E(I)U 43









                                                          Transcripit of Proceedings


                                 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE



                                                                                  W




















                                                                                           E'riclay,, 2x' Septeri)ber 1972


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  c                     DEPARTMENT OF HEALTIJ, EDUCATIO9, AND WELFARE
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                 4             RMPS,REVIEW COMMITTEE MEETING

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                                             Conference Room G-H
               12                            Parklawft Building
                                             Rockville, Maryland

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                                             Friday, 22 September 1972

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                                                                       C 0 N T E N T S
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                 714 9
      OLIG:                    2 ARTA:                                                                                               PAGE
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                               3 Mississippi                                                                                          3

                               4 Missouri                                                                                             52

                               5 New Mexico                                                                                           95

                               6 Northern New England                                                                                 139

                               7 Texas                                                                                                157

                               8 Indiana                                                                                              193

                               9  Memphis                                                                                             210

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                                                                          3
                                     P R 0. C E )E D I N G S
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                            DR. SCfU4IDT:  I think probably we should begin.
       149
               2 We thought that the order of the day would be to begin with
               3 Mississippi, which is the las t of the demonstration presentations
    ba 1
               4  for the committee and then stop and talk a little bit about the
               5  visual aids and the sources of information coming to the
               6  committee.' Then go on to a report of the Missouri Site Visit
               7  and kind of a status report on Missouri.  Them move to my state,
               8  New Mexico, northern New England,.Texas, Indiana and Memphis,
               9  in that order,!finishing before coffee break this@orning.
               iol          So we will begin then with Mississippi.  Dr. Iless.'
               11           DR. HESS:  Thank you.- I would like to begin just
               12 by giving Particularly for the hew committee members a little
               13 bit of background on Mississippi so that you understand a.
               14 little bit better what some of the specifics are in our discus-

               15 sion today.
               16           At the April 1971 Review Committee meeting, when
               17 Mississiopi'Pj4P was reviewed, a number of us were very con-
                  cerned because of a program which did not seem to be functioning
               18
               19 very effectively in a region which perhaps has some of the
               20 greatest needs of any region in the country by almost any
                  health or economic index you want to'pick.  Mississippi is at
               2 1
               22 the worst end of the spectrum, whether it be per capital income,
                  whether it be physician Dopulatio n ratio, whether it be neo-
               23
                  natal mortality, you name it, Mississippi is at or near the
               24

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                  bottom.
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                             We were very much'concerneci that rather than

         2       2 unduly punishing a region,.that this region above all else

                 3 needed some assistance in order to get'itself reorganized to

                 4 qualify for funding more appropriate to the needs of  the  people

                 5 of the region., As a result of that deliberation, an assistance

                 6 site visit was scheduled in September of 197l.- And a number of

                 7 staff and consultants visited the region.

                 8           We had two days of frank -- listening to  problems  and

                 9 discussion-and feedback to the staff, the coordinator, and to

               10  -select the members of the RAG. And then we returned to wait  and

               11  see what happened.  Some of us who-were on that Seotember site

               12  visit returned again to see what had occurred.

                             We might just indicate for you some of the     I
               13

               14  haven't had a chance to look at them, some of the recommendations

               15  that were made at that September site visit.  Concerning the

               16  regional advisory group,, we recommended very strongly that  they

               17  reviey7 th@ir committee structure and reorganize it more

               18  in keeping with the new directions in which RYIP was moving.

               19            At that time it was largely categorical in its

               20  orientation.  And we specifically recommended that they deal

                   i-iith,questions of planning and evaluation and help the -RAG'
               21
               22  become more intimately involved in these activities.
               23            The core staff was@nbt functioning  particularly  well.
               24  One of the,probloms was they were quartered in a variety of

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               25  locations around the University of Mississippi Medical Center







                                              5


       #1 I and this physical separation did lead to some fragmentation
  *a 3    2 and lack of coordination of activities.

          3      And we'also recognized that there was some need

          4for better communication and stronger leadership thrust

          5from the coordinator. We also recommended that they consider

          6setting back their time deadlines for their requesting a re-

          7vision in the time for application in order to allow them more

          8time to make the adjustments which we recommended.

          9      We offered the assistance of the regional office
         10 Iin Atlanta, M4PS staff in Washington and pointed.out they had

         11 a good deal of work to do. The items that we will report on

         12 and discuss today then deal to a large extent with many of the

         13 changes which have occurred @nce that September site visit, and

         14 @obert will begin the discussion of that as well as giving

         15 you a little more background on the region, Bill Tobert.

         16      MR. TOBERT: The Mississippi Regional Medical Program

         17 covers the entire State of Mississippi, serves a population of

           about two million two hundred thousand people. The region
         18

         19 is bordered on the east by Alabdma, on the south by the

         20 Gulf of Mexico and part of Louisiana..On the west by Louis-

           iana-and on the north by Tennessee.
         21

         22      So the upper counties.of Mississippi are somewhat

         23 shared with the Memphis Regional Medical Program in planning

           an coordinating of activities. There are two distinct geographi-
         24

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         25 cal areas of the state. The first area is the north and south





                                                                                6



                   Delta which starts in the Tennessee border, goes on down through,

         4       2 over to Vicksburg. It takes in.tlae whole area. It takes in

                 3 all that portion of th e Mississippi Plain which lies within

                 4 the state border and which comprises-what usually is referred

                 5 to simply as the Delta.

                             'This arba is one of the two geographical areas,
                 6

                 7 it is-by far the smaller taking up about one-fifth of the

                 81tbtal land area of 14ississippi.. It is the only section of the

                 9 state where agriculture still provid.es more perso@l income

               10I than manufacturing or government but this is changing due to-the

               11  influx of small industries, the inability  of crop producers to

               12 pay a minimum wage and the technological advances in farm

               1 3 machinery.

               14            The other area is the East Gulf Coastal plain

               15  stretching in Mississippi from the Tennessee hills of Appalachia

                   in the north to the Point Ilills of the south which  terminate
               16

               17  along 359 miles of Golf Coastal shoreline. Mississippi is almost

               18  uniformly rural in terms of population distribution.

                             The basic urban structure is the small  town,  often
               19
               20  housing one or more light industries'but frequently  few  phy-

                   sicians, nurses or dentists. Povorty-was and i@ a fact of life
               21
               22  for too many Mississippians regardless of race.

                             A total of 154,000 families or 50 percent of all
               23
               24  families in Mississippi earn less than $3,000 per year and are

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                   ranked in a poverty class. The Mississippi @IP
               25





                                                                               7


              #11 headquarters is located in Jackson which  is  also  the  capital

         5       2  and is also the location of the University Medical Center who

                 3 serves the grant@e for PIAP.  There were two subregional offices

                 4 of the RMP located in Oxford and in.Gulfport. These offices

                 5 were just recently established, with supplemental funds awarded

                 6 to the region for health services, educational activities..

                 7           The future plans include a joint  staffing  of  the

                 8 Oxford office with staff from the Memphis Pa'4P (Slide),  there

                 9 are ten economic development areas in the state.

               10            The Mississippi Pegional Medical Program recognizes

               11  the fact that health care generally  follows  trade  patterns

               12  in Mississippi and the ten districts form the  basis  of  any

                   approach to improving health delivery systems as  well  as  the
               13

               14  care peonle receive in the region.
               15            These ten areas are also designed to become the

                   comprehensive health planning areas of the state. CHP agencies
               1 6

                   located in Jackson and there are two  CHPB  agencies  currently
               17

                   funded, one in the southwest and the other in the Three Rivers
               18

                   area. Two more have applied for-funding, Central and Northeast,
               19

                   (slide) and the TUIP has been actively-involved in the develop-
               20
               21  nent-of the agencies and they have a close working relationship
               22  with this staff.

                             It should also be noted here that Memphis is also
               23

                   assisting in the formulation or development of  some  of  the
               24

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               25  agencies in the northern part  of the state (slide).  This







                                                                              8

          #1      I  overlay shows some of the regionalization of some of the

         6        2  activities they have proposed in the application of the review

                  3 today.

                  4           Part of this application,.the large majority of the

                  5 projects and activities were centered around the university

                  6 medical center in Jacl@son.  During the past year the Mississippi

                  7 PJ.,IP have concentrated their efforts in developing activities

                  8 which have outreach to all parts of the state. This simply

                  9 (slide) shows the geographical make up of some of the members

                10  of the regional advisory group.

                11            There are 37 members of.R.AG, with an adequate

                12  balance of consumers and providers. The involvement of RAG

                13  members this past year is one of the more positive stens the

                14  region has taken and Dr. Hess will comment more on this a little

                15  later.

                16            (Slide)  This chart depicts the distribution of

                17  funds for.the region during the three operational years.and

                18  it shows the comparison of what has been and what is to be durinj

                19  the next triennium period.  Clearly it illustrates the change

                20  from a categorical program to emphasi s'on multi or non-categorici

                21  activities.

                22           This has increased from an average of 15 percent'

                23  during the first three operational years to 49 percent which is

                    proposed in this current application. It should also be noted
                24
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                25  that previously a largo percent of the program staff budget







                                                                               9


          #1      went into the medical  school for supplementing some faculty

        7       2 salaries.

                3           This is no longer  the case.  All members of the

                4 program staff are full time employees of the RMP, with the

                5 exception of the As.4istant Director of Planning and Evaluations

                6 who is also a private practicing physician.  During the (slide)

                7 site visit of September 1971 one of the major concerns of the

                8 site visit team was the organitat ional structure of the region

                9 both in the piFogram staff and regional advisory @up.

               10           This overlay illustrates the complexity.of the organ.i-

               11 zation prior.to September 1971-and very clearly illustrates

               12 the categorical make up of the region..There were categorical

               13 coordinates, as you see here, that related directly to the coor-

               14 dinates of the PJIP, and program.staff had very little liaison

                  with these people.
               15

               16           -The regional advisory group, the categorical

                  committees were composed of non-RAG members. And RAG was no
               17

               .18 more than a reactionary group.,,.The categorical committees
               19 were actually directing the program.  (Slide)
               20           This is certainly no longer' the case and we feel that

                  the restructuring of RAG and program'staff has been a major
               21
               22 accomplishment for the region.This reorganization was begun
               23 during a retreat in early-Decembe'r of 1971.

                            The program staff are young, dedicated, very cohesive
               24
  Nce- Federal  Reporters,  inc- hard-@,lorkina group. All of the positions are filled with the
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        Ill       exception of the Assistant Coordinator who-they are looking for

        8      2 now. And the part-time Assistan-t Director  for  Planning  Eval-

               3 uation I have already mentioned.

               4            (Slide) The restructuring of  the  Regional  Advisory

               5  Group has resulted in total commitments and involvement of

               6  all RAG members. No longer are:there commitments of non-RAG

               7  members. Each member of RAG is, requested to serve on at  least


               8  one 'of the task forces.


               9            Each task force is responsible for one or more of the

               10 goals of the region, and members are involved in reviewing

               11 and monitoring the activities and projects that pertain to

               12 these goals.  And the goals of the region are shown in-each

               13 of the task forces, manpower, professional education, health

               14 systems design, EMS and public health education.

               15           DR. HESS:  As you can see from your previous  document

               16 there were four staff visits to the Mississippi Region   during

               17 the late part of 1971-1972, as well as numerous telephone

               18 contacts and various other forms of assistance. The site visit

               19 team for this visit as you can see included Dr. Merrill of the

               20 Council, Dr. Nichols, who is a black physician from Susquehanna

               21 Valley, Mr. Donald Tranto from Georgia RMP who was a very.

               22 valuable asset to the team.

               23          Mr. Van Winkle of Harvard, Mr. Ashby, Mr. Nelson,

               24 Mr. Ba.llou and Mr. Grift from the regional office in Atlanta.

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                  This application that we are to consider today includes a reques
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                   for triennial status; Expansion of  program  staff,  and  funds
         9       2 for additional regionaliza'tiori, developmental components, con-

                 3 tinuation of three previously approved funded projects and

                 4 funds for 19 new projects.

                 5           Going over now the review criteria as outlined in

                 6 the site 'Visit, as Already mentioned by Mr. Torbert the

                 7 roles-and objectives of the region have been revised and are MOZE

                 8 in keeping with the new direction s of IVIPS. The  coordination

                 9 between the university medical centers and the Miw-,issippi IUIP

               10  appears to be extremely good, there always has been good working

               11  relationships there and these continue.

                             The Mississiopi PI.IP has moved into new categories
               12

               l@  outside of the medical  center.  This has accomplished several

               14  things. First being that the staff are all together now

               15  -,ohysically, where they are able to communicate and work  more

               16  effectively together..

               17            And it also has removed  any -- some of the questions

               .18 that existed about undue influence  and too'close liaison with

               19  the medical center. 1,7e found no problems of real concern in this

               20  area. Some of the statistics which reflect  hopefully  in  part

               21  the impact of the Mississippi R14P are shown here in  the  site

               22  visit report.

               23            Some of them are very dramatic. In 1968, the neo-

               24  natal death rate was 28 per hundred thousand live births in

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               25  ITolmes County. This was reduced to 19.8 in 1970, and 7 in







                                                                           1 2

            f,l    1971. This reduction is so dramatic you almost question  the

         10      2  statistics. But the people.there feel that there is no question

                 3 but what the pediatric nurse assistance and midwife  program

                 4 and so on has had some influence in reducing the neonatal death

                 5 rate.

                 6          The regional satellite units have been.set up around

                 7 the state.  They have a very well organized and smoothly

                 8 functioning renal disease program there as near as we can tell.

                   One of the.imnortant accomplishments of this -program is to
                 9

               10  reduce the cost of dialysis for their patients.

               11           They bring families and.patients into the medical

               12  centers, train them in the use of dialysis and then through

               13  the'use of trailers which have been set up around the families,

               14  a@member of the family can come in with a patient and perform

                   the dialysis for the patient.
               15
                            Heart clinics have been s@t up around the state which
               -16

                   have been   have resulted in care being given to patients who
               17

                   previously did not have access to this type of care. The
               18
               19  existence of the stroke care untt in.the medical centers has

                   resulted in the treatment of a large'number of patients, the
               20

                   training of a number of physicians and nurses from various f:)arts
               21
               22  of the state who are now better.qualified and equipped to
               23  provide higher quality care to patients with this type of

                   nrobler,i.
               24
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               25           Pulmonary training programs and inhalation  therapy







                                                                            1 3

            llfl I has been established in a number  of inhalation therapy
   *a 11         2 aids trained who can now provide  this type of service in hos-

                 3 nitals outside of the medical centers located  throughout  the

                 4 state.

                 5           The.coronary care unit which initially was funded

                 6 and operative at the university medical center has trained.

                 7 120 nurses in coronary care and they now are functioning in

                 8 various areas throughout the state to provide a more sophisti-

                 9 cated and effective type of care for patients with coronary

               10  heart disease.

               11            Through the efforts of the Mississippi  @IP  program

               12  for training of dental hygienists was initiated and  this  has

               13  had more spin-off-, in that there is now discussion of the

               14  possibility of initiating a dental program there. But through

               15  the use of the training of these additional people, additional

               16  dental services are now available.

                            .They have been giving attention to the  question  of
               17

               18  continued support and an example of this is the Hollandale

                   midwife project in which through the fees which are being
               19
               20  collected for the services to patients, medicaid and so on,

               21  these fees are being put back in to help support the  cost  of

               22  the program.

                             There was some concern about what withdrawal of
               23
               24  some of the support to'the Med.ical School faculty night  mean
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               25  in terms of their availability to participate in P14P programs







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           O'l   I and continue education and so forth.'And the  Dean  indicated

        12       2  that there was some uncertainty as to how much of the time

                 3 of the medical school faculty might be -- he might be able

                 4 to fund and pay for out of other sources in order to continue

                 5 some of the thrust which they had begun in earlier times.

                 6           The region is giving-attention to  the  improvement

                 7 of health care delivery for underserved minorities,  this  is

                 8 a major area of emphasis for the.region, and all of these

                 9 projects that have been conducted in the past have had   very

               10 important impact and emphasis on the care of undersbrved

               11 minorities.

               12            The needs are tremendous in this area and  what  has

                  been done  is onlv beginning then to scratch the  surface,  but
               13

               14 the   region is certainly very conscious of these needs and

               15 appears   to be taking appropriate actions. As far as minorities

               16 on the staff, currently they have  one  minority  professional

                  and one minority secretary, and  this is an area that  we  gave
               17

               18 additional emphasis to, on the site visit, and they expressed

                  their intent to employ additional minority people in unfilled
               19
               20 positions  or as new positions open up.

                             One of the outstanding programs which.has been
               21

                  conducted there is one in which they are  seeking  to  attract
               22
               23 black medical students who are going-to school  outside  of  th.e
               24 state to come back to iiississ ippi and practice.

  Ace-Federal Reportprs, Inc.
                             As I am sure most'of you are aware there is suddenly
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          #1     I a nationwide competition for  qualified  black  medical  stuents,
   A&13          2 and many of the best  studehts,.black  students,  in  Mississippi

                 3 are being actively recruited by medical  schools  from  all  over

                 4 the country, and are going there  to  continue  their  education.

                 5           Through the black physicians in Mississippi,  @'llississ-

                 6ippi PMP, -these students have been,  many  of  these  students  have

                 7been contacted and brought  back.and  discussions  were  held  in  an

                 8effort to show them some of the-changes that are happening and

                 9to develop in them a desire. and commitment  to  ret@rn  to  14iss-

               10 issippi and practice when their training is completed.

               11            I was going to take sometime now  --  now  it  is  going

               12 to take sometime to know how effective this effort will be

               13 but it certainly seems to be an appropriate one. Along with this

               14 is a much greater awareness in the University of Mississippi

               15 itself, of the need to admit black students within their

               16 own state and they seem to be  making progress in this area.

               17            Going on to the coordinator, the -- Dr. Lamton   has

                  been coordinator  since  January  1-971, and we found  evidence  on
               18

                  -Ehis@site visit that he indeed i-s beginning to exert amuch
               19

                  stronger leadership role than when we' were  there  in  September
               20

               21 of 1971.
               22            At that time he was relatively new and feeling his way
                 3lbut after the site visit and the report which came back he has
                 4not hesitated to take the recommendations  seriously  and  to  move
   0
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                       #1          I                       There  seems  also  to  be  a  much  better  working  relation-

                  14               2    ship  between  he  and  the  staff.  And  whenwe  were  there  in  Septembe

                                   3   of  1971  we  were  getting  all  k                        inds  of  informal  feedback.in  the

                                   4   hallway  and  so  on  of  some  of  the  communications  programs

                                   5   and  leadership  problems  which  existed.

                                   6                       This  time  we  picke,dup  none  of  that  kind                                   of  tl-iing,.  And

                                   7  there  were  many  indications  that  the  working  relationships

                                   8  have  imoroved.    His  relationship  with  the  RAG  seems  to  be

                                   9  cordial  and  effective  and  we  found  no  evidence  of  any  discord

                               10     in  that  area.

                               11                          ".he    program  staff  has  been  strengthened,  they  have

                               12     hired  a  number  of  additional  peo'le  who  seem  to  be  quite
                                                                                                        p

                               13     capable..   Some  of  them  are  young  and  not  too  experienced  as

                               14     yet,  but  appear  to  have  good  Potential.  one  of  our  concerns,

                               15     however-   was  in  this  area                          in  th'at  the  Assistant  Director

                               16     for  Planning  and  Evaluation  is  a  practicing  physician.

                               17                         He  is  an  internist,  hematologist,  gynecologist  who

                               18     has  a  private  office  and  exactly  what  this  half-time  means  we

                                      are  not  sure.  But  it  was  evident  to.us  that  this  is  an  area
                               19

                               20     that  does  need  strengthening,  and  on'e-of  our  recommendations  is

                                      that-this  be  made  a  full-time  position,  and  that  the  new
                               21

                                      people  that  they  have  brought  onto  the  staff  be  given  some.
                               22

                                      additional  training  and  orientation  so  that  this  area  of  core
                               23

                                      staff  might  be  further-strengthened.
                               24
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                               25                         They  have  a  new  person  in  the  area  of  evaluation.






                                                                           17



          #1    I           From our discussions with him he seems to be a

        15      2  competent person, a lot of good ideas and a good approach to

                3 evaluation and we are hopeful  that the evaluation might improve

                4 -over the next year or two. Regional advisory groups  represent

                5 the key health interests in the region. And as indicated by

                6 Mr. Tober-L's presentations now much more actively involved

                7 in planning and decision-making for the region.  Attendance  at

                8 the RAG meetings have been running over 50 percent,  they  have

                9 requirements that if more than three meetins are @'ssed then

               10 the member is dropped from the RAG.

               11           The grantee organization  is performin  its  function
                                                                  9

               12 effectively as we could tell and we have  no questions about

               13 that. The major health interests are participating and there are

               14 a-%vide variety who are involved and they always seem to be  in

               15 full support of the  objectives, and -- of Mississippi P14P'

               16 and what it has accomplished  to date.


               17           Mr. Tobert indicated the -- how the state is divided

               @18 into subregional areas for health planning'and PIIP has been

               19 instrumental in helping to facilitate this development and

                       are working closely inthe
               20 they'                          development of these local

               21 planning areas.

               22          Active discussions are going on concerning organization

               23 in nine of the ten areas, and five of these are in the active

               24 planning stage at the present time. There is an adequate
  kce - Federal  Reporters,  Inc.
               25 mechanism for obtaining CHP'review and comment.






                                                                             18


                             The Mississippi RMP has participated  in  and/or  has
        a 16
                 2  available to it a rather large data.base documenting the
                 3 health fields and resources.of Mississippi. However, there
                 4 has been thus far an apparent lack of the expertise needed
                 5 to move from available data to program development. This'is an
                 6 area we emphasized to them a number of times and we are hopeful
                 7 that there.might be some immediate and,further movement on this
                 8 and iqe.have a recent letter from Dr. Lan@on indicating they have

                 9 already begun to take steps to address this issue-.

               10            All the current projects in the current triennial

               11 ap
                    pli.cation were developed concurrently with re-thinking
               12 of the goals and objectives and restructuring of the RAG and

               13 program staff. Consequently the projects have not evolv  ed as

               14 a,result of the re-thinking which has gone on  during  the  last
               15 few months although several of the projects are compatible
               16 with that expressed, by the.new goals and objectives.

               17           -Coordination program staff has improved substantially
               18 and they have developed a plan for systematic monitoring of
               19 individual projects both by written reports and site visits,
               20 by project monitoring teams which will  include program  staff,.
               21 RAG members and other consultants.  Written project progress
               22 reports and financial reports are also a  standard  requirement.

               23           We have already mentioned about the new full-time

               24 2valuator for whom we have a good deal of hope.  He did not have
  4ce- Federal Reporters,  Inc.
               25 an opportunity to have much influence on the evaluation aspects






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                   of the projects which are submitted in the triennium, but he

         17
                 2 does hone to have some influence on their  functioning.  And

                 3 we were assured they would have an active role in reviewing

                 4 and participating in the development'of all new projects so

                 5 that adequate evaluation is built in from the very beginning.

                 6           l@le identified some problems in their documents,

                 7 differences in evaluated criteria between the 8tated objective

                 8 the nroject development guidelines, the technical review cri-

                 9 teria, and developmental component priorities, t4o RAG rating

               10  forms and the program evaluation statement.

               11            TATE felt these all have been developed at different

               12  times and'@,,ith somewhat different people.and we felt, we

               13  recommended that they sit down with all of these now and.try to

               14  make them consistent and uniform with one another  to  avoid


               15                                                            ng
                   ,some potential confusion and improve the baiss for carryi,

               16  out their-evaluation.

               17            The region has established  priorities.  This  was

               18  accomnlished during the retreat-of the Regional Advisory

               19  Group in December of 1971 and they are congruent with national

               20  goals and objectives.

               21            They have begun a School of Allied Health  at  the

               22  Universitv  of Mississippi Medical@Center, and this is on its

               23  way--now.  The initiation of this school has been attributed to

               24  a signific  at degree by the PJIP, and the@-are actively on

  AC    al  Reportefs,  Inc.
               25  their way  now in recruiting faculty and students and hopefully







                                                                              2 0


            141  1  this will begin to supply a gap in health manpower in the regior

         18      2            Now getting down-to'the recommendations of the site

                 3 visit team I am going to save,  wait  on'the  financial  recommen-

                 4 dations until last. We did feel  they  were  ready  for  triennial

                 5  status.  There was no question that they had addressed all of the

                 6 areas of concern raised in the September  1971  site  visit.

                 7            And they were in a  substantially  better  position

                 8 as a region to manage their own affairs and to more effectively

                 9 address the needs of the people although  there  are  still  a

                10 number of important areas that they --  where  they  need  further

                11 improvement.

                12           We recommend that there be a full    timeldirector

                13 of a planning evaluation staff, and that this section should

                14 engage in a good deal of training and we  suggested  as  one  part

                15 of the training of the staff some @IP's  which  they  might  visit

                16 to learn the methods and techniques that  would  help  them.

                17           We emphasized the need for developing consistency

                18 with the statements having to  do  with  evaluation  mentioned

                19 earlier. lie felt that their applications, their projects, needed

                   better documentation of need and tliis-went back to the need for
                20

                21 strengthening their planning section4

                             We also felt that.they needed to improve their technics
                22
                23 review input to the PAG, that there were some projects that

                   we looked at, as examples, where vie questioned some of the needs
                24

  AC    al Reporters, Inc.
                25 as far'as the equipment and budgetary items  and  felt  that they





                                                                              21


           01    I  could well benefit from some qualified experts to work with

         19      2  them in reviewing these project  requests and  determining  what

                 3 was- actually necessary and the methods that would be most

                 4 effective in addressing the methods of the project.

                 5           V7e recommended that they should work  to  obtain  both

                 6 CIIP and state funding of on-going health planning data collection

                 7 There was one project in this.group which is directed toward

                 8 improved data collection, and apparently no one is in a

                 9 T)osition at the moment to undertake this activity, yet it is

               10  a very important and essential-activity for all health planning

               11' in the state.


               12            And we agreed that  this would be a worthwhile

               13  thing for M4P to initiate but  it should not be looked upon

               14  as a ma3or on-going activity.  Another question which came up

               15  during the course of the site  visit was the staff salary   scale

               16  which is determined by university salary scales.

               17            And we recommended that the salaries should be reviewe.

               18  wit]' the medical center administration to see if  the  mechanism

                   can be developed for more adequate  program  staff  compensation.
               19

               20  Our concern was that this might be a liability to the program

               21  in that they may not be able to retain qualified people and,

               22  therefore, continue to build a strong program.  I would end

                   my comments at this point.
               23


         d
               24
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               25






                                                                                 22
      #2


        arl
                I              DR. SCHMIDT:  I would remind the-committee that

                2  in front of them are  these  bl.ackbound books that  are  computer

                3  printouts, and some o f the questions yesterday that had  to  do

                4  with funding levels and money going'to projects and so on,

                5  are very efficiently and effectively answered  in  the  computer

                6  printouts, and I personally find them of great value  and  would

                7  recommend them to the committee for funding information.

                8  Secondary reviewer is Warren.'   1

                9             DR. PERRY:  I believe in. a characteristic way

               10  Joe has done a tremendous job in reviewing the program.

               11  My greatest.interest in the program, I have not been in the

               12  region, :Ctrs been only through application review in the  past,

               13  has been this tremendous concer n and development in manpower

               14  potential.  Educational progtams-have really moved in this

               15  state. It is a state that has not had that  level  of  expertise

               16  and such'to do this.. They have been calling in  in  the  allied

               17 health area, I know three of my dean type  colleagues  have  been

               18  down there in consultation.  They have been moving ahead, as

               19  has been said here.


               20             A member of our staff in Buffalo has been there

               21  in the dental.school and dental hygiene program and moving.

               22  They're doing a tremendous job as they look at their' needs

               23  in that state.  They  recognize  the importance of all levels

               24  of health care personnel in there, and I think this is a

  Ace-Federal Reporters,  Inc.
               25  tremendous development herb.




                                                                                  23


        aA-

                  I             My only concern is.going to be in some of the

                  2  recommendations on the level of funding here which I would

                  3  like to turn right back to Joe to make.  There  is  no  qIuestion

                  4  but this state has made a major turn and is moving in a most

                  5  positive way,

                  6             DR. SCHMIDT:  Bill, was anything left out that,

                  7  should be -- all right, Joe, can you put a proposal on the

                  8  table  then?


                  9             DR. HESS:  The site visits team had some difficult

                10   in arriving at a funding level recommendation.  I will place

                11   'that before the committee at this,time.  There was another

                12   wide variety of opinion as to what it should  be.  I  suppose

                13   that I ought to express to you some of  my  personal  res ervations

                14   about  this.


                15              This came as a sort of  compromise,  the  team

                16   recommendation--is,a compromise. And I happen  to  personally

                17   be on the lower end of the scale concerning the  spectrum  of

                18   opinions of the team for funding recommendations, but neverthe-

                19   less the recommendations which'we ended  up were in order  to

                20   leave and catch our plane.

                                                                                f
                21              DR. SCHMIDT:  The suspense is killing me.

                22              DR. HESS:  You can see here on your page  11 of

                23   the report the total figurE&  On the sheet over here we have

                24   broken these down.  We agreed.that with the expansion in
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                25@  more subregionalization, some of the additional activities





                                                                                  24


        ar3
                 I  that the program staff planned to get into and so on, that

                 2  the increase in program staff budget was justified.

                 3              We felt that they were ready and could effectively

                 4  use in the first year developmental component of @6,315.  The

                 5  total for operational projects we felt was somewhat high.

                 6  There were three specific projects there totaling about

                 7  $200,000 that we had some serious reservations about in terms

                 8  of their appropriateness when one  considers  the  total  health

                 9  needs of Mississippi, and we reduced their -- our recommendation

                10  was something about $230,000 below that requested by the

                11 -region for operational projects.. -

                12              So the total ends up with 2,110,138.  They had

                13  already received approval for, through supplemental fu    nding,

                14  183,634 in kidney, so if you subtract that,  it  comes  down  to

                15  1,926,504, which is the first year recommendation.

                16             The second and third year, you can see on the

                17  sheet the kidney money will be included in  that,  2.2  and  2.4

                18  million the second and third year.

                19             So I will place this recommendation on the table

                20  in the form of motion, but also say I,have some reservations,

                21  particularly considering the fact that the first year is a

                    10-month year for them.  I have some personal reservations'
                22

                23  about whether they can effectively use that 1.9 million during

                24  that first year.
  Ace - erat  Reporteis,  Inc. DR. SCIU4IDT': All right.   Dr. Hess then moves
                25





                                                                               25
       ar4


                    with  some reservations, then, the team report. 'Is there a

                 2  second?


                 3              Warren, do you second this or not?

                 4              DR. PERRY:  Yes, I am going to second it, to get

                 5  it started  here.  I -- not having been there, not having a

                 6  chance to,  you know, really be a part of looking at the new

                 7  projects and such, it is a -.- really a, more than a promissory

                 8  note.  It is really an accolade.in this funding amount.

                 9              I would like to ask Bill in relationship to his

                1.0 knowledge of the region of your feel for their ability to

                11' handle this increase.

                12              MR. TOBERT:  I share with Dr. Hess the 10-month

                    budget at that level.  I had no qualms on the second and third
                13

                14  year at all.  But I think there can be some justification in

                15  reducing the first year.

                16              DR. SCHMIDT:  Before I call, on Dr. James, Mr.

                17  Griffith, the regional office representative, is here, and I

                    had asked Ted if he has any comments.
                18

                                MR. GKIPFITH:  No Comments at the present time.
                19

                    I go along  with the proposed activities so far.
                20
                21              DR. SCHMIDT4.  Obvious and maybe stupid question

                    is if you are worried about the  10-month thing, why-not give
                22
                23  them ten-twelfths of that amount for the first year?

                                DR. HESS:  Personally I think that would be more
                24

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                25  reasonable.  I figured it'several different ways, and I think





                                                                              26
         ar5

                I that would be an appropriate way  to go about it.

                2            DR. SCHMIDT: Well, the chair  won't  intrude  on

                3 the workings of the committee.

                4            Dr. James?

                             DR. JAMES: As a new member of  this  committee,  I
                5               1
                6 get a gut reaction from the report as given and  as  stated

                7 in the site visit report. My gut reaction  relates  to  the

                  fact that we have seen a state that has long been known to  be
                8

                9 without, use its own resources to develop a kind  of  program

              io  that seems to be evolving with the professional  help  that

                  came about in December of 171, demanding new direction.

              12             And I think I would like to emphasize  the  fact
              13  that they have not had the professionalism and expertise prior
              14  to December of 171, apparently shows that the efforts  of  --
              15  of funding apparently have been.-- has resulted in the  train-
              16  ing of personnel which in the long run has affected  a  net
              17  change indirection of what I have heard  all  day  yesterday,

                  that is, in fact, the people have apparently been the
              18
              19  recipients of the funding of the efforts of  the  Mississippi
                  regional program, if this is in fact what is  absolutely  the
              20

                  case, as seems to be written in this program.
              21
                             And I, for one, would want.to  re-emphasize  the
              22

                  fact that sometimes when you don't have enough money to go
              23
              24  on, you don't have the.expertise and professionalism which
  kce   I Reporters, Inc. in turn helps to cloud'an issue and really you do not get  the
              25





                                                                             27
         ar6


                    services to the people, maybe this is 'What it is all about.

                 2             And I would strongly suggest that the expertise

                 3  and professional-ism be offered these people on a higher

                 4  scale so they can use their basics,, their abilities to

                    continue-their efforts to train more people in Mississippi
                 5

                 6  which net results in services to the people.,

                 7             The fact that infant mortality, this is an

                    absolute fact, it does sound, you know, almost fictitious,
                 8

                 9  doesn't it.?  But if this is an absolute figure, can we

               10   duplicate that same figure in any other region across the

               11   country?

               12              I think if the regional medical program did nothing
               13   else but to reduce the infant mortality rate, it has served

               14   a very useful purpose.
               15              DR. SCHLERIS:  I was-wondering if I could see that
               16   overlay to show how the direction has changed in Mississippi?

                    I confess by saying I always, in driving, have been told by
               17
               18   my family of a very poor sense of direction.  And in trying
               19   to review briefly, I do have some questions to ask about

                    specific projects.
               20

                               I am trying to discern what is really the changt
               21
               22   in direction.  The multiple is.probably where there is some
               23   reason for my questioning this.  I am sure heart disease is

                    probably about 13 percent.  But if I look at heart disease,
               24
  @ce- eal  Repoiters,  Inc. cancer and stroke, I would think that the numbers really don't
               25







       ar7


                    reflect some of the changes here  unless these are put  into

                2   multiple, because as far as some  of the new projects coming

                3   along the line, those to be supported- some of  them  appear

                4   to be very much what we have been looking at for a  long  time.

                5   The ongoing projects to be supported,$122,000.  They put in

                6   some projects, I don't know.what you did,  electrical  hazards,

                7   that probably went under multiple, but this is a set of a

                    model electrical hazard safety program, and the hospital
                8

                9   then to put it through the community. This  is  about  $80,000.

                10  This has now been used in most communities as the responsibility

                11  of the hospital itself.

                12             Radiotherapy.is coming in as a new project for

                13  $80,000.
                14             Edtcation of radiologists, setting up of peripheral
                15  centers, is coming in again at a significant level of support.
                16             PulmonaIry therapy  as a model project is coming

                    into a 50 to 100-bed hospital to treat pulmonary disease and
                17
                18  cystic fibrosis, stroke system to be set up for $58,000.

                               My concern, as I look over these projects,  is  that
                1 9
                    many of them are what we have been used to seeing  over  the
                20
                21  past several years, and my concern is that they ate isolattd
                22  projects related heavily to  hea.rt disease,  cancer,  stroke.
                23  and related diseases, rather than being a part of a new direc-

                    tion.
                24
  Ace- ederal  Reporters,  Inc' Some  of the' new directions concern me a bit.
                25





                                                                                2 9
         ar8


                    $39,000 for educational program   for mentally retarded

                 2  children is something that I am   sure is necessary, but I

                 3  again think that this is the RMP  picking up things that

                 4  should be done in other ways.  Controlled in effect in

                 5  hospitals, to set up a model unit and then  if  other  hospitals

                 6  are interested, help them, is $32,000.

                 7              I have only looked at a few  of these, but those

                 8  that I have looked at would suggest very much a  good  deal  of

                 9  what@has been going on in the past.  Now if the change of

                10 direction is in the interest of core, that's one thing, but

                11  -I don't see it reflected at all in these projects, and

                12  there are myriads of them and just scanning them quickly, I

                13  wanted to know how you define the change in direction,   admittin]

                14  that I have a poor sense of direction.

                15             DR. HESS:  Well, I had commented on that in passing,,

                16  in that their rethinking occurred at the same time the

                17  projects-were being developed md consequently, particularly

                18  the first year projects do not reflect that, so that it is

                19  kind of a phasing problem that'we have seen in many other


                20  regions.

                                                                                f
                21             And this, the very questions you  are  raising,  are
                22  some of the things that bothered me and raise questions  in'  my

                23  own mind as to how much of a favor we are doing  the  region  to

                24  get    give them enough moftey.t.0 get started and obligated  on
  Ace - ederal  Reporters,  Inc.
                25  some of these projects that I, in my own  mind,  thought  ought






                                                                                30
        ar9

                   to be  low  priority.

                               Now  some of these we   site-visit team     we
                2

                3  felt strongly   ought to really be looked at  very  carefully.

                4  We told them so in  feedback session, that we  just  questioned

                5  whether these were  consistent with the needs and so on  of  the

                6  region, and that they needed to go-back and rethink that whole

                   business and look at those projects again.
                7

                8              Now, I think they are developing the mechanism

                9  and the wherewithal to do that, but.this  application  does  not

               io  reflect that kind of thinkingly you see, and it is a question of

                   how much faith we collectively have in their  ability  to  go

               12  back and look again at these projects..

                               My own feeling is that there should be enough
               13
               14  restriction on funding that they can be  very  selective  about
               15  which ones they choose and which ones they choose  to  fund  --
               16  which ones they choose to fund and which ones  they  choose  not

               17  to.

                               And they are going to need some continued  help  and
               18

                   supervision in order to get things  organized  and  consistently
               19
               20  moving in the direction  that we would like them to be.
               21              DR. SCHERLIS:  Well, my concern is that once   we

                   gave them developmental compone nt, it should be on the basis of
               22
               23  our knowing that they have indeed demonstrated  a  change  in
               24  direction, because in looking at the projects, I have a feeling
  Ace-Federal Reporters,  Inc. of deja vu  as far as wha@ we would have a few years ago of
               25





                                                                             31
          arlo


                I  seriously challenged as being bits and pieces of projects

                2  coming in from all over.

                3             I am sure they will do something, but I don't know

                4  if they really demonstrate any program, you know; our concern

                5  should really be program, we shouldn't be talking projects,

                6  and'our chairman,has been most kind in letting us talk

                   projects, because I don't see it as a program, but as  bits
                7

                8  and pieces of unrelated projects'.

                              my immediate reaction is I question whether we
                9

               io  have had a demonstration of their change in direction,  but

                   rather what we have been shown is that they recognize there

               12  should be, a change in direction, have given us a list of

                   projects, that while they will-do good, I am sur e,  doesn't
               13

                   really reflect a level of maturation to demonstrate that they
               14

               15  are ready to go in the developmental component.

                              Iwould like to have.some other points of view on
               16

                   this.  I know this is not the view of the site-visit group.
               17

  2
               18


               19
               201
               21


               22


               23


               24

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      mea-1
                                                                            32
      CR 7149

       #3

                                DR. LUGINBUHL:  I would like to summarize my

                 2
                     views on what I have heard.  It seems to me this is  an  area

                 3
                     of desperate need.  We would like to give them as much
                 4   funding as they could well use.
                 5
                                Also it seems if they had made real  steps  toward

                 6
                     developing an organization, that we are all  concerned  that
                 7   they are-still pretty embryotic in their  development;  they
                 8   are still focused on projects that aren't very well

                 9
                     coordinated, and if we give them too much funding,  they  are
               10    likely to commit themselves very deeply to projects that will
               11
                     not readily be pulled together in a coordinated program.

