SILSBEE:   Does Staff have any additional

information about the negative CRP comments and the Regional ;

                                                                           /
Advisory Groups' response to that?           I
         DR.  SCHERLIS:  While he is making his was here, I

think this is an unnecessary proscription to place upon

this State.  We have never applied that to any other State, j
                                                                           ,

at least in a routine matter.   And I for one would not be     !

swayed either way as far as Indiana is concerned in relation-j

ship to the agency 'or agencies because we haven't explored

in all the other States when they had given adverse, unfavor-,

able comments.                                                                ,
        MRS. SILSBEE:  Thank you.

        DR. SCHERLIS:  I think it is highly irrelevant.    ,
                                                                           I
        MRS. SILSBEE:  Mr. Jewell.  We can't hear you,        /
                                                                           I
                                                                           /

Mr. Jewell.

          MR JEWELL:
                  .       Was it on the CHP relationships?      . j

' Was that the question?

          I!?RS.  SILSBEE:  You didn't hear the discussion?

         MR. JEWELL:  I didn't hear too much of it.

          MRS.  SILSBEE:  Dr. Miller was making the point that


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there are a number of negative comments.   fird he V;as also

suggesting that there be an amendment to the amendment, that :

the funding of any of these activities not be provided until j

that had been resolved within the region.

We would give them money, but the:*7 ?:ould have to

resolve it before the, v could put any money into those things

that the E agencies had said no to. Dr. Teschan disagreed.

we thought perhaps you had some information about how the

Regional Advisory Group looked at the B comments and what was

done locally.

        MR. JEWELL:  The only thing that I can add, Dr.

Miller, is that I was to the wedding of CHP and R!?P within

the last six months.  And I think they just began to feel

their muscles in the SHP --

         MR. THOMPSON:  Watch that metaphor, now.

         r-IR. JEPIELL:  I think the recommendation, this is

going to be done.  It is not included in this application,

but there will be nothing until these concerns are satisfied.

There will be no funding to the local areas where there is

a CHP.

I have been assured &at.   It is not  included in

'the application.

          DR. MILLER:  May I make a comment?

        MRS.  SILSBEEI:  Dr. Wller.

      .      DR. MILLER:  I recognize the reactions of some


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others on the Committee have been expressing.  And I share,

I think, the fundamental viewpoint that it is not too dis-

similar.

      The resolution of a conflict does not mean that

you acquiesce to CEP comments.  I means that the Regional
Advisory Group pays due consideration to their comments and

then acts in an appropriate manner.  That was my point, and
I doubt that this has occurred here, but I don't know, of

course.

        DR. VAUN:  Though I am. not sure what the question

is,  can I call it?  What are we voting on now?

         ?!RS .  SILSBEE:  If I understand it, we are voting
on $100,000 for the Indiana application.

        DR. VAUM:  Can you axend a motion without the pro-

poser acceptingthe amendment?

         MRS .  SILSBEE:  Nell, that is what I asked.  b?e wi 11

vote on the amendment.

DR. VAUN:  Then we've qot to vote on the amendment.

MRS.  SILSBEE:  The amendment is S100,OOO.

MR. CARROWS:  To make this clear, Judy, if we vote

down this proposed amendment, then we are back to 2i!r.
Thompson.

MRS. SILSBEE:   240.  Right. O.K.  Is everybody

clear what you are voting on no'c<J -- SlOO,OOO for the Indiana

application.  That is the motion as amended.  All in favor?


n53       1 !i           VOICI?S:  Aye.

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2 .,            FIRS.  SILSEEE:  Let's put your hands UD, please.
  :I
  'I                            .
3 ii  That is one, two, three, four.

  : _

Opposed?

VOICES:  Nay.

FIRS. SILSBEE:  The nays have it.

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/I       Now we are back .to the original motion, which is
8 /I  to approve the Indiana application at the level of S240,OOO.
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g 1  All in favor?
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                      Opnosed?
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MRS .  SILSBEE:  Let the record show three opposed.

1.4 ,i  But the motion is carried.

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Ii5 j/ .       DR. PEUSTIS:  May we put in tie record, Madam
   )!
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j/  Chairman, that I suggest that Council pay particular attention

17 /;  to the comments of Dr. Slater in their consideration of this
   i:
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"19 1'           MRS. SILSEEE:  Thank you, Dr. Heustis.  We will

   1;
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   $8
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F.IRS .  SILSREE:   NO67 we will cjo to Intermountain.

And that is Mr. Toomev and F!rs. Salazar.  This is another
                           a

one that the Council changed the recommendation.

MR. TOOMl?Y:  I have some real problems with

Intermountain.  There was a time back about a year or two

ago when there was a rather severe turf problem.   That was

followed by another problem related to the construction of

health development and service coporation.