               12
                                From that basis I wonder if it wouldn't  be  wise

               13
                     to take a hard look, particularly the first-year budget,

               14
                     with the thought in mind that if. indeed they do set

               15
                     priorities, that they do move.towards a coordinated program;
               16    that funding could be increased more rapidly in  the  second

               17
                     and third quarter.

               18
                                SpecificAlly it is not clear to me from the yellow

               19
                     sheets as to whether their first-year requests,indeed  for  a

               20
                     ten-month period or is it  for a 12-month period; if it  is.

               21
                     for a full-year period, I would think this  would  reinforce
               22    the suggestion that that be reduced to five-sixths of the
               23    amount suggested over here which would be about  $1,505  000.

               24
                                Can someone tell'me, is that  first-year  request
  Ace -Federal Reporters, Inc.
               25    for ten months or 12 months?





       mea--2                                                                 33




                                MR. TOBERT:  It is for ten months.

                 2
                                DR. LUGINBUHL: That would seem to me  to  be  a

                 3
                     rather large increase and I would like to move  an  amendment
                 4   if that is in order.
                 5              DR. SCHMIDT:  The Chair will accept  a move  to

                 6
                     amend.
                 7              DR. LUGINBUIIL:  To reduce the first year to
                 8   five-sixths of the amount up there, I-will  leave  the  exact

                 9
                     calculations to someone else. I did it very  quickly;  it  is
               10    about a million and a half dollars,and to omit the

               11
                     developmental component for the first year.

               12
                                DR. SCHMIDT:  There is a move to reduce the amount

               13
                     to five-sixths and omit the developmental component  for  the
               14    first year, leaving the second and third years at the

               15
                     recommended level but with obvious interaction between staff

               16
                     and the Review Committee prior to the funding-of  the  second

               17
                     year.
               18  -            Do you accept that total restatement of your

               19
                     amendment?

               20
                                DR. LUGINBUHL:  Yes.

               21
               -                DR. SCHMIDT:  All right.

               22
                                Is there a second?

               23               MISS KERR:  I would second.

               24
                                DR. THURMAN:  Jo6 is afraid to ask you what you
  Ace - Federal Reporters, Inc.
               21    thought. You said-you compromised upward  for  the  plane.




       mea-3                                                                      34




                     What would you really thinks

                 2               DR. HESS: Well, my feeling was  that  they  could

                 3   effectively utilize somewhere in the neighborhood of 1.6,

                 4   1.7 million.  This would cut out  about @400,000 worth of

                 5   projects and if I use my priority system, the  ones  left  in

                 6   would be ones that are truly helpful and directed to some

                 7   very urgent problems there.

                 8               But I share the concern which you expressed.  The

                 9   infections  in hospitals, electrical hazards and so  on  were

               10    ones which  obv@ously came up'--'we were very surprised that

               11    they got through their review process and this is one of the

               12    things that gave me some concern.

               13                The nurse or I should say the cancer  project  is

               14    just a one-year; this i s the final year or I should say,

               15    the stroke care demonstration is a final  year  for  that

               16    project so that 122,000 only appears  in  the  first-year

               17    budget and I think they are obligated  to  continue  that

               18    previously approved -- but taking all these things into

               19    account, it is my feeling that they could have  quite  a  bit

               20    of money to play with and, not to play with  but  to  use

               21    effectively, and still show them that we  had-confidenc.e  in

               22    what was happening, give them the support which they need to

               23    begin moving more strongly in directions which I am convinced

               24   'they will move in and not do damage to  the program.
  kce- Federal Reporters, Inc.
               25                DR.  TIIU@'4AN:    Mr.  Tobert,  what  is  your  feeling




       mea-4
                                                                                      35


                       about staff reaction to the business of cutting them, this

                       level or lower?
                  2
                  3                 We heard"a.lot yesterday  about  how  if  we  did  not
                       show our faith, hope and    charity that we might seriously
                  4
                  5    hurt  somebody.
                                    MR.-TOBERT:  No, I don't think this would affect.
                  6
                  7    the. operation at all.
                  8                 DR. THUPd4AN:   Wh.at.I am really asking is 1.5
                       or lower.    Let's look at   both.of those, 1.5 and then also
                  9
                       the lower  because I share   every concern that Dr. Scherlis
                10

                       had.
                12                  MR.  TOBERG:   If   it is any  lower  than  1.5  without
                       a   developmental   proponent, I-think it might have some
                1 3
                14     concern on the staff.
                                    DR. SCHMIDT:  The   move to amend was so
                15
                       inconclusive that it is a substitute motion and so really
                16
                       the motion we are talking about right now is the lower
                17

                       amount.
                18
                                    John, first.
                19
                20                  DR. KRALEWSKI:  I   am in sympathy with cutting the
                21     thing  back.  I have mixed emotion.over developmental
                       componen ts, whether we give it to them in programs and
                22
                       help them  organizationally  to-do  this  or  whether  we  give  it
                23
                24     to them as  a  pat  on  the  back.
  kce - Federa I Repor tvs, Inc.
                                    organizationally  speaking  I  had  been  inclined  to
                25




       mea-5                                                                     36



                 I   say the program would be  better of'if you would  reduce  the
                 2   budget in the area of projects and gave them some developmen-

                 3   tal money to play with.  I think I Would be inclined-to

                 4   believe though that ending up with 22OtOOO which must be

                 5   one of the larger developmental components ever  given  to  a

                 6   program would be fair.  But I would think that.developmental

                 7   component in terms of perhaps somewhere in the  area  of  that

                 8   first year's program,goiiig up perhaps around A  hundred  for

                 9   the second two years, with the cutbacks to  bring  the  total

               10    budget down to a million.and a half, taken out of the

               11    projects, might be'more helpful to a program  such  as  this

               12    and give them more running room and give them  a  chance  to

               13    turn it around if they are trying to turn it around.

               14               DR. LUGINBUHL:  Is that an amendment to my

               15    substitute motion?  If it is,  I will accept it as  a  change.

               16               DR. SCHMIDT:
                                               I will accept that as  an  amendment

               17    to the-substitute motion.  The seconder was Elizabeth.

               18               MISS KERR: Yes, and I would accept it,

               19               DR. SCHMIDT: All tight,  the  motion  now  includes

               20    a developmental component of .96,000,, which, for the  first

               21                How about the second and third years?
                     year then.

               22               DR. KRALEWSKI: I  suqqested  a  hundred  thousand

               23    isn't much of an increase but suppose we say 90,000 the first

               24    year, a hundred the'second two?
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               25               DR. SCHMIDT:  All right, 90,000 the first year and




      mea-6




                     a hundred then for years two and three.  So that is the motion

                 2   that is now on the floor.

                 3              Further discussion?  If not I will call, "Question."

                 4              Bill?

                 5              MR. TOBERT:  By reducing-the deve lopmental

                 6   component for the second and third year does this  in  effect

                 7   reduce the total amount you_are  awarding for those two years?

                 8              DR. SCHMIDT:  Yes, it would be a reduction of 1

                 9   110,000 year two, 120,000 in year three.  Year one, i t would

               10    be, without calculating centrigrade and Fahrenheit,  are  you

               11    going to take five-sixths of the amount after  the  subtraction

               12    or before the subtraction?  Oh, developmental component

               13    isn't subtracted.  So it is five-sixths of what?

               14               DR. KRALEWSKI'-. What I was suggesting is a  total

               15    budget of one and a half.

               16               DR. SCHMIDT:  Including  developmental  component?

               17               DR. KRALEWSKI:  Developmental component is 90.

               18               DR. SCHMIDT:  That clarifies it.
               19               Does the staff understand the recommendation?

                                All right. I will call for the  vote  then.  All  in
               20

               21    favor please say aye.  opposed no.

               22               I hear no dissent.
               23               I would like to just take a  few minutes now  before
               24    -moving' on to a report on Missouri to ask the committee to

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               25    express themselves concerning the staff efforts  at  presenting




       mea-7

                                                                              38


                 I    information to you about regions as part of the review and

                 2'   triennial applications,' that backgrounds the regions a little

                 3    more,


                 4               You have seen the slides that have gone up.  You

                 5    have heard two presentations by staff as part of the committe

                 6    review@  One  o-f them was done by John, I believe, as part of

                 7    his review.  He used the visuals that were prepared by staff.

                 8               And we have talked in the past about the informa-

                 9    tion that comes to the committee,. the amount o,& it, the

               10     detailed nature of it and so-on.   I called your attention

               11     purposely to these books because they do have some of the

               12     budgetbreakdowns that are most handy.

               13                You have the applications now in their new form.

               i4     And you have the reviews of these three regions that were

               15     done by staff.  So could we have some guidance from the

               16     committee  on what the  think?  Dr. Ellis?
                                          y

               17                DR. ELLIS:  Mr. Chairman, I would certainly like

               .18    to express great appreciation for the work of the staff in

               19     setting forth these audiovisual presentations.  I think they

               20     have been very, very helpful.

               21                Many times in trying to describe a region it is

               22     just impossible to do so  so that people listen and hear

               23     what it is all about when we are talking.  But they get our

               24     attention; we understand exactly what the region is like and
  A,ce- ederal  Reporters,  Inc.
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      mea-8                                                                     39




                 I                         ted region today.
                      present this complica

                 2               DR. SCHMIDT:  Elizabeth

                 3               MISS KERR:  I would also commend the staff for thi

                 4    and Iwould further make a comment and then a request.

                 5               As I review regions which I intended  and  plan  to

                 6    visit and also which I review for reporting,  I  have  done  the
                 7    same thing with my own little feeble handwriting  on  the  map
                 8    that is produced for me on the materials  trying  to  identify

                 9    locations, centers and so forth.
               10                This is very helpful I found but  my  request  would
               11     be, could.this kind of material be developed and -- and
               12     included in the review materials prior.to the review, the

               13     site visit even?  I think the  are that important.
                                                   y

               14                DR. SCHMIDT: I think that would be  a  goal  to  be

               15     achieved.  Certainly the maps of  the regions could be done
               16     for all regions that were coming up for  triennial  review  and
               17     some of the funding history and Particularly things like
               18     these pies that show that the whole yellow thing was the
               19     medical school and now the medical  school has been  cut  down
               20     to a little piece of pie and I think that these sorts of

               21     visuals are great, and could be done in advance.
               22                MISS KERR: For example Texas, as  large  as  it  is,
               23     I had to get some idea of locations of agencies and so
               24     forth prior to having a meaning ful review from  the  applica-
  @ce - Federal  Reporters,  Inc.
               25     tion.  So this would be very helpful.




       mea- 9                                                                    4 0



                                 DR. SCHMIDT:  Let me     I almost feel a consensus

                 2    of the group. Let me ask for  criticisms;  assuming  that  the

                 3    committee does favor these, let me ask for criticisms of

                 4    what has been done either in length of it or detail of it.

                 5               This doesn't include the Rochester  one  which  was

                 6    a 30-minute special but I am talking about the  five  to  ten-

                 7    minute quickies and particularly for  other  information  that

                 8    you would like to have that might be helpful.
       CR 7149
       End #3    9               Bill?,


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        CR7149


      #4 -ter-1
                                  MR. HILTON:    If  overused  in  our  initial  enthusiasm


                     with this kind of a    "B" approach, it can probably, I think
                   2

                     envision a'time it might    become monotonous.  I think it is
                   3

                     possible to guard  against  that  if  we  are  aware  at  the  outset.
                   4

                   5              I would suggest restricitng the use of the particu-

                     lar-approaches in the overheads to the background data.  We
                   6

                   7 have.50 local RMPs and even though we have been to the place
                   8 before, individual members may have been there before, it is

                   9 a  good  idea  to  have.that  background   refresher,   geoqkaphy-kind

                     of display of   territory, perhaps consider building up a library,
                 10

                     of that kind   of data for each region.

                                  I suggest, too, perhaps some    variety, like   for
                 12
                 13  Hawaii, we had -- in addition to the overhead we had the        little

                     plastic what do you call it, topographical models.  That          kind
                 14

                     of variety and other approaches'to variety would       help minimize
                 15

                     the boredom of this kind of approach, I would think.
                 1 6

                                  DR. SCHMIDT:  I  was hoping for some flowers, myself.
                 17
                 18               MR.' HILTON:. Yes, I  -would  too,.like  to  applaud  the
                 19 -staff for  the effort and I think it is great.

                                  DR. SCHMIDT:  All right,  Leonard?
                 20
                                  DR. SCHLERIS:  We had planned some really spectacular
                 21

                     events for Hawaii.  I can tell you     we  shared  every  bit  of  the
                 22
                 23  Aloha spirit at our presentat.ion.yesterday, that we had in
                 24  Hawaii.  Only those of you who were there will really appreciate

  AC    tal  Reporters,  Inc.
                     what that alludes to.
                 25




                                                                               4 2
      ter-2



                 I             I think these are excellent. I would  make  one  sug-

                 2  gestion, that is the value of'puttincr specific numbers that  we

                 3  are talking about on the wall chart that we have.  It is really

                 4  a great help and I would suggest that this be  done  previous

                 5  to the meeting, perhaps, someone on staff could write  down  for

                    each of the regions, what has been the previous level of

                 7  support and what is being recommended, because we can  all  look

                 8  at the numbers together, and it furnishes a great deal of


                 9  value.

               10              When you use a wall chart, just use a rough draft

               11   on the over head, where  someone can cross it out  and  modify

               12   it.

               13              DR. MARGULIES:  For'one thing, as you have pointed

               14   out, these presentations are al.1-on prime time, so the

               15   question  of durations is  signif icant.  Certainly, the kind of

               16   overlay  and in-depth analysis for the beginnin  of a triennium,
                                                                   9

               171  I would imagine is a first priority in putting this much effort

                    into it.

               19              It emphasizes two things, however, and I  would  hope

               20   that the review committee would help to guide us in one of

               21   them, rally, both of them; as much as possible.
               22              There is always the risk in presenting data  in  a
                    particular way as a preparation 'for a triennium review  that

                    we will begin to influence your thinking by the way in which
               24
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               25   we put it together.





      ter-3



                 I            It was quite obvious for example, we were making

                 2  a'point in presenting the Rochester regional medical program

                 3  as-a case study.  You could also see we could have picked other

                 4  programs for that purpose.  We are not going to deliberately

                 5 do that kind of thing, but in the selection of data and present-

                 6 ation, there is the risk that-that-will occur.

                 7            There also is a constant problem which will grow

                 8 in time in selecting data with the knowledge that no matter

                 9 what we present, it is rather incomplete.  A case in point, I
               1.0 think of Ted Gri.ffith, down at the end of the table representing

               11  the HEW REgional Office.

               12             It would be fine if-we could, in some manner, have

               13  a concept of what else is going on in other kinds of health

               14  activities within the region.  To do that is without really

               15  innundating you with materials extremely difficult.  But, we

               16  are going to have.-to do something abou:t how that might be

               17  achieved.

               18             It would be very helpful if.one knew that, what is

               19  going on in X areas or is not related to a lot of other things

               20  which are underway or are intended from other origins.  What I

                   am suggesting is sort of reorganizing the whole Governmental
               21

                   system in presentation.  We cannot do that.
               22

                              The other thing I would like to mention, we have
               23

               24  brought up and which Bob Chambliss spoke to you about,@yester-
  Ace-Federal  Reporters,  Inc.
               25  day, is the significance, under the circumstances, of the staff




                                                                                 4 4

        ter-4



                 I Anniversary Review  Panel,  beqause.if  we  are-to-continue  with
                 2 the kind  of  staff  review'for 'those programs, which are not

                 3  undergoing  intensive  review, by the review committee,  it  will

                 4  give us a greater  quality  of differentiation  for  what  really

                 5  requires full-time by the review committee;  what  needs  to  be

                 6  referred'to, and what does not present  major  problems  so  that

                 7  it can be kept in some kind of balance.

                 8             Obviously, you are'being  burdened  with  some  heavy

                @9  responsibilities, and you will have to accept o@ kind of

                10  discretion in developing for you what needs  to  come  this  way,

                11  and what reguires that kind  of time.

                12             DR. SCHMIDT: I  would  like.to-comment  on  the  Staff

                13  Anniversary Review Panel reviews from my   perspective  and  see

                14  if there is the consensus of the-committee.  If not, we can

                15  discuss the Staff Anniversary Revi ew Panel.. reviews  f  rther.
                                                                           u

                16  To me, these have been very high-quality  efforts  by  the  staff

                17  and the reporting of these, the information that is in the staff

                    summaries, the written word tha t comes to'the  committee that I
                18

                    look at gives me such a good feel for what  went  on  with  staff
                19

                    in their deliberations that I can  very  quickly  be  satisfied,
                20

                    or dissatisfied with what went on by my review of these reports.

                22             In the last number of years, I have detected no

                    dissatisfaction on the part of t he Committee  with  this  Staff
                23

                    Anniversary Review Panel process,  or the  information  it  gets
                24

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                    to the committee.
                25







       ter-5


                                 I think the  Committee  must  have  the  perogative  of

                  2  asking for explanations for actions if they do not understand.

                     But, I don't think there is any need, right now, or any desire

                  4  on the part of  the  Committee,  to,,change-that  process,  or  the

                  5  process of reporting the information to the Committee.

                                 That Was what I expressed to staff during the past
                  6

                  7  few weeks, and would  ask  if  the  Committee  members  disagrees

                  8  with that at this point?

                  9               WaIrren?,
                10              PR. PERRY:  I think,.  although  we  do  not  need,-.You

                11   know, no further approval, if..we   all agree in the     importance

                12   of the audio-visual, from one of    the comments made     yesterday

                     that indeed,  the review process,might be more open      and'less
                13

                14,  involved.
                15              This is another important reason to have     this qualit)

                16   and kind of material.  If.there, we can anticipate,     you   can

                17   anticipate other people around.  That would be most     helpful

                     to have those kinds of. things a'@ound, so that each person can

                     respond in relationshi@-.to it.
                19

                                Also, I think  that  there  can  be  judicious choice on
                20

                21   the part of the staff as Harold has-said.  Perhaps,     for   the
                ?2   -trie@nn:-LUM.  For the important ones. Let us not get  in the
                23   habit of doing it for everyone, let us do it for those that are

                24   really significant and we need for the review.
  Ace-Federal Reporters, Inc.   SISTER ANN-JOSEPHINE:    I would join the other members
                25




                                                                             46



       ter-6
                   of the Committee in complimenting staff on their presentation.

                 2 And, as I have had an opportunity to function on this committee

                 3 I begun to realize that the diversity between the regions,

                 4 not in the area of needs.  That is quantitative rather than

                 5 qualitative, but the diversity is rather -in where individual
                 6 programs are at 'the present time, as compared with other

                 7 programs in an awareness of how to go.about meeting the object-

                 8 ives of the program.

                 9            And I would think that this type of rWiew, carried

               10  on as part of the program should be very helpful to staff,

                   because in putting myself into the role of a member of staff,

                   and sitting there and listening to this,.I might well say, You
               12

                   know, in these two programs, that I am responsible for,.these
               13

               14  efficiencies have been met very effectively and I need  to

                   communicate them with those who are working with the other
               15


                   programs.-
               16

                             -And in this way we can really begin to share resourCE!
               17

                   that are resources of.the regional medical program.  And I
               18

                   think we have not done that as'effectively in the past  as we
               19
               20  can do it, now.  We have reached a-p6itt'in,-Eime, and it is

                   really sharing facilities.
               21

                             DR. SCHMIDT:  Let me end this by asking staff if
               22
               23  they have any questions of the Review Committee about  the

                   information or whatever?
               24
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      ter-7                                                                     47



                               DR. CHAMBLISS: I might say on  behalf  of  ttaff  that

                  2  we do appreciate your words of approval for these efforts in

                  3  the visuals.  Especially in the staff'of the division-of

                  4 operations and development and DPT, but I  think  this  committee

                  5 should know who has spearheaded this effort in terms of the


                  6 visuals.

                  7            I would like to just say Miss Judy Flasher, over her(

                  8 at the door, has spearheaded this, and also  with  equal  assist-

                @9  ance,"Mr.-Frank Schniowski, who has provided the data for the

                10  visuals.  Frank is over here and you all know him.

                               Thank you.

                12             MR. RUSSELL:  I woul d like to say one thing.  I

                13  think it would be helpful to the staff when on a.site-visit,

                14  if the site-visitors feel, if a particular visual would be

                15  helpful then this would give us direction,  we  would  appreciate

                16  it.

                17             DR. MARGULIE8:  That picks  up what I wanted to

                18  comment on, Dick, and,that is that in  the interest  of  express-

                19  ing the kind of diversity which you spoke  and Sister Ann,

                20  everyone has recognized, if I get the sense  of  this  committee,
                21  you,will accept the idea that the development of the visu@l
                22  materials and the manner of it.is something which might c6ntinu@

                23  to be left to the style, to the interest, to the motivations of

                24  the staff people connected with the program.

   Ace-Federal  Reportvs,  Inc.
                25             I think that would be better than.to say, we have




       ter-8




                  I  one single format which we want to  follow.  This will give.them

                  2  a greater sense of involvement and  I think,  they  can  probably

                  3  do better that way.

                  4             MR. SCHNIOWSKI:  Dr. Schmidt, as part of the experi-

                  5 ment we had one presentation given  by  staff,  another  one  that

                    was a joint-type, Staff Review Committee  and  a  third  one,,

                  7 by the  Review  Committee  members.


                  8             The Review Committee has commented on the audio-vis-
                  91 uals.  I wonder if we could find out if  they have any preference
                lo: in the future as to the type of delivery they would like to

                11 'see'.>

                12             MR.  HILTON.  I   would go for that second approach.

                13  Specifically,  with  staff  though there would be opportunities

                14 as  Merle  has  already  suggested, to someway propagandize present@

                15 ation to some  degree,  I  think  we will guard against it,

                16  particularly  the  staff  covering those things that are  of  a

                17  geographical and demographic objective, reporting kind of

                38  nature with regard to-the region,  and  with  committee  handling,

                19  the other kinds of concerns were here to address.

                               DR. SCHMIDT: I  like  the  quality  of  interchange
                20
                21  with-staff being part of the presentation.  I see all the @eads

                22  are going like this.

                               DR. KRALEWSKI:  I have always liked to use slides
                23

                                         While I agree, I think  the  background  data
                24  in a presentation.
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                25  is well presented by the staff;.I think it  is  useful  as  an





                                                                                 4 9
      ter-9



                 I  introduction.

                 2             I think it is'usef'ul during the presentation to  have

                 3  the use of slides, also,?though, so really, what we  are  saying

                 4  is part of what I am suggesting is part of each of these

                 5  approaches we have previously outlined.

                 6             And I think that the site-visit is the time  to  out-

                 7  line-the kind of, kinds of slides, that you will need  for  that

                 8  presentation, because then, you can highlight some of  the  parts

                    of the program you feel are necessary.

                10             I think this gets away from the fact  then  that  the

                11  staff may be worrying about their slanting it in a certain

                12  direction.

                13             DR. SCHMIDT:  We will want  to bring this to a  close,

                14  quickly, then.
                15             DR. JAMES:  Yes, I have' avery, very  quick comment

                16  to make.-

                17             Again, being new, I certainly enjoyed the audio
                    visuals yesterday, and I would.'concur that the joint  presenta-

                10  tion by Staff and site-visitors' of the committee, make it a

                20  presentation; I also would like to comment that this kind of

                21  presentation with the broader presentation of actual figures

                22  on the board, helps one to determine where the level  of  funding

                23  would be, because sometimes I se e coming about,  ceiling  figures

                24  that may apply to a funding, and I believe this would help to

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                25  deter the use of ceiling figures.







      ter-10
                               A figuteiout: of the'ceiling.

                 2             MISS KERR:  One other quick request, is if it were

                 3  so thit we could have-these graphs prior to a site-visit, and

                 4  then if there were such changes as were dramatic enough to show,

                 5  could this suggestion be made by the visiting team to the

                 6  staff member, and the staff memb6r@ at his  discretion,  then

                 7  develop the second audio-visual for comparative purposes?

                 8             DR. SCHMIDT:  We will accept that as a suggestion.

                 9             Sister Ann?
                               SISTER ANN JOSEPHINE:  Some of the regions are begin]
                io

                    ning to develop their own visual material, and it may well

                    be that some of'the visual material they have developed  could
                12

                13  be used for this type of presentation, without  a  duplication

                    of effort.
                14

                               DR. SCHMIDT: 1 think Staff will  be  sensitive  to
                15
                16  that.

                               MR. TOOMEY:  I would like to comment on the fac
                i7                                                              t

                    that seems to-me that we are,    we have been asked  to  look
                18
                19 'ka ther specifically, precisely,. and indepth, at  the  program

                    problems of the organizations that we visit and with which we
                20
                21  are concerned.

                              .Then, in the course of our discussions,  we  begin
                22

                    to focus on projects that are part of that. Yet,  it  is  very
                23
                24  incidental.  I cannot help but feel that the projects are

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                    extremely important in terms of ananlyzing the  congruence  of
                25





     ter-11



                 I  the project to the program.  And, I'am going back to Staff

                 2  Anniversary Review Panel, because I think those reviews are

                 3  great.

                 4              I think, perhaps, the  most  effective  presentation

                 5 on your charts have been  the  changes-from  the  categorical  to

                -6  the multiples-kind of projects. And,  I  think  if  one  further

                 7' facet of Staff Anniversary Review Panel  could  be,  because  we

                 8  are-not taking the time to review the  projects  in  any  depth;

                    that they probably know them better than anybody else, and if

                10  they could spend just a little bit of time on, or at least

                11  a comment in relationship to  the project,  itself, to the pro-

                12  gram that we are most specifically concerned with.

                .13             Do I make myself clear?

                14              DR. SCHMIDT: 'Yes, everybody says, yes,.-and  it  is

                15  captured and-While you have your microphone on, let us turn
                16  then to Missouri and a brief status report from the site-visit.i
  e-4/s-5       17              MISS KERR:  I am assuming we need not do anything wi I
                18  that on our evaluation sheet, right?
                19              DR. SCHMIDT:  That is correct.

                20              This is for information.

                21

                J2

                23


                24

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        CR  7149                                                                 5 2


               4-B
     follows   4-A
        by  TER  I             MR*.TOOMEY: I visited Columbia a  month,  in  company

                 2  With Dr. Thurman, Dr. Pellegrino, Dr. McPhedran, Donna Howseal,
           kar   1
                 3  Dr. Farrell, and Judy Silsbee.  There has been  a kind of  major

                   problem in the Missouri RMP.  Frankly, it has been a program ane

                 5 'organizational kind of structure problem.-
                 6             For instance, at the top level there is a problem wit'.

                 7  the regional advisory group.  it was initially established

                 8  under Dr. Wilson in three parts.  It was a tri-part RAG.
                 9             onIe part was an advisbry-council, the@econd part waE
               10  project review commit tee, and third part was a liaison committe(

               11  Which was p@o]ect oriented. When these  three  groups  met,  they

                   in a sensb, represented the regional advisory group.
               12
               13              However, they met separately as well, and with the
               14  advisory council being only 12-people and with the project revi(,
               15  committee and liaison committee being made  up  predominantly  of
                   the prior-groups and most.specifically, of the University of
               16
               17  Missouri people,, it was a very closed kind of corporation,
                   rather than an open advisory g.@.oup with input from much other
               18

                   than the University.
               19
                               When this problem was called to their attention, the,r
               20
               21  made the decision that the advisory council with  12  people  was
               22  in fact their RAG.  In fact, it does not meet the requirements,
               23  the legal requirements of a regional advisory  group  because  it

                   does not have all of the representation,  even-the  legal  repre-
               24
  Ace -Federal Reporters, Inc.
                   sentation, Veterans Administration group, and I think some othe
               25




                                                                               53




           kar,21  Bill, what was the other? 'CHP Agency?  In addition to which
                 2  it had only one minority or consumer involvement.' It was one,

                 3  one lead who was'black and who was a housewife, and she repre-

                 4  sented the female, the black and the consumer, all by herself.

                 5            Their focus in the past had beeon on,  naturally,  the

                 6 extremely categorical nature of the projects.' They had  been  --

                 7  they had been very equipment-hardware oriented.  They didn't

                 8 have adequate goals, subgoals or priorities and within  the  past

                 9  year, they-have had a group headed by, I think it is Dr. Mare

               10  who has worked, I guess, with great vitality and enthusiasm

               11  -in developing a set of goals and.subgoals and priorities.

               12             However, they felt that the objectives that should

               13  be established in order to achieve these goals should not be

               14  established by their goals committee and it should not be

               15  established by RAGI but in order to allow the local regions

               16  covered by the Missouri RMP to give to the establishment of thei-

               17  projects.and their objectives, the local flavor that was necessz:

                   they left the objectives out.  They felt very strongly and
               18

                   organizationally they have six or seven subregions and they  haVE
               19
               20  a part-time-,,coordinator in each.of these subregions and they
               21  felt-that each of the subregions was geographically so  different

                   and the'needs were so varied that for-a central group to establi@
               22
               23  the objectives for these regions was undesirable.  So they did
               24  not -- they did nothing other than establish the major goals,
  Ace - Federal RePDFters, Inc.
               25  the purpose, the ma]or goals and some of the subgoals.





                                                                                        54



            kar  31              Their major goals  are  the  enhancement  of  the  avail-

                  2  ability and accessibility of health resources, enhanceme     nt of

                  3  quality care and the  moderation  of  costs.,  And  they  have  under

                  4  each of these major goals, they'.have subgoals to the-total of

                  5  13.  Frankly,jthey have done an excellent job.  Their goals and

                  6  subgoals are great.  And if you can accept the fact thati-Ehe

                  7  regional area  should  be  able,  through-its  own  input,to  establie'

                  8  the objectives for that area to  determine  what  its  major  objecti'-

                  9  would be, then it is not an inadequate or  it  is  not  an  undesiral@.

                10   approach.

                11              The program staff was'--  had  not  had  its  organizatio  i

                12   structure changed from the time   that it was categorical in

                13   nature.  And I think I would put it in another framework.  They

                14   have an organization which is inadequately structured to carry

                15   out the goals and subgoals that they have established.  They

                16   did not have an evaluative mechanism.

                17              A committee was established, but it is a little bit

                18   hard when you have no objectives to evaluate whether or not whal

                19   you are doing is being accomplished as it should be.  So the

                20   evaluation committee really exists in    the same kind of a void

                21   as the specific objectives exist.

                22              We were concerned with tlie'part-time regi   onal

                23   coordinators, and really it wasn't until we had an opportunity

                24   to meet with these 4en tlemen, four or five of them being
  '%Ce -Federal Reporters, Inc.
                     physicians, and  retired  or  semi-retired  kind  of  situation.  And
                25





                                                                                    55



           kar 4 1  when we did meet with them, we found that.they were, in my

                  2  opinion, a very dedicated  group of  people.  The  problems  that

                  3 have existed really are the fact  that  they  were  part-time  and

                  4 there it did take them a considerable amount of time to travel

                  5 through the region for which  they  were  responsible  to  relate  to

                  6 the priors and other people in-that  region  and  to  begin  to  draw

                    out of the region the things.that the region might do.
                  7

                  8             They felt that they would be  better  if  they  had  some

                  9 part-time help themselves"in terms of secretarial help or data

                    gathering or kind of people who were  --  these  with  all  physician
                1.0

                  - and they felt they needed some nonphysician  help  in  the  --  in

                    their work. As part  of  the  organizational  structure,  I  think
                12

                    that we looked ver hard at the coordinator, and I don't -- I
                13

                    think I would feel mo re comfortable when  I  would  say  that  they,
                14
                15  and I quote from a review  of  their  fifth  year  application,  site

                    visit report in 171,  "The  site  visitors  find  the  organizational
                16
                17  effectiveness of the coordinator weak.  The doctor is not as

                    forceful an administrator as he could be.11@ And in@172 the rema..]
                18
                19  is, "Other leadership is.still   considered weak.  Not only does
                20  he exhibit through the lack of   organization within the program

                    staff itself, but in addition   to which he  is  director  of  health
                21
                22  program for the  University extension division and he is     director

                    of a HSMHA contract in consumer education, and to compound the
                23

                    weakness which seems quite apparent, he   is now devoting only
                24
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                25




                                                                                 56




          kar   51            Now, the  explanation for this is that  the  consumer

                 2 project is operated  through the University and  the  University

                 3 has said this is congruent with  the RMP program  which is operated

                 4 through the University and therefore,' we will put it in  RMP  and

                 5 'make Dr. Rickley the director.

                 6            These, I think, with the organization problems, the

                 7 structural programs of the organization, the  lack  of  specific

                 8 objectives even though the goals were considered to be  --  in  my

                 9 opinion they have done an  excellent  job.  I  thin@ach  of  these

               10  items was reported directly to their group.

               11             I would like to ask.-Bill if he would like to contribut

               12  anything to this,, Bill Thurman?

               13             DR. THURIl@l: I think that I  would  just  add  a.couple

               14  comments.  Bob has outlined  most.of  the  concerns.  One of  the

               15  members with us from council indicated, said this was.  nothing
               16  more than-a day-long feedback  session which is really  the feel

               17  you got for what we did because it was at times very sticky,
               18  uncomfortable and at times they,.kept coming back to us with
               19  questions like, what is the difference in definition between the

                   advice you send and the recommendations  that  you  send.
               20
               21             And we tried to respond to each of these and it was a
               22  long@,-drawn out type of feedback session.  I think that one
               23  thing that concerned them the-most was whether or not review

                   committee and councils handling o  f the VAS situation should
               24

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                   have been clearer to them than it was, and Dr. Pellegrino's
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                                                                                57



         kar 6     statement about that, and one of  the reasons I have  been  con-
               2   cerned today and yesterday about  out patting people on the back

               3
                   who haven't turned the corner is  the Pellegrino statement that

               4
                   they have had hit in the head with  a2x4 and still haven't

               5
                   changed.
               6              So I think this was'a  very worthwhile visit.  I
               7   wonder if we could have one word about councils feelinas about

               8
                   not: concurring with our recommendation last time  around  about
               9   triennial status for this group and I think the only  other  poin"-
               10  that I would add-to what Bob has said is that  the  coordinator
               11  problem represents a significant problem and lead  to our  ultima-(

               12  recommendation.
               13             MR. TOOMEY:  I don't know if the council is familiar

               14  with the fact that after the VAS project, which is  a  computer
               15  project, and Dr. Billy Jack's office related to the medical
               16  school, council of the advisory committee had recommended it be
               17  funded no longer; then a separate contract was signed with

               18  HSMHA in order to continue.
               19             DR. SCHMIDT: -Bill,  what did you mean by your  ultima@,

               20  recommendation?
               21             DRi THURMAN: Bob is.going  to  present  our  recommend-.

               22  ation in just a minute, I am sure.
               23             MS. IIOUSEAL:  In response to your council about why
               24  c'ouncil decided that, they felt withdrawal of funds in  the  amoui

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               25  of a hundred thousand and the site visit would  be  strong  enough,




                                                                                58




          kar   7   and they though it would be too harsh to withdraw triennial
                 2  status.

                 3
                               DR. SCHL-ERIS:  What will be the result of this site
                 4  visit, I gather it is  information  on.ly, or are there specific
                 5  recommendations?

                 6
                               DR. SCHMIDT:  I was a little puzzled,   obviously,
                 7  again-I am hanging on tender hooks because there   was some

                 8
                    recommendation made.

                 9
                               MSi. HOUSEAL:  The site visit team was@o go out and
                10  carry the m@ssage from last time.  The recommendation had alrea
                11  been met or.set by review committee@council,at their last
                12  meetings.' The program recommendation, those Mr. Toomey gave
                13  regarding settling the RAG issue, making the coordinator-full-
                14  time, making objectives more specific, evaluation section on

                15  core staff, the site visit made no funding recommendations.

                16             With regard to the computer contract, there was

                17  another site visit held by HSMHA officials this summer and con-

                18  tract funds.of contract will not be forthcoming from @IPS for

                19  this activity, but will be supp lied by national centers for

                20  research-and development.

                21            DR..THU@IAN:  I didn't mean to leave the Chairman

                22  hanging in mid-air.  I think Donna has outlined our   recommend---

                23  ations.

                24            A very specific reqpest   was made by the site visit
  kce- ederal  Reporters,  Inc.
                25  team which Bob outlined to have a letter forthcoming from P14PS




                                                                                 59



          kar   8   outlining these specific forms. My  apologies  to  the  Chairman.

                 2             DR. SCHMIDT: No.  Any  other  comments  then  before

                 3  moving on?

                 4             DR. SCHLERIS:  Does this go  to council with  a  re-

                 5  affirmation of our recommendation from  before, or is  it  just

                 6  where it was before, because I don't see where this is really

                 7  more than,,you know, it might be well if you did this.  Funds

                 8  have been our means for having some impact,   however transiently

                 9  on a regioni

                10             MRS. SILSBEE:   I think Dr. P61legrino, who used to b@

                11 -on the review committee originally-and  council,  descrived  it

                12  best as a therapeutic site visit.  There  were  indications,  not

                13  only beforehand, but at the time of the site visit, that letter3

                14  that had come and advice that had come from the review committe7

                15  and the council, again, the site Visitors looking over the

                16  material could not understand how the region  could  have  failed

                17  to have gotten the message, but when we got  there,  we  realized
                18  there was a filterihg.process and they had failed  to  get  the

                19  message.
                20             So this was an opportunity to  have  a  face-to-face
                21  discussion, to make sure that what  the!committee  and  coundil
                22  had been saying was understood by the regional medical program.
     E    4-B   23             DR. SCHMIDT:  All right.  We will move on.

                24
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                                                                               60



     CR 7149
                 I              DR. SCHMIDT:  We will  go onto Bi-State before
        5
                 2 coffee.
   dor 1
                 3              I guess we are still with  Mr. Toomey.

                 4              MR..TOOMEY:  The visit to  Bi-State was in regard

                 5 to an application for triennium status.

    xxxxxx       6              A review of the problems that existed with the

                 7 Bi-State, Bi-State RMP, indicated first of all that the

                 8 Regional Advisory Group had been-relatively inactive;

                 9              That there was a Scientific Educational Review

               1.0 Council, and an administrative-liaison council made up of

               11  representatives from three medical schools, Washington

               12  University, St. Louis University, and Southern Illinois

               13  University.

               14               And the indications were that these two

               15  committees which review all of the projects made the basic

               16  decision and made their recommendations' then to the Regional

                   Advisory Group.
               17

                                And the record would indicate that the Regional
               18

               19  Advisory Group met seldom.or perhaps three, perhaps four

                   times a year, and never for more than two hours at a time, and
               20

                   with-only approximately one third of the RAG members present.
               21

                                This led into the problem of.the grante6
               22

               23  organization, which was a joint organization, a so-called

                   consortium, made up of these three universities, who, as a
               24
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                                                                            61


     dor

                                Another problem apparently was  the-internal'

                 2  organization of the program staff, which was structured

                 3  in-such a way 'that all of the members of the staff reported

                 4 to Dr. Stoneman, the coordinator of the Regional  Medical

                   Program.
                 5

                 6              Additionally, because.it was a Bi-State area and

                 7 covered the area around St. Louis, Missouri, and, in

                 8  addition, covered the southern part of Illinois, which

                 9  included the state capital in Illinois, Springfield, where

               1.0 there was a concern because the Illinois RMP, which was  a
               II. growing organization and more aggressive  increasingly

                   aggressive organization, was concerned because the  state
               12

                   capital of Illinois was being covered by a Bi-State  RMP,
               13

                   rather than the Illinois RMP, as an expression of the
               14
               15  either of the agressiveness of the Illinois RMP.

                                They had just rece ntly funded a project it
               16
               17  Southern Illinois which theoretically was in tetritory'."..@.@'.-

                   covered by Bi-State RMP.
               18

                                Finally there was a concern about the relevance
               19

                   of goals and objectives tothe region's health care  needs.
               20

                                The specific issues were -- with which we were
               21

                   concerned were the organizational structure, the role  and
               22
               23  influence of the consortium, the internal  organizational
               24  problems of the program staff, the dispute over the Southern
  Ac    al ReporteFS, Inc.
               25  Illinois area with the Illinois RMP, the role of the program




                                                                            62


    dor 3


                I committees and  the  adequacy of proposal development and review

                2 process and relevance  of  go als and objectives to the Region's

                3  health care needs.

                4               In the establishment of-the go&ls and objectives

                5 which came about March 1971, their objectives and priorities

                6 were groupd around six major areas.

                                ?Their first was manpower;
                7

                8               The second, the health care delivery systems,

                9 rural and urban;

               10               Thikd,continuing education;

                                Fourth, medical care, primary, secondary and
               11

               12 tertiary,-and the cardiovascular, cancer,. stroke, and other

                  diseases;
               13

               14               Fifth, demography and statistics; and,

                                Six, medical information.
               15

               16               And their priorities followed this ranking.

               17               We were concerned about the categorial orientation

                      he objectives, recommended that there be deemphasis of
               18 of t

                  the traditional categorical interests.
               19
               20               The objectives tended to reflect highly pre-
               21 determined assessment of regional needs.
               22               During the categorical period, let me say this:
               23 one of the problems that had previously existed before the
               24 Bi-State RMP came into being was the inability of the two
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                                                                                63
     dor 4

                   carrying on programs in an effective manner..

                 2              The RMP during this  categorical  period  brought

                   these two medical'schools together and'their cancer and-
                 3
                 4 cardiovascular program seemed  to  be.particularly  successful.
                 5              Their other projects  that  they-had  accomplished
                 6 were in the training of coronary-nurses, and  in  a.library  -
                 7 network which utilized the services of,both Washington
                 8 University and St. Louis University and spread  through  great,

                   I think, in-terms of about a hundred hospitals throughout
                 9

                   the region.
               10
               11               During the past year.the Bi-State RMP became
               12  involved in developing a major medical service emergency

                   project which was funded this past spring.
               13
               14               In the area of continued  support,  the  radiation
               15  therapy program has become  self-supporting.  However,  it  is
                   being continued and the nurse coronary care unit is continuing.
               16
                                One of the projects that had been established
               17
                   under the old RMP was a -- under the categorical phase  of  the
               18
               19  RMP, was a project, Pruitt Sago; which is a housing section in
               20  St. Louis.  There they had .made.an effort to establish a
                   program and project which would provide  health  care  services
               21
                   through the utilization of medical students and  training  home
               22
               23  health aides at that center to provide care  to  six  thousand

                   residents of the Pruitt Sago area.
               24

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                                                                             64
     dor 5


                 I  to look at the problems in East St. Louis.-there had been no

                 2  indication of minority concern,.or minority interest  on  the

                 3 part of the Bi-State RMP. They are  now  concerned  with  it,

                 4 not only the urban health care, but the rural health care, and

                 5 they have -- part of their consortium  is  Southern  Illinois

                 6 University, which, in its new medical program has adopted

                 7 the -- its prime interest, that of developing delivery of

                 8 health care services to the people in the rural areas in

                 9 Southern Illinois.


               10               Andthey now have five new projects of the

               11  Bi-State  RMP directed toward the underserved.


               12               Dr. Stoneman.is the coordinator of the Bi-State

               13  RMP, and I think we agreed that Dr. Stoneman was a very,

               14  very dedicated and very, Very  fine,  dedicated,  intelligent


               15  person.

               16               However, it was our feeling that  he  was  over-

               17  stretched  in terms of attempting to relate to not only  all  of

               18  the areas  in the two states, but he was.on the faculty  of  the

               19  St. Louis University.

               20               He carried, continues to carry on a practice in

               21  surgery to  aminor degree, several hours a day,'two or t ree

               22  hours a  day, is what he has stated.

               23               And in light of this     and he also is  president

               24  elect of  the St. Louis Medical Society.
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                                                                                   65

  dor 6

                   of his desires to relate   individually to every person who

                2  works on the program staff'a   nd-the outside activities, we
                3  felt that, as much as anything, that Dr. Stoneman deserved
                4  a deputy coordinator, somebody to work with him in the internal
                5  organizational matters of the program staff.

                                 The Program staff,  individually,  as  we  met  with
                6
                7  them,  And talked with them and listened  to  them,  seems  to  be
                8  quite  an excellent group of people.

                                 They had one organizational structural problem
                9

                   which relate@ to the use of part-time associate coordinators.
                10

                   at each of the universities in..each  of  the  categories  and  in
                11

                   Southern Illinois, in their rural health care delivery system.
                12

                                 And it was our feeling that    these part-time
                13
                   categorical coordinators should be phased     out and that   full-
                14
                   time associate coordinators, who    would have an interest in.
                15
                   the organization rather than in    the category of medical
                16
                17 care, should be added to  the  staff,  or  should  be  substituted

                   for the part-time people.

                                 As mentioned earlier, the RAG    met just  three  or
                19
                   four times a year, and then for.only approximately two hours.
                20
                21 Their   attendanc.e was minimal, only averaged about a third.
                                 As businessmen, which is where it seemed their
                22
                   greatest strength lay, they felt that they were in a position
                23
                24 where they should delegate to the universities, to the SERC

  A,ce- Federal Reporters,  Inc.
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                                                                                  6 6
    dor 7

                I  program policies for that particular organization.
                2                And they did not feel that it was their
                   responsibility to  take as active a part   as we felt they'
                3
                4  should. Consequently, as we looked  at  both  the  RAG  and  the
                   grantee organization, it was  our  feeling  that  the  influence
                5
                6  of the universities should be phased  out  of  that  program  and
                7  one of our recommendations was that  the  SERC  would  be  phased
                8  out entirely and that the Regional  Adviso.ry  Group  would  be
                9  made more representative with more consumer interests and

                   minority involvement at the core lbvell
               10
                                 And as part of our looking  at  the  mechanism  by
               11
               12  which our projects came through   the various committees   .to
                   the Regional Advisory Group, Dr.   Mitchell  awnd  Maria  Flood
               13
                   reviewed, they did an audit @a:Ul,if you  will,  of  two  of  the
               14
                   projects, and I might interrupt and  ask  Maria  Elena  if  she
               15
                   would like to comment on the trailing of the projects?
               16
                                 MS. FLOOD: There was  some  concern  by  the  site
               17
               18  visit team that the  university  bad  exerted  some  tremendous
                   pressures to be assured the projects  were  named  only  at  the
               19
                   medical school emphais but,.-'indeed, as we  went  through  the
               20
               21  review process, we didn't   find this to be '-.true and  rather
               22  found that perhaps the medical schools', the universities, had
                   lacked support in helping  them  develop  mechanisms  for  proper
               23
                   review, but there were some  glaring  deficits  in  the  review
               24
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                                                                                      67
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                                    We were not provided with the    cover  sheet   that

                   2  the regional Advisory Grou' meeting,    page  one  of  the  Regional
                                                  p

                   3  Advisory Groug meetings that we reviewed,    which-carried     the

                   4  names and attendance records.
                   5                We were -- all three meetings, the review
                     started- with  page two.  It could have been an oversight.
                   6
                   7                The review process reflected some deficits in the
                   8  fact that if  the reviewer felt that there were conditions
                   9 to be met by   project proposals, there was no documentation
                 10  that this  information  ever  got.ba.ck  to  the  project  proposer
                     or that, indeed, funding was not approved until these
                 11

                 12  conditions were met.
                                    We thought  of  two  studies,  one'being  a  medical
                 13
                 14  school oriented,three-pronged nurse-physician assistant type of
                     concept, which was originally rejected and then subsequently
                 15
                 16  resubmitted with a little different approach and was         approved

                     on the second review.
                 17
                                    The other project  was  a  very  poorly   documented
                 18
                 19  project from a minority impact area, had to do' with the
                 20  educational,ifacilities  for  allied  health  training,  and  it  was
                    one of the problems we encountered in this, that there was
                 21
                 22  no  formal  development  of  a  format  for  submission  to,projects.
                                    Our opinion reflected some deficits in the
                 23
                 24  management  capabilities  of  the  staff  l@n'developing  a  format
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                                                                              6 8

    dor 9


                 I  process.

                                MR. TOOMEY:  Thank you.
                 2

                 3              Certainly, the prior groups were involved,

                 4 including the comprehensive  health planning agencies.

                 5              As a matter of  fact, the'relationship  was  be-

                   ginning to be so close and RMP-was  sufficiently   interested
                 6

                 7 in continuing this and working closely,with the Comprehensive

                 8 Health Planning Agency  that they-recommended to us  at  the

                 9 time that we arrived there that,'or  they  didn't  recommend,

               10  they requested that we give consideration to  a  funding  to

               11  strengthen and to allow the  Comprehensive  Health  Planning

               12  Agency to continue to become more and more  involved  in  the
               @13 in helping in the assessment of heeds and  in  the  planning

               14  for the  area.
               15               They-used the Comprehensive  Health Planning Agencies
               16  to the extent that it is possible to use  them now.  They see

                   that it is possible for further developments to take effect
               17
               18  with the Comprehensive.Health Planning Agency and they would
               19  like to make them an active ally and  provide them with  some

                   funds to enhance that whole record.
               20

                                As a matter of fact, as they  assess  the  needs
               21
               22  and resources, they felt that this continued active
               23  cooperation between RMP and CHP should be encouraged.
               24               Their program staff monitors all projects.  They
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                                                                                69

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                 I              Another problem that.they had was the planning

                 2 and evaluation was in the hands. of one person, a one-person

                 3 department, and they felt that even though this person was

                 4 a well-qualified Ph.D@ that this perhpas should be split.

                 5              Bi-State RMP has developed an action plan and from

                 6 the application and presentation of the visit, appears sound

                 7 and includes several excellent components.

                 8             The RAG has assigned priorities to  the  objectives

                 9 and they rank health manpower and health care systems  highest.

               1.0 Continued education and catogoticdl disease strategies were

               11  lowest.

               12              Their immediate priorities include data base

                   improvement, primary care strategies and medical information
               13

               14  systems.

                               We believe that the REgional Advisory  Group  needs
               15

                   strengthening and they need to direct need to direct themselves
               16

               17  to do a more adequate job of meeting the needs of the

               18  region.

                               Now, much of.this sounds, in a sense, it sounds
               19

                   negative and I think, I suppose it is easier to pick the
               20

                   program apart than it is to promote its strengths but they
               21
               22  have done an excellent job with the development of their

                   goals and their objectives.
               23

                               They have disseminated these goals, they have a
               24
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                                                                              70
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                                In addition. to the dissemination of this

                 2 information they used an interesting mechanism of requesting

                 3 back from the people to whom they mailed this information

                 4 requests  or projects and programs and specific areas.  They

                 5 felt they coudl establish a program of providing, it you will,

                 6 it was mentioned'yesterday as "mini-proposal,"  but these

                   are a.little larger than the five thousand dollar proposals,
                 7

                 8 these would be $25,000 proposals and  at the end of the year,

                   they would have, through their evaluative mecham     they
                 9

                   would be able then to focus in other ones which were most
               10

               11  promising and most desirable.

                               The staff, As I mentioned before, was excellent.
               12

                   They have one member of the staff, a Black professional,.who is
               13

                   extremely interested in the problems of the innercity and is
               14

               15  -working with groups in East St. Louis and in the Pruitt sago,
               16  and in the -Vhole Bi.-State,area, to develop projects which
               17  would be of assistance to the minority-groups, their health

                   service education activities, the non-AHEC, if you will.
               18

                               The AHEC which is non-AHEC, is in the hands of
               19

                   a new person, who is a Ph.D. in education and has begun some
               201
                   programs in this area.
               21

                               Their work in the emergency medical services was
               22

                   excellent.  They received, I believe, about a quarter of a
               23

                   million dollars to carry on this, or to initiate more planning
               24
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                                                                                                                                                   71

          dor 12


                                I  then.
     0                          2                           Their review'of                projects has certainly

                                3  improved, also.

          end 5                 4


                                5


                                6


                                7


                                8


                                9


                             10


                             11


                             12


                             13


                             14


                             15


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                             17


                             18


                             19


                             20


                             21


                             22


                             23


                             24
       0
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    CR 7149
                                                                           72
      6
     eak 1
                              In brief, it was our feeling that the organization,
                   while it does exhibit some weaknesses, that with th e addition
               2
               3   of a coordinator, deputy coordinator   let me go over it
               4   this way.  We feel that Dr. Stoneman and his staff have the
               5   capability, professional qualifications and interest to build
               6   a first rate RMP.  The goals,, objectives and plans were rele-
               7   vant and sound.  It has some organizational problems which
               8   presently hamper its growth but with a deputy coordinator,
               9   the reorganization of RAG and broadening of the involvement of
              10   people in the area, we think it has a great potential.  We also
              11   felt.triennial status should not be-withhe,ld because of the
              12   weaknesses but rather it should be approved on a tentative
              13   one-year basis -- if it is triennial status, but with the
              14   recommendation that it be'reviewed.-at.the.end of the.-year.
                   The recommendation for the request for funding was for a
              15
                   million four, the first year, a million 463 the second year,
              16
              17   a million-five the third year.
              18              Our recommendation.was a $1,150,,OOO be approved
              19   for the first year, $1,230,000 the second year, $1,316,000

                   the third year.
              20
                              This includes  funds for a deputy coordinator
              21
                   and a $50,000 discretionary fund for Dr. Stoneman.  Dr.
              22
              @3   Stoneman's concern as far as the developmental componen  as
                   opposed to,having his -desire for developmental component
              24

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                   was in order to contend with the problems that existed in
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                                                                            73

    eak 2
                  the fact that Illinois RMP had developmental funds and he had
               2 none and he wanted to be in a position to handle new projects

               3 as they came up when they came up.
               4             DR. SCHMIDT:  Thank you.  Secondary reviewer,

               5  Dr. Thurman.
                             DR. THURMAN:  I will have very little to add to
               6
                  what Bob has said.  I think just because of the fact that the
               7
               8  Missouri site visit came on at the same time the turf question
               9  will become a major question and we heard some question of
                  concern when we visited Missouri because of their interrelation-
               10
                  ship with Bi-State.  I think the question of the coordinator
               11
                  probably needs discussion by the whole Review Committee because
               12
               I  of the points that Bob has raised.  And I don't think any of us
                  would disagree that if he is to continue in his present
               14
               15 action, that a very strong deputy director is needed.  Lastly,
               16 my concern, as already reflected by Bo]5, is the continuing
                  project-type orientation.
               17
               18             It would appear that this tripartite of'RAG
               19 basically and their appointment of associate coordinators,
               20 if this is not constantly monitored by staff, will perpetuate
                  this type of categorical approach.
               21
               22             MR. TOOMEY:  I might ask Maria Elena if she wants
                  to add anything to this?
               23
   0                          MS. FLOOD:  Well the only comment I might add is
               24

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               25 that we got the feeling the first,day that there was a strong





                                                                              74


     eak 3


                I  staff capability and this was definitely reenforced as the

                2 visit progressed.  But the maInagement problems are acute, and

                3 there.has been comment here at this committee that you can't'

                4 correct a weak coordinator with a strong deputy but in  this  case

                5 Dr. Stoneman is not really weak.  It has just been his insecurity

                6 without someone under him to allow the staff to develop

                7 the mechanism of interrelationships.  They come to him, they

                8 answer to him, they report to him.  If he were given a strong

                9 deputy that could pull together the management  trends  necessary,

               10 I feel strongly personally that this particular staff,

               11 under the leadership of Dr. Stoneman, could indeed develop the

               12 program and follow the recommendation that we made to.begin

               13 a trend towards an improved RAG commitment and  RAG  participation

               14 in policy planning and in goals,objectives, and also broaden

               15 the scope of the program to really become a program and

               16 deemphasize this mini-project advertising that they have used.

               17             DR.  LUGINBUHL:  It is, of course, difficult to

               18 judge a program without  having visited it and just from

               19 hearing discussion and  reading the documents.  I  hope  my'remarks

               20 are not overly critical but I dan't help but raise a number of

               21 questions from the comments that I have heard and from the

               22 review of the material that we have.

               23             First of all, it appears'to me that there is some

               24 problem with this consortium, and I Wonder who is minding the
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               25 store.  You have got three different medical schools involved




                                                                             75


       k        1  in this.  I asked yesterday specifically who has the authority
                2 to replace a coordinator that is inadequate and I was told
                3 that it is the grantee.  I am not quite clear, who is the
                4 grantee in this case, and who has the-authority?  Who makes
                5 the decision?  You have got two vice-presidents of health
                6 affairs at large ifiedical schools, another developing medical
                  school-involved, but who actually makes the decision, who moni-
                7
                8 tor8 this program, that is question number one.
                9             Secondly, I can't help but have some  Uestion about
                10 the coordinator.  After a day and ahalf, I am beginning to

                  think that the terms hard work
                11                              ing and dedicated are euphemisms
                12 for incompetence and I can't help but think. that the suggestion
                I13that a deputy coordinator be appointed is simply a way of
                  patching a very worn tire.  I may.be wrong in this but
                14
                  I can't help but raise this ques tion.  From my point of view,
                15
                  a strong coordinator, a good coordinator is not necessarily a
                16
                  person who is a strong individual or who has a great deal of
                17
                  personal dedication.  I think one of the most important
                18
                19 qualifications of a coordinator is the ability to delegate,
                20 is the ability to organize and motivate staff and when I hear
                  the coordinator has not developed staff, that he does reserve
                21
                  judgments for himself, then that to me raises very serious
                22
                23 questions and I think that is.a very serious deficit to try to

                  correct with a deputy.
                24

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                              if he hasn't seen this need himself and developed
                25




     eak 5                                                                   76


                  the ability to delegate, I think that it is difficult to

                2  force this by the appointment of a deputy.  Finally, I would lik=-

                3 to raise a question about the budget.

                4             I see that the coordinator is listed as 93 percent

                5 effort but I read in the narrative that he-is a practicing

                6 plastic surgeon.  I can't help but ask, what is the control that

                7 we have over this man's total 'Income? 'I don't know what the

                8 relationship between this program and the consortium is, but if

                9 there is simply no limitation on his' outside ihco?re and the 93

               10 percent figure means very, very little, then I can't help but

               11 be worried about the amount of effort he puts into the program

               12 and the amount of time he puts into his private practice.

                              In summary, I would like to know who'runs the

               14 consortium; I would like to hear'a little more conversation

               15 about the real ability of this individual to run this

               16 program.  And I would like'to have some further insite into the

               17 financing.

               18             MR. TOOMEY:  The consortium has agreed that

               19 Washington University will be the grantee agency.  And they have@

               20 an arrangement through which Washington University is the,

               21 really, grantee agent,  although the three do work together,

               22 but it is Washington University.  Dr. Guzzi, I believe, was

               23 the name of the man from the medical school who is responsible
               24 as.far as Dr. Stoneman is concerned.' You know, as a fellow
  Ace-Fedeial Repofters, Inc.
               25 in management, I think I would agree with you under most






     eak 6                                                                   77



                 I  circumstances.
                 2            However, there are.some circumstances and this I
                 3have seen, that peopld have varying degress or Varying kinds
                 4of abilities.  Dr. Stoneman's ability is one in which he became
                 5a participant in the program as a volunteer member of the
                  faculty when he was a member of the faculty of St. Louis
                 6
                  University.  He is thoroughly dedicated to its goals, even its
                 7
                 8present goals.  He is, I would-sa.y, an extremely capable person,,
                  although to be honest with you, he would be better off if he
                 9
                  were trained in management rather than in surgery.
               10
                              But he has been trained in surgery and within, if
               11
               12 you will excuse me, those limitations, he.does a rather
                  fabulous kind of job.  He does need somebody who is trained
               13
                  in administration who understands the kinds of things that you
               14
                  are talking about to work with him.  He relates well to all of
               15
                  the universities. He relates well to all of  the  other
               16
                  physicians.'. He relates well to his own staff.  They are
               17
                  extremely loyal to him, I think-in every way, by  every
               18
                  indication. @He relates extremely well to the, if  ou will,
                                                                    y
               19
                  the power, the financial and economic power structure in
               20
                  the community.  They have a great deal of faith in him.  Perhaps
               21

                  too much
               22
                              I think this is one of the cases unlike the
               23
                  neighbor that he has in Columbia, M@ssouti, where I think the
               24
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               25





                                                                             78

      eak 7


                I  is concerned, we did ask him about this and he, his work

                2  is done basically at night-and on weekends as far as his home

                3  surgery is concerned.  I know it is a 'roblemand I don',t
                                                        p

                4 know any way around it but he says that in order to supplement

                   the income that he receives from the RMP, that he continues
                5

                6  a small private practice.  He also does continue. with his

                7  teaching at the St. Louis Oniversity.

                8             DR. PAHL:  Doctor, I would like to comment on

                9  Point 3.  You raised the question about what the control is

               10  over the total income of coordinators.  At the present time,

               11  there is no policy within RMPS, H$M.HA, or department that

               12  know of that provides any control over total income, other

                   than the usual ones of not being reimbursed twice for presumably
               13

               14  the same time expended.

                              However, there is increasing concern being expressed
               15

                   and much more so in recent weeks from both RMP and also the
               16

               17  department- andwe have been interested in this matter for quite

                   awhile ourselves.  Not so much the total salary as the matter
               18

               19  of part-time direction of RMPS programs and whether programs

                   which are running at $2,million a year-can,,in fact, be
               20

               21  effectively conducted without the full-time direction of

                   the chief executive officer.  It is almost impossible for
               22

               23  any single program in HSMHA to write a grant management

                   policy about salaries because you are very familiar with all
               24
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                   the  roblems involved with time and effort and we "ust get into
               25     p                                             3






                                                                               79
      eak 8


                1  a tremendously complicated activity.  But I shou ld say that

                2  there is very serious concern on the part of people within

                3  RMPIS.and at higher levels about the costs of managing a program

                4  and the results for the monies being expended, and what consti-

                5  tutes good management.  And I think there are continuing

                6  efforts that are partially underway-now.  We have some

                7  analyses going on now and I think we will be trying to develop

                8  some-reasonable kind of statement so that we can improve

                9  the management of these programsIwithout at the same  time

                   trying to impose.nonworkable definitions of time and effort that'

                   NIH and others have found so impossible to.implement.


                               DR. SCHMIDT:  We have two or three issues on  the
               12

               13  floor.  One other one that has been brought up is whether this

               14  region really is ready for' triennial status given the stated

                   efficiencies in the review process particularly in the area of
               15

                   discretionary funds and whether they h@ve the adequate
               16

                   review and decision mechanism that even meets the  minimal
               17

               18  standards set by RMPS for the use of discretionary  funds.

                               MR. TOOMEY: Let me comment on that  a  moment,
               19

                   because there was difference of opinion as to its  readiness
               20

                   to assume the responsibility for a triennial status.  And  I
               21
               22  guess what we did was to compromise the situation which  was

                   to say, triennial status but review at the end of the  year.
               23
               24              DR. SCHMIDT: Sister, were you,going  to  comment?
  Ace-Federal Reporters, Inc.
               25              SISTER ANN JOSEPHINE:, Yes, I would just like  --






                                                                               80
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                 I mr. Toomey, has this program done anything to provide services

                 2 in Cairo, Illinois?  I know this was requested.

                 3             DR. SCHMIDT:  The answer is no.


                 4             John?


                 5             DR. KRALEWSKI:  Just a couple of questions and

                 6 comment here that might go along some of the lines you were just

                 7 outlining but on the budgets it wasn't,clear to me whether we

                 8 were giving them money to add staff.  You were recommending

                 9 $750,000.  They were running 517 or -something suc;was that, the

                10 way it looks@  Could you,dlar.ify that for me quickly, what will

                11 they be able.to do with the 750?  Along with that are you

                12 recommending developmental component?

                13             MR. TOOMEY:  We were recommending full-time people

                14 rather than part-time people as associate coordinators  to

                15' replace the part-time coordinators that were at Southern'I'llinoi

                16' and at the other universities.

                I17            'Rather than having them as linkages to the

               @18 universities, having them in the area of rural health, urban

                19 health and taking a segment of the responsibility for the

                20 structure, itself, we were recommending in addition to that

                21 only,the deputy coordinator.

                22             DR. KRALEWSKI:  Do you recall how many FTEs that

                23 would add?

                24             MR. TOOMEY:  Four.
  Ace-Fedetal  Reporters,  Inc. DR. KRALEWSKI: Four?  And were you recommending
                25








      eak 10
                   developmental component?

                 2             MR. TOOMEY:   No, no. I. guess it is  semantics  but

                 3  it is called discretionary- funds.

                 4             MR. KRALEWSKI: One other comment  I  don't  know  if


                 5 I am reading this data, you know, from our book here

                 6 right or not.  But it seems to me that last year in terms

                 7 of the award that we gave them which  essentially  was  supposed

                 8 to be used for, you know, for the, to carry on their

                 9 program, develop some other projects then d evelop. a three-year

               10  program for us.  It appears that they implemented some 22 pro-

               11  jects with it at very low level funding and now  we  are  coming

               12  back this year and asking to inc rease that low level funding

               13  for all but two of the 22, up to, you know, much more substantial

               14  funding.  And I raise the question over whether,you know, that

               15  indicates any real,, you know, ability to really handle

               16  the question over what projects should we implement and how

  e 6          17  should we-best handle some funds.


               18


               19


               20


               21


               22


               23


               24

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                                                                               82
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         arl     I            MS. HOWSEAL:  This region had its budget stated

                 2 for three months in order to phase in to our three-cycle review

                 3 process, and they operated with the funds to discontinue some

                 4 of their old process and initiate some of the new ones with

                 5 this last three months funding, and they did it only with the

                 6 three months period knowing the projects could be turned off

                 7 if the reviewers felt they didn't have merit, but it's not

                 8 any--- they aren't projects started a year ago, they are brand

                 9 new projects being started the last three months of this presen--

               1.0 year, and it is because of our need to bring the region into a

               11' different review cycle that that this was done, not because

               12  of the


               13             DR. KRALEWSKI:  22 projects?

               14             MS. HOWSEAL:  Not only 22.  Some of those were

               15  held over from the last year.

               16             DR. KRALEWSKI:  They don't 'show that unless

               17  well, I may be reading this wrong.

               18             MS. HOWSEAL:  The printout probably doesn't  show

               19  when these projects were initiated.  If they were initiated

               20  during the last three months, the printout would probably show

               21  they started at the beginning of the year, when in reality

                   they would only get funding starting October.
               22

               23             DR. SCHMIDT:  Dr. Luginbuhl?

               24             DR. LUGINBUHL:  I would like to wk a question,
  Ace-Federal Reporters,  Inc.
               25  point of information.  I am looking at the budget in the actual






                                                                          8 3
          ar2


                 I  grant.  I note that the budget in the actual grant lists  a

                 2  number of associate coordinators, but they are categorical.

                 3  They are not the kind of associate coordinator that you are

                 4  recommending.

                 5             If this award is made under the terms that  have

                 6  been outlined, what assurance do we have that they will hire

                    the kind of associate coordinator that we are  recommending
                 7

                 8  as opposed to going ahead with the budget?

                 9            I am trying to.get some.feeling for @hat authority

                    this recommendation has, and I.am asking this  particularly
               10

                    because I got the impression that this program had been given

               12   some guidance in the previous year about.the need for re-

                    structuring the organization, and apparently did not follow it.
               1 3

                              MR. TOOMEY:  I don't know that it had the instruc-
               14
               15   tions of the prev.ious year, and I really  can't  answeIr honestly

                    the fact-that they will do what-we say.
               16

                              I would assume if you tell them that this is the
               17

                    basis on which the funding has'been made that'they will
               18

                    consider it directly enough. I don't think they  have  much
               19

                    alternative.
               20
               21             DR. SCHMIDT:  Seems to me at this point to
               22   enlarge a little bit on your question, that what has been
               23   recommended as one-year funding level was site visit, and so
               24   in theory, staff, et cetera, would carry back to the region
  Ace-Federal Reporters,  Inc.
                    the strong concerns of the committee and the assurance that
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                                                                             8 4
        ar3

                   the committee would be looking at what they have done, during

                2  the coming year.  And the  stick    that one has is the

                3  funding level or the'second and third years of'the triennium,

                4  if you wanted to use a bigger stick, what the committee

                5  could do would be to recommend withholding the triennial

                6  status and give them one more year, and have them revise

                   the trienn@al application and come in in one year with the
                7
                8  triennial request.  That would be a bigger stick yet.

                              Let me just ask a very simple question that hasn't
                9

                   been asked for a year or so around this table, but is this
               10

                   a viable region?


                              MR.,TOOMEY:  Yes.
               12

                              That's a simple answer.  But you have got interest
               13

                   in the community, you have got interest on the part of the
               14

                   medical profession, you have got a great thrust coming out of
               15

                   southern Illinois, as I see it,_in the future. You have,
               16
               17  you really'.have.  A personality of the man.  He is a good man

                   running that 9MP.  You have got-capable, qualified staff.
               18
               19  -You have got an interestin education.  You have -- you really
               20  have the backing of those three universities.
               21            One of our concerns had been that the university
               22  was exercising too great influence.  In actual fact what

                   they were doing was evidencing great interest.  Now at the
               23
               24  time that it was categorical, I am sure there was great
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                   influence coming from the university in terms of their
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                                                                            85
        ar4

                 I  pro3ects.  Right now what you have is great interest on the

                 2  part of the university in.extendin g its own services and its

                 3  own concerns through RMP.

                 4             So I think there is no question, as I look at the

                 5  total picturelthat this is a very viable organization.  This

                 6  was one of the reasons why despite our discussion as to

                 7  triennial status that we felt with all of these pluses,

                    despite the fact that you can focus on the minuses very
                 8

                 9  easily, in light of all of the intangibles, that this has

                    potentially a great future.
               10

                               DR. SCHMIDT:  Do you feel that the turf problem
               11

               12   with Illinois is a minor one or'moderately serious one or

                    very serious one?
               13

               14             MR. TOOMEY:  Well, I don't know how to evaluate it.
               15   We talked to Dr. Snoke who was out of the governor's office.
               16   He is not ready to make the decision himself.
               17             DR. SCHMIDT:  Dr. Snoke is totally confused by the

                    whole thing.  You wouldn't be able to get anything but confu-
               18

                    sion out of Dr. Snoke.
               19
               20             MR. TOOMEY:  Certainly the-recommendation that

                    the-two groups get together and there is some indication
               21
               22   that can declare areas  of  prima.ry concern which would be
               23   southern Illinois for the bi-state RMP, and perhaps what we

                    might call a DMZ in the Springfield area in which there would
               24
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                                                                           86

    ar5


                 I             But, you see, southern Illinois is up in the

                 2  Springfield area and relates to bi-state as far as its school

                 3  is concerned so that there are some problems, and this@perhaps

                 4  would be one of those areas in which there is an acceptable

                 5  overlap.

                               DR. SCHMIDT:  Dr. Thurman?
                 6

                 7             DR. THURMAN:  1 would just agree with Mr. Toomey's

                 8  analysis.  I think in answer to your question, it is a

                 9  viable region.

               10              My second question there, is there a motion on the

                    floor?
               11
               12              DR. SCHMIDT:  Yes, there is a motion on the  floor

                    made by  the principal reviewer.  I am not sure it was seconded.
               13
               14   I will ask at this time if the motion which was to-wit,

                    "approval of the triennial status without approval of the
               15
               16   developmental component, but with  discr.etionary.funds to  the

                    tune of 1.15, year one; 1.230, year 2; 1.316, year three"  --
               17
               18   is that the motion?

                               MR. TOOMEY:  With review at the end of the first
               19

               20   year.
               21              DR6 SCHMIDT:  That's correct, with review, with'
               22   a site'visit? In one year prior to the making of  the  second
               23   year award.

                               Is the motion seconded?
               24
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                                                                               87
         ar6


                I              Dr. Thurman?

                2              DR. THURMAN:  I would like.to offer a substitute

                3  motion going along with  the funding, but withholding triennial

                4  status with preparation of a triennial application for next

                5  year.

                6              DR. SCHMIDT:  All right., is there a second?

                7              DR. LUGINBUHL:  I will second.


                8              DR. SCHMIDT:  Substitute motion is seconded.


                9              Let me ask someone whether or not this would cause

               1.0  some breakage or to what extent would this be thought

               11,  detrimental?


               12              MR. TOOMEY:  I think I'd defer this to somebody

                   who knows the area better than me.
               13

               14              MS. HOWSEAL:  'Well, there are two sides of the

               15  story.  One is the tougher problem and how this will be

               16  settled in the next year.  That obviously is a consideration.

               17              The second is that this region last year came in

               18  with a triennial application and staff said that at that time,

               19  is that correct, that they weren't ready for' triennial status

               20  at that  time and held them off an additional year?

               21              Their program plan seems pretty well in order.

               22  But it is the organizational problems that need to be worked on

               23  I think it

               24              DR. SCHMIDT:  The question ig, breakage, damage
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                                                                            88
          ar7


                               DR. LUGINBUHL:  I have h-eard discussed several

                 2  times in the last day and'a,half this question  of  breakage,

                 3  or.injury to a program by the use of too severe measures

                 4  to try to bring about remedial action.  It appears to me the

                 5  two measures that are available are,-one, some form of budget

                    reduction; and, two, withholding :triennial status.  I would
                 6

                 7  gather that both of these have been employed on a  number  of

                 8  occasions in the past.  It would be ver  helpful to me in
                                                            y

                 9  voting on this kind of a question to get some  indication  of

               10   what kinds of damage have actually been observed  from  these

                    classes of action in the past.

                               In other words, has this really resulted in
               12

                    significant injury to some programs, or is this a concern that
               13

               14   possibly has been weighed too heavily?  If that is the case,

                    it would obviously indicate to me that we should use these
               15

                    measures more freely rather than  less-freely.
               16

               17              I just don't have any feeling for what effects
               18   these actions have been on  prog.rams and just how real a threat.

                    it is.
               19
               20              OR. SCHMIDT: I will try  to  answer that.  I think

                    that as you hinted At yesterday, the committee during the
               21
               22   five or six years that I have watched it,. has chosen the
               23   route of not stressing region, if there was  a question of too

                    .much breakage, it opted not to stress the region in that
               24
  Ace- ederat Reporters,  Inc. way. Usually other routes'kor effective action have been
               25





                                                                              8 9
     ar8

                    taken.   Either the chairman of the ite-visit committee,

                    such as  Sister Ann, or the director of the program, or
                 2

                 3  somebody went out and got to the people who had to listen

                 4  who were in a position to do something.

                 5             Then either the coordinator was removed or the RAG

                 6  chairman was removed or the.RAG structure was altered.  But

                 7  I don't think that a club has been used with enough force

                    in the past, to answer your question.
                 8

                 9             The committee, if it's erred, has erred on the side

               10   of being conservative,@using these other routes to get  the

               11   messages back.  And I -- actually the committee has talked,

               12   and staff knows the talk about stopping  funding,completely

                    of a region, for.example, withdrawing regional status,  let
               13
               14   alone,, you know, something else.
               15             And these methods have not been used for really,
               16   if you look back the regions, Indiana will be coming up,

                    which has more or less a cataclysmic  year that was achieved
               17
               18   really through two site visits in a row,.and we will be talking
               19   about that.

                              So that I ask the question.quite deliberately from
               20
               21   my experience, that sometimes you will run the danger of
               22   the RAG.or some of the critical.people just throwing up their
               23   hands and saying the hell with it, and going away.  And  we

                    haven't taken that risk deliberately in the past.
               24
  Ace - edeal Reportefs,  Inc. Mrs. Flood7
               25






                                                                          90
     ar9


                I             MRS. FLOOD: I would like to  comment.  My  point

                2  of view as to the potential breakage, I think the member

                3  universities of the consortium expressed to the site visitors

                4  a concern to fulfill their participation in the guidance of

                5  the regional medical program in the new light of RMP de-

                6  emphasizing the medical school,-oriented projects and

                7  emphasizing more trends toward a programmatic approach.

                   Seemed to be no qualms on Dr. Po-stals part
                911           I think that this is'true, Dr. Schmidt's  po.int,

              IQ   that perhaps the.problem of withholding triennium status

              11   to this particular region, which I think is viable and  has

              12   potential, would in a way give these consortium  people

              13   that feeling to heck with the whole thing, we have tried, but

              14   may be going the wrong way, and now we are getting no backing,

              15   and because of the tougher problems, not giving,them potential

              16   with some secure funding for the future of these years, I

              17   would put in a word for the triennium.

              18              DR. SCHMIDT: The issue should be  clear  for  the

              19   committee then.  The substitute motion would withhold the

              20   triennial status, but do everything else that the  original

                   motion did so that you will be voting really in effect on the
              21

              22   triennial status with the substitute motion.  Are you ready

              23   for the question?
              24              All right, all in favor    do you understand that

  ce-Federal Reporters, Inc.
              25   if you vote yes, you will be voting to withhold triennial






                                                                               91
       arl 0


                I  status?

                2             All in favor of the substitute motion, please  say

                3  aye.

                4             Opposed, no?

                5             The motion is defeated.  The original motion  then

                6  is for triennial status, et cetera, et cetera, as I recited it

                7  before.  Are you ready for that question?

                8             DR. SCHLERIS:  Like' to have a little discussion

                9  about the discretionary funds which sound like    evelopmental
              101  component to me.

              11              DR. SCHMIDT:  I will try to speed this up by comment-

              12   ing.  I @hink probably the reason they want them is to be

              13   able to compete with the Illinois regional medical program

              14   that does have these funds it can sprinkle around and stimulate

              15   this in their back yard, and they have got to beable to

              16   stimulate this in their back yard in order to  e a  e to

              17   develop the sorts of things that will change their  direction

                   that we are telling them they,have got to'do, and we have

              19   discussed before that sometimes the regions that deserve  the

              20   developmental component least need the funds the most in order

              21   to have flexibility, et cetera, and'I would assume that  this

              22   is the situation there.  Is that accurate?

              23              MR. TOOMEY:  That's accurate.

              24              MR. HILTON:  Are we endorsing the concept of
  %ce-FedeF31 Reporters, Inc.
              25   discretionary funds for other regions? As -- seems to  me  we






                                                                              92
         arll


                 I  had some discussion about the.developmental component versus

                 2  discretionary funds at some earlier region some months back,

                 3  this came up then, too.

                 4             Are we saying that this is a viable option for

                 5  folks who don't qualify  for  the  developmental  component?

                 6            DR. SCHMIDT:  I think that each region,almost has

                    to be looked at individually.  obviously the answer to your
                 7

                 8  question is yes.  But we aren't making any general pronounce-

                 9  ments or anything else.

                               DR. PAHL:  Dr. Marg ulies indicated  to  me  that
                10

                   'he will be presenting this general-topic of discretionary
                11

                12  funding  and developmental components and other names by which
                13  these funds.go before the forthcoming October council, not
                14  trying to make a policy at that time, but to clarify the issues

                    and perhaps come out with a def initive statement, because we
                15

                    do not have a general pronouncement  and  obviously  we  are
                16
                17  getting into this  area.

                               At the moment you are free to act as you choose
                18
                19  on individual case-by-case basis.

                               IR SCHMIDT:  I think we will kind of restrict this
                20
                21  to a couple more comments.

                               Dr. Luginbuhl?
                22
                               DR. LUGINBUHL:  Two  quick questions.  If we are
                23
                    indeed giving the developmental component, why don't we
                24
  Ace -Federal Reporteis, Inc
                    call it that?  Why do we use some other name?
                25






     arl2                                                                         93



                                 And number two, is the letter  that  goes  to  this
                 2   program, or is the advice that-goes to this program going
                 3   to include some expression of  concern  about  having  a  part-
                 4   time director with a -- with another outside activity?

                 5               DR. SCHMIDT:  The answer is yes.

                 6               All right, I am going to call the question, unless

                 7   there is some -- something new                      . St simply
                                                        Because we are 3u

                 8   not going to get through our day's work unless we shorten this

                 9   up.

                10               DR. J-AMES: The question  comes.then  to  my  mind,

                11   in this kind of situation, if, in fact, there needs to be

                12   some restructuring of organization and which eventually

                13   results in restructuring of program, then monies that are

                14   already allocated, if in fact they could.not be redirected,

                15   I am at a loss to understand why there should be.-- why

                16   that the RMP should be awarded additional funds for --


                17   whether it is called developmental or discretionary, when in

                18   fact it would appear that the base monies that are available

                19   need restructuring and when that is done, and    used to

                20   restructure, organize..restructure program,  then  it,  to  me,

                21   would show that the whole program then can very well use new

                22   funds for development, once it gets its base straightened out.