        MRS.  SILSEEE:   Excuse me.   F!r s .  Klein,  I tink

because of the geographic spread of Intermountain that you

should be out of the room.  Let the record show that Mrs.

Klein is out of the room.

        MR. TROMPSO'N:  You should also show for the record

that Sister went out for Indiana.

MRS.  SILSBEE:  Oh, Yes.  Sister Ann Josephine

was out for Indiana.

MR. TOOMEY:  There also, as well as having a con-

cern about the health developmen, + service corporation by the

Intermountain RMP, there was considerable concern about the

number of projects that were operated under the auspices of

the University of Utah.

      They had, as I would understand it, they had some

major problems in these areas.  There was the turf problem,

the overlap problem, the health services, health development

service corporation, there was University of lltah, there


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were conflict of interest prohle.ems.

In fact,  as I read this current  application, all

of those problems have been resolved.  They now have projects

which stay within their own territory.  When there is an       I

overlap,  the other FWPs in other areas have met with them,

and there is some degree of mutual funding or mutual agree- 1
ment as to the funding in,that part of the funding which
will be applicable to each of the RMPs that are concerned.

     The University of Utah has backed out of being the

requesting agency for the projects.   And I believe that all

of the projects this time have come from outside of Salt

Lake City.  And they pay attention to the rural needs of the

area.

     The problems as regard the health development

service corporation have been well resolved.  And there

apparently is no question any longer of conflict of interest.

And, in my opinion, with the advances that have been made

inthe resolution of the program problems, this RMP not only

was a good one, but with the resolution of'the problems it

seems to me they have moved into a situation where they are j
certainly :n a very good to superior classification and   . i

categorii:L ,:.>n.

     I have some more problems, however, with Inter-      1

mountain.  They.have five new planning proposals.  This is 1

the categorization that comes from Mr. Kohler, who is the       I
                                                                           I
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                                                                           I


1 /j deputy director.  There are two, four, six, eight, 10, 12,
:!
3, j: 14 rural health proposals.  Knd there are five seconda
  //
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fj // hood of 19 new I.  ,ect activities.  Mow,  this is how Mr.

Kohler classifies these proposals in the Yellow sheet in

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jl  our booklet. The application requests $480,000 for the
I/ support of 19 new project activities.                                 I
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Six projects address health quality improvement:

three,quality assurance: two, availability of health assis- !
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I  tance; two, accessibility to health care; three availability
I I[ of health care: and three, quality of health care.  The

  j.
i l3 11  application includes the CPI-! comments and actions of RAG

   .!
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jj

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.15 Ij      Then I have the problem of, aside from who is
    1
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I/ categorizing them and the fact that there is apparently
17 / not consistency in categorizing these proposals as I have
l8 Ii  read them, I don't think highly of any of them.  So that I

19  find myself in the position of feeling that the Intermountain

23  RF4P is a superior organization, has done a superior job in
21 Ij resolving the problems that it has had in the past, has
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          1


!   I don't think very highly of the projects.

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    So that I am in a very difficult and very much a
quandary on the basis of the program, which is what we
basically have been told to concern oursc   >s with.   I would

recommend that the entire $450,(100 that th..~ requested.

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But I think I would do it moreon the basis of the fact that
they had requested 4 million dollars previously in June,
and we had reduced it to 2.2 million, and on the basis of     ;
the fact that it is a superior group and it is a very fine

organization.

11       And even though these particular projects don't

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appeal to me, I believe that they may be able to develop

something within that region.  Now, that is, you know, this

is my quandary.  And Plrs. Salazar, I believe, is the --

        MRS.  SILSBEE:   Mrs.  Salazar?

MRS.  SALAZAR:  I share some of IMr. Toomey's con-

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cerns.  However, the projects, or not one of them, I think
the projects are fatly indicative of the new thrust to

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other areas of Intermountain.

Having looked at Intermountain for a number of

years on Staff, I am very delighted to see that some of      .

' the programs are now moving out into the hinterland. 1
think probably this is due in part to this intra-council
of the regional.medical programs and their participation in
RAG and in planning committees and in review committees.


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133 j

Some of the residual concerns that I have are        I
                                                                   I

statements that Intermountain seems to have engraved on all  !

their applicationsof minority representation.  And they

always justify this.  I can close my eyes and know exactly

what it is going to be.

      It is going to be -- they say this time, however,

that it is being carefully monitored.  And I don't under-

stand that.  By whom is that being carefully monitored?

Also, their staff is very dynamic and very able.  They have

a splendid opportunity, I feel, if they are going to move

into these areas of medically deprived areas then they could

be involving minorities on staff'as b:ell as on the review

committees and evaluation committees and indeed on the

projects.

     I think that probably a statement as to the legal-
ity of the health development services -- perhaps we should
have a clarification'of that and an updating of our last

review.

        MR. TOOMEY:  Dr. Pahl has that.

        DR. PAHL:  I was going to wait.  This might be

appropriate.

.

P!RS .  SALAZAR:  I have a little more.

         DR. PAHL:  All right.  Let me hold back, then.

         MRS.  SALAZAR:  The proposed rating and review
process has been revised, and I was very happy to see that.


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read.  There was one question that I had about these comments

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and planning review.

_ Noticed that they, the CHP groups submitted

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applicatio:,  c:nd they were shot down by the Regional Advisory

Group.  Now, the question that I have is perhaps generic to

the entire, all of the Regional Medical Programs.  F?ith the

exception of one of the applications I reviewed, I saw no

provision for the kinds of comments, the negative.comments,

Particularly'for CHP groups, to get fed back into the

programs and become part of the activation in terms of the

monies that we are voting today and that we voted for in May.

      Maybe Staff can clarify that.  If the reports came

in and we do not approve, how does that get plowed into the.

mainstream of the Regional Advisory Group.

         MRS.  SIISEEE:  Jesse,  if the covering letter from

the Regional Medical Program did not speak to that point,

STaff has presumably asked the region how the Regional

Advisory Group viewed these comments or if, indeed, they had

an opportunity to reflect upon them and what their followup

is going to be.

      In the case of this region, I think, would you ask

Miss Murphy if she has  additional information about how these

negative comments were viewed by the Regional Advisory Group

and what they presume to do about it.


        14s . .
             N?RPBY * .   PI r . Posta wrote to all of them and    ~

send a document recrucsting each comment.  And most of the

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CBP B and A directors sit on the IWG.  They are always in

at*:  .,dance when projects come up.

         MRS .  SILSGCE:  Does that answeryour question?

         MRS .  SALAZAR:   (Nods head.)             /
                                                                           I
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         DR. PAUL:  I would like to comment on the health    i

                                                                           I

services development corporation.  There has been a continuir

dialogue between the Regional &!edical Program, the grantee,

the University and ourselves since we last met concerning

this point.

And I can say two things:  First of all, the

Attorney General of the State of Utah now finds that a

corporation under the revised conditions not to have a con-

flict of interest with the Univeristy or the Regional Pledical

Program.

       And we, in turn, have met with Dr. John Dickson,

the dean of the School of Medicine and Vice President for

Medical Affairs, last week.  And in a somewhat lengthy and

very constructive session.  I think I can assure both

Committee and Council that there is now nopoblem on conflict

*of interest and that this should not play any part in this

consideration of this Committee or the Council.

        It is .an issue which has been resolved satisfac-

torily to RN?, to the grantee university and to the Attorney

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General's office of the State of Utah.

         IIR .  TO01'EY - .  I think is one of my points, :.:hich is
s!.-*ply that it was:a problem and ha3 been resolved, which has
t .in a good deal of action on the part of a good nuTher of

I?@OPb which really represents to me an excellent management,
excellent group of people.that has been able to take their

problems and resolve them.

        FR. THOMPSON:  I have one question.  When you

reviewed the projects, there were an enormous number of them

that were devoted to quality assurance.  And Utah is the

first one to have a PSRO.  Was there any mention made --

       ,MR. TOOMEY:  Well, that is not how they charact-

erize them, John.  That is how it was categorized -- and

who was responsible for these yellow sheets?

         MRS. SILSBEE:   Staff.

          MR.  TOOMEY:  They were categorized by Staff.

          FIRS .  SILSBEE:  Miss F!urphy, the categorization

that is en your yellow sheet, where did that come,from --

you know, that little blurb?

         MS. MURPHY: Mr. Kohler's accompanying letter that

came with the application.

*           :IRS.  SILSBEE:  So this is the RF!P characterization.

           MR .  TOOMEY :  Oh, yes?

          P!S .  WRPBY :  There was the letter that came in

to Vike that they revised.


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          DR. DP.I!L:  Vary, please use the microphone. Y:e

'!  can't get it on our record here, and it is important.

Mr. Posta?

         MR .  POSTA:  I think the question, the whole cues-

t.i  of quality assurance has given Staff quite a bit of.

                                                                 .

problems over the last two reviews., The demarcation you
are speaking of could be;I.think, tabulated from your form
15s when they fill in the appropriate information there.
     In terms of talking with the region on person to
person, we asked whether or not they had anything in the
application which they considered quality assurance.   "I-&e

answer was negative.

         Now, again, I do feel that if there was any project
in which the particular application that we in Staff shculd

refer to our people here, we would be more than happy to

follow through, the same as we have already earmarked, that

is, to put in that category.

          MRS .  SILSBEE:  Fike , could you clear up-where these
various categories that are on this yellow sheet came frcr! )

because we seem to be sort of splitting infinitives? That

is what we are trying to get.