                23               DR. SCRMIDT:  I think the way I will answer that

                24   is to say that the committee just voted not to deny triennial
  Ace-Federal Reporters,  Inc.
                25   status.  That means that in the committee's opinion, the region




                                                                          94


       arl3


                I  has the ability to make the necessar y decisions to expend the

                2  funds they have wisely.  One category of which is loose and

                3  not earmarked for projects now, but is, quote, discretionary,

                4  unquote.

                5             All right, I will put the question.  All in

                   favor of the motion, please say aye.
                6.

                7             And opposed, no.

                8             There are "nos," but the "ayes" have it, and the

                9  motion is carried.

               10             I think that we will at this point take a no more

               11  than, 15-minute break and start again promptly in 15 minutes.

                              (Recess.)
               12


               13


               14


               15


               16


               17


               18


               19


               20


               21


               22


               23


               24
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      mea-1
                                                                         95
      CR 7149
      #8

                               DR. SCHMIDT: We are'qoing out to the great state

               2
                    of New Mexico which has the largest regional advisory  group

               3
                    in the history of the program.
               4               During your comments I hope you will discuss  why
               5
                    they have a regional advisory group that seems to include the

               6
                    whole population of the State of New Mexico.
               7               MR. HILTON:  For'the record I can't be heard.  For

               8
                    the record, okay.

               9
                               Just a few preliminary comments and I will make

                    them very brief in view of the pressure of time.

                               My talk deals with specific sources, very general

              12
                    items, before we go into specifics to kind-of sensitize  you

              13
                    to some special problems of the New Mexico area.

              14
                               I should mention that since-the submission.of the

              15
                    printed documentation on New Mexico we have received much

              16
                    new data, as recently as the day before yesterday a phone
              17    call giving us additional information which I will bring  up

              18
                    at the appropriate points throughout the report.

              19
                               We were under, during our site visit, some time
              20    pressures.  The New Mexico Program staff had taken the

              21
                    liberty of preparing quite a fairly well stated    using

              22
                    overheads, other kinds of materials which pretty much blocked

              23
                    in our time.  lie were forced to subdivide ourselves and
              24    fractionate their well-organized plan in order to get a  lot
  kce-Federal Repottefs, Inc.
              25
                    of ground covered we wanted to cover.





       mea- 2                                                                9 6



                                 Some points pertinent to  the'consideration  of  this
                 2
                      region: The state is large -geographically  w.ith  a  population
                 3
                      of slightly over a million.  The  geographical  expansion  of
                 4    the state creates special problems that the region has
                 5
                      attempted to address itself to.
                 6
                                 The state  is  multiculturallemphatically  solwith

                 7
                      the major cultures being Mexican-Ambrican,  Anglo  and  Indian
                 8
                      and the feeling generally being that efforts to improve
                 9
                      health care have to take that fact into account  and  try  to

                10
                      work with the 'facts rather than try to change it  and  smooth

                      everything out and work with some kind of easy  glossy  kind  of
                1 2
                      program.
                1 3
                                 The state is poor,  I have been  told.  I  haven't

                1 4
                      been able to verify this.  The  military  installations-are  a

                15
                      major source of employment in  the  state.  Continued  support
                16
                      therefore for any of the projects being conducted by the

                17
                      program staff has been exceedingly difficult and if you look

                18
                      at some of the projects listed there, RMP has a largely

                19
                     .young staff, CHP agencies not awfully prominent  in  the  state.
                20               Then RMP in the absence of very forceful

                2 1
                      representation on the part of'these other kinds of health

                22
                      concerns in the state has really become very prominent.

                23
                      That prominence has been greatly  helped  by the large RAG,'
   0            24
                      that is a relatively new.development there.
  Ace -Federal  Reporters,  Inc.
                25
                                 But we had some concern, still speaking





      mea-3                                                                  9 7



                     generally, that R14P has become the center for so many things
                2    in New Mexico that we may in fact be  supporting  activities

                3
                     that in other states would be supported by other resources'.

                4               Going item by item, at a fair clip, too, through

                5
                     our evaluations, our site visit report, I should mention

                6    that the primary purpose of the Visit was to review their

                7:   '73-175 application, triennial application, and to assess
                8    their progress since June, 1971 site visit.

                9
                                In conducting that meeting for that  purpose,  we

               10
                     observed the following things:  That the goals of RMP as

               11    stated in materials certainly seem to be in keeping with the

               12
                     RMPs' mission, the increase in  availability,  improving
               13    quality care, moderating the costs of care,  et  cetera.

               14
                                We had some problem with the goals and objectives

               15    in that there seemed to be an absence of  measurable  short-

               16
                     term objectives in the context of what the  program  was

               17     ttempting to do.
                     a

               18               General priorities have been  identified  and

               19    there is a listed rank-order which aids the program i  n

               20    making decisions about what we found that if  resources  are

               21    reduced, et cetera.

               22               Under the area of accomplishments and

               23    implementations,, program staff has' stimulated several

               24    worthwhile activities throughout the state.     They do o
  %ce-Federal Reporters, Inc.
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                                                                                9 8
      mea-4


                 I    Registries, involvement in  the hatch area of  New  Mexico',,
                 2    programs internally to aid   staff,  things  involving  processing
                 3    centers, and a computer budget   monitoring  system  so  they

                 4    can determine on a moment's notice-how much they have got to
                 5    spend in each item, a cultural training laboratory which has
                 6    already'done some things and plans other things that will
                 7    help with that multicultural-nature.of the state I referred

                 8    to earlier.

                 9               They are developing'a statewide sys@ for
                10    statewide hospitals to  centrally  purchase  items.  The  hope  is
                11    they will.be able to reduce costs  of  certain  aspects  at  least
                12               other health agencies within the New Mexico
                13    region, as I pointed out  earlier,  do  rely  pretty  heavily
                14    upon the NRMP.  They have become the primary agency for

                15    data analysis in the state.
                16                Physicians do look upon the program for
                17    professional and technical assistance, consultation,

                18    information, et cetera.
                19                Under the area of  continued  support because  of  the
                20    problem of the general impoverishment  of  the  state,  they  have
                21    not been able to do as well as we'would have liked to have

                22    seen them  do.  There  have  been  some  accomplishments.  We
                23    have encouraged other kinds- of things be done to get

                24    additional help.
  kce-Fedetal Reporters, Inc.
                25                Dr. Stone of the medical school in his




       mea-5

                                                                          9 9


                     discussion of his grantees, stressed I think very  clearly

                 2   that the medical school-is unable to pick up many of these
                 3   kinds of efforts that they would like to. He'was  kind  of

                 4   emphatic about that.

                 5              On the matter of minority interests, the majority
                 6   of the-statels'population percentagewise is one minority

                 7   or another.  Representation on the program staff of

                 8   particularly the Spanish-speaking group was in my  opinion

                 9   quite poor; not my opinion, the team agrees on this,  that

                     representation was quite poor..  Very few professionals, very
               10

                     few clerical.


                                Now, it should be pointed out one of the  new
               12

                     developments that I referred to earlier that we did receive
               13

                     in our phone call information that the RAG for RMP has
               14
               15    met as of September 16 and that at that meeting they
               16    declared their intention. to initiate an affirmative action

                     plan which would remedy some of our concerns in this area.
               17

                     Even since our meeting with the NmRmp staff there were
               18

                     improvements in that additional persons were hired between
               19
               20    the time of our site visit and the time of the September 16
               21    meeting.  So there was visible evidence of intention  to
               22    improve an affirmative plan and it seems to suggest there wil.
               23    be greater pickup in this area-.
               24               I had the opportunity to get into the New Mexico
  kce- Federal  Reporters,  Inc. area a few hours earlier than I had expected I would  so
               25




       mea-6
                                                                         10 0


                      during that period Dr. Gay, the coordinator there, arranged
                 2    that one of his staff  would show me around. I did  get  a
                 3    chance to visit a couple  of the clinics and some of the local
                 4    reservations to get a kind of firsthand feel for what the
                 5    staff's relations were on the community level.
                 6              The staff, especially in the  community  health
                 7    service section of the NRMP staff, is pretty community-
                 8    minded, generally young, have not been as aggressive, at leas:
                 9    not as yet, as I would have liked to have seen but potential
               10     is still there. Talking to a-number of staff, even in the
               11     setting of the clinics,  and talking to the people in  the
               12     clinics, we were very well received.
               13               The manager of one of the  clinics I talked  to
               14     had great hopes for a continuing relationship and a

                      developed relationship.
               15
               16               We  did  something in this particular area in this
               17     region.that I don't know how frequently it is done; it  has
                      not been done on anything that I have had yet.  We  invited
               18
                      from the general audience comments, criticisms really,  any
               19
               20     kind of thing anybody wanted.to say about RMP, pro or  con.
               21     We did that somewhat expecting that we would be blasted'i
                      especially from the Spanish-speaking section of the audience
               22
               23     but found that on the contrary, while there were things that
                      people had to say and they felt very strongly about them,
               24
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                                                                        101
       mea-7




                     Seemed to be opposed to NPMP adtivities'that it was doing

                2
                     better than before and doing 'well.

                3
                                Concern seemed to center around its not doing

                4
                     enough or what it is doing isn't fast enough to please.  The

                5
                     general feeling was even from the opposition that the program
               .6
                     is having an impact.
                7
                                Again I relate this to a large degree to the fact
                8
                     of expanded RAG which was expanded by the way to intensify

                9
                     representation from throughout the state.  So our
               10
                     recommendation with regard to the minority area is that

                     there should in fact be increased representation.  More

               12
                     needs to be done certainly.

               13
                                Dr. Gay has provided, who is the coordinator,
               14
                     James Gay, has provided pretty strong leadership in the
               15    NMRNM. It should be pointed out it is another one of those
               16
                     programs which has undergone some pretty cataclysmic change
               17    in the past 12 months or so.  In fact, there is evidence
               18
                     of how change was, had been.undergon'e and was still
               19    undergoing. at the very.time we were meeting with the NMRNM
               20
                     staff; the changes being some of the literature we have had

               21
                     up to the moment of our going there to review and discuss was

               22
                     updated in the process of their presenting their visuals.

               23
                                one area for example, prominent instance of this

               24
                     was the complete change in management operations right in
  Nce- Federal  Reporters,  Inc.
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                     the middle of our visit, you might say, moving from a




      mea-8

                                                                        102



                     matrix kind of setup in which  staff operated on a task force

                2
                     kind.of basis, issue-oriented basis back to a more
                3    conventional organizational staff.
                4
                                We kind of got the feeling when this was cast on
                5    the screen that it was not only new to us but probably to
                6
                     mucn of the staff, as an indication of how this is

                7
                     developing.

                8
                                Throughout that, however, Dr. Gay,I think

                9
                     impressed us all with his ready  willingness to learn, his

               10
                     enthusiastic willingness to learn.  He.seemed to be

                     listening 'and took notes throughout the session of the things
               12    that were in fact being said.
               13
                                We began to feel a change both in the site  visit

               14
                     and of course with these recent phone calls.  We have.seen

               15
                     things happen since the site visit that go well I think

               16
                     generally.

               17
                                Dr. Gay has established excellent relationships

               18
                     with health providers and he@lth-related agencies in New

               19
                     Mexico and I guess that is best testified to by the fact
               20    that a great deal of them, if not all of them are on the RAG

               21
                     in addition to considerable consumer representation.

               22
                                With regard to program or core staff, the

               23
                     decision to dedategorize the program staff structure,
               24
  @ce-Federal  Reporters,  Inc. moving away from the traditional emphases appears to have
               25
                     been sound and effective and carried out, though you will





       mea-9
                                                                          103


                  I   notice in the projects themselves that there is still a kind

                  2   of mix of traditional emphases, plus-some of the newer things

                  3   that are coming   out.

                  4               Now,  traditional programs, or  I  should  say  the

                  5   projects, old projects  listed  in  your  printouts  have  been

                  6   supplemented by a  variety  of  what  they  call  developmental
                  7   projects, which we can go into some.discussion on a little

                  8   later on, but these  developmental  projects  then  are  to  be

                  9   run directly by the project staff.

                10                And there more than in the  old  projects  we.  see

                11    a real  emphasis  on  new  directions.  The  community  health

                12    services section of  the  NRMP  staff  represents  the  truest

                13    form of what  I  would  call  a  thrust,  one@of-the@truest  forms

                14    that I have seen in NRMP.  In fact, if you look at the

                15    projects, one gets the feeling as mentioned in another

                16    program, it said it was  being  a  program,  it  is  a  collection

                17    of  projects.  However,  in  their  reorganization  and  in  going

                18    back to more  traditional  organization  of  staff,  they  have

                19    gotten at least some of the i   dea of thrust.

                20                Community health services represents a compilation

                21    of kinds of projects in an area that relates to working with

                22    clinics,  working  in  Indian  health  rehabilitation,  workin g witli

                23    consumers; that thrust  also  has  become  what  they  call  their

                24    community response system.
  %ce-Federal Reportefs, Inc.
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      mea-10
                                                                         10 4


                     statewide basis and the exact dimensions of how that  shall
                2    be accomplished, by the 'way, I am not entirely clear, from thE
                     site visit ahd not satisfied from the material received
                3
                     subsequently that it is really all worked out yet, but  their
                4
                5    hope is that through a number of mechanisms available to them
                     the community health services com onent will be felt through-
                6                                     P
                7    out the state and will be the primary source, nerve center,
                     for receiving suggestions for things RMP should do in  that
                8

                     region.
                9
                                They have got a number of approaches, number  of
               I JD
                     ways they can go about doing this.  They have attempted I
               12    think unsuccessfully to use their RAG as a basis for  picking
                     up suggestions of projects and their RAG is quite extensive
               13

                     covering the entire state.
               14
               15               The problem there is that when they try to  hold
                     RAG meetings in Northern New Mexico to cut down the  travel
               16
                     they get the Northern New Mexico side of the RAG.  If  they
               17
                     go to Southern New Mexico, they get the Southern New Mexico
               18
                     side of the RAG so if they hold two meetings in the course of
               19
               20    a year they really get only one side of the state covered  in

                     each meeting.
               2 1
                                So we suggested to them there might be-other
               22
               23    methods they use; they might go to the community health
   0           24    education services which have already devided the state  into
  Ace-Federal Reporters, Inc.
                     four quarters, and to use RAGs or local advisory groups,  one
               25




       mea-11
                                                                           105


                 I    for each of the four; that might be another way in which  the

                 2    community health services group  might be able to pick up in ai

                 3    orderly fashion real grass roots kinds of input.

                 4               There is an interest there in any  event  in  really

                 5    relating more closely to consumerism as it was pointed out

                 6    in part their success or failure would depend  on  bringing  in

                 7    minority staff because as matters stand now there are only

                 8    three Spanish-speaking staff-on the NRMP and this  does  create
                 9    difficultieis in relating lanquage.and  cultural@se  the  people
               10     they are attempting to  reach.

               11                It is very confusing to look at now  on  graphs  and

               12     charts but has additional problems beyond that in  that  it  is

               13     a response system first and foremost.

               14                Many of the accomplishments of the region have

               15     really been in response to inqui ries from people outside of

               16     NRMP who say, "You know,. we need this, that or the  other,"and

               17     then of course the staff has been geared up to just  take  that

                      suggestion and run with it as. a response.

                                 We did have some  cIriticism that there  ought  to  be
               19
               20     more initiation on the part of RMP but we think in that
               21     regard that.people know about the-RMP, certainly not the
               22     case of many regions, so they do feel free to come to it
               23     despite the fact that it is-no@ itself initiating to the

               24     degree we would like to see.it.
  kce - Federal Reporters, Inc.
               25                The RAG seems-almost too large but as I say, it





       mea-12
                                                                                  10 6



                      does reflect combining of, a   broad  representation  and  I  think

                  2   more importantly, reflects a combining of two kinds of life

                      of the  program.'
                  3

                  4               lihen Dr. Gay took over, he inherited some   of that

                  5   and  felt  in,his judgment rather than trying to erace   what   had

                  6   come  before,  to integrate it in  a  newer  and'bigger  scheme.

                                  We had less problems with the RAG than the internal
                  7

                  8   organization,numbers of committees, task force kinds of

                      committee structures using RAG and staff personnel to carry
                  9

                10    out the programs' objectives.

                                  Again new  information.in  response  to  our  criticism
                11
                12    of the number of committees of which  there  were  some  14  in
                13    number,the September 16 meeting had at least, there     was some

                      indication in the September 16  meeting  that  these  would  be
                14

                      reduced to nine.
                15

                                  Consumers are  more  than  adequately  represented,  by
                16
                17    the way., on the present RAG and I think this is certainly

                      necessary in view of the fact of  the  limited  impact  of  CHP
                18

                      in the area.
                19
                20                One of last yearls.concerns,  in  response  to  the
                      Executive Board, as authorized it increased from eight t8 i     i
                21

                      members.
                22

                                  We also have some  concern relating again back to
                23

                      the coordinator that'the structures that had been
                24
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                25    developed did not allow enough coverage of central

                  I





       mea-13
                                                                            10 7


                      administration; I guess,, to 'ut it-another way, if Dr. Gay
                                                  p

                      got sick that the whole thin g seemed it would fall apart.
                 2
                      He didn't have enough direct help at the top.-
                 3
                 4               They responded to that too.  The nine-s3xteen
                 5    meeting did endorse the recommendation that there be two
                 6    deputies, one for support services and one for operation in
                 7    the programs that would assist Dr. Gay and in that way
                      further unite or bring together the organization.
                 8
                 9               The grantee agency, you know, of New Mexico has
               10     provided excellent administrative support to the RMP.  The
                      medical school no longer has-as it once did excessive
               11
                      dependency upon RMP,and grantee  and RAG relationships are
   *7E  149    12
        nd #8         quite good.
               13


               14


               15


               16


               17


               18


               19


               20


               21


               22


               23


               24
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                                                                              10 8



        7149                  One evidence  of  the  relationship  between  grantee
    4L  9        2  and staff, we were able to' determine what appeared to be in-
     ,ba 1       3  credulous, but
                                    delightful situation where the grantees is
                 4  apparently providing virutally rent-free facilities for the
                 5  'LIIUIP as they move into additional space. I say virtually becauSE

                 6  I don't know if that ever was investigated to ejeryhody's

                 7  satisfaction but it looks that it might in fact be the case.
                 8            On the matter of participation, key health interests,

                 9  institutions and groups are participating in the-program, this

                10  accounts again for the size of the RAG. We did hear from the

                11  'Red Cross ronresentative, the president of the New Mexico

                12  Nurses, the CHB representative, the Medical Association, Dean

                13  of the Pharmacv School, even testimony from    a dissenting

                14  student from the medical school locally, on    some of the activi-

                15  ties, but at least everyone was   there and the general feeling

                16  was that the problems remained with problems of-the rate

                17  of change-.

                18            We did have two recommendations  Iunder the  area  of

                19  local planning, site visitors were made aware of some problems

                20  arisen in regard to providing P@,IP prop osal to CIIP in advance.

                21  and for CIIP comment and there was feeling that this should be

                22  done so that CTIP would have the opportunity  to  respond  well

                23  in advance of a proposal going to us.
                24            The site vito'rs recommend that  the Chest projects,
  kce-Federal Repoiters, Inc.
                25 community  health education serVipes  projects  should  in  fact






                                                                          10 9



           If 9
                   create four local advisory grou
                                                  ps in the next year to provide as

         2
                 2 they are willing to undertake the appropriate responsibilities

                 3 and resources, their share.  lle did have concern about'the

                 4 actual representation on such a broad scale of the state and

                 5 we think.if representations focussed locally, as v7as  proposed

                 6 through the use of the community health education services-,,

                 7 that they will have more meaningful participation on  the  part

                 8 of each representative.

                 9           Feeling was that no one in the Norhteastern New

               10  4exico would be motivated to be concerned about Southwestern

               11  New l@lexico and to look really carefully into that but if the

               12  northeastern end of it has its own LAG, Local  Advisory  Group,

               13  relating to the program that you would get a lot more particip-

               14  ation and there would be a focal concern with the  local  needs

               15  there, other matters of assessment of needs and  resources  you

               16  may have seen some of the very nice little brochures, the

               17  informational services office of this outfit is great.

               18            Publications that they made available,  some  studies

               19  they have done on various aspects of NRMP activities,  maybe  a

               20  set of these booklets, some 14 or 15 in number on the table

               21  over'there. The orogram has done a good job of compiling

               22  community health profiles but again, I think that is'the

               23  last program we reviewed, there is a problem in utilizing this

               24  information in carrying out the                         TI
                                                 ..projects and programs.  -iey havc
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               25  done agood research job on this, at least  the  material  looks






                                                                               110


          if9    I  good, it is well written  material,, easily readable  and  I  have
   Rcba 3        2  got about 20 pounds of it  in the mail in advance of the site

                 3  visit.
                 4            The progrm does need to include assessment of need
                 5  and resources as criteria for review for determining program
                 6 staff activities;. programs should make  better  use  of  the  data
                 7  base for the fund priorities.  -under the area of management the

                 8  site team was impressed with the innovative management pro-
                 9  cedures and rated this as quite excellent, inclu@l among those
               10 a processing-pool, means  by  which  speedier  and  neater  pro-
               11  duction of information materials could be produced and also

               12  their   moni toring, compute r monitoring sys tem.
               13             Budgdt:  Other matters of evaluation,t,t-he full-time
               14  evaluation director comolements-the  agency  and  works  well  with
               15  PAGS evaluation committee.  Members of the evaluation committee
               16  staff and'PAG T3artic.ipate in the-programs  activities  where  new
               17  programs are developed  and  technical  review  committee  sessions
                @18 where the proposed programs are-technically reviewed.
               19             The team endorsed review quarterly progress reports
               20  by the evaluations committee and  these  are  required  by  all
               21  project directors. Other matters of  program  proposals  NP-,MP
               22  describes developmental projects as those considered'as line
               23  items under program staff.
                              This matter of te rminolo'gy was brought up. We had
               24
  %ce- Federal Reporters, Inc.asketch in which it was the effort of the coordinator, the
               25








       #9         1  entire staff to characterize RMP's and to define within that


    'reba 4       2  broad characterization exactly where NM4P came to rest.

                  3           Three models described to  us  were  the  traditional

                  4  P,@IP, the transitional PJIP and the developmental RMP. NMIP

                  5 classified itself as the last type  that  had  the  flexibility

                  6 within program staff to function quite  well  in  a,variety  of

                  7 areas and to really bring about chang@ -.-iithout depending  on

                  8 branch occies, some really object  to  that.  Some  asnects  of

                  9 their overall program in fact do look transitional.

                10            I alreadv commented on the character of the projects

                11  -they.wished to sulDport.  They ranged from the old categorical

                12  through the AIIT.,C right now to their developmental programs, the@

                    described what seemed to be pretty relevant kinds of thrusts.

                14  They want developmental component funds which will be used

                15  to study feasibility of identified program opportunities.
                16            The establishment procedures for reviewing new
                17  program proposals will be utilized for developmental component
                18  requests. Under dissemination  of  information  a  program  has
                19  efficiently disseminated information to key groups, other healtl
                20  related institutions. The team did  suggest  that  the  program
                21  could more advantageously utilize one  of  the  most  important

                    health resources that they apparently-are not using, the Lbvela(,
                22

                    Foundation for Medical Education and Research located in New
                23

                24  @--lexico.
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                25            I think we  should be strong on this, we would want






                                                                            112



             9     it to be collected in the advice letter to this region.

    @-ob,i 5     2  Utilization of manpower and facilities, the site team was

                 3 interested in and enthusiastically supported most of the new

                 4 directions, the new types of manpower that were described.

                 5           Ilowever, they were somewhat frustrated by the

                 6 fact that they still are basically intentions and are not well

                 7 developed programs of activity.  This.relates somewhat to

                 8 the response concept, responding but  not.initiating.  Again,

                 9 in talking'N,7ith some of the staff in certainly the areas, they

               10  have very good ideas there among this young staff.

                             There seemed to be some-iincertainty, however,  and

               12  I had here the opportunity to speak very personally with a number

               13  of the staff, seemed to be uncertainty as to whether  or  not

               14  these good ideas could in fact be implemented. There was some

               15  uneasiness and I am not certain whether the uneasiness is what


               16  it was or whether it was when the administration of the local


               17  PMP would-endorse them, perhaps both, I think the site visit

               18  in that regard would have been helpful.

               19            I think the leadership, we were liberal, encouraging,

               20  patted on the back where appropriate and withhold support where

               21  appropriate. There are some technical legalities on  some  of

               22  the projects.  Several of them in fact appear to be designed

               23  to assist established health professions, training programs of

               24  one kind or another,, specifically dental assistants, medical
  Ace-Federal Reporters, Inc.
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                                                                           113




           #9    1            This is a matter to be looked at very closely. The
   0
    T)eba 6      2 Programs intentions to emphasize new kinds of paramedical

                 3 manpower are laudatory but plans in this area are  not  yet  well

                 4 defined perhaps because of the uncertainties that I have

                 5 identified.  Through a variety of their programs they have

                 6 in fact contributed significantly to the  improvement  of  health

                 7 care in the area.

                 8            There are four New Mexico communities  who  applied

                 9 for a national health service core assistance  with  the  help

                10 of the NPJ-IP staff and there are several other projects, at  the

                11 'Tierra Maria Community Clinics where there have been some

                12 marked good apparently. Short term pay-off, reasonable to

                13 expect, the operational activity is proposed will increase

                14 the availability and the accessability to service groups and

                15 enhance the quality of care in the next two or  three  years,  it

                16 was the general judgment of the site visit team.

                17           Tie did at the time of our site visit on this matter

                18 of regionalization encounter some discomfort  on  this  matter

                19 of whore shall the control lie.'Dr. Gay had inherited real

                20 Problems because of the apparent emphasis on decentralization

                21 of N@IRP resources prior to his assuming that role.

                             In response to that condition  which  was  ve.ry
                22
                23 limited, created a lot of problems for him, he moved rapidly

                24 toward centralizing, p'utting everything prett,,7 much under the
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                25 central Albuquerque office control and there   appeared to  be

                       h @1 nne-iiiicyp @nri f-hp -- f-hp I,)nrTiincre of the an-olication and







                                                                       114


            9
                I  the thinking of the staff some uncertainty as to this issue

   'Peba 7      2 of, decentralization versus centralization of effort.

                3           1 think as we talked about the need for  represent-

                4 tation, the plan of using the local Chest LAGS, et cetera,

                5 that there began to be a feeling on the part of the staff and

                6 part of the coordinator, that there is a middle  road'between

                7 these.tv;o extremes.


                8           It remains to be seen whether or not this will in


                9 fact come out.in the wash.. But I have a strong @ling it

               10 will because-we approached the topic from several  different'

               11 directions from the point of view of projects and point of view

               19 of local tenresentation, point of view of staff recruitment


               1 3even.


               14           Not for example be able-to recruit people from  one

               15 community that is    to which they are indigenous to one  end

               16 pf the state to travel to the other.  You are necessarily

               17 talking about some kind of decentralization in that area as well.

               1 8          DR. SCHMIDT:  Bill, I.will ask if you can try to

               19 wrap it up in about five more minutes at the most.

               20           MR. HILTON: I think I can do it in two.  The region

               21 has provided evidence that they are trying to attract other

               22 support. They have not been successful largely because  other

               23 support really has not been available in many respects but we

               24 urged them to try it out on that and they said they would but
  kce - Federal Reporters, Inc.
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                                                                           115


        .a 9                The'state apparently is poor and local industry  is

        8       2 limited, too, in what it can contribute. All'in all this  is
                3 a general I guess,kind of summary of this before' we go into

                4 matters of budget, it was the site visits' feeling that on  the

                5 basis of what'has happened since Dr. Bay assumed office  that

                6 this is basically a strong program in need of-some guidance and

                7 counsel.

                8           They are willing to learn. It is not a program which i@,,e

                9 are going to be having to taDe record the same message  each

               10 year, at least we did not leave with the feeling it was. It  is

               11 ripe for counsel on some of its directions and goals and  so

               12 forth. And it is basically a pretty strong program.  I  think

               13 with that I would normally defer now to our second  reviewer

               14 who hapnens to be Sister Ann Josephine. Since she had to  leave

               15 she did leave me some notes, summarizing any questions or

               16 comments she had.

               17           I have not had the chance to look over the notes  but

               1 8I could do that you know, or while we are awaitin g questions.,

               19           DR. SCI-E-4IDT: If these notes Are legible why  don't

               20 you pass them down to the end of thelt-able and let staff-

               21 look at them, and we will ask him to summarize what she  hag

               22 to say Very briefly, And why don't you go ahead  with-recommen-

               23 dations?

               24           MR. HILTON: All right.  Site visit team recommended
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               25 that '.TtIP-dtIP be approved for triennial status for 05, 06 and 07






                                                                               116


           f-9   I  years and that developmental Component be approved  with  the

      b 9        2 condition that a mini-site visit be made within the next year

                 3 to-review the region's progress.

                 4           On the.matter of budget, briefly, the  request  was

                 5 in the area of program staff, $1 million 319,000.  Site visit

                 6 recommendation was $830,000 on-that.figure. Developmental

                 7 component request was for $138,000. Our recommendation was

                 8 $120-,000. operational projects request was for $223,000,  we

                 9 recommended $350,000 which does in fact include $118,000 for

               10  the tumor registry which in the -oast was reflected in  their

               11  program staff, moving into their operational -projects.

               12            DR. SCII,%IIDT:  This is.the first year or for all three

                   years?

               14            MR.'IIILTON:  First year and carryover, I think carry-

               15  over,   let's see.  Yes, for all three years.

               16            DR. SCHMIDT:  Level funding for three years?

               17            MR. HILTON:  Right.

               18            DR. SCHMIDT:  Frank, have you had time to glance

                   through Sister Ann's comments?  Could you cover anything there
               19

               20  that might be in addition to what Mr. Hilton has covered?

               21            MR. SCHIIIOWSKI,:  Basically, Sister Ann has six

                   statements here, I will rapidly  mention  these.  Onb,-Sister
               22

               23  Ann comments that support from other-resources must be developed

                   and this is, further supports the site visits team recommendation
               24
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               25  underneath the criterion number 3, continued support, and second

                 I







                                                                                   11 7



             9    1  comment deals with her concern that maybe the developmental

                  2           t should be reduced.
    Peba 1.         componen

                  3             There is no questionmark or     there is  no exclamation

                  4 point so I don't know how to interpret       this.   I am surprised.

                  5 The third comment deals with the question of whether @14PS,should

                  6 nrovide consultation and this deals'with the statement, if the

                  7 program is interested and seriously intends to facilitate state

                  8 11110-planning, it should bring people with appropriate experience

                  9 in managerial and financial aspects of HI,10 planning.

                 10            We tried to iron this out before the site visit


                @@ll report was written. This is one point that      was not clarified

                 12 and was asked to be included in-this. The       fourth point-deals

                 13 with underutilization of information due to lack of knowledge

                 14 of the resources availability. Again,, Sister asked for guidance

                 15 by R@IP staff to insure adequate use of available data in plannin(.,-,

                 16            The fifth deals with    evaluation process. And suggests

                 17 that evaluation process needs to be implemented. Then the

                 18 final noiht, final point concerns the tumor registry project

                 19 which is -- it is a question what plans are there to Phase this

                 20 out between the local Cancer Society.

                               These are the major concerns.
                 21

                               DR. SCILklIDT:  Is there  an answer to that la   st qtestion-,
                 22

                 23            MR. HILTON:WE spoke with the tumor registry people

                 24 Concerning this. We were impressed with the importance of the
  Ace.-Federal Reporters,  Inc. activity, apparently beyond'tliose who are directly involved with
                 25






                                                                                 8


            ,49  1  it.  There is also a feeling of its worth.  But  again  apparently

         11      2 they have run into something of a brick wall in terms of

                 3 attempting to get support for it. The feeling seemed to be

                 4 that the resources simplv were not there.  Ever@,one agreed

                 5 it was a good thing to have.

                             Of cou@se those who were closest to the  project  felt
                 6

                 7 more stronglv about it. We did.suggest that more aggressive

                 8 efforts should be made to seek-cohtinued support for  the  effort.

                             They assured us they would continue to try but  t  ere
                 9

               10 was this feeling of a real  frustration, that the  effort  really

               11 wouldn't pay  off so why bother in the first place  kind of

               12 thing.  That  in fact efforts in the past'despite  the amount  of

               13 @7ork that had been put into this by one of the physicians

               14 closely involved with it in attempts to recruit assistance

               15 have been so futile that there did'not seem to be any  real  drivcz
               16 on the part of the people who were  supporting  the  tumor'registrv

               17 to go out and as one guy said you know spend days, weeks and

                  months at trying to do something that simply was not there.

                             DR. SCIUIIDT:  We do have a motion on the floor.
               19

                  Is there a second for the motion?
               20
               21            DR. ELLIS:  Second.
               22            DR. SCI-EIIDT:'  All right, it is seconded, so we are

                  ready for  discussion. I believe first, well, let's see, John,
               23
               24 you have got the microphone.  When-you are through you can
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                 'hand it to Dr. Schleris.
               25

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                                                                                119
      CR7149


        #10-ter-1
                                DR. KRALEWSKI:  A   couple of  questions  and  comment.

                  2  One, I am in agreement that the state is a poor state and pro-

                  3  bably has some Limited ability to share in the    funding  of  RMP

                  4  Programs.

                  5             On the other hand there is a lot of Federal money

                  6  going into that state, OEO Programs in the state, HMO, a

                  7  couple HMO planning grants, I-believe,there is a National

                ,8   Center Health Services Demonstra  tion Grant, and I was wondering

                  9  how much effort is being devoted by the RMP Gro@ to,,:you',know,

                10   intermix their programs with  these  programs,  and.make,  you

                11   know, these funds useful to  some of their activities.

                12              Number two, one of the questions in the past was

                13   just how much of this budget is going to support that      medical
                141  school, I wonder if you would comment to that to see    if   theyl
                15   are really breaking away from it, and number three,,the dommenti

                16   on the question of.whether they,  should add staff with HMO
                @7   capabilities.

                18              I am not so sure they  should,  perhaps,  if  these

                19   other agencies of HMO Grants, like  the  Loveless  Clinic,  et
                30   cetera.  If they are developing that kind of talent, maybe-RM-P
                31   should stay out of it.

                22              MR. HILTON: Taking your questions backwards, I

                23   agree with you, our feeling was,  our  general  feeling  was,  and

                24   we do have a minority report on that by   the way,  that  they
  Ace -Federal Reporters, Inc.
                25   probably should, in fact , use the resources that are existent





      ter-2
                                                                             120


                  I  in their HMO planning.

                  2             Medical school support, one of the things that was

                  3  shocking to us or surprising, where we could not see they were
                  4  getting that much out of it.  They were giving away grant.
                    There was involved staff -- staff involvement, more specifically
                  5              1

                  6 on that.  The Dean, at the time we talked to'him.was on his

                  7 way to, I believe it was Harvard for a course in fiscal

                  8 management, and when we questioned him about this, he said,

                @9  perhaps that is why they have, in fact not benefited or

                jo  exploited the situation as much as they probably   could, and,

                    .in fact, may, in years to  come.

                12             But on the  matter  of other Federal help, perhaps,,

                -   Frank can give us  something  on that.
                13

                               MR.  SCHNIOWSKI:   In terms of coordinating with the
                14

                    two HMO Grants in  Albuquerque.@ 'Dr. Gay is on the board of
                15

                    one of the HMO  planning  groups and he is actively involved
                16

                    with the other one.  I had rather not  comment on why there  is
                17

                    two grants in one area.
                18

                               DR. SCHMIDT:  Miss  Kerr?
                19

                               MISS KERR:  Speaking. of other Federal funds available
                20
                21  I, too, was concerned when Bill was talking about the educationd.-

                    programs and as a point of information, the week of,Octobeir 8th
                22
                23  to 13th, there will be 75 hand-picked people, 25 each from the
   0            24  regional medical program, the New Mexico Medical Society and
  Ace  -Federal  Reporters,  Inc. from the Department of'Education, and they are bringing in two
                @5

                  I




      ter-3
                                                                                 121



                  I  consultants; one of them is myself, to talk about health

                  2  care education programs, and what might be available in the

                  3  State of New Mexico, maybe this is one reason they are-turning

                 ,4  to'this kind of conference, I hope.

                  5             DR. SCHMIDT:  Dr. Scherlis?

                  6             DR. SCHERLIS:  Do I read the application correctly,

                  7  that they are asking for 35 new staff positions, is that

                 '8  correct?

                 @9             MR. HILTON: You  are  a"little  under.  They  are,  in

                 10 fact, asking for, let us see, no, they  were  asking  for  25  new

                    .positions.

                 12             DR. SCHERLIS:  I added it up and got 35, I guess

                 1-3 from the pages 59 up to 62, or three, but  they  are  asking  for

                 14  something within that range?

                 15             MR. HILTON:   Yes.

                                DR. SCHERLIS:  Looks  like it is  closer  to  30.  The  1
                 16
                   .other question I have is in terms of page 30 of    your   site-visiti
                 17

                    report.
                 18

                                Do I gather that you all looked   at their individual
                 19

                 20 projects, And suggested a level of funding    for each  development,!

                    of'their developmental programs?
                 21

                                MR. HILTON:  What we  specifically did,  was  to  look
                 22

                    at their developmental programs.  We did this in a couple of
                 23

                    sub-group meetings.  There was such a lump of some involved
                 24
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                 25 there, in that area that we thought we better look and see what





      ter-4
                                                                                 122



                  I   it really was going into, so we did invite discussion from

                  2  those closely involved with the projects to get a clear under-

                  3  standing in our own minds, rally, what they had in mind; what

                  4  they were planning to do.


                  5              Yes?


                  6              DR. SCHERLIS:  I don't mean to suggest that this

                  7  was not the way to do it, but you assumed they had good

                  8  judgment and evaluation mechanism, and priority system that

                  9  they are able to set up their own developmental program.

                 10              What you have done-is,X out most of it, then turn

                 11  around and  give them a develo mental component and say, "Do
                                                    p

                 12  with it what you like."

                 13              I know the hour  is late but  this  is a rather

                 14  interesting approach.

                 15              MR. HILTON:  If I can recall   again, Frank, I   will

                 16  ask your assistance on this, too.  The're were clues which

                 17  preceded our taking this action with regard to the new programs
                 18  And, by the way, the team visit was chaired by Dr. Tamiroff,(?)l

                 19  of a hospital in New York  who  was  on  vacation, so he was not

                 20  present at this particular meeting.

                 21              As I recall, one of our   reasons for. taking this

                 @2  particular approach was  some  indication  we  got from earlier

                 23  testimony that  some  of  the  program,.referring, particularly

                 24  about the health education for public, there had been some
  Ace -Federal Reporters, Inc
                     intervention in the program thing, on the part of the
                 25





     ter-5
                                                                         12 3


                    Assistant or Lieutenant Governor of the state, which had

                 2  bloated that figure from something closer to $50  thousand  to


                 3  $250 thousand.

                 4             That may have prompted us to look closely  at  some

                 5  of the other new projects.  There is no p@an for that expansion

                 6  between what we recommend and what they ask for in health

                 7  education but that was not entirely a.staff decision, either.

                @8  That was, in a large measure,'a-result of -- I am not sure,


                    is the Lieutenant Governor a member of the RAG?


                10             Yes. That was largely the resiilt-of  the  represen

                    ation on the RAG.  And, I guess what we  found ourselves doing

                12  then, wai sort of going through these.projects with the staff

                13  to kind of weed out or give them an excuse for weeding  out

                14  some things that had developed,. problems they had inherited with

                    their RAG.
                15

                i6             DR. SCHERLIS: -Point'of information     the  AHECS,

                ,i7 was.that a'one"year shot of.funds?

                18             Was that planning or what?

                19             MR. SCHNIOWSKI:  There is four, National   Advisory

                    Council recommended approval for four geographically dispersed   1
                20
                I                                                                    i
                    community health education systems throughout the state.  These
                21

                22  are four separate projects, twenty, twenty-two thousand dollars

                    apiece.
                23             DR. SCHERLIS:  Was that just one year?  What is goinc
                24
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                                                                              124
       ter-6


                  I             MR. SCHNIOWSKI:  That is right.

                  2             DR. SCHMIDT:  This  is one year planning.

                  3             DR. SCHERLIS:  Was  that just planning?

                  4             DR. SCHMIDT:  Planning, yes.  other comments,

                  5 other issues,to raise?