.          MR. POSTA:   That came from the cover letter fro>

the region, correspondence from the region.

          MRS.  SILSBEE:  It wasn't the covering letter,   Xe

don't find it in the one we have.


         r"ls *  i.l'i!J7PJ'Y :  i?lso on the 15s for each   3 j e c t ,

they put under disease category p 3rd thr 1: is ho+,.7 they cate- :
.cjOrizc them. -'

r.I.s e  JmRPl?Y :   !?ach 15 .

f3R. POSTA:' That is what 1 was going to say.   But

I would as far as the feedback to the region like to have

those specifically any guestions brought to the attention

of Staff so we can feed it back.

         i4RS .  SILSX:IE:  Dr. Teschan?

        ??? ??? ??o?? o
                    ???? ?  I tsanted to ask either both .Wr.

Toomey and Mrs. Salazar relative to the projects that you

felt are a little less satisfying than some of them used to

be in the past as to ~7hether the cash f2ow in those is a

significant proportion outside of Salt Lake City.

     That is to say that where the application has been

put together by beneficiary sponsors in rural Utah --

         HR . TOONEY :   Yes.

         DR. TESCITAN:  Well, identify the fine question.

         MR. TOOMEY :   Excuse me.  One other thing 1 just

rememhe~. And that is that they also were generated by,

.
I think the specific number were nine members of the Regional

Advisory Group to help :flevelop some of these projects.

         DR. TESCJ?AJ'J:  m11, then my question is whether

you might consider.:  it reasonable that when people who are
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busy in the region try to get a I?.pIP application in that

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4   zrtainly it is our experience that as soon as we begin

tz   lvcikring people who really have major needs, their sophis-

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less.

     And we therefore felt you can have that, we really

had to make adjustments to that.  I don't know if that con-

ment is helpful here or whether it applies.  But if it dces

then it is a very significant point in terms of a funding

decision.

         SR. ApJPl :   Mr . Toomey, do you feel that with these
projects that are outside of Salt Lake City, as so many of.

them are, that as they design them the staff is going to
have the capabilities and plans to kind of monitor them and
give the support that is necessary, that they can overcome

the'problem that has been stated here?

         MR. TOOFVY:  I wish I could tell you yes.  I don't

know.  I just don't, the projects do not excite me as being

innovative or meeting great needs.  Whether theybe in the

. area 0;.   -inning or secondary or tertiary care.  They've

got a d;:nonstration on ecology ward, for instance, which
really is nothing but the establishment of a cancer treatment

center for children.


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want to show that; thev c::n treat cancer bEttcr than they have:

they have a rural rehabilita tion project which is sending

a physical therapist out into the field, to provide physical

therapy.

I

Some of them  aren't Cat physical assessment

training.  They have ruralareas and they are going to train
their personnel to do physical assessment, remote monitaring 1

for critical care. There are a number of hospitals with a _ :

minimum amount of medical services that can be provided,.so

they, perhaps meet the needs.

      But there is nothing really -- but yet the organiza-i

tion is pretty tremendous, and I recommend -- I tell you,

I recommend $450,000 which is xhat they requested, because

I think that they are a capable organization.  I think that

they can take the projects and I think that they can do those

things that have to be done to make this.

        Plus the factthat they were cut in half at the last

session.

DR.  NX'IIEDFW?:  YOU move that?

TiR.  TGoi~EY:  I move the $450,000.

YR. HESS: I ;.:;int to discuss a question with Fir. TOOF.:::

Even though they are cut loss time it concerns the fact that

they overlap with two other regions are they not still one of
the most generously funded regions in the country?

     MR. TOOMY: I think they are generously funded, yes.


5           P4RS. SAL, 1: One of the things I was pleased to
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ee in the applications covering letter was that they have a

zw scheme for monitoring their projects in the field by sign-

ng regional advisory group numbers,as advocates of projects.

zis to me is new and intermittent, which will tie in staff

Aion and staff monitoring, and staff follow up.

     They are also involved in the review and budget analy

think this represents a new dirnmxion for inter mcuntain as

sr as their' field activities, are concerned.

       r~Il-3 .  SILSEEE: The motion has been made and seconded

kat the Inter-mountain application be approved at $150,000. Is

here furtherdiscussion?

DR. CARPENTER: I call the questions.

MRS. SILSBEE: All in favor.

VOICES: Aye.

PUS. SILSDEE: Opposed.  Let the record shot: that

.ree opposed.  The motion is carried.

.     Do you want to bring Mrs. Klein back in, now?

     It's almost a quarter to one.  Would you like to eat?

       11R. TOI,UJEY:  Yes.

      .   DR. SCHERLIS: P/hat time should we be back?


e back

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-:ne at 1:20 p.m. the Sam3 diay.)

re co