                                MR. SCHNIOWSKI:  I would like to mention one factor.
                  6

                    I am not disagreeing with Mr. Hilton when he stated in concern
                  7

                    of the area of minorities but I think it is good to point out
                  8
                                    m,'s Reqional,-,--AdVisory Gro.up contains 44 minority
                  9 that the Progra

                    group representatives.
                10

                                This has tremendously.increased under Dr. Gay,-

                    from previous years.  The  executive  committee  has  increased
                12

                    from eight to eleven members.  Five of the eleven members are
                13

                    minority group representatives.  At the time of the site-visit,
                14
                15  the Program staff had  three  minority  group  representatives,

                    just on the program staff.
                16

                                After we left and made our  recommendations, our
                i7

                    suggestions, I might say, to the total site-visit, Dr. Gay    has
                18

                    increased this from three to six program-staff members.  All
                19

                    minority members on his RAG are actively  involved  in  all  of
                20
                    the committees and the one weekhess,we,did  point  out  was  wL
                21
                i
                22  certainly recommended an increase, we-thought he was maybe'doing
                23  not as good a job as he could, in terms of hiring program staff.

                    And, this is the main-weakness in terms of minority members.
                24
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                                I don't want to
                25





      ter-7
                                                                           12 5



                 I             DR. SCHERLIS:  How large is,RAG?

                 2             MR. SCHNIOWSKI:  One hundred sixteen members.


                 3             DR. SCHERLIS:  That can be representative of a lot

                    of the population.

                 5             DR. KRALEWSKI:  The whole population.  May I make

                 6  a comment?

                 7             DR. SCHMIDT:  Right.

                 8             DR. KRALEWSKI:  This-budget again, if I understand

                 9  this correctly, we are recommending more money than they are     i

                10  asking for on operational proj'ects?

                11-            MR. HILTON:  Only because of the tumor

                12             DR. SCHMIDT:  There is a switch of"fuhds  from up

                13  on top to down in there, actually-

                14             MR. HILTON: Yes, what we have done is  taken  out  thei
                15  tumor registry which was listed in their request, their   initiali
                16  request for program staff.  The distinction that has to  be  kepti

                    in mind here, is what they have'donethey have got two   sets
                17
                18@, of projects.

                               One, under program staff; and one  operational pro-
                19

                20  ject which is separated out. And we simply  removed  from  prograA

                    staff their tumor registry project, and reduced that whole
                21

                22  figure substantially in terms of the other projects under that.

                               DR. SCHMIDT:  Other questions?
                23

                24             Or issues?
  Ace-Federal Reporters, Inc.
                               DR. LUGINBUHL:  I would like to question the tumor
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                                                                          126
       ter-8


                 I  registry.  Seems to me that a very good test of the work of a

                 2  program is the ability to find.other funding and the fact that

                 3  th'is,program has not been able to find other funding suggests

                 4  to me that possibly it is  not quite as valuable as it might

                 5  appear at first look.

                 6             And I may be speaking from a general bias, because

                 7  I have not been impressed with the value of tumor registries,

                 8  generally, and I have yet to see any very hard data that suggesq!

                 9  that these have had a major impact on even the care of cancer

                10  patients, or advancement of our knowledge in this area.

                11             So, just as a general principle, I would favor fundi@(

                12  these programs from local resources, and  if  these  are.not

                13  forthcoming, I think this may be a measure of their true   worth.

                14             DR. SCHMIDT:  Well, the question has been answered,

                15  so I will limitlyour answer to what your  estimation is that they

                16  will seriously attempt to find  funding for that on the local.

                17             MR. HILTON:  If rather emphatic advice is made to

                18  them in an advice letter to them, I think  that  might  help

                19  to spur them to try again, harder this  time.  I  would  not

                20  make it strong enough though to make a  contingency.

                21             DR. PERRY:  I have the same  question, Sister, and

                22  asked about the amount of the developmental component here.

                23  This is one of the largest ones tha@ is being earmarked of
                24  'all the programs.  I would like a little fruther justification,
  Ace-Federal Reporters, In c.
                25  you know, that they are really capable.





        ter-9                                                               127



                  I              The questions that have been raised on some of the

                  2 problems that have been developed, I would like you know, a

                  3 little further comment on just that one part.

                  4             MR. HILTON:  With regard-to that developmental com-

                  5 ponent, as  I recall, in our deliberations-, we really did not

                  6 give that particular matter a great deal of thought.  We

                  7 certainly did not feel they should get as much as they requeste@

                  8 on it.

                  9             The question raised earlier, concerni.W the develop-

                10  mental program has been kind of turning round in my head

                11  since he raised it, because I.-can@see th  e direction he is

                12  heading,--on that.  Yes, we are all in agreement that under Dr.

                13  Gay's leadership, it all seems to promise real well for the

                14  future, but the reason. the developmental programs that are

                15  listed on page 30 of the site-visit report went       went the kind,

                    of sky thing that we gave.them, was because of the -- some of
                16

                    the builtin problems apparently in terms of what kind of input
                .17

                    would be made  to the program  de..spite Dr. Gay's'influence, et
                18

                19  cetera, and you know, I would have to, in view of that fact,
                20  and in the contention in which it was raised and I would also
                21  have to look myself, again, at the component as it now stands.
                22             I would, at this point then, perhaps, Frank, can
                23  recall some things I am forgetting now, with regard to what
                24  your deliberations were on the developmental component.
  Ace-Fedetal Reportets, Inc.
                               MR. SCHNIOWSKI:  I think Dr. Scherlis is concerned
                25




       ter-10                                                          12 8


                 I  with the developmental component.  Again, we have to kind of

                 2  repeat the statement that-the region indicated to us, that they

                 3  were going to control these through program staff, and'use

                 4  them as a line, item budget.

                 5            Our recommendations to treat these as individual

                 6  pro3ect activities, not as a line-item-budget within program

                 7  staff, reviewed by the RAG, monitored,by their systems, and

                 8  reviewed by CHP.

                 9           'Thus $222 thousand, which we recommend for these

                10  activities in essence, is taking this amount of money and

                11 -moving it down into the operational project area, not keeping

                12  it up at the program staff level.

                13            DR. SCHMIDT:  I would like to move the group along

                14 to making any specific modifications of the recommendation,

                15 or whatever.

                16            Mrs. Flood?

                              MRS. FLOOD:  I don't mean to delay the continuance
                17

                   of our schedule, but I do feel that there is some aspects of
                18

                   the economic picture of the Sta:te of New Mexico, that although
                19

                   it has been covered in some measure, should be expressed at
                20
                21 this-time.

                              I think, if you take.into consideration, the sparsely
                22
                23 populated areas of the state,-with the only large urban

                   impact area being in the City of Albuquerque, w3th the tremen-
                24
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                 i dous population of minority groups with underdeveloped educatio
                25





     ter-11
                                                                     12 9



                 I  oppor tunities, the economy of the @tate is only'dependent,

                 2  truly, on the military and the many diversified aspects of

                 3  military inpu@ there, Los Alamos, et cetera.

                 4            That, to put the pressure on discontinuance of pro-

                 5  grams, even the tumor registry, although I am not in a position

                 6 to state whether it is a value project at the moment,  but  to

                 I put the burden of pay or maintenance of this type  of  project

                 8  on the people of the State of New Mexico, at this time, is just

                 9 not feasible, it is not a realistic approach.

               10             There is not that forthcoming economic base  to

               11  support programs at home, so I would be reticent to offer  any-

               12  thing other than a recommendation to not cut program based  on

               13  the fact that they have not been able to find other methods

               14  of support locally.
                              DR. MARGULIES:  I wonder if I might comment, because!
               15

                   I think the comment just raised is terribly important  in  our
               16

               17  deliberations.

                              This is the most painful type of  consideration  we
               18
               19  have to go through.  If an activity, over a period of time,  is

                   not able to find other means of support, it either suggests
               20

               21  that it does not merit other support, or there.are no resources.,

                   Now, if there are no other resources available, that is a kind
               22
               23  of deficiency of a systemic kind which we are not in the
               24  position to resolve.
  Ace-Federal Reporters, Inc.
                              Whether it is the problem of the economic status of
               25




      ter-12
                                                                         1 30



                 I  New Mexico, or as is much more common,  the unavailability of

                 2  third party funds to pay for a service  which is  generated  out

                 3  of a demonstration activity, et cetera.

                 4             If RMP funds, or any other program like ours, which

                 5  is developmental, remain in support of some project or activity

                 6  because there are no alternatives, rather than becaus6.it

                 7  belongs there.  It very rapidly exhausts our resources, and

                 8  really cannot move.  In the case of the tumor registry, it

                 9  might be even more difficult to justify, because@here are

                10  so many doubts about the effectiveness of that as a program,

                11 but this is valid even when you  are  supplying  a  demonstration

                12  activity'in a service, and it is especia lly  troublesome,  when

                13  what you are doing, is really worth doing; but if  we  begin  to

                14  supplement Medicaid, or other types of activities with  RMP

                15  funds, we are lost.

  e-10/s-11     16

                17

                )8

                19


                20


                21


                22

                ?3

                24
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   CR 7149
                                                                          131

   Take 11
                 I             DR. SCHLERIS:  I know you are anxious to move us

                 2  along but my dilemma is I still haven't reached in my mind

                 3  how I would react to this and I think that is the position

                 4  of your review committee.

                 5             Looking at some of the projects for which they are

                 6  requesting support for the 05 year, some one, two, three,.

                 7  four, five of them began in the 01 year and if we give them

                    funds now to set up new projects, we are going to be faced

                 9  next time.with these being in the 06 and 07 year, as well

               10   as the new ones that have come aboard that they can't phase

               11   out because of lack of support

               12             My concern is that if everything that is started

                    in New Mexico has to be continued indefinitely because
               13

               14   there are no alternative methods for support, we better

                    avoid starting new proqr ams unless we know with assurance
               15

                    that they can be continued or unless we have the feeling
               16

               17   that our.beuget will be rising proportionately over the

               18  -years to take care of this.

                              Also, I reflect the-concern of the site visit
               19

               20   group which was impressed with.the fact that many projects

               21   go on through core, which means they really don't get the

                    evaluation they should get under other types of surveillance,
               22

               23   one way is to move them out of-core, the other is to insist

                    that all core projects have the same type of review.
               24
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               25             I am in a dilemma as far as the $120,000 for





                                                                              1 32


     dor 2


                  I  developmental since there are ways of cutting projects out

                  2  that have been continued'now-to the fifty year.

                  3              Will you respond to that?

                  4              MR. HILTON:  Well, I think what you have succeeded

                  5  in doing is pulling me into the dilemma with you a little

                  6  bit, however, I'did recall  some  discussion  with  Dr.  Gay,

                     that he has an intense interest  in  having  available  the
                  7

                  8  capability and this again harks.back to something said

                  9  either today or yesterday.in one of the other pro
                                                                         ,grams.

                                 He has an intense interest in having the dapabilit
                10                                                                    y

                     to be flexible in programing..
                11

                                 I think this is where  the  whole  discussion  of
                12

                     developmental component came up  in  the  first  place.  In
                13

                14   fact, we discussed at some point. his desire to:,be able  to

                15   rechannel funds in areas in which he felt there was    great

                     need.
                16

                               .There  may, in fact, and I  am  uncertain  of  the
                17
                @18  details on the  other  program,  .1 @here may, in fact, here be a

                     need for that kind of flexibility in order for NMRMP to become
                19

                     a better program.
                20
                21               I have, and  again, I think I am speaking for the

                     team, cons iderable   confidence in Dr. Gay's  ability  to  do
                22
                23   this in such a way  that  NMRMP does, in fact, become an
                24   asset, whether or not it be dote through discretionary funds
  O,ce  -Federal   Reporters, Inc.
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                                                                          13 3
     dor 3


                 I  flexibility ought'to be  there.

                 2              I am confident under his leaderwhip it will be

                 3  used to the benefit of the program.

                 4              Would you second, or any.comment with regard to

                 5  that,,Frank?

                               MR. SCHNIOWSKI:  Not to beat it to death, but the
                 6

                 7  Tumor Registry Project has drawn outside support from the

                 8  National Cancer Institute.  They rate this as one of the

                    three best registries in the nation, that is their judgment.
                 9

                               The project director, Dr. Key, has approached
               10

               11   the area of continued support.in the wrong manner.  He has

                    been advised by one of the -- Dr. Tucker, who  talked  to  him
               12

                    aside, and indicated it would be much  more  efficient  to
               13

                    approach continued support th rough the medical   stafft of
               14

                    the individual hospitals as well As with the hospital
               15

                    administrators which he had been working with in the past.
               16

                               By the end of  173, they will have  only  three
               17

                    remaining projects which  they  originally  were'funding.  One
               18

               19   of these is the tumor registry-project.  The  other,  we  have
               20   recommended the EMS project that has been going  on  for  four
               21   years to be locked with the new  EMS.activity,  which  was
               22   recently funded from RMPS.

                               The third projdct  is-their  leukemia  @ymphoma
               23
               24   project which was started in  their third year.
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               25






                                                                             134
   dor 4


                               DR. THURMAN:  I just want to add a minority report

                    to what Dr. Margulies has said.
                 2

                 3             A well-run tumor thing is a real asset.  Remember

                 4  during the Civil War we didn't think stethoscopes were

                 5  any good.

                               DR. MARGULIES:  They ate now?
                 6

                               DR. THURMAN:  Depends on the doctor, Harold.
                 7

                 8             DR. SCHMIDT:  I presume that resolved everything

                    for us.
                 9

                               PR. SCHLERIS:  I will listen to him on registries
               10

                    but hardly on stethoscope.
               11

                               DR. SCHMIDT:  All right.
               12

                               Does anybody want to do anything in.regard 'to
               13
               14   developmental component, then?.

                               I will ask for any amendments and we will test
               15
               16   out the  development.al component first.
               17              Does anyone wish to propose an amendment to the

                    main motion concerning the developmental component?
               @18

                               DR. SCHLERIS:  I was going to suggest two things.
               19
               20              One thinq,I think we would do this region a favor
               21   if we reduced.their total grant because it will make them

                    get rid of some of the projects they have had ongoing for a
               22

                    long period of time.
               23
               24              If we want to give the'coordinator of the New
  kce -Federal Reporters, Inc.
                    Mexico program some potential mobility, we wouldn't give it
               25





                                                                            135


     dor 5

                    .to him if we give'him money for projects which EMS  might

                 2  want to phase out.

                 3             I guess I also suggest reducing the developmental

                 4  component.  I was thinking in terms-of droping that 1.3

                 5  down to 1.15,, the second year, 1.2, the third year, 1.250, but

                 6  even that is being generous, but I think developmental

                 7  component should be significantly cut.

                 8             DR. SCHMIDT:  Would you make

                 9             DR. SCHLERIS: Drop it down to 80 th2,usand, 80

               10   thousand for each of the three.years, developmental component

               11   and the first year, the 05:'.y&.ar' 1.15; second, 1.20; third,

               12   1.25.

                               DR. SCHMIDT: Do you make that in  the  form  of
               13

               14   a substitute motion?

                               DR. SCHLERIS:  Yes,  sir.
               15

               16              DR. SCHMIDT:  This  includes approval of the.

               17   triennial status obviously.

                               Is there a second?
               18

                               It is seconded.
               19
               20              Discussion then will revolve around the substitute
               21   motion and we will limit discussion to the impact of this
               22   level of funds and their ability to do what they want to do.

                               Are there any comments?
               23
               24              MR. HILTON: Is there'an  assumption  here  that
  Ace - Federal Reporters, Inc.
               25   there is an inordinate number of programs that will be running






                                                                        136
   dor 6


                 I  beyond the 05 years?

                 2             DR. SCHLERIS:. Both the number and quality of them.

                 3  They are going into the 05 year now,-and if we'are going

                 4  to talk about a triennial status for a region that is

                 5  attempting to, as you say, get mobility, I don't think you

                    have mobility if you continue these projects and I think
                 6

                 7  this puts on them the onus of deciding what they are going to

                 8  continue.

                 9             Also, you have looked at their developmental

               10   programs, it was apparent you thought many of them were

               11 . markedly overfunded as far as what they were requesting.  I

               12   think this gives them the opportunity of sharpening up what

               13   they are looking at and I think $120,000 is an excessive

               14   amount, particularly since they are involved now with helping

                    implement the Emergency Services Medical Program, which will
               15

               16   absorb a great deal of staff and time because they are

                    funded for two years on that, aren't they?
               17

                              And this is going to absort more than they
               18
               19   recognize, as far as being involved, even though they may

                    not be the contractual agency.
               20

                              MR. HILTON:  At this  point I am inclined to
               21

                    agree with you on developmental component, which I might
               22

                    move as a motion after we defeat this one.
               23
               24             But on the.matter of continued programs, as I
  Nce-Federal  Reportefs,  Inc. understand it, there ire only three projects that will be
               25





                                                                        3 7

   dor 7


                 I  continued beyond the 05 years,  one of them being  the tumor

                 2  registry.

                 3             MR. SCHNIOWSKI:  I don't see any tremendous

                 4  hangover of dead weight in that regard.

                 5             DR. SCHLERIS: They are requ@@tiiig,:for the  05
                                 1

                    year, the continuation, besides the tumor registry, of
                 6

                 7  five projects. Now what we will be saying  is  beyond  the

                 8  05, but we are talking specifically about 06, 06, 07, isn't

                 9  that right, five projects which add up to  something  like

               io   $170,000 is being requested into the 05  year,  isn't  that

                    correct?


               12              DR. SCHMIDT:  Dr. Ellis, do you have a comment?

                               DR. ELLIS:  Yes, I do, Mr. Chairman.
               13

               14              I just wanted to point out that this  is  such'a

               15   poor area and it seems to me that perhaps the developmental

               16   component moght give them the opportunity to  work  toward

               .17  methods of health delivery that would really mean something

                    in the lives of some of these pepole, and I w-.as  thinking
               18

                    about the opportunity to develop nurse midwives and
               19

                    pediatric assistants and assistants for the elderly and work
               20

                    within that frame.
               21

                               But I was thinking  that technical  assistance,
               22
               23   it seems to me, might be helpful.in getting them  to  make
               24   the right choices in terms of program  without  necessarily
  Ace-Federal  Reporters,  Inc. penalizing them.
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                                                                              1 3 8
  dor 8


                  I              DR. SCHERLIS:  I just want to make one comment.
                  2  I am aware of their needs, and I would agree with       you.  There
                  3  are certain programs they  might  move  into  but  I  don't  see

                  4  any assurance that we  have  been  given  that  this  is  the

                  5  direction that they will take, as far as the expenditure
                  6  of their funds and the continuation of projec'ts.they have.

                     had, do not seem to be in that direction.
                  7

                  8              This is the other reason for my statement, not a

                  9  failure to- recognize their needs.
                10               DR. ELLIS:  Would you think that technical
                11  -assistance  might provide this way so we wouldn't have so
                12   much lag between the time that these problems appear?
                13               Some  of  these  are  very  long-range  problems.
                14               DR.  SCHERLIS:  Right,  but  we  are  talking  about
                15   developmental  component  and  triennial  status,  it   seems
                     beyond a little bit in  time  as  far  as  telling  them  they  need
                16
                17   a little-bit  of  technical  assistance,  this  is  my  concern.
                18               DR.  SCHMIDT:  We   ar.e  assuming  that  staff  is
                19   listenifig@ to this  and  that,  technical  assistance  will  be

                     offered and provided and so on.
                20

                                 John?
                21
                                 DR.  KRALEWSKI:  I  think  technical   assistance   will
                22
                     be useful,  I  think  this  budget as  being  proposed   here,
   0            23   however, under  the  new  recommendation  will  give  them  room  to
                24

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                25   run and develop that   .new thrustI, and if this  is  a  new  order,






     dor 9                                                                 139


                 I  I move we curtail debate, is that an order or is that --

                 2             DR. SCHMIDT:  -Yes, it is.  I will call the

                 3  question on the-substitute motion unless there is a violent

                 4  objection from the committee members.

                               All right, then, we will vote on the substitute
                 5

                    motion, which is triennial at a level of 80 for developmental
                 6

                 7  component and 1.15,, 1.2 and 1.25 for the three years.

                 8             All in favor please say aye.

                 9             (Chorus of ayes.)

               10              Opposed, no?

                               The ayes have it  so the substitution motion
               11

                    carries.
               12

               13              And I believe that the necessary assistance will

               14   be arranged for by staff following this discussion.

               15              I would like to move on to Northern New England
               16   before we break for lunch.

               17              Some of the committee members sneak some pie or

               18   soup or something like this.  So the record will show that

                    Northern New England left the room, Bill Luginbuhl.
               19

                               Dr. Thurman?
               20

                               DR. THURMAN:  This will be surprisingly short,
               21

                    mainly'because the conclusion of our-total visit was that'
               22
               23   this whole RMP is just like starting a first year.

                               I would point out that we had representation from
               24
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               25   the Advisory Council and Mrs. Wycoff, Tom Nicholas and:





                                                                               14 0


     dor 10


                 I  and Roger Warner from  operating RMPS, both  of whom were

                 2  valuable to a new RMP  in'that sense of the  word.

                 3              Particularly a word of the staff, in that I

                 4  think that C. C. Conrad and Spencer Crobin, as well as the

                 5  others with us were quite helpful to this group of people.

                                I mi@ht give you one quick work of history
                 6

                 7  about this about this group because that is where the real

                 8  problem has arisen in the past with Northern New England

                 9  RMP.

               10              It   became operational, had a planning grant in

               11   '66, with its   first operational year at '69.  At that point

               12   in time  a  committee from the Univers ty of Vermont Medical

                    School  actually  ran the program.
               13

                               The man who -,is presently coordinator arrived in
               14

                    the fall of 1969, but throughout all this period of time-
               15

                    their primary emphasis was on developing a data base.
               16

                               Some of  the questions that arose went high enough
               17

               18   to get to the administrator of.HSMHA, for-some type of

                    resolution and that RMP and CHP  tried to arrive at a merger type
               19

               20   situation, too, so that there would not be an overlap of

               21   any-kind.

                               This was partly at the request of the governing
               22

                    bodies of the state itself, to further complicate it because
               23

                    the state was small and because of this experience with RMP
               24
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                                                                              14 1
     dor 11


                 I  experiment in health service delivdry money, they requested

                 2  one dollar and received $932,000 for supplementary health --

                 3  mental health services delivery, so obviously they were not-

                 4  ready to use it.

                 5             This, created even more of-a conflict bet ween the

                    RMP and CHP merger.
                 6

                               What happened was  that they began to listen more
                 7

                 8  an,d-more to the signals from this committee and others, and

                 9  RMP actually began to change  to a true RMP, roughly in

               1.0  January of this year, 1972, with-the appointment of Mr.

               II-  Danielson as coordinator, reinstitution of RAG, as we know

                    a RAG, wi th removal of a lot of situations that had gone
               12

                    on before, I would hot leave you with the feeling that there
               13

               14   aren't still problems, because of the fact that some of the

               15   boards still overlap betw een RMP and CHP, the divorcing of

               16   the whole business of the health services delivery syst em

                    contract is still not a complete divorce, even though they
               17
               18   changed the name a little  bit.

               19              In this change it did make it possible for RMP
               20   to get rid of some of the people who have been moved to the

                    other corporations to help continue the data base in related
               21
               22   areas but in  this  reorgani.zation, they have been ---it has
               23   been necessary for them to bring about some of their staff,
               24   and RMP losing their job.
  Nce- Federal Reporters, Inc.
                               All of this has' been accomplished reasonably well
               25






                                                                           14 2
    dor 12


                 I  'by the people on board,  andIthink, in essence, represents

                 2 now, since January  of  19@2,a nine month, eight month period

                 3 of time when we  were  there, of reogranization, along,_-

                 4 traditional RMP lines.

                 5             Dr. Luginbuhl was present for much of the

                 6 situation because of significant questions in the past.,

                 7 in reference to the RMP to the medical school.  I think

                 8 they have well understood the'strong staff support  and  our

                 9 review committee and council comments  about  wha@was  wrong

               10  with their RMP in reference to collection of a data base

               11  rather than anything else.

               12             At this point in time, I think they have well

               13  understood that our feedback session was particularly good.

               14  Their request for specific staff assistance, C.C. and

               15  others, was very significant and meaningful, I think.

               16             And it represented, for me, at least, the

               17  opportunity to say very stronbly that this is an RMP that

                   is still back in 1966 and that.is hard to accept,  but  that
               18

               19 'that, the 1966 constitution of this group in 1972, leaves

               20  little question in my mind whether they will succeed.

                              The present chairman of,the RAG is a  little  bit
               21

                   still out of step and out of consonance with the new
               22
               23  direction of RMP but he is  a-very educable individual and

                   they have not developed goals and objectives in the feedback,
               24
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                   they actually asked us in-a way how much time they had to do
               25






                                                                         14 3
     dor 13


                 I  it and we left them with a figure of 90 to 120 days, which caME

                 2  off the tops of the heads of,the site team rather than

                 3  having any other direction.

                 4             I think the whole question of minority interest

                 5  in Vermont was raised and we were not able to speak to that

                 6  very well because of the particular structure of Vermont.

                 7            The only way a minority group'could be constituted

                 8  would be to have somebody who-was born out of the state and

                 9  then moved into it, because there are no other minorities

               10   in that sense of the word.

                              The poor are not the minority in Vermont.. If
               11

               12   we are going to get on another New Mexico, it is here.

               13             But I think that in-general,  in speaking to all

               14   Of the other segments we normally speak to in review of an

               15   application, I could say they presented to us a very good

               16   approach-of taking the best of what  they have had in the

                  'past, not related to development of a technic al data base,
               17

                    have coordinated it now with an approach to the future that
               18

               19 'looks to be well structured and well organized and that we

                    are now in the transition period.
               20

               21             This transition period is entirely different

                    from the one that is usually bandied around here about going
               22

               23   from categorical to noncategqrical, and instead, the

               24   transition from data collecting group to a true health care
  kce- Federal Reporters, Inc.
               25   delivery group.







                                                                           14 4

                                If we are going  to ever be able to evaluate any

                    RMP, we ought to be  able-to  evaluate this one because they have
                 2
                 3  got -Che best data base you have ever seen to see now what
                 4  is going to happen in the future in.all of their areas.

                                I think this will be meaningful, not only to us,
                 5
                 6  but'alto.to other branches of HSHMA and HEW, because they do
                 7  have a  truly  significant  data base and if you look at the
                    end of the site visit report,.you will get a feel, and this
                 8
                    does not represent all of the things they published.
                 9
                               You get a feel  for what the they have done since
               10
                    1966 in collecting information, so  we should be able.to

                    Very, quickly evaluate almost  any program that is brought
               12
                    about in the delivery of health care in   this area.
               13
                               I think that as we look at the process of their
               14
                    organization,  the  coordinators very firmly moving to take
               15
                    total command of  the  situation with strong assistance from
               16
                  ..the RAG, he is the one  who  has been responsible on going
               17
                    face to face with every single-person and.saying, "You are
               .18
               19@ -not really contributing, why don't you resign," or "We really
                    need you badly, you are the kind of guy who we hope can
               20
                    help us make the change in the future."
               21
                               Although the  RAG  is very small at the moment,
               22
                    it is open-ended in reference to-their by-laws, and I believe
               23
               24   the additions we have brought  about will be significant.
  @ce-  Federal  Reporters,  Inc. The RAG chairman clearly is a university man,
               25





                                                                          14 5

     dor 15


                    but he is a university  man who  has pioneered community health

                 2  programs throughout Vermont, which   is a reasonably tight

                 3  structured state.

                 4              So I have no concern about him carrying too much

                 5  of the idea of the university.

                 6              In speaking to the university and'its relationship,

                 7  one of our fellow committee members has led the charge to

                 8  get the offices of RMP off the grounds of the university to

                 9  cut down a tremendously spectacular overhead rate, and he

                10  has now succeeded in this and they are moving and they will

                11  now have an off-grounds place,  although the university will

                12  still be the grantee.

                13             We have no concern in any way about the management

                14  or effectiveness of funds because they are moving very

                15  comfortably in their structure'to make sure that all of their

                16  so-called advisory committees, which is their mechanism of

                17  action, have a very firm.budget.

                18             T hey have a definite plan, with each budget

                    there will be a timetable and if that timetable is not met,
                19

                    that the money will no longer be there.
                20

    end 11      21

                22


                23
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                                                                          14 6
     #12


        arl
                               Going back to our earli6r discussions, money is
                 2  one of the clubs that we have,. and they are using it well in
                 3  their approach to programs.  I think that the program staff

                 4  is presently being realigned, as I indicated, they are phasing

                 5  out a total of 11 jobs, actually more than that, but 11 are

                 6  being phased out, some going to other opportunities and some

                    just being phased out.  They have brought on a young physician

                )8  to work in the area community development.  And his

                 9  enthusiasm and capabilityhdth are significant, and I think

                10  on that basis we don't have any real concern that they will

                11  begin to derive programs from throughout the state that

                12  have A strong community base and meet the need for delivery of

                13  health care in an entirely different way.

                14            This is his cup of tea.  If they can keep him in

                15  the program, it will be great.  I have some concern that they

                16  may lose him because his type of talent is in bad need all

                17  over the country today and so he may go.  The RAG understands

                18  the way to go.

                19            I think that they have -- will make future

                20  appointments on the basis of knowing exactly what should be

                21  done before they got into it.  They have pulled again, as

                22  I indicated, not only at RAG, but committee management, they

                23  have pulled their best people from the best and have let

                24 'most of the dead wood go.
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                25            They have done'this very, very well which is a real






                                                                              14 7
      ar2

                 I  tribute to the coordinator in that I think his experience

                 2  in the program for over two years before he became

                 3  coordinator made it possible for him to get an honest

                 4  evaluation of what is going on.

                 5             I think our only concern is the site team, about

                 6  his role., was that in'the area of continuing education and

                    manpower development, if he has a blind spot, this is  it,
                 7

                 8  and we tried to emphasize that pretty much in our site  visit.

                 9             I think staff is well aware of it as a  reasonable

                    blind spot.. It is emphasized enough in the feedback  session
                10

                11  to make everybody else well aware of it, and I believe that

                    will probably answer the most significant problem that
                12

                    exists at the present time in their entirely new  development.
                13

                14             I believe I would stop now in this discussion becaus

                15  there really is nothing else that I can firmly put   hand  on
                16  at this point in time to say about this program  because,I

                    think we should look at it as a program that really  developed
                17
                18  a coordinator  no coordinators'in January of this year.

                               The RAG is working well, though small, to  make
                19

                    itself meaningful.  And they really have nothing else to
                20
                21  present except a truly significantdata  basis  accomplishment
                22  and now with the opportunity to turn around and move on.

                               Rather than recommend, we might listen to  what
                23
                24  the secondary reviewer has to say first.
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                               DR. SCHMIDT: The secondary reviewer is  Dr.  Lewis.
                25




                                                                            14 8


      ar3


                 I  who is not here. So, Spence, do you have any  comments  on

                 2  let's move on then to your recommendation.

                 3             DR. THURMAN:  Spence, you'don't have anything to

                 4  add, let me add, do you agree with what I have  said?  No,

                          I don't know whether you heard about what I said  of
                 5  C.C.,,

                 6  the possible blind spot of the coordinator being in  man-

                 7  power coordination and education, and we leaned very

                 8  heavily on that with the hope that we would do away with his

                 9  blind spot.

               10              MISS CONRATH:  Yes, I think one thing the review

                    committee might be interested in.. The Kellogg  Foundation

               12   has made a grant to the University of Vermont Medical School

               13   for the introduction of the problem of oriented medical

               14   record in medical practice in Vermont.  This offers an
               15   opportunity for the northern Now England RMP and the medical
               16   school through the department of continuing education to join
                    forces in a way in which they have not been able to  join
               17

               18   forces before.

                               I think this offers a mechanism and advisability
               19
               20   as to how the continuing education resources can be addressed
                    in a meaningful way that is a very real promise, I  think
               21
               22   in terms of case history, maybe of interest to know  that

                    one of the graduate students of the University of  Vermont
               23

                    did a master's dissertation on the case history of the
               24
  Ace-Federal Reportets,  Inc' northern New England'RMP. This person is now on the staff.
               25





                                                                             14 9
         ar4

                 I  So if you need a good case history; there is a@100-page

                    dissertation.
                 2

                 3             DR.   SCHMIDT: Recommendations,   then-?

                 4             DR.   THURMAN: The recommendation of the site

                    team was  that  triennial status not be granted at this time.
                 5

                 6  This was  quite  honestly discu.ssed.with the entire group, but

                    that it receive two year approval so they understand, or we

                 8  understand they understand we understand they have turned

                    the corner and are ready to develop a good RMP at thi  s  period
                 9

                    of time, but with this two year approval at the level of
                10

                11  $850,000 each year that we also grant them developmental

                12  component or discretionary  funds, and our recommendation for

                    the first year there would  be 10 percent of the  present  fund;
                13

                    for the second year, continuing 10 percent of whatever the
                14

                    funding is for the first year.
                15
                16             DR. SCHMIDT:  We will have-to label that discretiona-
                17  and that amount is within the 850,000 obviously.
                18             Is there a second to that motion?

                               DR. ELLIS:  Seconded.
                19
                20             DR. SCHMIDT:  It is seconded by Dr. Ellis.  Comments?

                               DR. JAMES: I would like to have  one  to  explain  to
                21

                    me the relationship of the research  and  development-of  health
                22
                23  systems incorporated which is the recipient of HSMHA's

                    experimental systems contract.
                24
  Ace-Federal  Reportvs,  Inc' I see where the@ were awarded $900,000 to develop
                25





                                                                             150


       ar  5
                 I  experimental delivery system there!  It occurs'to me that

                 2  with the geographic and demographic information we have as

                 3  far as Vermofit is concerned, that there will possibly result

                 4  some kind of conflict -- well, can't say conflict, but I

                 5  wonder just how much overlapping of-effort in such a small

                 6  state, that Vermont represents.

                               It seems to me that there might be some turf
                 7

                 8  interference, and I get the  feeling that one is going to  take

                 9  precedent over the other in view of the fact that the   popula-

                10  tion is small.

                               DR. THURMAN:  I might respond  to that by saying
                11

                12  this is the one dollar they requested for  which they  received

                    932,000. And it is very clear in everyone's  minds  that  there
                13
                14  will continue to be some-degree of difficulty in understanding

                15  the role of each of these because of the fact that RMP in

                16  Vermont has had an image of a data system and it is, this

                    divorcing of the data system from RMP as we think of RMP now
                17

                    that the new program actually represents.
                18

                               The overlapping of boards, who will do what, all
                19
                20  of that is still a bad situation.  I think this will not be

                    clarified over the next several years because.of the fact
                21

                    that RMP actually helped with the development of all  of the
                22
                    plans for what is now the experimental system to the tune of
                23
                24 .roughly $150,000.  Isn't that right, Spence, over the years?
  Ace -Federal Reporters, Inc.
                25  Okay, 350,000, missed by 200,000.  It is a piddling amount.





                                                                           151

        ar6


                 I  So I think there will continue to be some real problems with

                 2  this.  The medical society is well aware of this,Dr. James,

                 3  and their concern, the board, they have actually changed

                 4  the name of this now to call it a Vermont, it now has VHSI

                 5  to get around some of their problems and their board is made

                 6  up of providers; politicians, public and the payers.  This is

                 7  part,of the thing they are going through.

                 8             I think Dr. Danielson as coordinator and

                 9  the early development of the present RAG, nine @ 12 people,

               10   are so burdpned by this whole situation that I would not be

               11   concerned about RMP being hurt.  I am more concerned, not

               12   truly that concerned about it, about HS! being an ineffective

               13   program because of the emergence of a strong HCP.

               14              I think staff will have to continue to look at it

               15   and I am sure the northern New England RMP will be coming back

               16   to staff-and saying why can't you do something with those other

                    guys in Washington, because that is the way they feel about it
               17

               18   right now.  Point out that one.person whols been not so

                    burdened, but very concerned about the situation, is  Dr.
               19
               20   Luginbuhl because he and others wonder what they are going

               21   to do with this @32,000.
               22             DR. SCHMIDT: I will  comment  just  briefly.  1
               23   don't think that blame, with.the word "blame" in  quotes,
               24   for the situation can be laid at'the door of PMP at  all.
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                    RMP is a victim of essentially HEW muddling and  meddling
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                                                                           152
         ar7

                     in the state of Vermont, and if so@ebody's got red ea3sover

                     this, it is the Secretary of HEW.  And this is an incredible
                 2

                 3   blunder by HEW,.and in effect a manipulation of a state

                 4   plan.

                                I thinkthat the RMP and people in Vermont are going
                 5              1

                 6   to have to kind of recover.from a reeling blow that was

                 7   dealt to them by feds coming up there and manipulating the

                 8   state, and I think the RMP will be in great part,,part of

                 9   the solution of this problem.

                               My words are quotes from HEW people who have been
                10

                11   investigating what went on in Vermont and how a request for

                12   one dollar got turned into a forced upon the state 1 million

                     by HEW.  it is an incredible story.
                1 3

                14             Are there other comments or questions then?

                15             DR. ELLIS:  We don't understand the $1 request.

                     Could you tell us?
                16

                17             DR. THURMAN:  They were told that with this
                1 8  tremendous data base in hand, where else.could you -- could
                19   really you document what you were doing with experimental

                     health services delivery and other approaches, and so they
                20

                     said don't you want some of our money?
                21
                22             And in essence, the .answer back was we are really
                23   not ready for it, which is an honest statement, so they said
                24   at least put your hand in the pot, and they put their hand
  Ace-Fedetal  Repofters,   Inc' in the pot for a dollar, and were showered with greenbacks.
                25




                                                                            15 3


          ar8


                                DR. KRALEWSKI:  Aside from who would apply for a

                 2  dollar, I am hesitant to vote, I like.your funding

                 3  recommendations, but I am hesitant to vote that two year kind

                 4  of thing since generally we deal with a triennium, or say

                 5  look, here's another year, you can try to work out an applica-

                 6  tion.  Would you comment on this?. Do you think we have to

                    go give them a two-year kind of period?
                 7

                                DR. THURMAN:  We discussed this at some length
                 8

                 9  and Spence  can comment when I finish.

                10              Our feeling was that they really had made a marked

                11  change in their approach.  They  had the people now who under-

                    stood what the story is all about.  And therefore that if we
                12

                    would seriously inhibit particularly the development of their
                13

                    community-related program under Dr. Robins and he would not
                14

                15  be able to add additional people, he could only talk to them

                    on the basis of one year, and  that then triennial status if
                16
                17  everything continued to go well.
                18'             There's been so much problem and so many people
                19  like our chairman's  refe.rring to, so many HEW investigating

                    groups   that have passed through the state that the crown
                20
                21  sits on uneasy with  s.o much money.

                                We felt strongly that if we just went for one
                22

                    year with this group that he would have real troubles continuing
                23
                24  to develop what he wants.
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                                DR.'SCHMIDT:  This would not, you know, by the two
                25





                                                                       154

        ar9


                 I  -years  are you saying that under no circumstances next

                 2 year could they come in with-a triennial?

                 3            DR. THURMAN:  This was discussed at the feedback

                 4 session, nothing prevented them from coming in for

                 5 triennial status next year, but we wanted to give them the

                 6 feel for-two yecArs for continuing development.

                 7            Spence?

                 8            MR. COBURN:  It is.btiilt into the recommendations

                              DR. SCHMIDT:  It is part of the recommendation.
                 9

                              DR. THURMAN:  Yes, it is.
               10

                              MR. COBURN:  They Ake not going to be able to write

                   you a triennial application after the site visit.  This will
               12

                   be then applied in the second year as you are suggesting here.
               13

                   If we go in with the recommendation that here is a base
               14

                   for a couple years, and although we'd like to have you move as
               15

                   rapidly as possible in formulating a program thrust and
               16
               17  developing.a three-year program, and sending that program
               18  in here for approval, I'd be agreeable to it.'

                              DR. THURMAN:  I think to finish it off, we said
               19
               20  there would be a site visit next year.  This they understand,
               21  and-if they wanted to before that site visit actually prepare

                   a triennial application, fine, but if it looked like they
               22
               23  need another year to actually go on as they were, that was
               24  one of the reasons for the recommendation of level funding,
  Ace-Federal Reporters, Inc.
               25  that they would then know.that they had to talk to that group






                                                                          155
               arlo


                  I  or some group again next year   about'an increase in funding.

                  2              But we felt that the security of this program with

                  3  its past problems and the actual divorce now o  f HSI  with  a

                  4  whole change from RMPS staff that they may or may not be

                  5  ready to tryltriennial application this year in order to meet

                  6  site visit next August again.

                  7              DR. HESS: I would like to  think  that  with  this

                  8  recommendation we are coming very close to a leveling off

                  9  of funding for this particular RMP.  So it happens with your

                10   recommendation they will be funded at  about  $2  per  capita,

                11 . which is the highest, as far as I.can recall, the highest

                12   funded RMP, on a per capita basis of anywhere in the country.

                                 True, they do have scattered  population,  but  no
                13

                14   more so than Arizona, New Mexico or the mountain states.
                15   Low income, yes, but no more so than Mississippi.

                                 I would think there ought to be a point where
                16
                17   certain RMPs begin to level off while others are coming up.

                     Particularly when so much other federal  money  is  coming  in
                18

                     which is addressing itself to health care  systems,  so  I  am
                19

                     just concerned that we don't get into  a  situation  more  and
                20
                21   more simply because they got in and got something going.

                     Seems to me that we have just about reached a plateau.
                22
                23               DR. SCHMIDT: Other comments prior  to  a  vote  on

                     the motion  then?
                24
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                                                                     156
         arll

                               The motion is understood.  All in favor, please

                    say aye.
                 2

                 3             Opposed, no?

                 4             And I hear no dissent.

                 5             It is 1:15.  Cafeteria is'out of soup, but there

                    are a few other things left.
                 6

                 7             We will reconvene at 2:00,olclock sharp.

                 8             (Whereupon, at 1:20 p.m., the hearing was recessed,

                 9 to reconvene at 2:00 p.m., this same date.)

  el2
               10


               11


               12


               13


               14


               15


               16


               17


               18


               19


               20


               21


               22


               23


               24
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     CR 7149
        13                                                                 157
     eak 1
                                         AFTERNOON SESSION


                 2                                                    (2 p.m.)

                 3             DR. SCHMIDT:  It is two o"clock.  I have been asked

                 4  to remind the Review Committee members to be filling out

                   your rating sheets.  All of the regions that are under review
                 5

                 6 should be rated by Review Committee members.  So.be sure you
                 7 fill these out.  We have three left to  do, Texas, Indiana

                 8 and Memphis.  We will begin with Texas and Miss Kerr.

   xxxxx         9             MISS KERR:.  Thank you, Mr. Chairman.  I think we

               10  want the records to show Mrs. Plood has excused herself.  She

                   was an important part of this visit, so.  The visit to Texas
               11

                   was made in August of this year.   The State of Texas makes
               12

               13  up the region and it consists of 254 counties with a population

               14  of 11,200,000 people.  I feel somewhat pressed for time here and

                   I think this is unfortunate, not'because it is so big but because
               15

                   it has accomplished so much and has  so much potential that I
               16

                   would like to share it more in detail than I will be able to.


                               The grantee institution is the University of
               18
               19  Texas at Austin.  It is made up-of 17 institutions of higher

               -   education, three of which have medical-schools.  Dr. Charles
               20

                   LeMaistrO is Chancellor of  the system.  Physical agent is
               21

                   the same' institution.  The coordinator is Dr. McCall' central
               22
               23  office is in Austin, with projected ten subregional offices.
   0           24              At the moment six exist, at tl Paso, Houston,
  Ptce-Federal Reporters, Inc.
               25  Tyler, Abilene, Laredo and Lubbock.  They expect to add to this






        eak 2                                                                     15 8


                  I list San Antonio; Dallas will then leave two to develop.  In
                  2 Texas there are 21 CHP  "B" agencies, 19 of which have councils
                  3 and have been  funded  from  between  $10,000  to  $@0,000  per  agency

                    by state funds.  The last site visit was made in
                  4

                    July of 171.  Dr.  George  Miller  is  Chairman  of  that  group.  Also
                  5

                    on that site visit  team  was  Alfred  Pompa.  And  I.Say  this  becaus
                  6
                  7 these two gentlemen were oh the visiti   ng team  one  year  later.

                    The region  appreciated  this  continuity.  As  Chairman  of  the  team
                  8

                    I appreciated this continuity.
                  9
                 10              In the meantime between the last site visit and the

                    one in August, there  were  four  interim  staff.visits  to  the  Texas
                 11

                    region,  on an introductory visi:t from Buddy Says here oh
                 12
                 13 my right, one relative to health services education
                 14 activities, one relative to health services activities.
                 15              Also the members on 'the team in addition to Dr.

                    George Miller and Dr. Al Pompa were    Mrs. Muriel  Morgan  of  the
                 16
                    council, @nd Dr. John   Low, director of the South Dakota
                 17
                    regional medical program.      Regional  medical  program  staff   were
                 18
                    Mike Posta who is present in the room, Joe     dela Puente and
                 19
                    Dr. Roberts who is here.  And I am hopeful     that they will feel
                 20
                    free to contribute after I   am through with   the  initial  report
                 21
                                 In addition to  this group,. we   had David Eubanks
                 22
                    from the HEW  region  6  as  program  representative.  The  purpose
                 23
                    of the site visit was to assess program progress, processes
                 24
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                 25




    eak 3                                                                    159



                               Now, following the last site visit a  year ago in

                2 August of 1971, there was an advice  letter sent  out  following

                3 council meeting which  contained  five major concerns for  this  are@

                4 relative to this-area.  I  will  visit those in a moment.

                5              However, I would make  it clear that we had  a  team

                6  visit the night before at which  time the team decided

                7  that while we were focusing and basing.our observations on  all  ti

                8  criteria for review, we would focus primarily on these five  area@=

                9  to be sure that we were probing deeply enough to have answers.

               10  for this review committee and council when we returned.

               11              The five concerns and there is somewhat overlapping,

               12 at the time  of a year ago, it was identified that  this  region

               13 needed to establish priorities under its  new  program  direction.

               14 The subregional staff members, it was felt,  needed  more  assistan:

               15 and support from the central office and RAG members in  the  devel-.

               16 ment of specific program activities.  it was felt that there

               17 needed to be more and better representation  from  allied  health,
               18 one- more, additional representation from minority  groups,  the
               19 fifth one, some of the reviewers felt the process seemed to be
               2'0 more of a central office academic review rather  than  peripheral

               21  involvement in input.

                               In developing into these more deeply, I think
               22
               23 they will come out as I progress along through the report,
                  'just how we did find these five concerns'being based  and  attendet
               24-1
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                   to.  From the time of the last site visit until December,  it  is
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     eak 4                                                                 16 0



                I  unbelievable what this region had done with the development
                2  of goals,objectives and priori ties, riot only the amount of work
                3  done but the process in which it was done.

                4  It involved not only the coordinator'and staff, but many meetings

                5 of the regional medical program, representatives  from the

                6 subregions, the executive committee, and it was a  well-organized

                7 process coming out with seven priorities well understated

                8 by pertinent goals.

                9             There was only'one question about this whole  area

               10 of goals, objectives and priorities and this was

               11 Dr. Low who felt that perhaps the objectives could be stated

               12 somewhat more in measurab le terms.  Didn't seem to be a glaring

               13 omission but this was a suggestion for improvement.  The-RAG

               14 was divided into seven major committees, each one  responsible

               15 for one of the priorities and they worked individually in"

               16 task forces coming back at@intervals   to compare notes and

               17 finally came up With the seven priorities accepted by the

               18 total group.

               19             The objectives by testimony during the site  visit

               20 are understood by all of those participating and they are supporti

               21 by all those participating. Chief of program  development  evalu-

               22 ations to be employed and more expert consultation will be

               23 sought in strengthening the evaluation committee. They  did  have

               24 a man on staff full-time on evaluation but in the process of
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               25 further developing the subregions and giving them the kind  of





                                                                         16 1




        k 5
                 I  assistance they felt necessary to come from central office,
                 2  this agent who is a very capable person was put in a position
                 3 to coordinate and assist with the activities of the subregion
                 4 programs and, as a result, it vacated the position of one
                 5 full-time evaluator but this is in their plans to  replace  this

                 6 person very shortly.

                 7             It is very clear  that the -subregional offices are no,
                 8 providing more input into the system and.this was  verbally
                 9 supported by every one-of the:subregional representatives
               10  that was there including Mrs. Flood.  They all were very vocal,

               i;l 'very.supportive and very appreciative of the kinds of

               12  assistance that they were getting.  The issue of advisability

               13  which was done by the council and sent back to the advice letter

               14  the issue of advisability @of developing local  advisory  groups

               15  was discussed and the concensus was that the CHP  "B"  consumer-

               16  oriented planning councils are being developed and that potentia

               17  activities of local RMP advisory bodies would constitute

               18  duplication of effort.

               19              It seems it would also be detrimettal- to  community

               20  efforts in Texas because not all potentially effective,

               21  articulate and well informed consumers have been introduced

               22  into the system.  An effort to train consumers in participation,

               23  however, is presently being supported by RMPS.

               24              In addition, five contracts for developing an enviroji
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               25  ment for Chicano health consumer,participation is being supported






     eak 6                                                                  16 2

                 I  by RMPS in Texas, California, Colorado.  These priorities

                 2 when appropriate have been followed in the funding

                 3 of operational activities.  They are addressed to regional needs

                 4 and reflect the possibility and instrumentality for continuous

                 5 development and improvement. @,As far as@implementation, there

                 6 is much evidence of continued accomplishments  by-RAG  committees

                 7 and staff.

                 8             For example, support of planning effort toward

                 9 comprehensive proposal with reference to renal di.sease has

               10  resulted in promising activity.  If successfully funded, it will

               11  bring to Texas one of the first efforts addressed  to  compre-

               12  hensive care of a particular group by regional basis.  Without

               13  a doubt, in my experience of project proposals, whether it be

               14  RMPS or any other, this proposal for the kidney program was

                   probably as well thought out, pl anned through a committee,
               15

                   advisory committee, bringing everybody across the state of Texas
               16

                 "aboard that could  have any input to its implementation and it
               17

               18  was exciting really to hear about this.   It has been so  well

                   done.
               19

                               While many traditional pro'jects have been  supported
               20

                   in previous years, these are now being terminated.  A new
               21
               22  generation of projects as was presented to the  visiting  team
               23  promised to deliver  improved  accessability.  Representatives

                   of various multi-disci'line professional  organization  testified
               24                        p

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                   favorably oh behalf of RMP.  I bring this out  primarily  because
               25





      eak 7                                                                       16 3


                  I  historically this has not been true.' The relationships,

                  2  the acceptance of RMP by the medical association has

                  3 improved.  I would go a step further and say that the executive

                  4 director of the Texas Medical Association was the one who was

                  5 there to speak with us.  And what is 'robably a little more
                                                           p

                  6 reserved in his openness and acceptance of RMPS than I

                  7 understand about 90 percent of the physicians in that state are

                  8 so this was encouraging.  But the other thing about the change

                  9 in the predominance of physicians can be told, I think, relative

                1.0 to the adivsory Committee.  The advisory committee at one time

                11  was almost entirely MDs.  At   this point in time, numbering

                12  51, there are 29 physicians on it.  And it was recognized

                13 that the region serving an effective role toward the delivery of

                14 health services because it, for one thing, it is serving

                15 as a bridge between what we call on the site

                16 visit among ourselves in family, town and government.

                17              In other words, it is bringing together the practici7

    e 13        18  specialists and general practitioners..

                19


                20


                21


                22

                ?3

                24
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                                                                             16 4




        149                  As far as continued.support is concerned, in
     14          2
                   response to questions bv the -Visitors, the regional representa-

                 3
         1         tives reviewed the continuing status of the activities fund
                 4 trhough 1970 to 1972.  Of 22 projects supported, only two will
                 5 continue after the close of the current period.
                 6           Eight will be supported by self, or other support
                 7 that has already been  arranged@  Seven,will  be  discontinued.
                 8 Either because they have been completed or because through
                 9 evaluation they have proven to be' not worthy of      tinuance.
               10            And there is a question about the continuance of
               11  three others. Relative to minority interests and you will recall
               12  that this -was one of the concerns of the last advisory group,,

               13  and we went armed for bear to find some  answers  to  this,.and

               14  I would have to say, that as we  -looked at the advisory committee

               15  constituency there was some concern and a little more than'

               16  concern, that not as.much has  been done in this area as wehad

               17  hoped would be in the entire  interim  period.

               18            However, there has  over the  period of the last five

               19  years been an increase in minority  groups  to the number of 11,

               20  which seemed not too bad in view of  the  fact that they only

               21  had a' quarterly turnover with replacements. And we can't

               22  exnect an unusually rapid increase in this number through

               23  but there are also some other rea sons.


               24            I think we all acted like generals for  two  days  in
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               25  this area and I think Dr. George Miller's hat was the hardest an'.




                                                                                 16 5




          14       1  the biggest. Ilaving been there.before, being the one that made

    TZeba 2        2  the recommendation for increased involvement of minority

                   3  grouses, he really peppered away at this.

                   4            We even checked this out'with Dr. Le@lader relative to


                   5 their civil rights compliance and so forth and so on. They had

                   6 as I say improved the minority representation on the RAG, -not

                   7 as much as we would have liked but there is a strong commitment

                   8 to do this.


                   9            And words can be words, but it is in print. Their

                 10  procedure  for employment of  people  with  a  focus  on  employing

                 11  -those who are of the  minority  groups.  I  think  at  this  point

                 12  I will say that Dr. McCall, as f   orthright as  he  is,  we  could

                 13  not back him into-the corner on this because he was so       honest


                 14  about it and-said, "I am looking for these people, I have been

                 15  looking for these people. I will continue to look for these

                 16  people and bring them to the  board  as  soon  as  possible  but  I

                 17  @will not commit myself to bringing aboard a black face or

                 18  Chicano or a white person unless they have the competency and

                 19  capability that we can build on'to make them an active con-

                 20  tributing part of our staff and-RAG."'
                 21            The minority groups are extremely well and consu4er

                     group  in the subregions. Much of the'program is arr'ng d 'arounc
                 22       s                                                   a  e

                 23  the innuts from  these  people.  There  are  a  significant  rumber

                     of minority personnel 'on project staffs. 'I would want to     tell
                 24
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                     you t)lis:Dr. Sid,Geroa, who sat there, and he is not a very
                 25






                                                                            16 6



         #14    1 vocal person, but he rose to his fee't after much'probing

        3       2 in this area, and this was the second day, he rose to his feet

                3 and-in a soft kindly way, a Chicano, made it very clear to us

                4 that the RAG, the Executive Committee and indeed the grantee

                5 institutions as they moved ahead in their pgoram planning and

                6 implementation, he felt and it.was like a sermon, he felt that

                7 they had the well being of everybody in that state in mind

                8 regardless of race, color, creed, age or anything else.

                9           And it was beautiful to hear. If he had been more

               10 vocal before I don't think it would have been quite so impres-

               11 sive. T,?,elative to process, Dr. lIcCall, the coordinator, has

               12 undoubtedly provided some of the strongest leadership with able

               13 administration in his three year tenure that one could expect.

               14           There is a very-viable regional advisory group and he

                  has utilized them, diversified talents of its membership, in
               15

               16 establishing the plan as presented in the triennial application.

               17 Dr. lIcCall has excellent rapport with members of the RAG and

               18 manv other health representatives throughout the state.  Agencie3

                  and associations, individuals, and so forth. As an aside, at
               19

                  this particul ar time Dr. McCall was being interviewed for a
               20

                  Coroner's position in my own state And as a member of the colleq@
               21

                  and faculty there I was aware of this, somewhat involved in
               22
               23 this I think he and I treated it with very low profile, inten-
               24 tionally.
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                                                                         167


           f@14  1 Of changes, I would say,, despite the fact we knew change was

   Tlf-ba 4     2 possible, we felt that Dr. !,IcCall had developed astaff, had

                3 allocated responsibilities or delegated responsibilities

                4 and given it the authority to carry out these responsibilities,

                5 and if he had, we felt  that I,lr. Forguson,.his deputy could very

                6 well move-in and move  ahead with the program they were planning.

                7           I hasten to add before you get excited he has

                8 decided to stay in Texas. I think Texas is fortunate and I

                9 think we would have been fortunate to get him but,44e will carry

              10  on.  Relative to program staff,-the staff consists of 1'9

              11  professionals, all but two of them serving 100 percent of the tin

              12  There has'been almost no turnover in the last two years.

              13           I think this speaks well both for staff and for the

              14  coordinator, and six additional.professional staff members are

              15  requested during the next year and include a director of edu-

              16  cational programs, chief of public development and evaluations,

              17  nursina education and three subregional representatives.

              18           The site visitors believe that these positions as

              19  budgeted are justified. The program staff reflects a high

              20  quality of broad branch of professional discipline, particularly

              21  impressive was the quality of subregional representatives

              22  to demonstrated thorough knowledge about their responsibilities

              23  with respect to geographical assigned areas.
              24           The 51 member RAG group was very active from the
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              25  time of the last site visit through December and continues to






                                                                          16 8



           #14
                   be but were Particularly active at,tliat time with attendance
        5
                 2 never going below 70 percent, and with people coming  from  all
                 3 over that state of Texas to work on RAG meetings, that attendance
                   of 70 percent seemed to us to be very good.
                 5           Geographic distribution of its membership was con-
                 6 sidered to be satisfactory.  I-lowever, as with many regional
                 7 medical programs T)hysicial representation proportionately was
                 8 high while consumer interests rem ain relatively low.  I alluded
                 9 to that earlier but I need.to go a step further I'Othink and
               10  indicate agai-n there are still 29 of the 51 who are physicians.
               11           This question was raised as to why. And  the  chairman
               12  of the RAG, S.   Bradshaw, not Bradshaw, Dr. Eastwood,  who  is
               13  a Ph.D. and director of the medical center at Houston, quite
               14  a personality, highly respected by the group who relates well
               15 with the RAG group, and in staff and the rapport seemed excellent.
               16           But anyway Dr. Eastwood explained that with  the  four
               17   with the three medical institutions within the system, and with
               I 8Baylor and one other medical schi6ol in the state, ---
               19          MR. SAY8:    University of Houston is the medical

               20  school.

               21          MS. KRPR:  Getting underway. If they were to have
               22  Representation from general practitioners and so forth so on
               23  --hey could see that this could not be cut too much more if they
   0           2417ere to keen the good faith of the physicians that had taken
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               25  o long to get it built up and he convinced us that this was






                                                                            169

        ftl4    I           And after our visit I thinIC we felt that this too

  'Reba 6       2 was proper, too.
                3           The executive committee meets  more often than the
                4 RAG committee and.provided ample guidance  for  the  coordinator
                5 and staff. Effective in providing leadership in the process
                6 and in utilizing regional advisory groups, 51 committees and
                  task forces. These were not left in limbo, they were well organ,:-,
                7
                8 izod 'and coor'indated task forces and committees.
                9           Development committee assumed an active role   by
               10 establishing short term objectives,.  The Chairman of each
               11 program committee is a RAG member and  serves.on  the  executive
               12 committee. General program activities for each of the seven
               13 priority statements and funding allocations projected   for  use
               14 of growth funds in the second and third year of the proposed
               15 triennial event application. All this is to go to say that t ere
               16 has been much planning, thinking, brainstorming,  and  so  forth
                  prior to the submission of their  level of request for funding.
               17 -
                  1 have talked about the grantee organization.
               18
                            There was some feeling at one time that perhaps there
               19
                  was a little bit too,much control from the grantee organization.
               20
                  We came away from th eir havin  probed rather deeply on this
               21                               9
               22 too to find that the coordinator, the PAG, feel very-free to
               23 move ahead with decision making with-absolutely no interference
               24 or control from there, from the grantee institution.

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                                                                            170


            #14 1  arrangements, as far as participation is concerned.  14any
         7        2 health interest groups are' actively.participating in the region

                  3 as evidenced by the number of persons who attended this two

                  4day visit.

                  5          llo major group has captured a controlling interest.

                  6In orc-paring the 'budget request for that of last year there

                  7was a.complete turn around with respect to funding the major uni-

                  8versities and institutions. This accomplishment has made more

                  9funds available for the community. D.ut -- as a r@lt it has

               10 not brought 4bott less cooperation from major health institution

               11 The political-economic power of the regions involved in the

               12 regional program, the CAP agencies and local -- not only this

               13 but there is CHP representation'on the RAG, representation

               14 from JTTIP other PI.IP on the CITP Council.  CIIP and B agencies

               15 are involved in the process.

               16           I have already talked about the CHP'S, and their
               17 situation.  -Durii-ig the last R'14PT the review cycle there was

               18 ample evidence that the Rt-IP's minimum review requirements and

               19 standards for local review have been carried out in a very

               20 satisfactory manner and this continues to exist.

               21          As far as the assessments and resources there was

               22 ample evidence the region is conscientiously accumulating a

               23 great deal of data as evidence-by'(inaudible) -- the data is

               24 utilized in identifying specific and measurable needs of the
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                                                                171

         414   1         Management, the capability of the region continues
      a 8      2 to be excellent. Program staff and project activities are
               3 well coordinated including monitoring b RAG members and sel-
                                                  y
               4 ected ad hoc members. Progress and financial reports are require
               5 on a quarterly and monthly basis respectively. Relative to
               6 evaluation as I indicated earlier at the present time there is
               7 no full time evaluations director in the program.
               8        I have talked about the termination of funding on
               9some projects that come about by evaluation and the limited
             10 funding being put on others as a process of evaluation and
             11 their.need and expectation to fill this position shortly. As
             12 far as program ptonosal the action plan is comprehensive,
             13 Priorities have been thoroughly prepared with much review
             14 and are clearly congruent with national goals and objectives.
             I 5Fhe proposed activities relate to stated priorities and ob'ective
                                                                 3
             16 ivbn to the needs of the region. 1,4ethods of reporting accomplish
             17  nts and accessing results are proposed but address individual
             18 ctivities really more than they.do program achievement but
             lg)eriod review and updating of priorities are planned.
     end  14  20

   15 fls    21

             22;

             23


             24
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      mea-1
      CR 7149
      #15                                                              172

                I               As far as dissemination' of knowledge is concerned,

                2    most programs have focused on appropriate groups and

                3    institutions that will benefit.  Knowledge, skills and

                A.   techniques to be disseminated everybody identified to

                5    varying degrees among the projects.'

                6               There is a notable degree of involvement of

                7    health education and medical institutions.  Better care to

                8    more people is a goal to which-projects are  directed.  Some

                9    solid measurement of result remains to be seen.  However,

               10    they are also Addressing themselves to moderation of costs

               11'   of care.

               12               Utilization of manpower, the regions utilize

               13    community health facilities and it is apparent in the

               14    projects that are proposed.

               15               Allied health personnel utilization has improved.

               16    Although new types of health manpower is a sensitive  issue,

               17    further attention is being given to this and this  statement

               18    revolves around the fact that the medical profession in  the

               19    State of Texas is not yet ready to accept the position of

               20    assistance.  Maybe this will change but this was why this

               21    particular statement was put in there.

               22               Improvement of care, access,to health care, is

               23    their first priority and projects'are being addressed to.this

               24    issue.
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       mea-2                                                              173



                      this is an important  element in several  of  the  projects.

                 2    Less attention is given'to health maintenance and disease

                 3    prevention in the proposed activities.

                 4               As far as short-term payqoff the proposal is

                 5    directed more toward the ability of access to services than

                 6    simply gathering more  information  about  health  problems.

                 7               The need for feedback  is projected.  Support of

                 8    projects not planned beyond three years.  Plans for

                 9    transition to other sources of support are inc@ded in their

               10     proposals zo that three years is the limit of funding.

                                 As far as regionalization, we have talked about

               12     the different regions.  It is a major goal of the program.

               13     They do share existing resources when possible and now

               14     linkages among providers are indicated in the     three-year

               15     plan.

               16                There is ample evidence that the region has and

               17     will attract funds from sources other than RMPT. Though not

               18     discussed in detail the region account provided the staff

               19     with a document which indicates non-RMPT funding, to be

               20     new and continuing projects and terminating projects

               21     $150,380.

                                 it was the feeling of visiting team that Texas
               22

               23     has much going. That it is well on its way to doing some very
   0           24     exciting things based on  sound  priorities  and  objectives
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               25     which have been developed cooperatively with-a great deal of






                                                                            174

   CR 7149
                  I  consideration by all people involved.  They have been accepted
         15
       d.         2  by all people involved and it seems as though they are

   flq. MEA       3  collectively ready to move out  and  do'something  with  these

   dor 1          4  things.

                                 We also felt that the region  is  under  excellent
                  5               1

                  6  leadership from the coordinator,  who  uses  well.his  central

                  7  staff of people who do bring to the central staff competencies.

                  8              We have before us the funding level requests and I

                  9  think we can all read that the  site  visitors  did  recommend

                10   that they be approved as requested.

                11               Now, I would draw your-attention to the fact

                12   that these do include the kidney pro3ect and that there are

                13   questions about that.

                14               Dr. Roberts pursued that more in depth, but it

                15   was the unanimous opinion of the visitors that they be

                16   approved at the level requested.

                17-              It was also the unanimous feeling of the visitors

                18   that Texas kept its A rating.

                19               DR. SCHMIDT:  All right, John.

                                 Dr. Kralewski:    Just a couple of comments.
                20

                                 I didn't visit Texas oh the site visit.  As a
                21

                     matter'of fact, I have never visited-Texas RMP, so I really
                22

                23   don't know the program.

                                 I am reacting to the application; I am reacting to
                24
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    dor 2                                                                 175


                 I             Unfortunately, the reports are striking me a

                 2  little differently than they apparently struck the group

                 3  that visited Te'xas, but let me just give you my impre8sion,-.

                 4  then we can go from there.

                 5             First of all, it looks to me as though that RAG

                 6  is still dominated by producers of services even after  the,

                 7  you know, team previously had been very concerned over it

                 8  and wanted to make changes.

                 9             Changes have been minimal, and the addition of

               10   women to the Regional Advisory Group, and then putting

               11 - minorities on there, to me, is a-cop-out and, secondly, it

               12   is a cop-out, I think, to say we don't want to take  someone

               13   because he is a minority group, we have got to wait until

               14   we get that fantastically qualified guy.

               15             I have had about three programs tell me  that  and

               16   it is a strict cop-out, because they don't look.  There is

               17   plenty of good guys out there if they search for them, so

               18   I think they are not doing the job in that.regard.

               19             Secondly, when I lo6k at the projects, I think

               20   this shows up because, of course, in'their screening of  the

               21   projects, this is the group that sits down and sets the

               22   priorities and determine what should,be in and what'should

               23   be out.

               24             If you look at these projects, a good many of them
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               25   are self-serving to the group that is on the Regional





   ao r .5

                                                                        176


                    Advisory Group, self-serving to pr6ducers of  se.rvices.
                               I know this is'a conservative state and they
                 2

                 3  will have to 'chip away a while before they can do things.

                               I find, on the one project, they are going to help
                 4

                 5  someone develop an HMO, and I was looking that over to see

                    who it was going to be, and sure enough, it is the Medical

                    Society.
                 7

                              So, now we will have-another foundation developed
                 8

                 9  at our expense for the Medical Society more than likely.

               1.0            Well, you know, these-are leaving me some real

               11,  questions.

                              Also, I note in here that it appears that a fair
               1 2

                    amount of projects are carry-over projects, they are not
               1 3

               14   being phased out.  It may be that this again is an indication

               15   of some excess money that was given to them in the middle
               16   of the year and it just@ doesn't reflect that in this

                    application.
               17

               18             Well, on the basis,,on that basis, of my feelings,

                    as I read through this and the feeling that I get, you know,
               19
               20   for what they are doing, I can't really recommend that level

                    of funding, nor an A rating.
               2 1
               22            On the other hand, as  I said,.I have never visited

                    the program.  I am acting on the basis of information that
               23
               24   might be limited.
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                                                                              1 7 7
     dor 4


                  I   -spent a lot of time with it, therefore, I am in a bit of

                  2  a  dilemma.

                  3             DR. SCHMIDT:   Let's see.  Let me see.  Would you

                  4  second  the motion that was made?

                  5             DR. KRALEWSKI:  For that funding le,,rel?

                                I coUldn-t second that, no.
                  6

                  7             DR. SCHMIDT:  All right, there is.a motion on the

                  8  floor for approval at the level.'requested.

                  9             Is there a second to that motion?

                10              MR. HILTON:  Second,

                11              DR. SCHMIDT:  All,right, it is seconded.

                                All right.  Further discussion?
                12

   e   15       13              Dr. Luginbuhl?

   take 16      14              DR. LUGINBUHL:  I w as interested to check the

                     population of the area.
                15

                                I'think it is 11 million people, and I don't
                16

                17   really  feel that coming up with per capita figures should

                     be t he  way in which we determine allocations.  I do think,
                18

                     on the  other hand, that we have  to  give  some  consideration
                19
                20   to the  size of the area and the numbers  of  people  that  are

                21   being served.

                                I think that the amount  of  money  proposed  works
                22

                     out to something like  22  ce nts per person.
                23
                24              I know in  one  of the other programs, we have given
  Ace - Fedetal Repotteis, Inc
                  ' probabl@. five times  as  much on a per capita basis.
                25






                                                                             17 8
     dor 5


                 I             My question is, if it is'an A  rated progr am, why

                 2  isn't it a bigger program in view of the  size of the state,

                 3  the diversity of income levels, the magnitude 'of the problems,

                 4  why aren't they able to utilize more funds and meet some of

                 5  these needs that are there?

                 6             DR. MARGULIES:  I think that is an interesting.

                 7  kind of a question to raise.  It is more a matter of history

                 8  of program development than it is geography or population.

                 9             it is a problem that we have wrestled  with  at

               10   various times in RMPS.

               11              This particular program was one with a miserable
               12   record up until the time of the' last sit e visit, when George

                    Miller was down, sort of astonished at the change about it.
               13

               14              On the other hand, if you are asking the
               15   question, why, if this program is as strong as it  is  and
               16   has that many people it is tot able to identify more
               17   activities of value to those people, that is a  perfect  y

               18   valid question.

                               I just don't want to mix the two issues in the
               19

                    discussion.
               20

                               DR. LUGINBUHL:  Well, my major question really'de alt
               21

                    with the last issue.  I can't help but wonder, in view of.
               22
               23   the population, why isn't it a larger program, and to lead
               24   me to  queIstion the wi-sdom of having a single program cover
  Ace-Federal Reporters, Inc
               25   such'a very large geographic area and such a very large






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                 I  population.

                 2             I am not familiar-with the California program

                 3  because we have not reviewed it at this time,  and  I  gathered

                 4  they have dealt with their large population by some sort

                 5  of great division and I know that New York, which  may  not  be

                 6  the best-example, of how to run a region, has divided that

                 7  state into several different regional, medical  programs.

                 8             The question I am really raising, is  this  too  big

                 9  an area to manage through a single.program?

                               Is there enough emphasis being placed  on  the  sub-
               10

               11   regions or on dividing ijp the-problem so that it can  be

                    addressed?


               13              MISS KERR:  There was consideration.given to.

               14   having three -- Texas make up three  regions  originally,

                    and it was decided to go with one.
               15

               16              The other thing is the regions are comparatively

               17   new, with their representatives just getting out there and

               18   getting involved, and I think.Ithat to use-Mrs. Flood as an

               19   example in the El Paso area, where there are many Chicanos,
               20   she knows their problems, they relate well and there is a

                    Sister Strohmeyer down in the lower-valley who is equally
               21

                    as -- and I assumed, all of them were, from the way they knew
               22
               23   their subregions as they discussed them with us, they were
               24   identifying problems.
  kce - Federal Reporters, Inc.
               25              I am  n.ot sure at this point in time, though I






     dor 7                                                                   180

                     am sure that they, too, will want more funding eventually, but

                     I am not sure at this point in time but what the  'coordinator
                 2

                 3   and the RAG feel that at this particular time @erhaps,that

                 4  "We better take this much money and do well with it and then

                     go the next step."
                 5

                 6              DR. MARGULIES,:'  I would like to pick up  something

                 7   John commented on, he used the same words in my  mind when  he

                 8   said "cop-out".

                 9              I react, I guess, with some suppressed violence

                10   to this business of, "Oh, yes, we are interested in

                     minorities and women but they must be of the)best kind and

                12   of the finest kind of qualifications."

                                Well, I have a couple objections. to that.  One
                13
                14   is that it can easily be used as a facade for inaction.
                15              Secondly, if there was absolute equality as
                16   equality  is usually measured, then there wouldn't be any
                17   minority problem in the first place, that is really what
                18   we are talking about, and
                19              The tlird is I doub-t very much that a program

                     which has to deal-with issues of the-kind that they have in
                20
                     Texas, particularly with the issues of Mexican Americans,,
                21
                22   migrants, and so forth, can do.so from the kind of experience
                23   that they get from people who have never had anything  in  the
                24   world to.do with those problems.
  Ace-Federal  Reporters,  Inc. I think it'is a programmatic weakness but what I am
                25






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     dor 8


                 I  real ly wondering about is, if you'believe in general in

                 2  these concepts, at what point does this become an issue of

                 3  priority in determining what grant levels should be?

                 4             Now,,we.have identified on several occasions in our

                 5  review that there are deficiencies but there are signs of

                 6  progress, and so on.

                 7             This is one of the criteria.  The weight one

                 8  gives to it, I supposek can be put down in some kind of

                 9  arithmetic form, but I think there is more to it than that.

               1.0             And I think it is only fair to say to you that our

               11   own kind of judgment is going to be very strongly influenced

               12   by just how much evidence there is of commitment to the issues

                    6f@,fair play with minorities, with women.  This is so
               13

               14   inseparable from the concept of an effective Regional

               15   Medical Program that I find it impossible not to be

               16   influenced greatly when we come to the question of grant

                    award.
               17

               18              Obviously, if there,is a marked disparity. in my

               19   view. and that of the review committee, we will yield to the

                    position  of the review committee and council, but I do hope
               20

                    that question is be ing given as much consideration as it
               21

                    should.
               22

                               DR. SCHERLIS:  I just wanted to take up some more
               23
               24   questions about the recommendation of the site visit group,
  Ace-Federal Reporters, Inc.
                    since apparently it, in giving all the funds that were
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                                                                              182
     dor 9


                  I  -requested, apparently  decided all the funds were to be

                  2  wisely  expended.  Looking  over  some  individual   projects,

                  3  they are of interest.  I question, though, how much impact

                  4  they will have on health care delivery systems.

                  5              The health project Number 691  Health Evaluation

                  6  Acdess and  Resources Development, Ector County Medical

                  7  Foundationt as I read it,  it  is  a  computerized  effort  to

                  8  aid in diagnosis and seems rather expensive, it is

                  9  $118,000 for each of the years, 16-ok at some sixthousand

                10   people.  If I  read this correctly,   have,a,'@tandardized

                11   medical history questionnaire.in English or Spanish,.and if

                12   anyone has tried to set up computerized,methods for getting
                13   histories to go beyond that, this is a tough area.

                14               Perform basic physi cal workup, which   consists of

                     urinalysis, blood pressure, vis  -aal test and hearing  test.7
                15

                i6   These are the only ones that are listed.

                                .You will then have  electronic  data  processing,,
                17

                     printout, a physician will look at the printout, and decide
                18

                19  'whether any medical care is necessary.

                                Then from that point, I sort of lost track
                20

                21   because they say diagnostic and treatment services will be

                22   obtained from public volunteer and private sources without

                23   charge when possible, and  hea,lth,delivery  is  dependent  on
   0            24   that vehicle of access, if it   is,'it is really a very thorny
  4Ce-Federal Reporters, Inc.
                25   type of project,to look at.




     dor 10

                                                                        1 8 3


                               Yet,  it is one hundred eighteen for each of

                    two years.  It is fairly-routine.
                 2

                 3             I was wondering if you could tell me what GRO".

                 4  is, or  GRO are, since it is taking place in five places.

                               MISS KERR:  Grass roots.
                 5

                 6             MR. SAYS:  This essentially is seven to twelve.

                 7  in each group that get together.  The, whole idea is a

                 8  sharing of services.  Thus far, about the extent of the

                 9  actifity has been sharing in service training, but we

               10   believe that it will go far beyond that.  They are now looking

                    at this.


               12              It certainly is an activity that is popular

                    among the consumers as well as the providers.
               13

               14              DR. SCHERLIS:  The other program is an electrical

               15   safety servicei one which seems' similar to many of the others,

                    except here they are paying $50,000 for manuals, I guess to
               16

                    be put out.  Then to have it self-supporting, I question
               17

                    if at this period of time, knowing what we do about safety
               18
               19   hazards, since all this is so well documented and available

                    through many agencies and otherwise, I just question if this
               20

                                                                              f
               21   should be part of what RMP should support.

                              MR. SAYS:  Well, this is a: pickup on an activity
               22
               23   supported by program staff for about a year.

                              DR. SCHERLIS:  But they plan to support that again,
               24
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                                                                          184
     dor 11


                                                               different.
                                MR. SAYS: No, it  is  a  little.
                 2              The core staff'activity, they  demonstrated   the

                 3  feasibility of this in six hospitals and   the Texas Hospital

                 4  Association, which is very progressive, very cooperative

                    with the RMP, as well as other  prior,organizations, has seen
                 5

                 6  fit to take this activity, asking.for support for one year

                    only, after which it@:.will be continued through fees.
                 7

                 8              It goes far beyond putting a manual for hospitals,

                 9  but offering them assistance, actually going in and taking

                10  a look at the way they go about checking out their equipment,

                    and so forth, and possibly,  even in some  of the smaller

                12  hospitals, sharing electrical engineers,   where the single

                    hospital may not now be able to do so.
                13

                14             DR. SCHERLIS:- Well, the lutline doesn't go that

                15  far.

                16             MR. SAYS:  If you look at the   full-blown

                    application, it does.
                17

                18             DR. SCHERLIS: I guess you  had  the  raw  project.

                    I question if this is the way  to do it, since there are other
                19

                20  ways of approaching it.  This was the question  that  I  had.

                               DR. SCHM IDT:  Mr. Toomey?
                21

                               MR4 TOOMEY:  I couldn't find any mention of an
                22

                23  HMO proposal, but I would like to comment that  if  there  is

                    s.uch a proposal, and if it does concern itself with a
                24
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                25  medical care foundation, then I would recommend  that  it  be




                                                                        1 85
    dor 12



                 I  supported.
                 2             I am concerned about the medical  care  foundations
                 3  that are established'on A as a defense mechanism against more
                 4  and different and, if you will, innovative kinds of pro-
                 5  visions of medical care, and to use the foundation for
                 6  medical care as-a mechanism to defeat something which  is  new
                 7  and different,turns me off, but to fund a project which has

                 8  as its base and concept great.numh_ers o  peop e or
                 9  representatives of hospitals, public health  agencies,  CHP
               10   agencies, RMP people, physicians, medical schools,  and  so
                    on, it would be very refreshing and as & matter of fact, it
               12   might just possibly come up with something which would
                    be very worthwhile in terms of-an HMO foundation  for  medical
               13
                    care kind of proposal and would be different.
               14
               15              I would like to see'it.

                               MISS KERR:  I am not sure but what there is some
               16
                    misunderstanding about this because the HMO activity has
               17

                    been as a result of RMP involved staff assistance,  but  it
               18
               19   is being funded by HSMHA, county medical society,  but  the
               20   region itself is not involvedlin any funding of the HMO.
                               DR. KRALEWSKI:  My comment to HMO was along the
               21
               22   lines that this is the way they devoted some of their
                    discretionary funds, I believe,.and core staff effort, and
               23
               24   it may be appropriate.  It only occurred to me that I suppose
  %ce-Fedeial Reporters, Inc.
                    there was a lot of different areas that could have  used  that
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                                                                           186


       r 13       1  kind of help, and as I was  reading  through  it,  where  they

                  2  talked about the fact they were giving help to groups to

                  3  reogranize the health system, lo and behold, it

                  4  happened to work out that way, and it may be good.

                  5              I'don't wish to speak against it, but I think that,

                  6  you know, this is a big region, they have got a lot of people

                  7  they are trying to subregionalize, and I hope that that will

                  8  help a bit.

                  9            ..The site team obviously  thought  that  they  have

                10   some strength and will be able to grow and so I guess,

                     really, though, that my reflection:: on this is that I feel

                12   it,.would really be giving them'a bit too much  of  a  pat  on

                13   the back to go one hundred percent of what they have asked,

                     both in light of the accomplishments that they have achieved
                14

                     and in terms of what has   been made on these projects.
                15
                16              Therefore, I guess what I would really like to do

                     is offer a substitute motion, of funding at levels of 1.9,
                -17
                18   2.1, and 2.3, with developmental funds  in  the  range  of  80

                     first year, one hundred and one hundred for the second and
                19

                     third year.
                20
                21               I think this will give them an increase in funds,,

                     and -as-.,has been pointed out, this is.a large population
                22

                     group and probable that budget is not out of line.
                23
                24              Y et, I think it will  indicate  to  them  that  we
  Ace-Fedefal Reportefs, Inc.
                25   still have some questions about exactly what is going on and






                                                                             18 7

     dor 14
                  I  where that money is going.

                                DR. SCHERLIS: 'I second that.
                  2

                  3             DR. SCHMIDT:  All right, there is a'second, then,

                  4  to the substitute motion.

   end 16                       Their level last ye ar?
                  5

   take 17        6             DR. KRALEWSKI:  1.58.

                  7'            DR. SCHMIDT: 1.58, so this  would  be  up  to  1.9.

                  8             MR. SAYS: Doctor, I know  there  is  a  motion,  but

                  9  I think there are some things perhaps you  are  not  aware  of,

                10   Dr. Kralewski, in this whole situation.

                                Dr. McCall is an  extremely capable coordinator
                11

                12   and he understands that to pull off a.successful program

                     takes the commitment of the people to whom it is to be
                13

                14   delivered, and also those who%are  involved  in  the  process.

                15              If you look at the application  very  closely,,  it

                     took him from July, when the 1 ast site visit was made, up
                16

                17   until December of 1971, through a  very.long  hassle  with  his

                     RAG and his development committee.  The priorities were
                18
                19   developed once and rejected by the  RAG.  They  went  back  to

                     the drawing board.
                20

                                They had only two months to bring in some kind of
                21
                22   pro3ects for this application, hence, the reason for his
                23   growth funding in the second and third year.

                                I happen to know that sinc e  this  application  got
                24   -
  PAce-  Federal  Reporters,  Inc. into the hopper, in Januar@, they could use  easily  a  half  a
                25





                                                                       188
     dor 15


                    million dollars more now.


                                For an example,  in Houston, they are now
                 2

                 3  operating,  or talking with  a group, this program has almost

                 4  developed,  it would take $150,000. -It involves two barrios,

                 5  where  they would like to employ six half-time:'.-health advocates

                 6  in each barrio,'under the  supervision  of  Chicanos.  This

                 7  dove-tails in with a program by Baylor, the Department of

                 8  Community Medicine, which is  als'o involved in a  hospital

                 9  district that has the direction@of.seven clinics@ rom that

               10   city that deal with very poor neighborhoods, an excellent

               11   opportunity perhaps to examine access  or  evaluate  access

               12   and quality performance on a patient population of 60,000.

                                This is just, you know, a couple of
               13                                                    prograr6s. that

               14   have been examined and are in the hopper at this time.

                                This application started almost a year ago.
               15

               16               D@. KRALEWSKI:. Well, I appreciate that additional

                    informatio n and I feel that if you are  correct  that  this
               17

                    gentleman is a really good manager, that he would be able

                    to take a million nine and probably reorganize some of the
               19

               20   things that he is doing and probably, as a matter of fact,

               21   go through these projects and come out of there with, you

               22   know, ten or twelve or fifteen percent savings, at least,

                    and then devot e that to these very worthwhile activities
               23

               24   that you are mentioning, and I suppose he  does  have  also
  lkce - FedeFal RepoFteis, Inc.
               25   the opportunity, to come back with an application a bit later






                                                                          189
     dor 16


                     for some additional activities as they   develop.'

                  2             MR. SAYS:  One year hence.

                                DR'. LUGINBUHL:  I am certainly very much influenced
                  3

                  4  by your evaluation of the leadership of the program, but I

                  5  think the information about the timing problem is quite

                  6  significant.

                                What I would wonder about is this:  Would it be
                  7

                  8  possible within our ability to make some cutback in terms

                  9  of the project part of the money, but give that money    to  the.

                1.0  program in a way that they could-use it flexibly over the

                II-  coming year.

                12              If he is a really good man, he has come up with

                13   good new things, now that he has gotten priorities

                14   straightened around, I would like to  give  him  the  flexibility

                15   because it already is a fairly limited sum of money for the

                     population  and  problems.
                16

                17              I don't see the imaginative  approach  to  the  large,

                     unserved segments of that population in this application,
                18

                19   and maybe if we  could  pr.eserve the dollars but give  some  more

                     flexibility to the director, he could begih@.,to address those
                20

                21   programs.

                                Finally, I am somewhat concerned  about  the  RAG  and
                22

                23   the fact that it does appear to be heavily influenced by

                     professionals.
                24
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     dor 17                                                                19 0


                  I  discussions, about the    size of these groups.  This  one,  I

                  2  think, is 50 or so people,   and  Iwonder how  well  they  are

                  3  really able to  meet  and  set some of these priorities and

                  4  particularly how  do  some  of the underserved get their priorities

                  5  into the  application,  if  the group is  dominated  by  priors.

                  6              DR. @CHMIDT:  Well, I think one of the points that

                  7  John.was making was that if this is  a  wise  manager,  he  can

                  8  get discretionary funds  out  of  the money he has just by

                  9  simply not spending it for some  of.the  things  that  in  the

                10   application.he said he was going  to  spend  it  for.  You  are

                11   saying can we force him by earmarking discretionary funds and

                12   the answer to that is, he can be advised or it can be

                13   recommended but we haven't been in the habit of so ear-

                14   marking funds.

                15               DR. LUGINBUHL:  My  concern is a little bit

                16   different.

                                 If I am correct in my understanding of the process,
                17

                @18  whereby some of these  projects.get  into  an  application,  I

                19   think what happens at times is'that people propose these

                20   pro3ects and they are nominally  within  line  with  the  goals

                21   and objectives and the group making-the decision at the local

                22   level finds it very, very hard to say no, especially when therE
                23   is not some other proposal at  that  point  in  time  competing
   0            24   for those dollars.
  Ace-Federal     Reporters, Inc.
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                                                                         19 1
     dor 18


                 I  setting priorities is getting passed on up to us.

                 2             If you have the money or the potential for getting

                 3  money and you are not forced to set priorities, frequently the

                 4  easiest thing to do is just not set them.

                 5             What I am suggesting is that by cutting back  on

                 6  the project money, you are going to force them.to set  some

                 7  priorities and you are going to let them reallocate those

                 8  dollars or force them to reallocate those dollars by

                 9  increasing the discretionary funds and I would think that for

               10   at least some coordinators, this would be a very  welcome

               11  -opportunity to set priorities and-to, in fact, strengthen

               12   their hand in dealing with their regional advisory  group

               13   and dealing with some of the priorities that are making

               14   demands for project support.

               15             DR. HESS: Just a question  to  further  clarify

               16   this.

               17             It is my understanding  that an RMP may shift

               18   developmental components into projects but the reverse is

                    not true unless it is authorized, is that correct?
               19


                              DR. SCHMIDT:  That is correct.
               20
                              DR. HESS: So the implication of  your  statement!
               21

                    is, would be to approve the developmental component-at  the
               22

               23   requested level and take the cut in the project section  of

                    the budget in order to achieve your goal; if that is what we
               24
  Ace-Federal  Reporters,  Inc.
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                                                                           192
    dor 19


                I             DR. SCHMIDT:   All right, is this acceptable to

                2  the mover as a piece of  legislative history that will be

                3  directive then?

                              In other words, developmental component is given

                5  at the 10 percent level, the maximum allowable, but  the  cut,

                6  the reduction down to 1.9 comes out of the project funds.

                7  That-we can do.

                8             DR. KRALEWSKI:  Acceptable.

                9             DR. SCHMIDT:  All right.to the secondW, is

               10  that acceptable?

               11             DR. SCHERLIS:  Yes.

               12             MISS KERR: I would like  clarification  as  to'what

               13  the motion of the moment is now?

               14             DR. SCHMIDT:  It is.for approval of  the  triennial

               15  period at the levels, 1.9, 2.1, and 2.3 total  funding levels.

               16  The original substitute motion was for developmental

               17  component of 80, but this has now been changed to a

               18  developmental component that would be the-maximum allowable

               19  under the policy, or ten percent of the award, really,

               20  which would give them, what did they ask for?

               21             MISS KERR:  They--,asked for first year $160,000,
               22  second, two hundred thousand, and the third,  two  tw6nty-five

                   thousand.
               23

                              DR. SCHMIDT:  Well, that would still be permissible
               24
  %ce-Fedeial  Reporters,  Inc. then because it could go up to 10 percent of the award. So
               25




     dor 20
                                                                            19 3



                 I  that gives them some amounts of flexible funds.

                 2             All right.

                 3             Other comments or questions then?

                 4             If not, I will call for a vote on the substitute

                 5  motion which,we just reviewed.

                 6             All in favor, please say "aye".

                 7             Opposed'.Ino?

                 8             Dissent is recorded.

                 9             Thank you very much.

               10              I think that is the first time we have ever

               11   completed  adiscussion of T exas.in 55 minutes, 65 minutes.-

               12              We can conclude a discussion of Indiana in 30

               13   minutes.

  xxxxxx       14              DR. PERRY,@.'-  The word catalyst has been used

               15   so I will just say there has been a most dramatic transition

               16   here in Indiana in the past year.

               17              A site visit has not been held in Indiana, although

               18   an August site visit was set up, it was canceled by RMPS

                    for the following valid reasons:
               19

                               Dr. Stonehill, the coordinator of Indiana resigned
               20
               21   effective April 30, 1972.  The  triennial application that Iwas

                    submitted was submitted without really the assistance  of  a
               22
               23   coordinator, was reviewed by the staff here at RMPS, did not

                    clearly present a three-year plan, thus the site  visit  was
               24
  Ace -Federal  Reporters,  Inc. cancelled.
               25






                                                                                                                                          19 4
         dor  21


                               1                         RMPS  recommended  the  submission  of  a  one-year

                               2    anniversary  application which would  lead  to  a  much  stronger

                               3    triennial  req  uest  next  year  and  this'has  been  done.

                               4                         Dr.  Schmidt,  the  second  reviewer  and  I  have  been

                               5    on  two  separate  site  visits  at  Indiana.    Dr.  Brennan  and  I

                               6    in  1970,  representing  the  council  and  the  review  committee,

                               7    were  there,    We  were  not welcomed  back  for  the  next  site

                               8    visit.

                               9                        Dr.  Schmidt was  in                Indiana  in  1971  and  I  am not  sure

                            10      ;of,-@   his  reaction  about  being                   welcomed  back  for  a  site  visit

                            11   this        time,  but  the  purpose  of                  the-site  visit  and which was

                            12      communicated  at  the  site  visit                       periods,  I  believe  have  led.,"

                            13      to  the  most  important  decisions  for  change  in  this  region.

                            14                          If  there  is  anyone  thing  that  I  would  say  was

                            15      probably  the  greatest  strength'of  all  is  this  attitude  of

                            16      desire  to  change  that  is  recorded  in  this,  not  only  in  the

                                    application,  but  by  other means.
                            17

                            18                         I  am  delighted  that  Bill  is  here  at  the  table

                                    with  us  because  members  of  the-staff,  since we  have  not  been
                            19

                                    there  during  this  period  of  thime,  there  are  members  of  the
                            20

                            21      staff  that  have  been  in  the  Indiana  region  and  it  i  some  of

                                    their  reflections  and  their  reactions  and  certainly-the
                            22

                            23      recommendations  of  RMPS  that will  be  a part  of  my  recommenda-

                                    tions  here  today.
                            24
    Nce-Federat Reporters,  Inc.
                            25                         To  evaluate          Indiana,  let's  look  at  some  of  the





                                                                            19 5

    dor 2 2


                 I   strengths and then some of the  weaknesses for, indeed, even

                 2   with the problems and dramatic  changes'.-that have taken

                 3   place,.there are strengths that can be indicated  here..

                 4              With Dr. Stonehill's departure, which  was

                 5   requested two months earlier than his date of resignation by

                 6   the RAG, I think this tells a little about the.story there.

                 7              I am putting this as a strength and it must be

                 8   taken as a plus, as far back as the time of the, of this 1970

                 9   site visit, in which I participated, there was a great deal of

                10   antagonism expressed between many Indiana Medical Associations,

                11   and by various groups, representatives of the Medical School

                1 2  at Indiana,@haVe stated.--.toBill.-@ to others.that they have

                     been misinformed on the status of IRMP.
                13

                14              And that the tight ship that had been identified

                15 and I  guess these are words that both Al and.our group used, that

                16 this  man  was running what was evidently heading for very

                17 rocky  shoals.

                18              With his departure, Dr.Behring, Associate Dean of

                   the  Medical School, has been appointed the interim or acting
                19

                   coordinator  and a search committee has been set up for his
                20

                2 1replacement.

                                I recall Dr. Behring, he has served with-this
                22

                23 group and with the RAG for a considerable period of time,

                   perhaps an indication,-h6wever, that this RAG was not that
                24
  Ace - Federal  Reporters,  Inc. active'and not that  inv.olved.
                2 5






                                                                             19 6
     dor 2 3

                               Already the relationship', and I would put this as

                   a strength, already the relati onship of the Medical Society
                 2

                 3 and other health-agencies have indicated a marked improvement

                 4 in the few months recorded since the resignation of the

                   coordinator.
                 5

                 6             Dr. Behring reports, as the interim.ooordinato.r,,
                 7 thatthere are improved relationships wit hthe Indian Hospital

                   Association, many of the health associations that have been
                 8
                 9 identified.in relationship to this program, that they are,
               10  indeed, sharing with them their request for help in putting
               11  this region into better shape.

                           The RAG, with many of the problems,.,Ii-will@list under
               12

                   weaknesses.
               13
               14              I feel, however, the complete review that is

                   taking place with the RAG today-is absolutely essential.  It
               15
               16, is still in the process of major revision.  Although the

                   lar
                     .ger number are from Indiana University, and there have been
               17

                   comments on this from the beginning, Indiana4@ in that setting
               18
               19  and in that state, certainly Indiana University deserves and

                   should be in a major relationship to this RMP.
               20
               21             But in addition to  this group, we find here other
                   institutions, other groups, their relationship with CHP,
               22
               23  w ich I will speak to further her e, other organizations

                   throughout Indiana are.being represented in some of the
               24
  Ace-Federal Reporters Inc.
               25  planning that is going'on.





                                                                            19 7

    dor 24

                               There is no question abo-ut the still-great  need

                   for consumer input.  Representatives of some of the other
                2
                   health professions, the health professions are 'physicians
                3
                   and nurses only. Dr. Behring, however,  again  has  expressed
                4
                5  his eagerness to the members of the RMPS here.  He  plans  to
                6' answer the criticism that IRMP.has received and that, indeed,
                7  the Medical School will assume a different kind of relationship
                   on the RAG and in relationship to the total program.
                8

    end 17
                9


               1-0


               11


               12


               13


               14


               15


               16


               17


               18


               19


               20


               21


               22


               23


               24

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               25






                                                                              19 8

      CP 7149


        18
                              Perhaps the most exciting strenc
                                                               ,rth to mention is
    Tlcba 1      2  the regionalization that although begun several years ago
                 3 has culminated in the  nast few  months with some  very   strong
                 4 effects.  Nine area action grouos have been formed and the
                 5 formulation of active relationships with five existing CIIP agen-
                 6 cies has been car'ried out.

                 7           The formulation of two othdr,CHP's are being planned
                 8 with I P@,'--. I Wnow in a working  assisting  relationship  with  them.
                                                        1
                 9 On just a nersonal level I had the opportunity of@,peaking
               10  it my home town which is Richmond, which does not.liave any

               11  I guess'T)roblem here in terms of into-rests in the project.

               12            I was speaking to the Medical SociOty of Wayne County
               13  and it invited Liberty County to' this meeting. They did not

               14  know my relationship to @MP in any way and in the business

               15  agenda of that meeting it was pretty exciting to hear them

               16  putting toqeth er, having received  a  request  for  Indianapolis

               17  for the first time to get involved, to select the people to work

               18  with them.

               19            To be a part of action' groups. There  was   certainly

               20  to me as I look back and as I read this application, an indi-

               21  cation of the little small town out there of  40,1000  that  had

               22  been asked for the first time  to  participate  in  this-project

               23  and this nroaram and really their'excitiement that Indian-

               24  anolis was looking out to them for  them thev felt for the
  Nce- Federal Reporters, Inc.
               25  first time.







                                                                                   19 9


               018               So this regionalization p
                                                             .lan is a most important
         2         2 r)lus.  Development of effective comprehensive data base

                   3 which is one of the major concerns of the 1970 site visit which

                     deplored the lack of any really major statistical basis .for
                   4

                     nlanning T)riorities and   needs, this has been accomplished al-
                   5

                     though there are barts of it that need to be looked at out in
                   6
                     these scoarate marts of the areas that are being put together.
                   7

                   8            The state-wide basis has been accomplished and listed
                     in this. I am sure Dr. Brennan will be happy to s@ that since
                   9
                     this is one of   his major pushes at the 1970 visit.
                 10

                                23 now major data sources have been obtained.
                 12  These have-been obtained through contra.ct.sources and such
                     there in the state.  And certainly there is a working set.to
                 13
                     ,-fork with here in looking at the.regional characterization.
                 14
                     Their set of objectives, broad objectives that have been put
                 15  ;
                     together certainly has to be better defined than they are at
                 16

                     the nresent  time.
                 17
                               But they have this bas@4s for the firs@ time to look
                 18
                     at it and really to work with it'. The strengthening of the
                 19
                 20  program staff has been looked at as one of the major commitments
                     and needs of this program. And already there is a reassignment
                 21
                 29  Df responsibilities of some of the people  on the program staff.
                 23            This is a relatively.sma'll staff those      of you that
                     are looking at any of the material and whether one considers
                 24
  A,ce -Federal Reporters, Inc. --hat the amount of money at an annualized level for the program
                 25






                                                                               20 0



           #18  1  staff is around $379,000, this.has been a small staff that

    reba 3        2  the former coordinator wanted in relationship to running

                  3  the program.

                  4           In the projects area, particularly those of a categori-

                  5 cal continuing educational nature, it is exciting to find

                  6 that there has been a transfer of many of the    larger funded

                  7 projects to local funds. The coronary pare project that they

                  8 have-carried for years, their  stroke  project,  these  have  been

                  9 taken over'by the other levels and other kinds of. funding.

                10             ,lore about this also in the recommendations. As

                11  I said you know and  I  will go back-to that  as another major

                12  strenth  attitudinal  desire now to change, it is very strong and.

                13  I happen to feel  that  they do have the  capacity  to  bring  this

                14  about.

                15            What are the @,7eaknesse s? The major weaknesses,

                16  Proaram staff, there must be additions to this. There are only

                17  -two vacancies, in the list of what has been requested. This
                18  must be done in certain areas particularly, planning, evaluation,

                    essentially. They have  an  educational  Dsychologist  there,  and
                19
                20  he needs additional staff help.-He needs a model, he needs
                21  some help on how  really  to relate  their  projects  an  eva  uate

                    them toward  program  goals.
                22

                              Mr. Smith who I  had the privilege of knowing through
                23  this project and have had  a working relationship in many other
                24
  Ace-Federal Reporters,  Inc.
                    ways who was responsible for allied health and nursing has been
                25







                                                                        20 1


                 I  so succesful in that area and he really got quite a  bit  going

       a 4       2 there, he is so successful he has been moved'into  another  job

                 3 there and he is going to be head of all the active planning

                 4 in the regional parts of the program.

                 5           May 'I say that leaves quite an opening, however, for

                   allied health and nursing there, and they do need staffing.
                 6

                 7 ulo in that area, particularly since they have begun to turn

                 8 the people on there in that area in relationship to this. As

                 9 a weakness again, from personal background, they have no one

               10  yet from there major division of allied medical professions v7hicli

                   is in the medical school at Indiana.wliich is recognized as one
               11

                   of the most broadly developed T)rograms because there is only
               12
               13  one medical center in that state, has responsibility for all the
               14  community college programs throughout the state.
               15           Still thev have no voice in any way although some
                   T)rojects in the RAG or in any of the relationships there to the
               16

                   program I do not know for this is an excellent program. They
               17

                   have peonle of national stature in that setting, some of them
               18

                   serving with me on two AMA committees in relationship to allied
               19
               20  health.
                            A weakness, the revitalization of this RAG,  a  spefli ng
               21
                   out of responsibilities, certainly a leadership  role,-planning
               22
               23  role, rather than just a reactor role to what has been bubbling
                   un or coming in is essential. Must be a major reassessment of
   0           24
  Ace -Federal  Reporters,  Inc. the regions review process. If one looks.and one has pointed'thi
               25






                                                                                                202



                018 I  out in the last two reviews there                              @-,,d site'


     P,eba 5          2  visits.


                      3              Many members of     the                            of the program

                      4  have made   all of the major decision-.,                         have    a

                      5  very poor   history of turning anyth'..@@                     indications

                      6 are that this review process                                 ..t and already

                      7 in the N-7orks, some of the T)lanninc;                         c must be done.

                      8 minority representation in         the t@'.                   .,.ee are  no

                      9 minority professionals yet         on t],@

                    10               Two    professionals    are                         their

                    11  projects and three minority peop"t.,                              It is an

                    12  inadequate     representation      still                      ovement over

                    13  two   years   ago.   They   still   have                       i). However,

                                                                                      1.1  had  and
                    14  in   the   oroject   orientation,    the

                    15  I  remember  quite   well,   visits   wi                         physicians

                    16  who was heading up.one of the                                   jects, neigh-

                    17  borhood health projects in India7@..                            ave    some

                    18  good projects going in this are-a.
                    19              Of approximately 15 piErij,@                         in    this

                        -program only three old ones are.r,-,@',,                     @inuation.
                    20
                    21  Of these the neighborhood health c.,                            a    tracti tionet3
                    22  are two of these.   There are                                   eel are

                        ready'to  ao.   These   are,   some   of                        from    the
                    23             1

                        categorical.
                    24
   Ace-Federal  Reporters,  Inc.
                                    Thev   have   some    health                        relationship
                    25







                                                                             20 3


                    to their newer goals.  I will.quickly make  a  recommendation
         6       2
                   to get this on the table  then 'I certainly want Bill  and

                 3
                   particularly Al., who has been on site visit and Bill who has
                 4 been there recently to respond to this, but  let's  get  the
                 5 recommendation out in relationship to this.  They are currently

                 6
                   funded in this region at $1 million  121,000.  They  have  re-
                 7 quested a million five hundred-thousan!l in  round  numbers.

                 8
                             The staff having looked at this total plan have re-..
                 9 commended an increase of only  around  $80,000  to  Trillion

               10
                   200,000. And-the breakdown for this. As I said,  they  are  in
               11  -- their major needs as I see their projects  in  this  core

               12
                   staff so f am recommending or approving actually the recommen-
               13  dation made by the RPT-1 review staff here of  approximateIly

               14  $500FOOO of this amount for staff..

               15            This will give them increases in salarv.  This will

               16  provide for the new director.  This will add some  to  their

               17  evaluation staff. It will give them an opportunity to really

                   staff up there where they are really going,to need it in

               19  staff that has been held certainly to  the  bare  bones.  In

               20  relationship to one of their other major needs,  and  that  is

               21  to continue with the projects as they relate to the regi6nali-

               22  zation and into these areas, they  have  requested  $500,000

               23  for this.

               24            In contractual  services.  The  recommendation  of
  Oice-Federal Reporters, Inc.
               25 the review staff here was that this  be  cut  to  approximately




                                                                            20 4




             #18 1  $300FOOO. With this they should indeed be able to go on further

       a 7        2 with their feasibility studies, their expansion of    subregional

                  3 T)lanning, and staffing in relationship'to the regional-program.

                  4           They have made a request for approximately $600,000

                  5 for continuation projects and for new projects.The recommendatit

                  6 is breaking this down to $200,000 each, $200,000 for contin-

                  7 uation and $200,000 for new projects. Adding this $500,$300

                  8 two $200 ones, we come up with a total of $1 million 200,000.

                  9 1,7hat this does give this program, an opportunity to do with

                10  even this small increase of $80,000,  which  is  recommended,

                11  is to -- they have turned  the corner and made  the  decision

                12  to change.

                13            They have 6 long way to go to make  this  the  kind

                14  of nrogram that we really can believe is ready for a triennial

                15  review and I believe with discussion with Bill that any recorm-

                16  endation that we make with the changes and things that they

                17  need to do, rather than insist or even ask  for  a  trieenial

                18  review next year, that they be held at this level for two

                19  years, during this period of transition.

                20            They have turned the corner,-they have  got  a  lot

                21  of plans going, things thev have to do during this period

                    of time.'  Getting a new director although I am sure they ate
                22
                23  going to be moving right Ahead with  this, with the Associate

                    Dean of the Medical School that is working with  them  but  I
                24
  Ace-Fedeial  Reportefs,  Inc.
                25  think thev need a period of time and we are not increasing the

                    amount in the recommendation more than this $80,000.






                                                                             20 5




        149                   That is my recommendation I  put  on  the  board.
                  2           DP,. SCI-TT4IDT: Okay..I am the  secondary  reviewer
      @a 1        3 and'I will trv to just bring out the issues as    I see  them.
                  4 At the time of the site visit last year there was just a god

                  5 awful program. They got P's straight across the board and it is

                  6 a nrogram that if substantive changes had not occurred one would

                  7 be considering whether to just stop  all  funding  and  just

                  8 declare the thing defunct and tell them to start over gain.

                  9           Problems with  ineffective  coordinator  who  had

                10  a small staff they ran tightly'and  the  staff  really  was not

                11' doing the riaht sort of things. They  had  the  worst  kind of

                12  possible relationship with the  medical  school.  The  medical

                13  school completely dominated it.  The majority of people on the

                14  executive committee than ran the program were from the medical

                15  school.

                16            The principal person  involved',  George  Lucameyer,

                17  Assodiate Dean of the School, did not and does not understand

                18  regional medical programs. For reasons easy to understand

                19  the medical school is scared to death of the Indiana Medical

                20  Society because their legislative support comes from the Indiana

                21  '-Iedidal Society. Indiana Medical Society did  not  like  the

                22  coordinator or regional medical program.

                23           The medical school dictated exactly what P.MP could

                24  a.nd could not do.  The coordinator's primary allegiance was to ti,c
  Ace - Federal Reporters, Inc.
                25  medical school.

                  I







                                                                        20 6


                             ITe said if T)ush came to shove his medical school


        2        2 appointment was far more'important than anvthiiig  having  to

                 3 do with P-MP.  The Exedutive Committee was not functioning well,

                 4 there was no data, no objectives, no.priorities, there was

                 5 no nrograms, there was no plan, there was some projects. There

                 6 was no subregional effort. And it was just terrible.

                 7           The site visit two years ago told them  this,  they

                 8got real mad, said it was an unfair site visit  and  they  just

                 9stayed mad for a whole year. And I  walked  into  the  biggest

               10 trap I have ever seen set bv a region that  was  pulling  site

               11 visitors up against everybody and the coordinator took a

                  day to realize that we had been set up.
               12

                            And we left essentially escorted to  the  state  line
               13

                  by the highway Datrol. And I doubled back to one   ray of  hope
               14

                  who was a bright and new lady of' the regional  advisory  group
               15

                  and we just did suggest that the  program leadership needed
               16

                  to be changed, the medical school  put off at arm's length.
               17

                            We had to get the people in the school  who  did  not
               18
               19 know what Pd4P was about out of the picture. And  so  on.  One
               20 member of my institution is for'liaison purposes  a  member  of
               21 the Indiana regional advisory group..Done Casely.  And lie would
               22 come back from Indiana RAG meetings just  cackling  with  glee
               23 and hand me the minutes of the. meeting which took  apart  one
               24 by one the site visitors and challenged the  integrity  and  so
  kce- Federal Reporters, Inc.
               25 on and so on.






                                                                        207


            419  1           But largely through Haver and some  other  people,

       a 3       2 and through the supportive. staff I would like to point  out

                 3 to the review committee the importance'of staff support and

                 4 consistency of staff support in taking to the regions the

                 5  recommendations of the review committee and sticking by them

                 6 and really accurately reflecting and confirming.and supporting

                 7 review committee in this.

                 8           They came in to see Harold, they probably came in to

                 9 see Henrv Kissinqer, I don't know who all they came in to see

               10  but they got the same message each time and there was a revo-

               11  lution. The coordinator resigned and RAG decided he did not

               12  resign quick enough and threi-i him out.

               13            Baring,.I think it is a cop  out.  Medical  school

               14  is suddenly saying we did not know. Well, you know it was


                   IM'OOSSI
               15        'ble that they couldn't have known what was  going  on

               16  because they were the program.  They just were not paying

               17  attention, And I really think that they did know but they are

               18  having a change of heart and they are withdrawing.

                             The program is doing somethings that I think really
               19

               20  are terribly important and if we are going to have a program

               21  there, merit the supoort of the RI,4PS -- they do have a data

                   basis.  'They have new leadership there inorganizing the staff,
               22
               23  recruiting a new staff.

                            They have,a different  relationship to the  school.
               24
  Ace-Federal Reporters, Inc.
               25  They have a very strong and excellent RAG chairman who seems






                                                                       2 0 8



          #19    1  to have taken over.  They have the new goals, priorities,

     (,-@a 4       and plans.  There is an excellent exercise in subregionali-
                 2

                 3 zation.  They have phased out projects'and they are phasing

                 4 out projects.

                 5           They are restructuring their committee structure

                 6 and they have for the first-time a really pretty.good relation-

                 7 ship with the Indiana State liedical Society. Their area, groups

                 8 are very important, the@ are finally recognizing the fact

                 9 that their.CIIPB agencies are around and they are beginning  to

               16  internhase with fantastic amounts of dollars that  poured  into

               11  -Indianapolis, millions into OEO and M4P just said man, we have

               12  to stay away from that power an6 that influence and  all  those

               13  dollars and so on, because the medical school said we have got

               14  to keep a low profile.
               15            They are beginning to-interphase with the things
               16  that are going on in the real world about them. I think that
               17  I will support the idea of funding them at 1.2.  I think they
               18  need this money to do the things that they are doing.  I  don't

                   know if they are falling into the trap of continuing the
               19
               20  old activities.

                             The ones they are continuing seem to be in  the  rTght
               21

                   direction. I think there must be absolutely strong word from
               22
               23  here that what they are to do with these funds is to build

                   their staff, to continue the subregionaliz.ation efforts and
               24
  Ace - Federal  Reporters,  Inc.
               25  put money into that, to use their data base to get specific






                                                                                           209



               f- 1 9
                     I   rogran  plan,  to  get   a   specifi(:4
                                                                              @-in conjunction

    'Pcba 5          2  @-i'lth  the  agencies  and  subreq'Lc,-                                 ihere
                                                                                  to evolve


                     3  they are going.

                     4              That is the  third  tl-i--':               :."iiue the involvement


                     5  with   Indianapolis   OEO   and    all                    ltiplicity of

                     6  programs  that  are  active   in   tli..                       which     range

                     7  from  a  very  rural  thing  in   tl-.@-                (on up. Finally to

                     8  keep-that    damn    medical    school                   headquarters

                     9  and  let  them  be  the  fiscal   ag(-.@               @@.s terribly op-


                                                               .i               -.eek   the    recommen-
                   10   res@ive  school  out  of  the   T)ic',--

                   11'  dation  then,  feeling  that   if   tl'.                 .,od     coordinator,

                   12   I  think  Baring  will  bring   thi.@-,.                 and'he    has    gotten

                   13   the word.

                   14               If  they  will  get  a  c@@.                 will continue

                   15   what  he   is   doing.   whether   th-@-                .:ith   a    triennial

                        neXt  year  or  not  I  am   not   surc,                @@.ould  be  good   to
                   16

                        give  them   the   business   of   you                      year's     support,,
                   17

                   18   you  can  have  another  year's  sii-,-;                ,-a  triennial  if   you

                        need it.
                   19

                                    We  will   look   at   you                   visit in a       year
                   20

                                                                                  re doing    and
                   21   or staff   site  visit  in.a  year   i.,                 a

                                                                                                phase.
                   22   offer   staff   support    while    they

                        Discussion?
                   23
    0              24               DR.     SCITLERIS:     Would               @@--..ostion   seconded
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                        bv a member of the committee                            @-@@--he chairman?
                   25






                                                                                                                                       210


                           @ig                         DP.  SCTIIIIDT:    Let's  see.  Yes,  somebody  get  me  off

                                2 t
                                      he  hook.

                                3                      DR.  SCHLERIS:    I  second  the  motion.
                                4                      DR.  SCIIMIDT:    All  right,  thank  you.    John?
                                5                      DR.  KPALEWSKI:    We  are  moving  this  then  for  two.
                                6  years  instead  of  the  one.

                                7                     DR.  SCIRIIDT:    That  is                 right,.at  the  level  funding.
                                8  And.i4ith,         you  know,  if  they  can                  dome  in   with  a  whiz  bang
                                9  triennial          next  year,  great,  but                   if  they  can't,  let  them  have
                             1.0   the  feeling  theyqot  a  little  -Eime'.

                             11                       DR.  K-RALEWSJ'\I:    Thank  ybu4'
                             12                       DR.  SCILr4IDT:    Other  comments  or  questions?   -It  is

                             13    an  example          of  a  region  that  was  turned  around.  Florida  was

                             14    another  one  I  can  think  of                     and  so  on.  I  think  the  main  things

                             15    that  have  turned  it  around  were  the  site  visitors,  who  had  the

                             16    strong  support  of  staff  who  said  yes,  they  are  right  you  know,

                             17    quit  looking  for  an  out.

                             18                      All  right,  I  will  call  the  question  then.  All                                    in

                             19    favor  please  say  ave.    Opposed,  no?

                             20                      Last  but  not  least  then  it  is  Memphis.    And  the

                             21    primary  reviewer  is  Dr..Ellis.

                                                     DR.  ELLIS:            Thank  you,  Mr.  Chairman.  I  have'been  told
                             22

                             23    that  I  did  not  have  to  many  minutes  to  do  this  by  some  of  my.
                             24    friends  and  I  am  going  to  try  to  be  brief                             so  that  they  won't
    Nce- Federal Reporters,  Inc.
                             25    e  unhappy  with  me  this  time.






                                                                           211


           fl9   I           Memphis is a very interesting region and  I  would

       a 7       2  just like to mention before we go into the discussion of the

                 3 visits something of the background and demographic information

                 4 because this is a very large region and it is culturally diver-

                 5  sified.

                 6           The region actuallv consists of parts of five

                 7 states, and it is made up really of what  is  traditionally

                 8  a trade area.  Also the area that is based on hospital care

                 9 that is given to people in this 75 county area.  21  of  the

               10  counties are in Tennessee, West Tennessee.  16 in Arkansas.

               II.  27 in P-lississipni.  6 in Missouri and five in Kentucky.  And yot

               12  know that in this it is extremely difficult.

                             There is a population of two and a  half  million,
               1 3

               14 that is the 1970. It is interesting also  that  there  is  an

               15   essentially rural area, except for 4emphis which has abo  ut

               16  800,000 people, 600,000 people, and then the  next  largest
               17  city in this whole area after that is Jackson, Tennessee, with

               18  50,000 people.

               19            In terms of the racial composition there  are  31
                   percent roughly a third  black,.  A few Orientals and the rest
               20

                   a                                         also inter
               21   re white. Many of these are poor. It is             esting

                   to note that in the Kentucky section there are  quite-a  few
               22

                   old oeople, the largest number of people over 65 in Kentucky.
               23

                             With reference to the racial matter while I am here
               24
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               25  I will say that' this 31 percent does not reflect the situation





                                                                                           212



         19            in some of the counties.         In  Tunica County, Mississippi, there
    0
    'Peba 8          2  are 73 nercent of the population is black.  While in the

                     3 Ozark area you will have about         the  same kind of thing with

                     4 reference to white people. And         nine of the 27 counties in the

                     5 Mississippi subregion having populations of more than fifty

                     6 percent are black'.

                     7             The infant mortality.rate, I will mention this because

                     8 it is very significant and will have a lot to do perhaps with

                     9 the long range
                                          programs which can bring about institutional

                   10  change.   And.while we have liere.an infant mortality rate this

                   11  is 28.9, comnared for -- to this region and this is compared

                   12  to the national average in 1970 which is'21.7, it is lower than

                   13  that now.

                   14              The thing we want to point out, that in Mississippi,

                   15  in the subregions in two counties the infant mortality rate

                   16  was more than    twice the national average. When you see an

                   17  Infant mortality rate of 28 and you recognize that there are

                   18  counties with more than half, I.mean twice-as much the national

                   19  average, you really know you have a very, very serious problem

                   20  and oftentimes this is overlooked.

                   2 1             Now Memphis region did not-have a site visit. This

                   22  time.  The last, well, I might just tell you in passing that

                   23  this region became operational. in'1967, I mean started its

                   24  planning in 196G and 1967, became 'Operation in 1969, and in
  kce-Federat Repoiters, Inc.
                   25  1971 had site visit in response to the triennial application.







                                                                        213


          4fl9   1          1 will just go briefly through what the site

   Tleba 9       2visitors had to say. The main -- I will point out the  main

                 3orol3lems.  And the main problems that they found in the'site

                 4visit and that was really known before the site visit was made,

                 5was that the RAG, the Advisory Group of a health council, and

                 6that this advisory group consisted of about 156 people, and most

                 7of these people were in the priors class. And this was  a

                 8purely untenable thing to have the -- this committee  and

                 9council combined in this way so that the coordinator of  the

               I 0n
                          really was not in a position to carry out the program

               11 in the way that was in keeping with-the expectations of  the

               12 regional medical program.

               13           Also the administrator, the coordinator of  the

               14 program, was thought by everybody to be greatly overextended.

               15 And he, Dr. Culverson, was the only medical person in the

               16 program. And he did not have a good manager under him to carry

               17 out the administration of it, the administrative aspects  of

               18 the program.

               19           So it was felt that bdcausb of the conditions

               20 existing in the regional advisory group and because of the

               21 lack'of proper supportive staff, that the -- a developmental

               22 grant could not be given. Now there was -- with some'definite

               23 strengths noted at that time.

               24           These concerned the fact that the University of
  Ace-Federal Reporters, Inc.
               25 Tennessee had given the program the authority. While  the






                                                                                 214


              #191  regional medical nrogram grew under-the guardianship of the

       a 10       2  university, it really changed, after the visit in 1969, and

                  3  made it possible for the PAG to develop on its 'own.

                  4            The excellent thing about the program seen in 1971

                  5 was the fact that five CHP, five agen-cies and probably five

                  6 or six B agencies worked very closQly with the R14P program. It

                  7' was described as being a really excellent, because PIIP provided

                  8 staff to help the B agencies with their work, and also worked

                  9 with them in planning and all kinds of outreach activities in

                10  the community.

                               The staff really developed well. And in the community

                12  they were  described as excellent brokers for the PD4P program

                    and also  they were not just trying to sell programs but t'nr-,y
                13

                14  were reallv architects, too, after they got over the operational

                15  phase in the program. I said that the coordinator over extended

                16  himself but the people  the sit   e visitors felt that the

                17  program had potential for being'one of the best programs.

                18             And while they did not fund, I mean suggest a develop-
                19  mental component, they did grant triennial status as a result

                    of the visit. flow with the suggestion that there be a complete-
                20

                    overhauling of the @G and    the administrative structure and that
                21
                22  some effort be made to   correct certain things.
       end  -   23

                24
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                                                                         215

     #20


        arl
                 I             Now I have said before that this is a very
                 2  difficult region to describe'with so many people who are

                 3  very poor.  Black and white.  But one of the things that was

                 4  pointed out was that there were -- there was only one black

                 5  person, female, on the staff.  And also there was very little
                 6  input, opportunity for input from the people being  served.

                 7             Now I will go right on quickly to say that for a

                 8  year after this visit, after this 1971 visit -- and there's

                 9  nobody from the advisory committee-who made tha @ isit,  we

               10   did have members of the council who were on that.visit, these

               11   recommendations were made, and I would think, I said I didn't

               12   make it,'but I would think from reading-the records that Dr.

               13   Culverson made everyeffort to begin to do something  toward

               14   correcting the things that have@been pointed out.

               15             The -- there was a site visit made in the s @ er


               16   by staff-to take a look at what the situation was at the

               17   present  time.    And  I  would  like  to  say  that Mts.Kyttle

               18   knows this situation very well.and can add to it after I

               19   have just said a few words.

               20             It seems now that the RAG has been reconstituted.

               21   I didn't tell you that that 156 member group has  executive

               22   committee of about 45 members. And it was  just  absolutely

               23   impossible to get anything done'that they didn't themselves

               24   want because they met every month, while the @G met only
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               25   once a year, I guess.  Twice.  Once or twice a year.






                                                                         2 16
        ar2

                 I             Now the situation has changed quite  a  bit.  The

                 2  RAG consists of 36 members. They are well  chosen  from  the

                 3  geographic areas'. They are old and young, reflect the' racial

                 4  composition, and women.  I think that there are nine blacks

                 5  and six women oh this new RAG.  And it is a freestanding

                 6  group, not encumbered by the old  pattern.  Dr.-Culverson  has

                 7  moved immediately to see that guidelines have been developed,

                 8  bylaws, that is, and also that three committees,  policy  --

                 9  the planning committee, and the policy and  review  committee,

               10   and also reference committees.


               11              Now, these reference committees are made up

               12   primarily of the people who  had to do with categorical programs.

               13   There has been also a change in focus.  The  program  activity

               14   actually is looking at the underserved.  In the subregional

               15   areas where, like in the  crowde d areas of Memphis and  in  the

               16   rural areas there is an attempt to extend servi.ces to  the

               17   people through cardiac  clinics.

               18              Also there is a  very important high  risk  infant

               19   component which is  regional.  Ithink this is  funded  jointly

               20   with the other agencies, too, isn't it7 Yes,  it  has  just

                                                                               f
               21   started.  Also family planting services.

                               It is hard in this brief time to tell you ever thing
               22                                                             y

               23   that's been done here.  I think it is extremely significant

               24   that the regional program has.applied staff to other agencies
  Ace -Federal  Reporters,  Inc.
               25   in order for them to get very much needed services  in  the




                                                                     217


       ar3

                    family planning area and also to do something about getting

                 2  ambulatory services to these-greatly deprived areas that they

                 3  are working to develop Lee County cooperative clinic in

                 4  Arkansas and so on.

                 5            'I said before that the University of Tennessee

                    has been-supportive, has helped in making decisions, but has
                 6

                 .7 not forced its own views. And I think that  the  management

                 8  aspects of the program have not 'been reviewed yet.  Right?

                              MRS. KYTTLE:  That's correct.
                 9

                              PR. ELLIS: But it is expected  they  will  be.  I
               10

                    mention this because the visitors in 1971 talked about  the

               12   kinds of-positions which should be filled and talked

                    specifically to the point of not having the staff expenditures
               1 3

                    be -- grow any larger until some of the operational aspects
               14

                    could be shored up.
               15

                              I'believe there was a recommendation that, by the
               16
               17   staff, though, that because of the fact that the coordinator is

                    greatly overextended, that he be given an-assistant administrate
               .18

                    to look at the management affairs particularly.
               19

                              We have said there is no problem  with  assessing
               20
               21   resources and.so on.  Now the evaluation component is not
                    strong because of the fact that, well, they can't work  too
               22

                    well because one of the weaknesses that still exists in the
               23
                    programs, there is not a clear statement,of the objectives,
               24
  Ace-Federal  Reporters,  Inc. goals and priorities. They have stated some broad goals,
               25







                                                                        218
          ar4


                 I  very broad, to make health care more accessible and to make it

                 2  more available, and to compare the health costs,  lower  the

                 3  health costs where possible in doing these two things.

                 4             But there are no clearly-stated objectives as to

                 5  how broad goals can be accomplished; consequently it  is  hard

                 6  to'evaluate the-program because most everything can  fit  into

                    what has been stated as objectives.
                 7

                               I think the staff,.khowing the whole  story,  and
                 8

                    unfortunately I have never beeninto this section at  all,  I
                 9

                    just know what people have told me about certain  things,  I
               10

                    feel that the direction in which this program is moving is very,

                    very excellent indeed.  And the staff feels that  the  changes
               12

                    that had to be made as recommended by the site  visitors  in
               13

                    1971 have been made in the main.
               14

               15              Mrs. Kyttle is here, and I would like her to

                    add a few things because she has visited the area twice,
               16

                    rather recently, and has talked with the coordinator  and  the
               17

                    other people.
               @18

                               DR. SCHMIDT:  Okay,.would you make any comment
               19
               20   that you would?
               21              MRS. KYTTLE:  Dr. Hess has to leave at fourish,

                  so perhaps he would like to make his comments now.
               22
               23              DR. SCHMIDT:  Okay, Joe?

                               DR. HESS:  One certainly is at a disadvantage in
               24
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               25   trying to evaluate the region from what appears on paper alone.





                                                                                                                           219
                  ar5


                               I     And  I must  say when               I  first  started  going  through  this  and

                               2     looking  carefully  at               what was  there,  the  first  question  that

                               3     came  to my mind'is  how with  all  these  problems  with  the

                               4     RAG  and what-not  did  this  region  ever  achieve  triennial                                       status.

                               5     And,  but,  however,  in  talking with Mrs.  Kyttle,  I  gather  that

                               6     what  is  actually  going  on down  there  is  probably much better

                               7     than what was  reflected  in  the  paper  and  so  that  one  has  to

                               8     somewhat  separate  the  activities  that  are  being  carried

                               9     out  from  the  --  what  you might call  in  a  general  way  the

                            10       organizational  structures  of  the  region.

                            11                          But  I would  like  to  point out  a  few  things  that

                            12       are  of  some  concern  to me  in  looking  at  this  total  picture  and.

                            13       trying  to  render  a  judgment  concerning  the  funding  request.

                            14                          One  particular  feature  of  this  region we  need  to

                            15       keep  in mind  is  that  it  overlaps  with  three  or  four  other

                                     MIPs  in  terms  of geographical  area                        and  population,  so  that
                            16

                            17       there  is  the  potential  for.  funding  coming  into  certain  areas

                            18       from more  than  one  source.

                                                        The  problems  of  coordination  have  been worked out
                            19

                                     fairly well  and  a  couple  of  these  others  remain  to  be
                            20

                                     resolved.
                            21
                            22                          It  is  alluded  to  in.the  presentation,  the  RAG  has
                            23       recently  been  redefined  from  the original  150  some  odd  person

                                     group  to  36  person  group  and  the  bylaws  have  been  approved  now.
                            24
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                            25       But  a  lot     of  the  further  reorganization  in  terms  of  factories,




                                                                      220


         ar6


                 I  so on, remains to be done, and so that at this point it is

                 2  unknown to us exactly how that is going to shape up.

                 3             The new bylaws do spell out certain subcommittees,

                 4  but there is a broad category of -- appointive committees

                 5  which we have no information on what is going to happen there.

                 6  So that the new RAG is one question mark.

                 7             Another question that came to mind was the size

                 8  of the staff and the way the staff is organized.  In the

                 9  submitted.budget for this upcoming year, there is a place

               10   for 59 core staff situations, 54 of them full time, and

               11   there are 13 vacancies shown on the staff budget list.

               12   I haven't taken the time to go through and enumerate other

               13   core staffs, but this certainly seems to be close to a

               14   record for number of staff people in relationship to the size

               15   of the program and fundi ng and'so forth.  So that is another

               16   question.

               17             And in  looking at what one can tell from the

               18   internal organization of staff, the data.that is in the

               19   application, I have some question about the tightness and

                    adequacy of internal organization of.-staff.  As mentioned,
               20

                    there a3n goals and some related objectives, but the prior'l'ti es
               21

                    are statements which, as one looks at them, may or may not be
               22

               23   related to goals, exactly how they fit into their system of

                    logic is not clear to-me from the application.
               24
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                              In summary,  Iperhaps would have to say that I
               25




                                                                        2 2 1


         ar7

                    am taking on faith what I have learned from Mrs. Kyttle's

                    comments to me informally', that they are  doin.g many good
                 2

                 3  things.  Somd of these are enumerated  in their progress report.

                 4  But I do have some qiestions about it, what is happening in

                 5  terms of the program management system, including the RAG

                    and core staff.
                 6

                               The new projects which are proposed, there are two
                 7

                 8  of these which stand out in my mind as most consistent with

                 9  some of the things stated in their goals and objectives.

                               One is project 36,.extension of services, neighbor-
               10

                    hood health centers,and the other, 42


               12


               13


               14


               15


               16


               17


               18


               19


               20


               21


               22


               23


               24
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               25





     CR 7149
                                                                            22 2
       21
     eak 1


                 I              DR.  SCHMIDT: Let's continue on and get a data

                 2 base, ask Mrs.  Kyttle  if there is anything she wants to say.

                 3              MRS.  KYTTLE: The Committee work

                 4              DR.  SCHMIDT: Could you put the mike right  in  front

                 5 of you.

                 6              MRS. KYTTLE:  The Committee work and task force

                 7 structure is not doomed. It was done.so  recently  that  it  could

                 8 not get into this document.  The, staffing pattern is  a  proposed

                 9 staffing pattern.  It does-not list.vacancies.    @se    vacancies

               10  are new positions and that is what we intend  to  have.  There  is

               11  only one vacancy in existing positions and that is the vacancy

               12  that Dr. McCall left quite a while ago.an.d it has never been

                   filled and it separately needs to be filled but to say that
               13

                   there are 56 positions in this regional medical   program is not
               14

                   quite right.  There are 44.  One is vacant.
               15

                                Ihave attended the three meetings of the new RAG.
               16

                   It has kept-me down  there a lot but I thought if this is the new
               17
               18  blood here, then that is where.,the action will be.  It wasn't
               ig  a redefinition of the regional advisory  group.  It  was  creating
               20  a new one and it did break off from its parent, which was the

                   14-county CHP-"B" to the Memphis-Shelby area MMCC, just about
               21
               22  everything.  It was also regional medical programs. -And It

                   was not easy to get away from-thdt parent and still have good
               23

                   parental ties.  And Drs. Culbertso n and Cannon have done it, and
               24
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               25  in my view done,it.very well.





                                                                           22 3
    eak 2


                 I             Dr. Johnson at UT was helpful in getting it  done.
                 2 The old regional advisory grou p was representative of only those
                 3 14 counties, and that is what raised the legality of the regiona

                 4 advisory group and that was the single factor that disqualified

                 5 them for developmental component funding when they were placed

                 6 on triennial status.

                 7            The big funding issue or one of the big funding issu@

                 8I believe, is the middle contract under core.  And  when  staff

                 9met to try to identify issues, that-was one that @me up
                                I

               10 immediately., Essentially Memphis is pursuing two  things,  its

               11 own concept pf area health education centers which  it  calls

               12 model learning centers which it thinks.shbuld'be in the hospital

               13 and then development of the involvement from  that  rather-than

               14 developing the consortium and including the hospital.

               15             They competed unsuccessfully for health services

               16 money last June. Then the,second large component  of  it  is,

               17 Memphis submitted AEMS application for supplemental funding,

               .18 received one year planning funds to sharpen a data base which if

               19 Memphis has anything it has a sharp data base.

               20             Coming from MMCC, it has received as the collector

               21 of the data since 1966, so Memphis is writing back  saying  b
                                                                              y

               22 January 1, which is their next year, we will have sharpened our

               23 data base and they are reapplying for the operational dollars thE,

               24 applied for before for emergency medical services and that
  Ace-Federal Reporters,  Inc.
               25 ties into something I said before.  Their task forces have  been






                                                                          22 4


      eak 3
                   established 'and one of  them is a task force for emergency medica

                   services.  And at a metting of the regi onal advisory council las--
                 2

                   week, I heard Dr.-Cole who is the new RAG Chairman and Dr.
                 3

                   Culbertson feeling this group out on beginning to think now abou-
                 4

                 5 priorities on funding levels that might not approach the

                 .1 3.2 that they asked for.
                 6

                               And where -- beginning to think now  about where  the
                 7

                   emphasis would be.  And I heard this regional advisory council
                 8

                   say that if we have to make choices under that million dollar
                 9

                   contract category,;.then the choice will be emergency medical
               10

                   services.
               11
               12              The whole state of Tennessee, Dr. Tur.bshen and
               13  Dr. Culbertson have worked together quite sometime on  the  state

                   of Tennessee's program.  Dr. Culbertson has all buy revived
               14
               15  the Mississippi Emergency Medical Plan   that was almost in
                   disarray.  No work yet is underway with  the Arkansas  Department
               16

                   of Transportation, hos ital association,  traditional linkages.
               17                        p

                   But the State of Tennessee and State of Mississippi -- a scale
               18
                 - of 1 to 5 are about 3 on emergency medical services and they are
               19

                   so deep into it that I don't know, it would be difficult to turn'
               20

                   back,
               21
                               DR. SCHLERIS:  A few questions.  A few questions
               22
                   first,then perhaps a comment.  If I read this correctly, their
               23

                   RAG met Once last year, is that correct?
               24
  Ace - Federal  Reporters,  Inc. MRS. KYTTLE: That is traditional with the  old  MMCC
               25





                                                                         225
    eak 4


                 I  which was their RAG at the time this'application,was prepared.


                 2 That is the old RAG.

                 3             DR! SCHLERIS:  Right and emergency health services

                 4 met accordingly at the time of the application, zero?

                 5             MRS. KYTTLE:  That is the-emerg6ncy medical group

                 6 out of the old RAG.  That is MMCC. You are right.

                 7'            DR. SCHMIDT:  Wait a minute.


                 8             DR. SCHLERIS:  I am trying to get an indication

                 9 of  activity.

               10              DR. SCHMIDT:  Right  but the RAG now, recently has

               II- met how many times, the new RAG.

               12              MRS. KYTTLE:  The new council is three months old

               13  and it has met three times.

               14              DR. SCHMIDT:  -Right, okay, so that

               15              DR. SCHLERIS:  Well, this is important because

               16  I think in terms of developmental component and reaching deci-

               17  sions according to priority, accotding'to what would be supporte,.

               18  it is of interest to see what their past record is for the past.-

                   year and not just for the past three months.
               19

               20              DR. KYTTLE:  Dr. Schleris, it is  not the same group.

                               DR. SCHMIDT:  Do you see they have constituted reall,
               21

                   for the first time a regional advisory group three months ago.
               22

                               DR. SCHLERIS:  Well, you.see my dilemma.  I know
               23

                   this.  I try to count the number too of RAG, and the old group,
               24
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                I  doing is supplying us with additional and very important new

                2 data.  I appreciate it but at the s.ame-time, it is difficult

                3 to get an objective judgment on this. In other words,  the  new

                4 group which is how many now, 36, but the program here was put

                5 together by the old group, isn't that'right and the report we

                6 are looking at in the application is from the old group, is


                7 that correct?


                8             MRS. KYTTLE:  Dr. Schleris, you can appreciate that

                9 a regional advisory group of 151 members that had R&D's

               10 experimental contract, CHP and,RMP, didn't give a lot of time

               11 and this was quite a bit of the Memphis regional medical

               12 programs application but it nevertheless had to go  through

               13 a regional advisory group that had EMS committee that never met.

               14             DR. SCHLERIS:' I am not trying to put a qualitative

               15 judgment on it. I am just trying to get an  understanding  from

               16 this document. Looking at some of  the'specific  proposals,

               17 1 will ask out of curiousity about the proposal to  improve

               18 death statistics by teaching, individuals, examinations,  post-

               19 mortem, where they don't have legal rights to do autopsy and so

               20 on. I wonder if you have any more information on  what  appears

               21 to be a-very intrigu ing and difficult proposal, how that cleared

               22 RAG and what priority.  Did you see that.. It is'project

               23 number 33.

               24             MRS. KYTTLE:  No, I am afraid -- I can tell you that
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               25





       eak 6                                                                227

                  I  in the first five because it was one   that Memphis chose

                  2 to drag up from an approved  but  unfunded  when  they  were  extended

                  3 and had money to'activate, they  activated  that  one  but  the  tech-

                  4 nical aspects of it I don't know.

                  5              DR. SCHLERIS:  I don't know what communication

                  6 you got as far as emergency medical services @as,concerned.

                  7 They haveapplied for let's see, $1,100,000, were given

                  8 $80,000 for the planning.  It goes to more than just

                  9 data base,.I assure you. I  don't  know  the  details  but,  perhaps

                10  Dr. Rose does.  This was one of the requests for larger amount

                11  of funding.   It was felt that they -for many reasons weren't at

                12  that stage.   It wasn't just getting  numbers  of  cases.  There  was,

                13  a lot of homework that had to be done.  Can You comment on

                14  that, Dr. Rose?

                15              DR. ROSE: Yes, in fact  a  large  part  of  the  concern
                16  of the reviewers related to how this Memphis or .suburban,
                17  if you will, EMS-type activity was going  to  relate  to  what  else
                18  was going on in Arkansas.and Mississippi  and  in  the  rest  of  that

                    particular state.  In speaking with Loraine subsequently on
                19

                    several occasions about that,  I.tend  to  believe  that  they  really
                20

                    did have considerable more information  than  was  included  in  the
                21

                    application which, of course, the reviewers had to act on.'
                22

                                DR. SCHMIDT:  Okay then.  John?
                23

                                DR. KRALEWSKI:  I am not sure we have a motion on
                24
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                                                                         22 8
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                 I            DR. SCHMIDT:  No, we are going to return to Dr.

                 2 Ellis for proposal.

                 3            DR. KRALEWSKI:  Okay, I will hold up then.

                 4            DR. ELLIS:  The application which is before us

                 5requested roughly 3.267 for this year'five.  The staff

                 6reviewing this made the recommendation that the amount to be

                 7granted be 2.25, and that this would inlcude $162,700 for a

                 8developmental component.  Also, in talking about the supplements

                 9request that we have been talking about, staff suggested that

               1.0 $237,000 be granted to support'selected new activities, includin]

               11 the expansion of component number 36.  That is greatly strength-

               12 ening the neighborhood centers and giving them something in orde-

               13 to really build the program and extend it.  And then $225,000

               14 to pursue selected activities under the contract request, this

               15 being primarily to be used for EMS.  I would move that this,

               16 these recommendations be accepted.

                              DR. SCHMIDT:  Is the re a second?
               17


                              DR. HILTON:  Second.
               18

                              DR. SCHMIDT:  All right.  That is a second so
               19

                  the motion can be discussed.
               20

                              John and then Joe.
               21

               22             DR. KRALEWSKI:  I am inclined.to believe that in viei7

                 Iof the organizational, some of the organizational concerns
               23

               24 that have been expressed here even though they are changing,

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                                                                        229

     eak 8
                I  you really believe this organization is.go.ing to really do it.

                2  But we are giving them substantial.developmental component

                3  plus a fair amount of contract money and that is placing

                4  a fair amount of.bucks in their organization without many

                5  restrictions on it and that makes me 'a little bit nervous.
                61            DR. HESS:  I would-like-to make a substitute
                7 motion.

                8             DR. SCHMIDT:  All right, before I accept that, I

                9 will let Dr. Ellis respond.

                              DR. ELLIS:  It is my understanding that the
               10

                  monies which they have now are very tightly budgeted and that
               11

               12 there would be very little room for growth and expansion  in

               13 these new directions. And so it seems that  a  developmental

               14 component of some magnitude might be very desirable in  this

               15 instance.  In order to give the new director, I mean he

               16 is not a new director  ut     is almost like a new director becalm

               17 he does not have all of those 156 people and all of the problems

               18 with no committees or anything to work with him.  That has been

                  eliminated and I think he does need a chance to show how  he
               19

  e2l             can expand th e program.
               20


               21


               22


               23


               24
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       CR 7149                                                              230

               22


            kar  11
                                MRS. KYTTLE:    Dr. Kralewski, the original structure

                  2  complication arose not   so'much because it wasn't working, Memphi!

                  3  made it work.  And it very quietly went about a very good

                  4 program. It was  the  legality  that  raised  the  issue  about  the

                  5  CHPBL MNICC, with a mandate to serve 14 counties being the decis:(

                  6  making body that'was serving 75.

                  7             I would not want you to think that it was a compli-

                  8 cated, unworkable structure.  It.'was a complicated, of doubtful

                  9 legality, structure.

                10              DR. SCHLERIS:  It only met once that year, didn't it'

                11              MRS. KYTTLE:  The full body traditionally met twice,

                12  that year'it met once.  The real decision making was in the

                13  board of trustees,, 45 members, 'still"serving 14.counties.

                14              DR. SCHMIDT:  Let's   see, do you have a comment --

                15  in order here we  have  someone  who  wants  to  make  a  substitute

                16  motion.  If y ou have a comment on what is being discussed now,

                17  please speak.

                18              DR. ELLIS:  I do.  I.  wouldn't think'a program, regari.

                19  less of legality, that only serves 14 communities when it is

                20  supposed to serve 75, is really functioning and functioning

                21  properly.  And neither will I think-that the guidelines, which

                22  they were  using in terms  of  developing  the  new  programs,  were

                23  appropriate to get  services  to  the  underserved,  which  is  part

                24  of the thing we are talking about'.
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                                                                          2 31


           kar 21  and I wanted to ask the question,.did the-regional council rule

                 2  this out of order legally?  1 know,it was requested that he

                 3  giv'e.a ruling.

                 4            MRS. KYTTLE: We thought we might work  with  the  regicr

                 5 in obviating that necessity and they got a new council and so

                 6 we didn't have to seek an opinion.'

                 7            MISS KERR:  I would like to make a comment, but I

                 8 would be willing to wait until after the substitute motion and

                 9 action is taken on that.

               1.0            DR. SCHMIDT:  Joe, the'floor is yours.

               11             DR. HESS: Perhaps somebody might just  make  some  notES

               12  of this other paper there.  I would like to suggest for program

               13 staff, eight hundred thousand. For  contract,  two  hundred  thousen

               14  and I am assuming here that some planning has gone on and that

               15  as  ar as this emergency medical service is concerned, I gather

               16  that that owuld be their priority use.

               17             It is somehow, some proven need in the community.

               18 That developmental component of.a hundred thousand included, an@

               19  projects of nine hundred.thousand.  To provide  money to  accomplis

               20 Project No. 36, which I gather is a key project  in  their  strategy

               21  and through re-examining some of. their currently funded  projects,

               22  that they should be able to find money to-fund the  other  projects

               23  or two in their new list, which is compatible with the new
   so              directions in which they say they are going.
               24
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                                                                        2 32



           kar  31            DR. SCHMIDT:  Is there a second for the substitute

                 2 motion?

                 3            MRS. F'LOOD:  Second.

                 4            DR. SCHMIDT:  All right, Mrs. Flood's second.  We

                 5 are now discussing a two million dollar funding level.

                 6            Miss Kerr?

                 7            MISS KERR:  ilhile it is late, it is not so late and

                 8 I am not so tired, but I feel I have to speak my piece.  In view

                 9 of decisions made earlier by comparison and in view of ingrodien

               10  of a viable potentially exciting program, I cannot, in all con-

               11 s,ciousness, support either one'of-these recommendations at this

               12  point.

               13             DR. SCHMIDT:  You say either one?

               14             MISS KERR:  No.


               15             DR. SCHMIDT:  Lorraine?

               16             MRS. KYTTLE:  Miss Kerr  this is an anniversary withi-

               17  a triennium and it comes to committee without any site visit

               18  report that would give you the flavor of some of the exciting

               19  things that this region is doin4.

               20             But it is a quietly efficient region.  It has some

               21  very-exciting things ongoing and even though it is late, I don't

               22  know if you would have the time.to hear about them.  Can I just

               23  tell you about one?

                              Memphis has'two multi-pliase screening projects ongoing
               24
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                                                                       2 3 3



           kar 41  Mississippi, two and a half years. ago.

                 2            MISS KERR:  Was this thrust of RMPS?

                 3            MRS. KYTTLE:  Two and a half years ago it was startec

                 4 It is just widening up.  The companion one with an intercity

                 5 Memphis, predominantly black stationary multi-basic screening.

                 6 In anticipation of this year, they'will have completed the

                 7 targeted screening.  The multi-phasing screening activities acrcE

                 8 the 'country have gotten together-and they met here in Washingto

                 9 to develop a protocol to evaluate what we have done and nine

               1.0 were selected, axid both-6f Memphis' were.

               11             Memphis' multi-p4asic screening have  screened  more

               12  people than all the others combined.  They are going to be a

               13 pivot for a contract to evaluate what we  have  done.  And  they

               14 -have just gone about it very quietly.

               15             Inter-mountain is in there, Ohio vallies is in there

               16  and so is Memphis'.  And I just    if you would like to listen

               17  to some of the things that they have done like that,  there  is

               18  more excitement there, but this is not.that kind of application.

               19  It is not a triennial.  It doesn't have a site visit report and

               20  I think it is at a disadvantage here.

               21             DR. SCHMIDT.:  Mrs. Flood?

               22             MRS. FLOOD:  Well, again, recognizing the'disadvantage

               23  of trying to evaluate on paper, looking at the  print-outs  for

               24  the components sort of descriptor devisions that  are  provided
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                                                                            2 34


          kar 5 1  under the previous contractual fundings we have talked in the

                 2  history of the region of the tremendous impact of the 21 and

                 3  under, of the minority groups, yet if you study  the   print-outs,

                 4  which is not a very good way to evaluate, but there is no emphae

                 5  utilized  from the central core staff activities to address

                 6  these high priority needs of these,particular types of populatic

                 7  and as Dr. Schleris pointed out,'our point of reference has to

                 8  be.the track record and, again,.I will realize staff is at a

                 9  disadvantage trying to present to us this changing flow.  But

               1.0  I am not sure that we are adequate in giving  them  the  requested

               11   funding and perhaps even at the level that Dr. liess has proposed

               12              DR. SCHMIDT:  John?

               13              DR. KRALEWSKI: Would you refresh  my  memory  again  on

               14  the contracts, what do they hope to accomplish with that?

               15              MRS. KYTTLE,.  On page 19 of the document, I have

               16   written out the five categories of  the'million  dollar  contract.

               17   And the three large portions 'of it, one half of it is for
               18   emergency medical services and.we have seen their application

               19   on that.
               20              And, here is emphasis, Mrs.  Flood.  Through  the  work

                    of the staff, which surveyed emergency rooms, its'needs, their
               21

                    uses, the population that they serve, the  State  of  Tennessee-in
               22
                    developing a statewide emergency plan  zeroed in on  the  regional
               23
                    medical program as the lead role for the' emergency, stemming
               24
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                                                                                  235



          kar  6  1             DR. KRALEWSKI:  Well, have they applied for emergenc)

                  2  health service grant?

                  3             MRS. KYTTLE:  Right.

                  4             DR. KRALEWSKI:  And they-have been partially funded?

                  5             MRS. KYTTLE:  Right.

                  6             DR. KRALEWSKI:  Why.is that showing up as five hundr(i

                  7  thousand dollar contract?


                  8             MRS. KYTTLE:  There'is no mechanism for them to

                  9  reapply for the operational dollars..

                10              DR. KRALEWSKI:  Have they   completed  their  planning?

                11              MRS. KYTTLE:  The region   felt they had completed

                12  their planning before we told them to plan.  Very strongly.

                13              DR. SCHLERIS: Is there anything to prevent their

                14  coming to RMP for emergency medical  service  plan  in  the  future

                15  as part of  their  RMP  program?

                16              MRS.  KYTTLE:   That is-'what they are doing.

                17              -DR.  SCHLERIS:  But they are asking for a contract

                .18 here to do  it locally, isn't that right?


                19              MRS.  KYTTLE:   Yes.

                20              DR. SCHLERIS:  Without there being any documentation

                21  of what it  is they are actually planning to do.  At least a

                22  part of their document is concerned.

                23              MRS. KYTTLE: They.lo6k  activate  the  same  plan  they

                    presented to us  back  in  June.
                24
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                25







                                                                              236


           kar  7 1  is, there is a great deal of differe nce between  putting  somethit

                  2 in writing and then verbal reports.  This  disturbs  me  a  great

                  3 deal. I know you are familiar with  the  area,  but  qoin'  through
                                                                             9

                  4 volume one and two, I don't come out with a  great  deal  of  in-

                  5 formation about what it is that they are going  to  do  with  these

                  6 funds and the Memphis application as it came   in  for  emergency

                  7 medical service didn't reflect all the planning  that  you  indica-:

                  8 took place, and this is troublesome even to  be  told  that  well,

                  9 they had already done all the planning.@.:They  thought  every  bit

                10  had been done.

                11             It wasn't  reflective of-what they  said.  I  do  have

                12  considerable concern  about the level of funding.  I question

                13  whether emergency is  the way to go as the first step.

                14             MRS. KYTTLE: It is a  part  of  civil  steps.  That  is

                15  RMP's role. @IP's role in this  state  consortium  is  the  emergen@


                16  room.

                17             DR. SCHLERIS: As I see  it,  if  we  apkove-,.thesefunds,

                18 we are saying we  think  that  contract  is-a  great  idea.  I  for

                19  one --'if-you want me to have faith, believe me, on a Friday
                20  afternoon after two days, my faith increases  more  and  more  and

                21  more and I will become a believer if you like, but it takes     an

                22  awful lot of conversation even:this late in the day-.
                23             MRS. KYTTLE: No, we didn't  think  it  was  worth  five

                                             s why.@he staff  recommended  225,000  for
                24  hundred thousand, that i
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                                                                                                                                         2 37




                   kar 8 1 choice. And they have told.'us thei'r choice is still EMS.

                               2                        DR. SCHMIDT: Okay. Where we are is With the

                               3 substitute motion at the two million dollar level.

                     22        4


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      #23

         arl     I              Are there other points to be brought  up?  If  not,

                 2  then I will call the  question.

                 3              On the $2 million level with the breakdown of

                 4  900, 100, 200 and 800, as you see on the board

                 5              DR. JAMES:  I would like to make a comment, I

                 6  believe.- I think I am still hung   up on    and will be as

                 7  long-as I possibly will remain on   this committee, in regard

                 8  to geographical locations  of  R'MP s, especially as they are

                 9  related to populations.  Like Mississippi.  Lik     ew  Mexico.

                10  Like Memphis.

                11             And I think that we  have heard that there'-- in

                12  the Mempfiis area that there has  been a restructuring of their

                13  administrative structure, which   is too young yeti I think, to

                14  have a real impact in terms of.what really are we going to do,

                15  because we just haven't had time, but I believe from the'

                16  statistics and information we have received in terms of,

                17  again, going back to the neonatal infant mortality which is

               .18  an indicator of the lack of health services in  the  area,  and

                19  I don't think that that needs any further elaboration, I

                20  would feel that these are the areas that need the strongest

                21  support of staff continuing technical advice to the RMP,

                22  to stay on top of the RMP to be surethat it is creating the kin3

                23  of program that will benefit-the people. And  this  is  what  I

                24  hear are services.
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                                                                      2 39
        ar2

                 I   long ago in another area.  I don't want to get anything

                 2   confused, but I realize that-this is an opportunity for RMP

                 3   to begin to shore up some of those ends that were not

                 4   covered in some other areas that have to do with the same kind

                 5   of circumstances.

                                I realize that I don't have as much information  as
                 6

                     even,maybe some of the rest of you have, because you are famili
                 7

                     with some of the programs that were going on prior.  But  just
                 8

                     in terms of the situation.and the effort that is being put
                 9

                     forth and the direction, we may be at a disadvantage when we
                10

                     heard Memphis yesterday mornixi  to start out with, we may be
                11                                 9

                     a little-bit more, would have been a little bit more under-
                12

                     standing of the problem that exists there.
                13

                               But I think that I can only say  that if we can go
                14

                     with Vermont and a 400,000 population, with the excess amounts
                15
                     of money,that have been poured into that community and that
                16

                     state, then we can go with Memphis and help them to improve
                17

                     their services.
               @18

                               DR. SCHMIDT:  There-are some issues raised there,
                19

                     Leonard.  Do you want to comment?
                20
                21             DR. SCHLERIS: Be outrageous to try to  answer  that,

                     but @erhaps I can try only in one way.  This is not-meant at
                22

                     all as a rebuttal because Ishare your concerns.  Our  problem,
                23
                24   though, is I think a little different than looking at an area
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                25





                                                                 2 40


           ar3
                    at whether the funds requested really go at those needs and

                    whether they would be handled eMctively.

                 3             I think RMPS would fall flat on its face many

                 4  more times than it already has if it were to say that because

                    an area has desperate needs that therefore we should be
                 5              1

                 6  uncritical in our judgment.as far as these needs are concerned.

                 7  My reason for referring to the fact that it is late  in  the

                 8  day is that I think the group is getting more  lenient  late

                 9  in the day and,not harder late in the day.

               10              My concern about these funds relate  to  looking

                    at the pro jects as submitted and some of these  are  frankly

                    experimental.  The one,about more accurate death certificate,
               12

                    certification, I question manyespects of it.  I would  like to
               1 3
               14   know more about it. It is essentially  a  research  project.

                    I am surprised it has cleared RAG.
               15
                               The problem with mul tip@asing screening is of
               16
               17   interest., too, because of certain RMPS statements on  this
               18   sort.  Included in this is a project on home care, which again

                    many of these have been supported around the country, there
               19

                    are certain statistics on this.
               20
                               One   can  go  through the various  projects  and
               21
                    come away with a feeling that RAG has not set its priorities.
               22
               23   I am a little unhappy about the response of  the  emergency
                    medical services and how they are going about this,  and  it
               24
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               25   would'be better.if we






                                                                       24 1
          ar4

                 I on faith the contract of 200,0.00 or part of it,  even  though

                 2 there is need and heaven knows there is need  all  around  the
                 3 country for EMS, $200,000, I don't know how they  are  going  to

                 4 use it.

                               We,are being told we should depend on  the  group,
                 5
                 6 but if you  go about their decision-making capability reviews

                   to what we  have been told, RAG met once, the county-, three
                 7
                 8 times, the  EMS met zero, so I don't know what went into that
                 9 formulation. so it isn't a question of feeling Memphis doesn't

                   have need.  It is a question o f my inhibition in terms of
               10
                   whether or not they are going about meeting these needs in the

                   most effective way they can.  I  am just trying to  equate  it
               12
               13  on that basis and I think $2 million as advised  here  is  for
               14  what we have seen, I think, a very generous way  of  meeting  it
                   because they still have the developmental components.
               15
               16              I, fot.one, will support the $2 million.  I may
               17 'have come up with a lower sum.  If this.fails, I might still
               18  offer that as a suggestion.
                               DR. SCHMIDT:  I think unless there is something new
               19
                   to put before the group, we should call  the question.
               20

                               John?
               21
                               DR. KRALEWSKI: I would like to  offer  an  amendment
               22
               23  to this alternate proposal here and that is that we strike
                   the contract money, w& keep that project money  at  the  900,000
               24

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   ce - Federal Reporters,  Inc' that's being suggested, and we give them  a  full  developmental
               25





                                                                          24 2
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                 I  component to the limit of what that-would run wild be  about

                 2  there, essentially what they are asking, 162, maybe a  little

                 3  more than that as it would work out in the final budget,  but

                 4  then out of the contract they can rethink their whole  plan

                 5  of slipping into an emergency program here that might not

                    have been outlined and still have some money under
                 6

                 7  developmental for some discretionary kinds of activities.

                 8             DR. SCHMIDT: Well, if I am with you,  you'd  give

                 9  them the 800, program staff, and the 900 for projects,  and

               10   that is 1 million 7.  10 percent of that is 170, and that

                    would come down then to l..87 millions That is an  amendment

               12   to the substitutd.,motion to the main motion.

               13              Is there a second?
               14              DR. SCHLERIS:  I will second it4
               15              DR. SCHMIDT: All right, it is seconded,  so  now
               16   we are down to discussion of the amendment to the  substitute
               17   motion.. Anything hot germane to that is out of order.
               18              MRS. KYTTLE: I think.some of.the flavor  of  the

                    amendment came from comments by Dr. Schleris and we have  got
               19
                    to do something about these printouts that led you to  think
               20
               21   that this home health care is less than winding up.  It  was
                    something that was started two and a.half years ago.  The-
               22
                    multiphasic screening projects were started two and a half year@
               23
                    ago, and if you are going to look at these printouts and  not
               24
  Ace-Federal  Reporters,  Inc. equatb proper time with them to realize that that is the part
               25





         ar6                                                              24 3

                 I  of this program,that that is.the.part of this program that is

                 2  phasing out, then they are misleading.

                 3             I have heard this group several times today get

                 4  hung up on that.  That's the phasing out program.  The high

                    risk infant.  The expansion of the home health center.
                 5

                 6  The satellite clinics.  That is the new part of this program

                    that-is building up and the part that disturbed you is the
                 7

                    part that was started two and'a. half years ago.
                 8

                 9             DR. SCHMIDT:  The current level ther @ s at 1.627.

               10   What is being recommended now is 1.87, which is not too much

                    of an increase.  I think we wi 11 test the sentiment then by

                    vote onthe amendment to the substitute which is 1.87, with a
               12

               13   170,000 developmental and no contract.

                               All in favor of this,. please say aye.
               14

                               And opposed  no.
               15

                               All right, the."noes@' have it, and the amendment
               16

                    is defeated.  We are back to the 2 million level, and I will
               17

                    call the question on that.
               .18

                               All in favor, please say aye.
               19
               20              Opposed, no.

                               I will have to ask for a-show of hands.  Please
               21

                    raise  our hand.
               22        y

                               I have four ayes..
               23
               24              Noes?
  Ace-Federal Reporters, Inc.  Four.
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                                                                              2 4 4
       ar7

                 I              The chairman will vote to break the tie.  And vote

                 2  aye.  So that the substituted motion has it.

                 3              Before we adjourn, I would'like to ask the one

                 4  question.   At the request of staff, we did prepare

                                DR. JAMES:  Excuse me, sir, I didn't quite under-
                 5

                 6  stand that.  You said the substitute motion pas.ses?  You

                 7  voted aye for which motion?

                 8              DR. SCHMIDT:  The substitute motion.

                                DR. SCHLERIS:  $2 million.
                 9
                10              DR. SCHMIDT:  2 million level, which  is 800, 200.,

                    100, 900.

                12              DR. JAMES:  Thank you.
                13              DR.,-SCHMIDT:  Is there a question about procedure?

                14              DR. JAMES:  No.

                                MRS. KYTTLE:  I am @orry, which one?  The 2 million?
                15
                16  Okay.
                17              DR. SCHMIDT:  It is approved  at a 2 million level.

                                DR. JAMES:  Yes.  Okay.
                18
                                DR. SCH14IDT:  Staff-has-requested that I request
                19
                2o  the committee recommendations remaining, if there are any
                    comments about this chapter four that I asked you to look'at
                21
                22  last night.  It has to do with.the functions of review
                23  committee and council and so on.  This will go to council.
                    For their essential, essentially their approval.  I am asking
                24

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                    if there are any substantive  queries or comments on that at
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                                                                                24 5
       ar8


                      'this time?


                  2              MR. HILTON:    1 would say only that I would have

                  3   appreciated having that   document of that upon   joining the

                  4   committee.  I have since that time just about    figured it out,

                  5   but it was an awful loss in productivity while     I figured it.

                  6   So I am very glad to see that this will be available to the

                      future members who join the committee.
                  7

                  8              DR. SCHMIDT:  I will.strongly urge that a letter

                  9   be sent  to review committee members asking for s@ecific

                 10   comments prior to this going to council.  I will express my

                      personal appreciation to a most -- somebody turn off-their
                 11

                      mike.  -- To a most hardworking and understanding committee,
                 12

                      particularly for understanding and tolerance exhibited to
                 @.@l 3

                 14   the cha irman.  Thank you.

                                 Be sure to pull out   your rating sheet and have that
                 15

                      available for staff pickup.  Thank you.
                 16

                                .(Whereupon, at 4:40 p.m., the hearing was
                 17

                      adjourned.)

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